|Tuesday, 19 August 2003|
Doctoring - time to change?
by Ravi Perera
The recent controversial strike action by some of our doctors (practising western medicine) resulted in much suffering to the helpless patients. This action was so unpopular that it even brought about a rare bi-partisan unity in the house of parliament in the criticism of it. It was an action that won no friends for the medical profession.
The pros and cons of the convoluted reasons that led to the strike action will be little understood by the poor patients or the general public for that matter. We expect the doctors who represent a higher calling to act with the temperate outlook of the learned as opposed to the hot headedness of a politicized unionist. This unfortunately did not happen.
It is appropriate that at this time we examine the medical practice and the process by which our doctors are produced. The health of a nation is too important to be left in the hands of the doctors alone!
In this country there is a general feeling that alls not well with our medical profession. In a way this is not surprising. The system of western medicine and the practice of it developed in a culture and a climate very different to ours. In the process of adopting them as our general medical system surely we have localized its standards.
This is true of most European institutions we have adopted. The parliamentary system, the legal system, administrative system, democracy, social clubs and even sports are mainly European in form. Having adopted them, in practice we use them quite differently, and often in contradiction of their very purpose. In reality we do not understand the pith and purpose of these institutions.
In the western world by and large the practice of medicine is a dedicated and a highly competent service. I have had occasion to consult doctors in developed countries and unfailingly found them friendly and helpful encounters.
In Sri Lanka, perhaps due to the shortage of doctors, an encounter with a doctor is often a perfunctory and cold affair. Our tendency to be ceremonious and the deep-seated diffidence of many of our doctors also distract from a truly professional performance.
In most medical consultations, going by the conduct of the supporting staff and the doctor himself the main actor of the encounter is not the dying patient but the glorified doctor! This may sound comical but is often the reality in our so-called professional culture.
In the context that western medicine is practised in Sri Lanka there are things that are not easily changed. Our particular cultural evolution and national underdevelopment prevents the easy adoption of foreign concepts. But there are things that can be changed. We cannot help much our cultural bias and tendencies. We tend to treat a doctor not as a person who is holding out that he could treat some ailment on the basis of a certain education.
Instead the doctor becomes in the public psychic a sort of a miracle man. The average patient in Sri Lanka thinks that a doctor is in possession of a mysterious body of knowledge, which can be drawn out only by a long process of supplication. These deep-rooted attitudes have been fashioned through years of social evolution which is quite different to the social evolution of Europe. The efficacy of our culture of course will be reflected in the overall performance of our nation.
We also cannot do much about the fact that many of our doctors are not as well paid as they ought to be. This is true of all most all employees in third world countries. Poverty of a nation brings along many complex and intractable problems seemingly beyond the capability of that nation to solve.
But there are things we can and should do. Foremost among them would be to introduce private medical schools.
Private Medical Schools
There are two main reasons for having private medical schools. Firstly, it is apparent that with the limited resources at its command the State is unable to produce sufficient doctors to meet the requirements of the country. Secondly, it is also obvious that the public would stand to benefit if we were to have doctors produced by institutions run on different ethical and professional standards.
There are very determined opponents of this idea. Most of these opponents are politically motivated and subscribe to outdated philosophies. Some of them fear change.
The rest are professional agitators.
Private medical schools are a fact of life in all the developed and fast developing countries including India today. It is highly unlikely that we could be the only exception to a world trend. Besides, it is hard to imagine that the taxpayer of a poor country like Sri Lanka can support a good medical education system on a long-term basis. For a limited period a system of public education can be run on the taxpayers money. But eventually bureaucracy, leathergy, lack of funds and reluctance to change will corrode the system.
On the contrary, a private education system in order to attract students will have to be abreast of world trends and quality conscious. Those who pay for services they receive can demand quality.
It is observed quite commonly that a person who has paid for his education values the learning and is dignified by it. Human nature is such that a receiver of free services cannot act with dignity. If at all he might be pompous but never truly dignified. We need as a nation to build value systems and dignity in our professions. How would private medical schools impact those who truly cannot afford to pay for their education?
Here, it should be noted that we are not recommending the abolition of the public medical school. We plead only for the right for other medical schools to co-exist.
Therefore, it cannot be argued that private medical colleges would deny anyone of an education.They will only make medical knowledge available to more students.
However in time, it would be apparent that the education one receives in private institutions would be several notches superior and more comprehensive than the public ones.
They will challenge the existing medical college to raise its standards. Surely we all stand to gain from this! There will be students who wish to attend private medical schools but cannot afford it. One way of making these private institutions available to all would be by way of student loans. These loans given on easy terms by the State to be repaid when the student becomes a wage earner can make these institutions available to them. But the main point we must adopt as a national policy is that nothing should be given for nothing. Making dignified and responsible citizens should be the priority of our education system. A free education does not appear to do this. After more than a half-century of free services we must open our eyes to the folly of becoming a nation living on hand outs.
Doctor, cure thyself
The other important requirement for the transformation of the professions in our country is for the professionals to regulate themselves more strictly. Our culture is all too willing to accommodate acts of misfeasance from the professional classes. The number of doctors doing things they should not or not doing things they should in their practice would be amazingly high in this country.
This is unfortunately true of all professions. But in medicine the victim of any negligence is often buried!
No trade or profession can exist without rules. More vigilant a profession is about its standards and rules the stronger it will be. Mature professional bodies in developed countries have realized the importance of self-discipline and do adhere to a stringent code. Recently in the United States the Bar Association imposed a short term bar on the former President Bill Clinton from appearing in court because it was thought he was less than completely truthful in a deposition relating to the Monica Lewinsky case. This case as we all know involved an extremely personal matter, which was seized on by parties politically opposed to Mr. Clinton. Despite these obviously extenuating circumstances the Bar association of that country maintained its policy of demanding high standards from its members when dealing with the matter of Mr. Clinton the lawyer.
In Sri Lanka, the public is often unaware of the professional standards that are expected of doctors.
Our doctors are most times absurdly late for appointments, give very short consultations, do not communicate with the patient on an equal footing and do not maintain medical records. These lapses are taken as a doctors prerogative here.
The professional body of the doctors surely has enough good sense even at this stage to introduce a code of ethics for its members and enforce it.
If we are to break out of the trap of poverty and underdevelopment we need to act with foresight and courage. At the time of independence we were a poor nation. The promise of subsidized services then was irresistible to the voter. Undoubtedly, these subsidies helped to bring services to the needy and raised their general living standards. But like every thing else its results were not wholly beneficial. These free services created a certain mentality where most assumed that handouts are a way of life. They did not know or did not care that the services they receive were poor quality. As long as it was free people accepted these services.
Today our health and education services although available widely are not good quality. We have slowly become a nation where poor quality has become the standard.
We are also unable to raise ourselves from our poor nation status. Nations that adopted more business oriented and pay for your services philosophies have taken huge leaps over us in terms of wealth creation. Ultimately, it is by making people take responsibility for themselves that we will bring the best out of them.
Produced by Lake House