Saturday, June 21, 2008

The ‘P’ words

“The words ‘health’ and wholeness’ come from the same root—old Saxon and early English words like hool, heil, and hail (as in ‘hale and hearty’) meaning ‘unwounded, entire, sound’. These concepts in turn echo the ancient idea that health is a form of bodily and mental integrity, in which nothing is missing or amiss: a balance, as the ancients had it, between the wet, cold, hot and dry ‘humours’.” ~ AC Grayling, The Meaning of Things, Applying Philosophy to Life; 2001, Pheonix Paperback, Orion Books Ltd, London, p171.

“The meaning of things lies not in things themselves, but in our attitudes to them.” ~Antoine de Saint-Exupery.

“The means by which we live have outdistanced the ends for which we live. Our scientific power has outrun our spiritual power. We have guided missiles and misguided men.” ~ Martin Luther King, Jr. (U.S. clergyman and civil rights leader, 1929-1968)

In November 2000, Dr I Hedley Piper wrote a paper in the Annals of the Royal College of Surgeons of England, where he discussed clinical governance, the profession, the ‘p’ words and responsibility.

That timely reflection came about in the aftermath of the Bristol scandal, where at one regional heart centre, pediatric cardiac surgical mortalities were found to be abnormally high, and that there were systematic lapses in oversight which led to these excess deaths.

Following this scandal, public confidence in the British health care services took a nose-dive, with politicians and authorities all scrambling to try and stanch the frenzied hemorrhage of public outcry and media criticism.

This became one of the lowest points in the history of the National Health Service in the United Kingdom, and seriously undermined the previously hallowed prestige of the General Medical Council—the regulatory authority for professional conduct and practice of doctors in the UK.

Following this there was another public uproar when a Dutch-born pathologist was found to have kept several hundreds of patho-anatomical specimens (body parts), some in his own home, which the current public felt breached the sanctity of proper doctor-patient relationship.

Fueled by an already hostile media, the public was influenced to believe that such unauthorized retention and irreverent treatment of body parts (without permission or stated authority) was an affront to the dead and their loved ones.

Notwithstanding the medical reasons why these body parts had been retained (for pathological analyses, pathology or anatomy museums or otherwise), many felt that these eviscerated bodies had been defiled and were incomplete when returned to their relatives for interment.

This scandal clearly showed the changing climate of public opinion and their diminishing acceptance of all that the medical profession had been dishing out all these years.

The public even in stoical UK has become more discerning, more demanding, more questioning and importantly more empowered and knowledgeable—no longer are they willing to be passive recipients for the historical paternalism of doctors.

Like the rest of the modern world, patients worldwide are gaining a new embolden voice to be heard, and they are not afraid to say so, even to demand for more disclosure and transparency.

The hitherto opaque, esoteric and jargon-laden medical profession is slowly but surely becoming unraveled. Indeed the last ten years following the explosion of the internet, have witnessed the unprecedented equalization and equilibration of the knowledge economy—empowering almost everyone, from the poorest to the wealthiest, from the simple-minded to the more informed, indeed from all walks of life.

We are no longer sole keepers of the healthcare monopoly, nor are we the sole purveyors of healing salves and panaceas. We are no longer hoisted on the pedestals as the heir-descendents of Asclepius, whose exclusive rights to all that are health- or medically-related, are guaranteed.

We now share the podium with disparate systems of beliefs and alternative approaches which range from organic naturopathy to traditional herbalism to New-Age pseudoscience.

Our Hippocratic mandate has been repeatedly punctured and many now believe that its tenets have become irreparably emasculated to continue as a reliable guide and beacon for the modern-day medical practitioner. And it would seem that we are not averse to taking lives as well, condoning torture, and turning blind-eyes to medical errors, mishaps or even professional misconduct by fellow practitioners…

The other major scandal that shocked the world was the ghastly murders perpetrated by Dr Harold Shipman, a seemingly benign-looking soft-spoken general practitioner, who was convicted for 15 murders but thought to have murdered some hundreds of his patients.

Whether he committed these mass murders for monetary gain, or for some obscure motives which we simply cannot fathom, we will never know.

Shipman carried his taciturn motives with him to his grave—he committed suicide in his prison cell some time ago. Perhaps he was inherently evil, or was a covert sociopath, but perhaps he simply got away with it for so long because he just could, with the powers of life and death that every medical practitioner carries in his hands…

Among those who have now to answer to the General Medical Council are some of his compatriots in the district where he had worked—fellow doctors, coroners who had co-signed many of Shipman’s death certificates without sufficient scrutiny, for failing to suspect that there might have been foul play—perhaps negligently so, by failing to report these out-of-character deaths and dying.

This new action has now been decried by some, as overblown knee-jerk reaction of the GMC to placate public wrath at its earlier inaction.

Many are asking if medical doctors are now duty bound to be their brothers’ keepers. Rivalry and professional jealousy aside, it is recognised that most doctors are reservedly indifferent to their compatriots’ performance as doctors, believing that once a doctor has graduated, he or she must be sufficiently capable of making the right decisions in every aspect of their medical vocation.

Most of us would like to believe that because every patient is individually distinct, then the physician-in-charge should have the best knowledge to treat and manage that person.

Most of us would still hesitate to second-guess our colleagues, although increasingly because of intense competition these days, many are blatantly or covertly undermining the credibility and skills of their rivals—an unhealthy development which borders on ethical misconduct.

However, we would be very hard pressed to formally disagree with, much less challenge a possibly errant practitioner, unless some very egregious deed has occurred as a result of willful or negligent action.

We baulk at having to testify against our peers or even to offer a contrary opinion or to cast blame or aspersion whether this was deserved or otherwise. Most of us have to be coerced or subpoenaed to report in an adversarial manner. Perhaps this approach is simply too late and may be too co-conspiratorial.

Hence, many among the medico-legal community have long accused medical practitioners of being too complicit in perpetuating a tightly-spun shroud of professional silence, to purposefully deny society’s probing into our purported frequent mishaps and our not-inconsequential errors.

In a recent essay on “patient-centred professionalism” in the Medical Journal of Australia, Dr Donald H. Irvine (past-president of the GMC, UK) lamented the fact that the public inquiry into the Bristol affair demonstrated that “doctors’ collective attitudes to audit, teamwork, whistle-blowing, consent to treatment and complaints about poor practice…,” were conspicuously at fault.

We have been found wanting as well as too inward-looking, too reactive like the recoiling leaves of the mimosa plant—we simply close-up and cover-up when exposed to perceived threats.

In short, doctors tend to be terribly myopic with regards their faults and misdoings as well as those of their counterparts! Collectively we have elected to be very reluctant to find fault or whistle-blow any errors which might be the result of professional incompetence or grievous errors.

We choose to proffer excuses and turning a blind eye, perhaps because many of us are conscious of the fact that we may ourselves fall prey to this mishap, some time, some place…

The inexactitude of medical science and the uncertainty of some outcomes still defy our best efforts—and doctors are very poor acceptors of failure. Yet we know deep down that some of these could be prevented, avoided or simply shouldn’t have happened—we are just not comfortable attributing blame to particular practitioners.

We are also aware that some treatment choices shouldn’t be done, yet we remain forgiving that perhaps the difference in opinion, in styles, in approach, was justifiable…

These are the grey areas of medical practice which occur day in, day out. Some of us anguish over this, and are consumed by angst of insecurity, anger and feelings of being shortchanged, misunderstood and injustice. But we remain aloof and suffer in tongue-tied silence.

Yet indeed, this must surely be one recurring theme that all of us must revisit every now and then, to keep alive that already tenuous linkage with our professional calling, and our ethical moorings.

Do we indeed have the right to remain reticent when obvious wrongdoings take place within our sight and experience?

We now have reports of medical practitioners colluding with prisoner abuse in the Abu Ghraib scandal in Iraq. These are military doctors who have chosen to ignore the abuses of clear-cut torture and inhumane treatment of the detainees in war-torn Iraq, Afghanistan and elsewhere.

Our duties and responsibilities as medical doctors have become suborned to military authority, political expediencies and/or personal emotions of indifference, hatred or vengeance.

Some of us have become lesser mortals, by becoming too human (and therefore subject to our inherent foibles, our baser instincts), too remote from our underlying ethical bearing.

We have failed to remain true to our vocation—we have failed in our professional duty, indeed our professional dictate to heal, to alleviate suffering, to comfort and always to avoid harm at all cost…

Some of us may even have become complicit in engaging or tolerating torture which by any civilized world accounts must be a serious breach of any ethical framework—much worse if these take place within the ambit of our medical profession.

It is under these circumstances that the GMC has now enunciated more clearly some of the expected concepts of good medical practice, which every medical professional are enjoined to embrace. These must now include the following:

• Make the care of your patient your first concern
• Respect patients’ dignity and privacy
• Give patients information in a way they can understand
• Keep your professional knowledge and skills up to date
• Recognise the limits of your professional competence
• Be honest and trustworthy
• Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practise.

The ’p’ words? Some of these are: patient, physician, probity, patience, prescription, prerogative, privilege, power, pay, and professionalism.

Let us renew our faith in our profession, by giving some thoughts to the ‘p’ words, and see how each of these mean to us individually as doctors.

Let’s renew our commitment to professionalism as the highest order of our vocation.

(MMA News Editorial, September 2004)

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