Saturday, June 21, 2008

Professionalism: Are We Made Of Better Stuff?

“The patient-physician relationship is at once constant and dynamic. Nearly a decade and a half ago, I described this interaction as a ‘covenant of caring - one individual with a need and the willingness to trust and another with knowledge and the desire to respond.’ Yet at the same time, this relationship must accommodate changing needs, perceptions, and expectations. Today, the patient-physician relationship is as much involved with advanced technology, innovative medical treatments, and high tech diagnostic tools as it is the delicate interaction of two human beings.” ~ Mike Magee, (Presented to the World Medical Association, on the occasion of the WHO Assembly Meeting, Geneva, Switzerland, May 13, 2002)

We live in very troubled times.

The science and technology of medicine appears to have outstripped our capacity to fully comprehend much less to contain its scope, reach and ultimate benefits for mankind.

Yet the art of medicine appears inflexibly tethered down by seemingly antiquarian concerns of traditional ethics and professional benevolence.

Since our accidental historical tryst with destiny, doctors have been propelled into the celebrated roles of saviours, salvaging heroes, curers and ameliorators of pain and suffering.

We have allowed ourselves to be persuaded that we have to continue our never-ending quest to alleviate or eradicate human suffering and postpone death—so much so that the general public has grown so accustomed to our seemingly relentless streams of healthcare advances and modern therapies. We all expect that someday every conceivable ailment will be conquered, simplistic as this may seem…

Doctors and scientists are therefore expected to doggedly pursue advances and improvements in medical or health-related diagnoses, investigations and therapies—in an inexorable yet spectacular search for the Holy Grail of immortality, and a complete dominion over ill-health—anything less would have been unthinkable.

Yet of late, many have come to realise that whilst all such advances are most welcomed, cost considerations and cost-efficiencies and benefits have to be factored in.

Runaway and unrestrained costs are not a sustainable option for modern society—because we simply cannot afford it for everybody. Besides, many of such new and costly tests or therapies are just too wasteful, and could have been inappropriately utilised. Some rationing and rationalization have to be considered.

Thus, in recent years, we have seen the advent of more rigid and well-tested clinical research, comparative studies and the development of evidence-based medicine.

Newer technologies and therapies have now to be tested against well-tried or previously accepted practices, before they can become accepted as mainstream medical practice.

Unfortunately, or fortunately, many of these stupendous advances have erupted so quickly, in surges and spurts, that they have simply overwhelmed the ability of the scientific and medical fraternity to quickly reconcile or to separate what’s considered still investigatory and/or what’s now acceptable practice…

In order not to be left out of the loop of advances, most physicians have jumped in with both feet, to quickly learn and adopt or adapt such technologies for the benefits of their patients, and perhaps also for their own personal enhancement or ego.

Importantly however, many of our patients appear to have benefited, and few have actually suffered ill-consequences as a result. In most instances, these advances helped create more demands and generate wider public acceptance.

With such well-publicised success, it is not surprising that our public expects and respects many if not most of our medical decisions.

True, intermittent reports of medical mishaps and errors have dampened our love-affair with modern medical practice, and skyrocketing health care costs have severely dented many an economy.

Yet, the system appears very much alive with no end in sight for more and more diagnostic and therapeutic developments and advancements—indeed despite the fact that they almost always encourage more cost, and further generate demand…

Into this scenario is thrown the physician, whose role has changed with the times. Primary care physicians while still the core of most healthcare systems, have of late faced the daunting tasks of gate-keeping and contending with patient-expected referrals for specialist or tertiary care.

With the model that we have however, everyone can seek specialist opinions and treatment directly.

This is perhaps the free-market option that we have adopted for years. In the past, when access was more limited and private or public tertiary healthcare centres more scarce, this could indeed be less of a problem.

However, these days, anyone who thinks he or she can afford it, would not hesitate to choose direct access to specialist care—whether this is medically necessary or cost-effective or otherwise.

Despite this, our private healthcare services constitute just about 30% of our total Malaysian healthcare services. Most Malaysians continue to patronize our ever-growing and modernizing public centres of excellence, which are increasingly well-equipped and whose specialist care is at par with the private sector, if not arguably better in some cases…

Most of the differences between the private and public sectors are perceptive and perhaps related to the degree of promptness, luxuriousness and individual-attentiveness of its ancillary services in the former.

This dichotomy has indeed served the Malaysian public well, with competitive pressures (on both sides) to provide better and better services to our more discerning patients. We are proud to say that nowadays, Malaysians enjoy a standard of healthcare second to none in the world, and yet at a relatively low cost, when compared even regionally.

However, the rapid development of our private health sector and the brisk expansion of our public tertiary care and services of late have provoked some disquiet that this might have led to indiscriminate uses of expensive resources, which could be put to better and more cost-effective use, for the betterment of a larger proportion of the public.

Cardiovascular services have become one of the most explosive in the world and indeed so too in Malaysia and the region. Its technological advances have also been one of the most intriguing and awe-inspiring.

What with Malaysia having the Number One killer in cardiovascular diseases for the past 3 decades, the growth in cardiological services has been mind-boggling. The advent of angioplasty, stents, coated stents, and other keyhole techniques have also added impetus towards the greater expansion of expertise and availability, in the past 10 years or so.

But this must also be seen in the context of an overall growth in every aspect of the medical-healthcare industry—including drugs, devices, tests and diagnostic and therapeutic amenities. Indeed there has been accompanying tremendous growth in pharmaceutical approaches to most medical ailments as well.

These days, besides surgical treatment and/or secondary prophylaxis, primary prevention has also been developed aggressively with promotion of the use of aspirin, statins and lately of some ACE-inhibitors.

Gone are the days when the cardiac patient once “bypassed” is pronounced “cured” by the cardiac surgeon, and then duly discharged with an aspirin a day, and nothing more… We now know that he or she has to be better managed for the longer good of the ultimate prognosis.

Still there are concerns that perhaps doctors and specialists have become too mercenary, and have lost their objectivity in choosing what’s best for their patients. While this is certainly not unheard of, it is nevertheless, a serious implication that every doctor should consider and ponder upon.

I have on innumerable occasions reminded our medical fraternity that we should always be firmly anchored on our inherent moral compass, and remind ourselves that we not lose our soul to our more venal desires.

There can be no denying that the lure of filthy lucre has become the catchphrase of modern society. And just like everybody else we physicians have become ensnared in the same tussle for an ever-enlarging piece of the materialist pie.

This can lead to promotion of subconscious or even deliberate pursuits of self-interests and possibly unfair monetary gain. Some and perhaps even everyone of us—at some point in time—might have been guilty of placing our own interests above that of our patients, when the overarching God of Mammon supervene our befogged conscience—long inured of amoral relativism.

Such conflicts of interests as well as potential moral hazards are becoming somewhat starker and are being voiced by the many ethically-challenged and concerned amongst us as well.

Increasingly, it is true that as physicians we can and do practice medicine which impinges upon the slippery slopes of ethical conundrums and contretemps.

However, this fine line of moral or ethical correctness must be judged within the context of society’s current realism and pragmatism. I have already cautioned against too much immersion into our senseless pursuit of material goods so much so that we lose our soul as human beings.

Yet, love it or hate it, since the collapse of communism and socialism, the sweeping triumphalism of free-market capitalism has become the predominant thought and philosophy of life---its universal reach being felt by even the staunchest of religious ascetics…

Thus it is hardly surprising that doctors—being lesser mortals than saints—have also become unwitting followers of this new creed of wanting more and more…

Therefore, it is perhaps timely once and again to review and renew our faith in life and goodness. It is good to reassess our priorities, our humanness vis-à-vis our fellow beings. It is also time to ponder upon our medical profession and what it truly means to practice as or belong to a “profession”.

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