Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_321_17
Source of Support: None, Conflict of Interest: None
“No other gift is greater than the gift of life
The patient may doubt his relatives,
His sons and even his parents,
But he has full faith in his physician.
He gives himself up in his doctor's hands.
And has no misgiving about him.
Therefore, it is the physician's duty
To look after him as his own son.
Those, who for the sake of living, make
Merchandise of medicine, bargain for a heap of dust, letting go a heap of gold.”
The first day you decide to be a doctor/neurologist/neurosurgeon, you will have entered into the colourful fabric of a branch of medicine which is highly selective, arduous and totally fascinating. To quote Dr. McDonald Critchley, “The life of a vestal virgin was divided into three portions; in the first she learnt the duties of her profession, in the second she practised them and in the third she taught them to others.” The training of a neurologist/neurosurgeon is rigorous and lasts for 3-5 years. Learning continues throughout his/her whole life. It is a period of long demanding working hours and repeated coercion by teachers to work harder, “You cannot make a first rate neurologist/neurosurgeon out of a third rate scholar, a fifth rate teacher, a no rate scientist and an irate doctor.” But if you succeed, you become a whole human being and as the opening paragraph of Harrison's Text book of Medicine says (I quote)--- “No greater opportunity, responsibility or obligation can fall to the lot of human being than to become a physician. In care of the suffering, he needs technical skills, scientific knowledge and human understanding. He who uses them with courage, humility and wisdom will provide a unique service for his fellowmen and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this: he should be content with no less.”
The doctor in our country has to play an active role in the prevention of disease and in the removal of ignorance and long standing superstitions surrounding illness. It is unfortunate that even today, in the 21st century, poverty is the main social cause of disease. The poor in India are deprived of basic medical care and services. Medical neuroscience has undergone a rapid change in the latter part of 20th century. This is the era of super-specialisation and proliferation of advanced technology, which the physician/surgeon could not even dream of encountering earlier. We are dependent on computed tomographic (CT), magnetic resonance (MR), single photon emission computed tomography, and positron emission tomography scans; genetic tests, video telemetry, video electroencephalography (EEG), nerve conduction velocity (NCV), electronystagmogram, electromyogram (EMG) and other sophisticated tests. Sometimes, a doctor does not even have to take a history or examine a patient, as the rapidity of tests give the diagnosis and surgical or medical therapy is started as indicated in reports. We are becoming technical experts; micro-neurosurgery; robotic surgery, gamma knife surgery, laser etc., are available in many centres. Neurologists now use video EEG, NCV, EMG, brain stem auditory evoked response, MR and CT scans, and video telemetry for diagnosis. Medical therapy involves plasmapharesis, intravenous immunoglobulin therapy, botox injections, magnetic resonance and deep brain stimulation and newer drugs. The art of medicine is getting a bit nebulous and there is often no rapport between the patient and the doctor (a far cry from the age of Charaka). In the event of complications setting in, or an increase in the morbidity or mortality, the patient or his/her relatives seek help from the court of law to punish the doctor. It is common to read about doctors/surgeons being verbally and physically abused, and of clinics and hospitals being vandalised by irate attendants or relatives of patients. Both sides are on the offensive leading to lawsuits. COPRA (Consumer Protection Act) was introduced in 1986, despite objections from the Indian Medical Association (IMA) and the Medical Council of India., This has led to further deterioration in the quality of medical practise, since doctors are being treated as consumer products rather than as professionals with ethical standards. Almost all registered medical men and women undertake medical indemnity insurance. The neurosurgeon has to pay a higher insurance. These developments to me, as a neurophysician who finished training by 1969, are quite appalling. No doctor, unless she/he is a complete mercenary would like his/her patient to come to harm intentionally. Errors in judgement and/or management sometimes occur; hence, it is important that the neurologist should have a deep in-depth knowledge of his/her subject and should always take informed consent from relatives or patients for any invasive procedure, even as simple as a spinal tap! The procedure as well as its side effects, if any, have to be explained in a simple language. It is mandatory for all medico-legal cases to be reported to the authorities, which is not always done. Attempted suicides are usually referred to the psychiatrist. Despite the doctor usually working in good faith, why has the distance between the doctor and the patient increased? To avoid such an unhealthy confrontation, it would be wise to introspect.
There are a few rules that a doctor has to keep in mind. Most of these were imbibed by us from our own teachers, who were role models; they mentored us well so that we were saved from many pitfalls. There was no COPRA then. Have we failed as teachers? Could we not instill in our students those ethics which we subconsciously imbibed from our older teachers/gurus. Let me try to recapitulate some old rules: Our apprenticeship in medicine began with the Hippocratic oath. Ancient physicians Sushrut and Charak have also defined this aspect. To simplify there are five types of ethical duties which should guide you. There are duties towards your teacher, your patients, your colleagues, your society and yourselves.
Duty towards your teachers: You have a duty towards your teachers, as they have the most important role to play in your training apart from your parents. Not only the University or College professors, but any physician/surgeon/nurse or paramedical staff from whom you have learned something of the art of dealing with or treating a patient, is a teacher. His/her behaviour, interactions and ethics when dealing with patients having an incurable diseases or with those facing death are important lessons. Honouring teachers with devotion and friendship is greater than a mere extension of “lip service.” A good teacher is always delighted and intensely happy when his/her students win plaudits and do well in life.
Duty towards your patients: Your duty is to act with them as you would like to be treated if you were sick, i.e. with courtesy, kindness and honesty. Considering all those patients who come to you, some cannot be cured, and some others may have an incurable illness or a devastating disease with a bad prognosis; while some may be relieved of their ailments by your treatment and some recover spontaneously. Your words and actions have to be couched in tactful language. If truth may be perceived to cause harm, do not directly tell the patient about his/her dire condition but the close relatives may be taken into confidence. Hope for recovery even in desperate cases need not be removed. Keep in mind that all the tests conducted are not correct or infallible; needless tests are not needed when the diagnosis is obvious. However, doctors today practise defensive medicine in order to avoid litigation later. A balanced and judicious interaction with patients and relatives can improve confidence, faith and provide much consolation. It is wise to remember that the influence of every doctor is also like administering a drug. His/her encounter with the patient can produce side effects, toxicity and exhibit a duration of action. His interaction may serve as an overdose or an underdose, at the right interval or the wrong interval, and most of all, if given properly and adequately, may produce a placebo effect. Learn the pharmacology of being a good doctor. There is no substitute for direct observation. I remember a patient having a chronic fluctuating headache who had undergone a CT scan, MR imaging, the entire biochemistry profile, an EEG and a psychometric evaluation, when all he had was hypertension. A single blood pressure (BP) measurement was missed. His BP medication relieved his symptoms completely. Again, patients with chronic disease always improve transiently when they change doctors or medication. Patients with chronic symptoms may be asked if they have missed their medication. In my experience, most of them do miss taking their daily medicines. Ask them, “What are you doing that you think that you should stop doing?” and “What are you not doing that you think that you should be doing?” Learn to listen to the patient with full attention. Difficult patients are always a part of a doctor's life. They may be irritating, hysterical, seductive, demanding, critical and complaining all the time of past experiences with doctors. If they demand a second opinion, always accede to the request; or, if they come armed with data from the internet and cross-question you on everything and contradict your well-meaning advice with something some neighbour or relative has told them about, or what they have read in a magazine, learn to conceal your impatience and divert the attention of the patient. If a patient is not better despite your ministrations in three visits, she/he may be refereed to another expert in whom you have faith. Be sensitive to the natural deficiencies that may be present in the elderly patients, such as decreased hearing, decreased vision, mumbling speech, poor appetite, insomnia, forgetfulness, and repetitiousness of symptoms. All these elderly patients may not be having dementia. More time is needed for them. They have psychological needs and are fearful of being a burden to their family, are fearful of death or of losing their mind, and are having loneliness and depression. Many of them have children, all settled abroad (USA, UK), who visit occasionally, hustle them through many medical tests and check-ups and leave them under your care. To these elderly patients, maybe a visit to the doctor is the only “break” in the monotony of day-to-day living. Always tell your patient about the possible side-effects of therapy so that they do not get alarmed; answer all their questions and give very few medications (always keep medical pharmacopias and drug indices handy), so that the side effects of the medications may be checked and incompatible drugs are not given inadvertently. All patients from the 'very important persons' to the rural illiterate villager want “magic” from the doctor. “Magic cures” do not require pills or surgery (except for emergencies); empathy is the key. Some disorders like the late stage motor neuron disease or muscular dystrophy are, at this point of time, incurable. Common sense and palliative care are required in such cases. The patient may not be able to afford a nursing home or a hospital but can be made to follow inexpensive treatment at home. A doctor who has relatives of a patient (who died under his/her care), still come to him for advice, has obviously built a good rapport with the family. Their faith is a pointer to his/her professional expertise and caring attitude.
Duty towards your colleagues: You have the obligation of sharing a path to a common crusade against diseases with them. Medicine, in spite of all its disadvantages, has great social prestige among professionals. In this regard, it is better not to speak ill of your colleague. If you have something good to say, express it everywhere; if not, then silence is golden. Trying to keep up with all the necessary medical knowledge, procedures and recent advances is difficult. Hence, there is an advantage in regularly attending continuing medical education programs, both locally or nationally. The Neurological Society of India, Indian Academy of Neurology, Indian Epilepsy Association, and Indian Epilepsy Society annual meetings provide great scope for keeping one updated. These venues also enable a warm camaraderie to develop with fellow colleagues from other cities (national and international) and one may build lasting and mutually rewarding friendships. There is great competition in metropolitan cities, less so, in lower grade cities. In the past, it was considered inappropriate to advertise one's medical/surgical abilities or expertise; rather, we considered it as something that only quacks practised. Today, the media is at centre stage and medical professionals are advertised in the same way as consumer goods. No one objects to it, as it is a method by which public is informed of the treatment facilities available to them. Money and financial security are important but not at the cost of demeaning oneself and taking cuts, commissions/keeping touts for getting patients. From a “God” like status, we have fallen in the eyes of the educated public. If you are a good and an ethical doctor, your own patients are the best sources of advertisement that you can possibly have. We would be less than human if we did not enjoy praise or recognition for our own endeavours. A little modesty is befitting. From time to time, the press highlights the “greed”of doctors. Today, the cost of living is high and, therefore, altruism as practised by many of our teachers is not practical. The acquisition of wealth should not, however, be the primary aim, though now it appears that is the norm. I do not mean to advocate financial bankruptcy in anyway. We are following the American pattern of medical care where billing, insurance and mediclaims are important issues. In India too, medical insurance is a norm. The cost of medical training is very high. The Medical colleges, postgraduate institutes and medical universities provide free outpatient clinics, consultations and a subsidized rate for various medical tests such as a CT or an MRI scan as well as surgical implants. The hospitalisation costs for various services such as intensive care unit care/dialysis/surgical implant procedures are expensive. The law has made it mandatory for some percentage of in-patients to be treated free of cost. Some private hospitals waiver charges from the poor, if requested by the surgeon/physician incharge, and these hospitals are regarded highly by the patients.
Corporate and multi-speciality hospitals now employ doctors to get business to sustain the hospital outreach. If the doctor's input in terms of money is less, his chances of getting an enhanced pay is reduced. Business managers, insurance companies and pharmaceutical companies are now managing and influencing the way the doctor will deliver healthcare. Some eminent neurosurgeons have left corporate hospitals as they were pressured to admit cases who did not need more than an outpatient care. Some five-star hospitals have high rates and neurological tests are alarmingly expensive, converting 'illness into business,” exploiting the patients financially. The medical profession is now an ancillary to “health business.” Not all high-ended hospitals have such a reputation but then medicines/surgical procedures are often expensive, and only the rich and those covered under medical insurance can afford to be treated in them.
Duty towards the society: A doctor has to educate the public about healthy habits, diet and about health practices that benefit the common man, by means of radio, television, newspapers and magazines. An astute clinician can observe the effects of lifestyle, toxins, drugs and diet on community health and help to prevent far-reaching ill-effects on future generations. To quote an example, the effect of thalidomide on pregnant women that produced phocomelia in their offsprings was discovered by a paediatrician in West Germany in April 1961 and an obstetrician in Austria. The manufacturing of the medicine was halted in USA in 1962 by Dr. Frances Kelsey, who was awarded the US President's gold medal for her service to society. In India, observations regarding the neuro-toxic effects of organo-chlorine and organo-phosphate compounds on the nervous system led the government to ban these pesticides in food products and cold drinks. Many unrecognized toxins have been detected by an alert medical doctor, for example, the presence of arsenic in drinking water, or the use of lathyrus sativa or cassaca in diet leading to paraplegia. This alertness can save the general public from ill health.,, Lifestyle changes such as a diet of fast food, addiction to television and internet chatting have also led to several disorders in children and adolescents. Exercise is neglected, and games and sports are not mandatory in many schools. Recently, yoga has been highlighted by the Prime Minister as a major initiative and this may help in reducing stress and other health related problems. It behoves a good physician to help and preserve the health of the society at large.
Finally, your duty towards yourself: Every doctor is exposed at an early age, during training, to the negative side of life, that includes disease, distress, death and the dying, painful illness and loss of limbs, trauma and ailing, despairing and depressed patients. Despite all the care offered, the patient often dies. Herculean measures in trying to preserve life by surgeons and physicians fail. After sometime, one gets inured to such conditions and this can be misinterpreted as callousness. Most patients do not realize how much a doctor agonises, and is sleepless and anxious, when a case fails to respond to treatment. Learn to see everything in perspective, in a holistic manner. You owe it to yourself to have some hobby, some recreation which gives you enjoyment; be it music, art, photography, sports, writing, reading or even cinema. Contemplation of nature in out of the way places can be relaxing. Above all, do keep some quality time for your family for this is the greatest support system you can ever have. Your children should never become strangers, but should remain your friends and be a source of pride and joy. Your spouse should not be neglected as she/he has already sacrificed quality time with you due to your busy and unpredictable schedule. If they too are equally busy in their respective professions, it calls for an even greater understanding. Above all, have faith in yourself. If you believe in a Higher Power, spend some time in doing meditation, yoga and prayer. The choice should be in doing whatever you feel suits you the best and makes you feel recharged. “More things are wrought by prayer than this world dreams of.”(Tennyson).
I have learnt much from my teachers at King George Medical College and in the USA (Tufts and Harvard Universities) but my maximum learning has been from the “living textbook,” the patient. My other teachers are students, residents, technicians, ward staff and even the cleaning personnel. Many a time, a patient from a village used words or phrases that I could not decipher like –”Garmi ho gya” meaning some 'veneral disease,' “devi charh gayee” meaning 'convulsions or seizures.' All said and done, the patient is the purpose of our learning. I hope that all neurologists/neurosurgeons, of the present and future generations, will achieve their dreams and mentor the next generation. I conclude with Dr. McDonald Critchley's words from an essay on the training of a neurologist, “From an inability to let well alone, from too much zeal for what is new and contempt for what is old; from putting knowledge before wisdom, science before art and cleverness before common sense, from treating patients as cases and making the cure of the disease more grievous than its endurance, Good Lord, deliver us.”