Supported by an Unrestricted
Educational Grant from
Professor of Cardiology, Editor-Indian Heart Journal
AIIMS, New Delhi
</b> The subject is slightly different on what we discuss routinely, but it is a very important topic and it is the need of the hour. In the medical curriculum both MBBS as well as post graduation, it has been found that the focus is entirely on the algorithm based approached diagnosis and treatment of the patient. Often in this approach, the patient angle or the patient’s emotional angle gets neglected and that results in lot of frustration and end result is that even when the right therapy is there and right diagnosis is there the patient’s are not satisfied and they leave the hospital and Doctor with a grudge. Sir, I would like to have your opinion on this subject.
</b> I think you are exactly right, the classical approach for medical profession has been that you have to treat the patient who is on board and disconnect with emotions. So you kind of treat the patient like a machine and if that machine has got wrong you fix that machine. So that process starts right from the day one. When you enter your anatomy lab you see a cadaver lying there and what you are expected to do is to go and cut that and dissect it and to find out the disease or whatever anatomical correlations between different things. Completely ignoring that now this was a form of human being actually who is lying there and all the emotional aspects are actually taken away, you do not treat it like a human being who has been unfortunate to lie there, but treat it like a machine and kind of cut it apart and find out what is what. So, I think that particular training goes right on till the end of the training where the prospective doctor is trained to keep the emotions away and treat every disease like a machine process which has gone wrong and like a machine which requires fixing and fix it like that. So you might heard people saying that okay this is my father how can I treat him, so we find another physician to come and treat my father. Because I can not treat my father, because then emotions will come in, but I think that particular approach is completely flawed in current circumstance, because what happens is that emotions are integral part of the disease process not only disease process are the integral part of the human being that we are treating. We are not treating particular defect, we are treating the whole human being and if you ignore the emotions then you ignore the human being human component and you try to treat him like a mechanical problem.So that is why this whole things comes up and that is why you know what happens now we see that there is a disconnect between the doctor and the patient so that disconnect happens a classic example is say terminally ill cancer patient.You know the main reason for medicine as many people will tell you is to prevent death, but in a terminal ill cancer patient you can not prevent death that is inevitable. In any case, every human being who has come here has to die. So if you focus as medical professions, first job to prevent death then it has already failed, because everybody who has come in will going to die some point of time, so that means that medicine has already failed, because although you can prolong life, but you can not prevent death. So that is why I think the focus of medicine should shift from preventing death to holistic approach to the whole patient were all these concerns are addressed in a terminally ill cancer patient you can not prevent death, but you can give him support, you can give him emotional comfort to bear the death to bear the pain that accompanies that particular thing and I think at that point of time that is the most important thing to do. So I feel that medical curriculum should be completely revised. Another problem of medical curriculum is that they take the course of science, which is completely away and that make the person who is engaged in that particular process, because the training is very long and it might take 10-15 years to train properly into the medical profession and by that time, the doctor gets disconnected from society, because he is focussed into only himself and the patient’s sometimes he may ignore his family because 14 -15 hours, he has to spend with his job, with learning, education etc, so he even ignores the family and therefore you see that the suicide rates are highest in the medical profession among all other profession suicide rates are highest in the medical profession, because it completely disconnects. Man is a social animal and if you give away the society you become disconnected from the society very high chance of suicide rates so paradoxically doctors have the highest suicide rates and that is the exact reason because they disconnect so I think you know not only medical thing should be included in curriculum but some literature some philosophy should included as a part of their curriculum so that you know they have a overall development in the society rather than act as an observer outside the society looking at the patient’s.
</b> Any suggestions or any ideas you will give, you have already said that philosophical should be one of the subject, but to make it more practical any suggestions you can give?
</b> I think simple suggestions are that you know in the curriculum itself there should be care scenarios with emotional attachments and you can show them those particular case scenarios, where terminally ill cancer patients there can be sensitization towards death there they visit the wards were people are dying actually and then they will not ignore death. People kind of postpone this death and they just like at life, but death is also a part of the thing so have training there another very actually very interesting experiment, there was a movie I don’t know whether any of you have seen that particular movie which was ‘A Clockwork Orange’ where there was a kind of criminal person with a criminal bent of mind so what they did was they sensitized him to all the violence in the society. So in that movie what they did was he was shown these images graphic movies where his mind was changed as a result of these images and he became more receptive to the society so that experiment was carried out. Similarly, I think you know some of these tragic movies may be shown to doctors where they can appreciate the pain of people who are involved there and that can help them. So these are some of the practical examples also philosophy should be part of the curriculum they should have one course in philosophy one course in arts, because arts does two things, it shows you the similarities and also the dissimilarities so that doctor also can basically associate with the patient and also disassociate both these values will come out so arts philosophy they should be regular part of curriculum.
</b> how far the doctors also see patients as one individual they forget that every patient has a family and their relatives are there and once he goes back there will be a family life there will be a society in which the person is going to leave. The focus is entirely on the disease management so any ideas on that that how the instead of patient keeping as one individual the entire family in which the patient lives can be taken together.
</b> So when patient is visited there should be family member their anything that is discussed should be done in context with the whole social situation and I think all these things are part of it and that particular training should start right from the beginning.
</b> Another different topic although somewhat related is in India, we have been seeing increasing violence against doctors and this has happened more commonly now a days and this is actually resulting in lot of frustration and kind of a separation. It is increasing the gap between the doctor and the patient. Doctors are becoming more and more careful they are ordering for more investigation, they are trying to be more cautious in discussing with the patient’s about their prognosis and treatments and so on. In a way, it is affecting the way that patients are getting managed. Sir any of your opinion or any ideas on that.
</b> I think you are exactly right. I think violence against doctors and other health care workers is now taking an epidemic proportion.There does not go a single day where you do not see a report, where we have recently heat that one dengue patient died and the relatives got together and beat up the doctors and also the staff.. You know dengue is sometimes can be life threatening likewise if cancer patient dies how is doctor is responsible, doctor can not give you immortality, they can only take care, prolong life may be take care of some discomfort that’s all a medical personnel can do.They can not prevent somebody from dying more or less, I mean negligence apart.This is the usual story.So how do you make doctor or any hospital or any body else responsible for an unfortunate circumstance that any way happens. If somebody dies of road traffic accident you know you can not hang the prime minister of the country because somebody died. So I think these are some grossly over reaction in many case, but let us go philosophically into why that happens what has happened over a period of time. Initially, between the patient and doctor relationship has changed. Initially, it was a parent-child relationship. So patient was a child and doctor was the parent and as we know that parent knows what is the best for the child and child accepts whatever the parent tells and he acts on his behalf and there is no kind of big discussion or argument between the parent and the child on any aspect including even sometimes later on in marriage and in jobs etc. Initially that kind of relationship was present. Now that relationship has changed. It has kind of became a client and deliver or a vendor kind of relationship, so I think that change in relationship is the reason for all these problems. Now you would ask me why this relationship has changed. So fifty years back dominant population was divided into two classes, either they were elite which were of course a minority 5% or so 95% were working class. So working class basically the whole philosophy is discipline following the rules and you will see that these working class are always in the uniform and things like that so basically for them discipline is the most important thing they will never go against the rules but what has happened is suddenly the another class has come in between, which is the intellectual class. Now intellectual class is defined by challenging the authority by asking questions by questioning everything as a matter of fact and if satisfactory answers are not given for these questions, so if the parent does not satisfactorily answered the child then child gets violent. Same kind of thing is happening. You know the patients have certain questions they have certain dilemmas. They have lot of things and doctors somehow does not have either time or does not want to answer these questions, does address these question then there is a disconnect and then naturally no other option but to resort to violence some times. So as you said how to address these problems. Now the time has come where you need to carefully discuss everything with your patient give him/her the right perspective. Give them lot of literature to read and so that they themselves come to the same conclusion as the doctor has already released that okay this is the best course of my treatment and these are the issues, these are the mishaps that can happen. What commonly happens is in our context for eg if somebody comes for angiography, you ask him okay we will do an angiography we will find out what the diseases is? But the doctor did not tell you that angiography can be risky sometimes very ocassionally, people can even die out of it. Now if this person has come walking got an angiography done and statistically some people die out of angiography and if he unfortunately, one of them and he dies then very likely the relatives may behave violently against the doctor. Because now he understand that the gap has been at the level of communication. So I think this is the era of communication and doctors need to effectively and accurately communicate the problems with the patient and if they are unable to do so for any reason whether they themselves lack that information or whether they do not have time or whether they have that still parental-child kind of attitude, if any of these things are there then there is a high probability that violence will happen So people how come for dengue they have to be clearly told that some of them can die, we will try our best to save it this the problem of your patient he is higher risk for dying we will still try but we can not promise and then if dies then you can say that we tried., but if you say dengue nothing no problem we will give some fluids that and also don’t address their concerns properly so they come out with some symptoms, no doctor he is gasping something and you say okay we will see him. We will come and then if you dismiss those things then that is the point where this disconnect will happen, but of course there is a societal aspect society also needs to understand that you have to follow the rules even if the doctor is negligent there are some other authority who will address this problem you are not the one to address that problem. You can take him to court, they can decide the kind of compensation they can even put him in jail if the gross negligence is found but the patients are nobody to react against this because the law and force of authority they should be informed so if that particular part clear from both sides I think these problems will resolve.
</b> Thank you so much sir very nicely you have summarized both the sides, doctor needs to be more careful in addressing the prognosis and also needs to be talking to the patients and their relatives about what is going to be the end result of the treatment which he is going to not promising falsely that everybody can get cured and similarly on the patient side we understand that there is an emotional angle when the relative is dying but violence cannot be justified in any situation. There are authorities whom they should talk and they should discuss. Thank you so much sir.
</b> Thank you