Modern healthcare system provides little opportunities for Doctor Patient relationship

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 Modern healthcare system provides little 
opportunities for Doctor Patient relationship

We need to promote concept of Caring
Physicians- Prof. Ejaz Ahmad Vohra

These days Residents and medical students describe patients in their
Lab value and information obtained through imaging procedures

KARACHI: Modern health system provides limited opportunities for doctor patient relationship. Introduction of third parties (insurance companies, employer and hospitals) have become further obstacles towards healthy doctor patient relationship. In all humanity during 59 years of my professional experience I have practiced medicine as caring profession and my students are witness to it. However, during last decade I am appalled that students and residents describe patients only in their laboratory values or information obtained from imaging procedures says Prof. Ejaz Ahmad Vohra, a noted physician and Director Postgraduate Programme Clinical at the Ziauddin Medical University, Karachi. He has made a passionate appeal to members of the medical profession to promote the concept of caring physicians.


Prof. Ejaz Ahmad Vohra

Recently Bernard Lown inventor of defibrillator and cardioverter, Prof. Ejaz Vohra says was hospitalized and his attending resident documented his hospitalization. His major complaint was that treatment is there but care is absent. In modern health system patient sometimes become digits rather than individuals. In 1996 Bernard Lown, Prof. Ejaz Vohra says published an article “The Lost Art of Healing” “Doctors no longer minister to a distinctive person but concern themselves with fragmented, malfunctioning” body parts. Now, two decades later, he’d become a victim of exactly what he had warned against. The hospital, he lamented, is more like a factory — “it tests every ache and treats every laboratory abnormality, but it does little to heal its patients.” Treating and healing are both necessary, but modern health care too often disregards the latter.  Dr. Lown identifies first and foremost as a healer. In 1996, in “The Lost Art of Healing,” he made an appeal to restore the “3,000-year tradition, which bonded doctor and patient in a special affinity of trust.” The biomedical sciences had begun to dominate our conception of health care, and he warned that “healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures. “The crux of humanistic medicine is "holistic healing"—defined as treating not only the physical body of the patient but treating the metaphysical soul as well. (Wikipedia)

Speaking about the powerful factors working against humanism in the practice of medicine he quotes Paull B. Rothman Dean and CEO of Johns Hopkins who had mentioned them as,” Time constraints, the need to handle large volumes of patients, the distancing effect of increasingly sophisticated technologies, more bureaucracy and documentation, Burnout or disillusionment”. Continuing Prof. Ejaz Ahmad Vohra says that in 1996 the Association of American Medical Colleges (AAMC) embarked on a major new initiative to assist medical school in their efforts to educate medical students. The project title was  “the medical school objectives project (MSOP)” It identified altruism, knowledge, skill, and duty as the four attributes necessary for medical school graduates to thrive in the current and future health care environment. Humanistic medicine is now taught in many medical schools of developed countries enabling doctors to practice medicine with empathy compassion, pragmatic and trustworthiness.


Michael Baum gave a lecture at New Members Admissions Ceremony at the Royal College of Physicians on 22nd January 2002.  It was stated that the study of ‘medical humanities’ will enhance the empathy, communication skills, ethical standing and, paradoxically, the scientific literacy of the next generation of young doctors. The study of literature and theatre might have three important roles in the education of doctors: Rebuilding medical idealism. Deflating medical pomposity. Providing a window into social injustice and personal suffering.

He further elaborated medical idealism giving example AJ Cronin’s the citadel. During my students days this book inspired me a lot. These stories, Prof. Ejaz Vohra stated  fueled our idealism, and there was no sense of shame in admitting at the interview for medical school entrance to the desire to become a doctor out of idealism and a wish to serve humanity. According to Michael Baum Medical pomposity has inhumane, pompous and arrogant doctor.

Medical students Prof. Ejaz Ahmad Vohra feels should read the preface to the Doctor’s Dilemma by George Bernard Shaw, as well as the play itself. Sir Ralph Bloomfield Bonnington, the character satirized by Shaw, still exists among the higher echelons of the medical establishment, but sadly this attitude is also seen amongst young doctors who know all about molecular biology, on the one hand, or management jargon, on the other, but little about the feelings of the patient in the middle. The recognition of the impact of social injustice on health will educate the undergraduate in the true meaning of the ethics of distributive justice, health economics and the inevitability of rationing.

Implementation strategies

Prof Ejaz Vohra believes that some of the approaches used to encourage the practice of a more humane medicine are narrative medicine and patient empowerment. Narrative medicine is a way of educating physicians, nurses and other providers that uses storytelling (and active listening) to emphasize the humanity of patient and provider, enabling the "physician to practice medicine with empathy, reflection, professionalism, and trustworthiness." Patient empowerment seeks to create an equal partnership between doctors and their patients, placing values at the center of the healthcare encounter. Both of the practices emphasize the importance of the human experience in the practice of medicine, and help to ensure that the humanity of the patient is not obscured in a morass of lab results, patient charts, and insurance regulations. Humanistic medicine strives to create ideal and balanced care that sacrifices neither cutting-edge science nor the gentle art of creating a caring relationship.


Professional schools across the United States  have begun to integrate humanistic medical teaching into their curricula in an effort to offset what some view as an over-emphasis on medical technology to the detriment of individual patient care. (Wikipedia). Narrative based medicine have been elaborated by Trisha Greenhalgh and Brian Hurwitz in a series of articles in BMJ in 1999 and 2005. It has been summarized as follows:

Why study narrative?

In the diagnostic encounter, narratives:

  • Are the phenomenal form in which patients experience ill health
  • Encourage empathy and promote understanding between clinician and patient • Allow for the construction of meaning
  • May supply useful analytical clues and categories
  • In the therapeutic process, narratives:
  • Encourage a holistic approach to management
  • Are intrinsically therapeutic or palliative
  • May suggest or precipitate additional therapeutic options
  • In the education of patients and health professionals, narratives:
  • Are often memorable
  • Are grounded in experience
  • Encourage reflection
  • In research, narratives:
  • Help to set a patient centered agenda
  • May challenge received wisdom
  • May generate new hypotheses

My proposal for encouraging humanistic medicine Prof. Ejaz Ahmad Vohra says  is based on study of literature and encouragement of experience with patients and descriptive (narrative form) on weekly, fortnightly or monthly as literary hour (humanistic medicine). Students selected for presentation will be encouraged by gift on non-medical literature. We can do individually in our institution or form a collaborative group of likeminded persons. Once we succeed in this endeavor we can institute national prize for best presentation based on patient illness experience. I would encourage further proposals for implementations and a younger responsible colleague for formation of WhatsApp group on humanistic medicine.

All those interested in Humanistic Medicine can benefit from the following:

Professionalism has been defined as a set of values, attitudes, and behaviors that results in serving the interests of patients and society before one’s own.


Justice Louis Brandeis believed a profession had three features: training that was intellectual and involved knowledge, as distinguished from skill; work that was pursued primarily for others and not for oneself; and success that was measured by more than the amount of financial return.

Ref: Preston Reynolds Ann intern Med; 1994: 609-14

“A physician should be of kindly disposition, characterized by rational thought and possessed of excellent intuitive power. Intuition is a movement of the mind whereby it hits at correct opinion, that is, a quick passage from the known to the unknown …… Now, a physician who does not recognize the nobility of man cannot have a kindly disposition, one who is not well-versed in logic cannot have rational thinking, and one who does not have God’s support [a divine gift] cannot possess an excellent intuitive power”.

Ref: Nizami; Four Essays

FURTHER READING

Books

  1. Health and Medicine in the Islamic Tradition by Fazlur Rahman published by Crossroad New York
  2. On Doctoring: Stories, Poems, Essays by Richard Reynolds, and John Stone published by Simon & Schuster
  3. A Life in Medicine: A Literary Anthology by Robert Coles, and Randy Testa published by The New Press New York
  4. Being Mortal: Medicine and What Matters in the End by Atul Gawande published  by Metropolitan Books

REFERENCES

  1. Teaching the humanities to medical students: Michael Baum Clinical Medicine Vol 2 No 3 May/June 2002
  2. Practicing Humanistic Medicine John Hopkins Paul B Rothman www.hopkinsmedicine.org
  3. Narrative Based Medic.
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