K.R. Palaniswamy

Modern medicine desperately needs to rediscover the human touch. It needs to blend modern techniques with the art of compassionate healing.

IT ALL started with a patient of mine a young woman who was suffering from recurrent abdominal pain and vomiting. She had been subjected to an entire battery of biochemical and imaging modalities. When these extensive investigations came out negative, she was passed on to a psychiatrist. His treatment proved futile as well.

It was at this juncture that she was referred to me. When I saw her, she was hunched over in obvious physical distress. All it took was sympathetic conversation, close observation, and a careful hearing to make it apparent that she was afflicted by pancreatitis. To confirm my diagnosis, we decided to perform a repeat ultrasound, even though prior multiple ultrasonographies and CT scans had turned out normal. The ultrasonography confirmed the initial diagnosis showing that the patient had a painful pseudocyst and needed surgical intervention.

So what is the point of this anecdote? Not that the patient was misdiagnosed. Not that she was shunted from one specialist to another. Not that she was exposed to a series of tests and scans. No, it has to do with the fact that the patient's trauma could have been minimised, if not altogether avoided, if only an attempt had been made to listen to her with compassion and time spent to make a thorough physical examination.

Unfortunately, the case that I have described is the rule rather than the exception. In an era where healthcare provision follows corporate guidelines; where insurance pressures undercut the delivery of optimal healthcare; and where cost rather than clinical benefits determine hospital bottom lines, the casualty has been compassion, consideration, and sensitivity towards patients. The advent of high technology diagnostics has resulted in clinical medicine, that is, a detailed study of the patient's clinical history and a methodical physical examination, being neglected. In its stead has arisen diagnosis at a distance with tests, scans, and other medical modalities wedging themselves between doctors and patients. The result has been a gradual attenuation of old fashioned, direct communication between physician and patient.

The situation has been exacerbated by external, often non-medically related stresses and strains. These demand rapid, quantifiable outcomes; there are no rewards for careful listening or focussed care giving.

An eye-opening study conducted in the late 1990s in North America revealed that nearly three quarters of young physicians in 75 of the largest metropolitan areas in the region felt that they were not spending adequate time with their patients.

Such statistics underlie a grave ongoing problem. Even as time spent with patients decreases, many of my colleagues have confessed that their energies are being dissipated on cumbersome procedural and administrative tasks. At the same time, restrictive insurance and reimbursement policies have meant that they are being compelled to see an ever increasing number of patients in order to sustain their income levels.

The unfortunate outcome of this situation has been that it is the patient who ends up suffering the most. In several private hospitals, the credo of `profit first' has meant that patients are often denied optimal care. In charity hospitals and hospitals that offer subsidised care for the poor, the situation is no better. My personal experience in this area has been that of doctors who seem to equate free or subsidised care as an excuse for being negligent, performing the most cursory examinations, and spending more time at lucrative private clinics rather than in service of the deprived.

Not surprisingly then, despite sweeping advances in diagnostics and treatment, the distrust between patients and doctors and that between doctors and health care administrators is at an all time high. Frustration and dissatisfaction are the norm. Informal chats reveal that patients change their doctor frequently because the latter did not spend enough time with them; was unfriendly; did not make the effort to fully answer their questions or explain the problem in a simple, understandable manner; or simply because the doctor did not treat them with respect.

The root of these problems lies in our medical colleges. When I attended medical college in the early 1970s, I was taught by dedicated, inspirational professors whose mission was to mould doctors with well-honed medical skills and, just as importantly, a strong sense of ethics. We were taught that patients came first, that quality, not quantity was important, and that empathy for the patients was the key to medical success.

Sadly, I find that today several medical schools lack the competence to impart high quality education and training. Not only does this plead for a complete overhaul of our medical colleges and the training they provide, but it also places a greater responsibility on students and teachers alike to develop the basic attributes skill, knowledge, altruism, and duty required to be a good medical practitioner.

Compassion is the bedrock

The need to nurture such qualities in physicians was recognised almost a decade ago. In 1996, the American Association of Medical Colleges (AAMC) embarked on a major new initiative to assist medical schools in their efforts to provide a more holistic education to their medical students. Titled the "Medical School Objectives Project' (MSOP), it identified altruism, knowledge, skill, and duty as the four attributes necessary for medical school graduates to succeed in the current and future health care environments.

Today, there are a few shining examples of institutions that have internalised these attributes. In the United States, Mayo Clinic and Johns Hopkins have outstanding reputations for patient care. I have witnessed how doctors in these institutions spend considerable time interacting with their patients and relatives, the way the number of patients is consciously limited so as to ensure complete attention to each case. I have also seen the way these doctors are driven to provide exceptional care no matter the costs or the time needed to every single patient of theirs.

At the end of the day, the lesson is quite simple: time, understanding, compassion. Don't dissipate time on analysing and re-analysing data; instead take the time to listen, to explain, and to ensure that the explanation is understood. Fully study the patient's history, recognise the virtues of complete physical examination as well as appropriate objective testing to help the patient get better, and feel better. And finally, make compassion your keystone, engaging patients with sympathy and thoughtfulness.

The reward is also the personal bond forged between the doctor and the patient one that provides arguably the greatest satisfaction to any medical practitioner. This is the lesson that all medical students today must be taught.

As we move forward, some words from 2500 years ago still ring true. In The Laws, Plato described two types of doctor-patient relationships. In the first, slave physicians `cared' for slave patients by denying them information about their complaints and, instead, delivering restricted empirical information with an air of finished knowledge and then promptly moving onto the next ailing slave. In contrast, citizen physicians treated the medical problems of free men and women by examining matters in a thorough and scientific manner, always taking patients and their families into confidence. Here, physicians actually learnt by listening to their patients, and did not make prescriptions until they had won the patient's support and could thereby persuade them into compliance with treatment regimes.

A final thought: we must continually search for new technologies and applications while never losing sight of the importance of human contact. We should emphasise the need for a strong, reciprocally beneficial physician-patient relationship and cultivate a healing relationship one that balances caring and compassion, curiosity and competence, humility and humour along with gentle encouragement and a warm touch.

(Dr. K. R. Palaniswamy, M.D., D.M., F.R.C.P., is Senior Consultant, Gastroenterology, Apollo Hospitals, Chennai.)