Protecting the values of a noble profession

Excerpts from SLMA Wijerama Endowment Lecture by Dr. Preethi Wijegunawardana

Dr. Preethi Wijegunawardana was invited by the Sri Lanka Medical Association to deliver "the Wijerama Endowment Lecture" at the foundation sessions of the SLMA, at a joint meeting with the Kandy Society of Medicine last month. Published here are extracts of his speech:

I am standing before this distinguished gathering of medical professionals and guests, to pay homage to one of the pioneering leaders in the medical field - the late Dr. E. M. Wijerama, with a deep sense of humility.

Dr. Edmond Medonza Wijerama has been aptly described as one of the most distinguished medical personalities in this country. The Sri Lanka Medical Association was his foster child. He nurtured it, and gave it a home. He was a member of the SLMA Council for several years and served in the posts of treasurer, secretary and editor. He was the honorary secretary, when the SLMA organised its first annual scientific sessions in 1937. He was elected president of the SLMA in 1947.

The greatest act of philanthropy in the 127 year history of the Sri Lanka medical association was Dr. E. M. Wijerama's gift to the association in 1964, of his magnificent house and spacious garden at no. 6 McCarthy road, which was where he lived and practised for many years. During his lifetime this road was renamed as Wijerama Mawatha as a tribute to him.

Few men have lived so well and yet enriched the life of others.There is no doubt that his teachings will continue to educate,inspire and illuminate the paths of generations to come.

Today in paying tribulate to this medical luminary, I have chosen to speak to you on the subject of "Protecting the Values of a Noble Profession", which is appropriate for his life and work. Definition of a noble profession A group of professionals displaying admirable personal qualities such as honesty, integrity, generosity and courage. Noblest professions do not revolve around money. The most important hallmark is not a high income. Noble professions are humanitarian and in practice they exemplify truth and justice. At least four things specific to medicine impose an obligation of effacement (Altruism) on the physician, and that distinguishes medicine from business, and most other careers or forms of livelihood 1. Nature of illness 2. Knowledge that is non proprietary 3. The nature of treatment that is likely to

cause harm (ie. Patient safety) 4. The oath- a public promise to be competent and to use that competence in the interest of the sick It is not enough to obey the law of the land, neither is it enough to merely observe the ethics of rights and duties. The virtuous doctor will do the right and good thing even at the expense of personal sacrifice and legitimate self-interest. This if anything, is what makes the practice of medicine noble.

The practice of Medicine arose out of concern for human pain and suffering, a desire to help those who are ill. The relationship arises out of the pain and suffering of an individual, and offer hope by another human.

The conduct of a physician or one who practises the art of medicine, was held in the highest esteem and regarded as one who dedicates his life in the service of fellow beings in the community. Thus, a physician is described as a kind, self-sacrificing patient man, empathetic, tolerant at all times, to give of his best to heal the sick - mentally and physically, not expecting gratitude or reward.

I beseech each one of you,my colleagues present here, to reflect on your life as a medical professional from the very beginning of your career, and see where you stand, and how various changes have affected your life and how you could contribute to the health of the people.

Yes, there is so much change in medical science today from when, each one of us started our career. It is fast changing with rapid development in technology and research. Although modern medical care has improved the health of communities, and people have medical management which was not available in the past, the holistic approach that considers the nonmedical needs of the individual patient has been forgotten.

With technological advances, doctors have become more like technicians, and regard patients like disease entities, requiring to be fixed. Therefore I'm addressing this distinguished audience to reflect on the status of the physician, the change from then to now.

In the eyes of the community, the respect for the medical profession and its image has, sadly dwindled and is at a low ebb. In the recent past there has been a sharp decline in the ethical conduct of some medical practitioners. Materialistic influence has produced a highly selfish mentality, and while engaging in professional activities they have lost sight of the ethical, values which make our profession noble.

Project of the Committee on 'Patient Safety and Safety in Practice', of the College of GP's(General Practitioners of Sri Lanka) researched for nearly 3 years and published two posters,on how doctors and patients should conduct themselves, and complement each other in patient care.This has been a landmark production,and the Minister of Health truly appreciated our efforts.

The conduct of many medical professionals who have made the beautiful art embodying the science of medicine, seem like a business for monetary gains, has overstepped the norms of ethical standards and the values of a noble profession. Such conduct has been difficult and sad for me to witness. I'm sure many of you in the audience feel the same way.

Conniving with patients, to defraud insurance companies. Instances where falsification of medical records which would have put the carers in a bad light. Issuing false medical certificates. Fee splitting between doctors and institutions. Unwanted, unwarranted investigations being ordered at the expense of the patient. Some members of the profession seem to be of the opinion that they are God's gift to humanity, without realising that they could well be a scourge to mankind. Let us together try to sensitise men and women in our profession, to protect the values of our profession, and refrain from actions not befitting a medical professional, particularly in the process of consultation and referral of patients between the levels of health care.

As far back as 2002 the College of GPs of Sri Lanka realised the need for facilitating good values among family practitioners and produced a book advising ourselves about values in "Family Practice".

In the same year the joint project in which medical professionals on either side of the Atlantic, resulted in the development of a "Physicians Charter" which was published simultaneously in the Lancet and "Charter on Medical Professionalism appeared in the "Annals of Internal Medicine" and what is interesting to note that the values laid down in our book, have more than covered the aspects more extensively mentioned in the "Physicians Charter".

The causes of failure to up hold the values of a noble professionare multi-factorial beginning with entry to Medical school. An inadequate selection process for medical students exists, where only highest achievers at a highly competitive Advanced Level Examination seem to be the deciding factor. The attitudes and aptitude of the student, and reasons for a career choice in Medicine, should all be assessed at entry point, and a broader processed, comprehensive selection should be in place. This is a difficult and complicated task,and would involve the careful formulation of a structured assessment, and a genuine viva voce interview.

Planners of the medical undergraduates course should take into account student thinking, their expectations and the difficulties they are likely encounter. The medical curriculum should have an emphasis on Community Based learning, and what people expect from healthcare.

All this seems to be well taken care of by the planning units of medical faculties, and even taken into consideration by the Ministry of Health. However, there seems to be something missing, and it has not been possibly to inculcate the principles of commitment, dedication, loyalty and honesty, into all, who pass through the portals of a medical school.

I have been involved with the Family Medicine Teaching programmes of three medical faculties, and the PGIM (Postgraduate Institute of Medicine),since the late eighties and have had the satisfying experience to enable young students to learn, the principles of Family Medicine which are. Establishing rapport Building up a good doctor-patient relationship Good communication skills Maintaining confidentiality Continuity of care Availability and accessibility Follow-up care Discussing plans of management Explaining a disease process Rational prescribing, etc. 95% of them enjoy their GP (General Practice) attachment and they find a clear difference from the hospital medicine they see throughout the rest of their training programme.

All teachers in the field of medicine, whether its community based or hospital based should be "role Models" for students. We must be examples of competence care and compassion towards our patients and do so in a trustworthy manner. When students have completed their short five day attachment I discuss with them professionalism, decision- making and communication. I bring to them attention to the fact that 80% of our population is poor and they cannot afford many things in life, even basic requirements such as housing, water, food and facilities for health care, in spite of a well-developed Primary Health Care System in the country.

I make it a point to tell them - "Do not exploit somebody else's pain and suffering, to enrich your life" I hope they will remember but sadly it seems to be forgotten fast.

I also tell them my daily prayer when I have five minutes in my shrine room every night "May the patients I saw today be free of their pain and suffering"

The following are a few take home messages. We could give those who learn from us.

Treat all your patients as one of your own family

("He who looks on the pains and pleasures of all beings as he looks them in himself, is a supreme person" - Bhagawat Geetha, Chapter: 6) Solve the problem of your patients to the end of the encounter, even if and when Consultation or referral, becomes necessary. Involve your patients in the process of management Write your prescriptions clearly and legibly using generics names and a preferred brand name If you become aware of the unethical conduct of a colleague, discuss tactfully with your colleague without causing hurt. Do not make your profession a business. A developing country cannot afford it. We family physicians strongly recommend a "National Health Scheme" similar to that in other countries.We recommended that every citizen will have access to a family doctor who can solve most of their primary care problems and make appropriate referral to the next level of care - for opinion and /or services -necessary, and do so by proper procedure.

Universal Health Coverage, Global Health, Equity in health issues, Social Determinants of health, Multi Sectoral Health Systems are all my dreams, and are all mandatory issues to be considered side by side with values of a noble profession in a wider, broader concept, by all of those, who as carers of the health of the people in our country.