I was talk­ing to an old school friend the oth­er day. Like me, he has chron­ic, old age-re­lat­ed dis­ease. We kept say­ing to each oth­er how agree­able it was liv­ing in T&T, where we had the op­por­tu­ni­ty to old talk with fel­low Tri­nis who must be among the most sym­pa­ti­co peo­ple on Earth and how for­tu­nate we were to have doc­tors in our midst who were com­pe­tent and car­ing.

All this is very good when the sys­tem works. What hap­pens when the sys­tem does not work?

The first rule of med­i­cine is, “First, do no harm!” Es­sen­tial­ly this means, “Doc­tor, be care­ful … do not do any­thing to make your pa­tient’s ill­ness worse.”

At its most ba­sic, it refers to mak­ing the cor­rect di­ag­no­sis and start­ing the ap­pro­pri­ate treat­ment of the pa­tient’s ill­ness. But it is much more than this.

In the same way as health is not mere­ly the ab­sence of ill­ness, a sick per­son is not mere­ly the pres­ence of a dis­ease. Health al­so in­cludes men­tal, emo­tion­al and so­cial well-be­ing, three huge con­cepts that af­fect your ill­ness. If you like your sur­round­ings, if you feel pos­i­tive about your life, if you are sharp in your busi­ness, all that af­fects the ill­ness you have.

A sick per­son is not a dis­ease, a can­cer or a heart at­tack. A sick per­son is a per­son … with a dis­ease. Dis­eases are rel­a­tive­ly easy to di­ag­nose and man­age. Un­der­stand­ing and man­ag­ing the per­son’s re­ac­tions to the dis­ease, the emo­tions, the wor­ry, the eco­nom­ic con­cerns, the fam­i­ly in­ter­ac­tions, every­thing that goes in­to the make­up of a per­son, that is dif­fi­cult and equal­ly im­por­tant. These things are part of the di­ag­no­sis and af­fect the treat­ment.

This con­cept of the pa­tient be­ing more than a dis­ease was best ex­pressed in 1927 at Har­vard Med­ical School, by Dr Fran­cis W. Peabody, who de­clared, “One of the es­sen­tial qual­i­ties of the clin­i­cian is in­ter­est in hu­man­i­ty, for the se­cret of the care of the pa­tient is in car­ing for the pa­tient” and, “the treat­ment of a dis­ease may be en­tire­ly im­per­son­al; the care of a pa­tient must be com­plete­ly per­son­al.”

“Do no harm” then, means much more than man­ag­ing the di­ag­no­sis and treat­ment of a dis­ease. Mak­ing a di­ag­no­sis and in­ject­ing a drug is not car­ing for the pa­tient. Car­ing means tak­ing in­ter­est in their men­tal, emo­tion­al and so­cial needs, and main­tain­ing their dig­ni­ty, self-es­teem and re­spect. It means car­ing for your pa­tient be­cause the pa­tient who feels cared for, man­ages her dis­ease bet­ter.

There’s a pub­lic hos­pi­tal clin­ic in Port-of-Spain which is run by very com­pe­tent and pleas­ant doc­tors and nurs­es. It takes rea­son­ably good care of mak­ing a di­ag­no­sis and in treat­ing peo­ple.

But the build­ing in which the clin­ic is sit­u­at­ed is old and run down, gloomy and dirty. The wait­ing room chairs are un­com­fort­able and crowd­ed. Main­te­nance is es­sen­tial­ly ab­sent. Clean­ing and mop­ping takes place dur­ing clin­ic, in and about pa­tient ac­tiv­i­ty, wheel­chairs and crutch­es. The cor­ners of the wait­ing room are grimy and haven’t been prop­er­ly cleansed for at least five years that I am aware of. The fe­male bath­rooms have not worked for months and women have to go to the male bath­rooms, which are as filthy as the wait­ing rooms and where there is of­ten no toi­let pa­per so peo­ple walk with pa­per.

Where is the dig­ni­ty? This is do­ing harm.

There are no fa­cil­i­ties for buy­ing or eat­ing food. Pa­tients bring their own and since wait­ing time of­ten runs over four to five hours, at noon, when every doc­tor and nurse dis­ap­pear for their lunch hour, peo­ple ei­ther try to hide and guilti­ly eat out of a brown pa­per bag or get up, go out­side, where there is no place to sit, and eat stand­ing up.

Where is the self-es­teem? This is do­ing harm.

It’s com­mon to see doc­tors walk­ing out ear­ly in the af­ter­noon be­cause they have “fin­ished see­ing their quo­ta” of ill pa­tients, leav­ing be­hind old peo­ple who have trav­elled long ways, have to trav­el back and have been wait­ing for five or six hours to see a doc­tor.

Where is the re­spect? This is mak­ing your pa­tient’s ill­ness worse.

Pa­tients need to feel re­laxed, com­fort­able, cared for, even loved. When doc­tors walk out on them, they suf­fer.

Peabody went on to say: “The sig­nif­i­cance of the in­ti­mate per­son­al re­la­tion­ship be­tween physi­cian and pa­tient can­not be too strong­ly em­pha­sised for an ex­tra­or­di­nary num­ber of cas­es, both di­ag­no­sis and treat­ment de­pend on it.”

It is the ba­sis of suc­cess­ful out­comes in med­i­cine. Or­di­nary com­pe­tence is manda­to­ry and brings good re­sults. Add in kind­ness and com­pas­sion and you get ex­tra­or­di­nary re­sults.

Com­pe­tence and com­pas­sion can­not ex­ist with­out each oth­er. The doc­tor who los­es sight of that is lost.