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.
