Is The Hippocratic Tradition Still Relevant in Today's Medical Practice?

Dr David KL Quek

Once again, there has been an increasing chorus of concerns being voiced by both the public and media regarding the medical profession and its so-called lack-of-caring attitude.

The much delayed but recently announced revision of the MMA Schedule of Fees did the medical profession little favour, in the eyes of some. It was understandably met with disapproval among the consumer associations and the public. By trying to be transparent (and hence to help protect the patient from excessive charges), we have been accused of being insensitive to the nation's current economic woes.

Perhaps, we might concede that the timing was awkwardly less than optimum. But obviously, the MMA leadership must have felt that this was delay enough and could no longer be put off.

The Ministry of Health has taken upon itself to try and regulate the medical profession as never before. This is evident with the new all-encompassing Private Health Care Facilities and Services Act.

There is talk that the Ministry might even impose what it believes to be fair medical fees for the profession. While the government has every right to levy its own charges and fees on the public hospitals and health care facilities, it is against all precedents to try and impose such controls on the private facilities.

In a free-market economy, and with the MMA acting as a rational bulwark against arbitrary excesses, private professional charges will be better served if left free to decide its own level, within set guidelines. Doing anything else to artificially drive down health care cost is unrealistic and will push the medical profession into despair and disarray. This smacks ridiculously of trying to place medical care as a price-control commodity, and will no doubt generate great debate and physician angst, if it follows through. Perhaps, soon all professions such as the legal, accounting, engineering or even the housing fraternities, will be subject to this style of controlled economy.

Lately, the Health Ministry has also embarked upon trying to improve the image of the medical services in public institutions. It hopes to instill this "Caring Attitude" by making every public-employed health professional undergo courses to address this issue.

It is hoped that such seminars and workshops can change the mindset of doctors and other allied health professionals so that they would be more sensitive and receptive to the rising expectations and potential grouses of our health-recipients i.e. the patients.

However, aside from the very attractive idea that these courses can have important ethical and socio-psychological contents imparted, there is no certainty that these will be appropriately applied by attendees. Does attending these courses make anyone a better, more caring doctor? Who can really tell? Besides, shouldn't doctors already be cognizant of their expected and much vaunted demeanour?

Nevertheless, these constant reminders to be empathetic and sensitive to patients and their concerns, are important to help forestall inadvertent misunderstandings which usually arise when less-than-the-desired clinical outcomes occur.

Perhaps more importantly, we can be taught how to handle and approach difficult situations and demanding patients. Perhaps, these should include stress management techniques to help becalm the harassed sleep-deprived, overworked doctor! Include too, techniques to smile and melt away criticism and angry demands from patient number 101, after you have seen and dismissed patient number 100, in one normal day of outpatient clinic. The day before was just as busy, just as harassed, perhaps even worse...

Still, one wonders if such efforts are mere futile attempts at appearing to be doing something – anything is better than nothing – much akin to closing the gates after the horses have bolted.

Would these correct behavioural emphases not have been more beneficial during medical school curricular teaching? Even so, can we expect uniform and unfailing compliance of such caring attitude by every medical practitioner who graduates accordingly? Is the medical profession one that should only be aspired to by potential angels of mercy and do-good humanitarian stalwarts? Should every doctor be a ultra-benevolent superhuman?

Perhaps, in our relentless march towards consumer activism and increasing patient awareness and perspicacity, expectations from our patients have attained too unrealistic levels.

Nonetheless, shouldn't the medical profession itself endeavour for the best possible scenario in trying to maintain the highest of ethical and service standards? It is becoming increasingly clear that we cannot escape the overpowering pervasiveness of the knowledge explosion now readily available through the media and the internet.

Our medical profession must therefore, take pre-emptive measures to keep up with such trends, which have slowly but surely eroded the know-all concept of the physician of the past, one who can do no wrong. The days of co-participatory health partnership is now upon us, and we should not fear this. Rather we should be active leaders in remodeling our role as patient-advocates more meaningfully.

While all of us aspire to be the best that we can be as medical practitioners, none of us can pretend to be the perpetually congenial Dr Marcus Welby or Dr Kildare, much less to be able to respond to the immensely diverse types of patients, with exactly the type of manner and/or service that these individuals (and their families) expect and increasingly demand.

Doctors as a whole have never asked to be revered as saints, although historically many have come close to becoming so, by their own very nature.

Notwithstanding this, a great many are proudly dedicated to their jealously-guarded craft and profession, so that their lives revolve almost entirely around looking after patients, and helping to heal many, if not most. This is due in large measure, to the carefully nurtured patient-doctor relationship which is centred on the patient, but which in turn, is reciprocated with, and strengthened by, the implicit trust and deferential compliance from the patient.

With increasing demands and expectations, and a little more knowledge (which can be a dangerous thing!), this special relationship is slowly being eroded away. Many people for some reason, cannot accept their physician's diagnosis or therapeutic decisions, straight-away, and are increasingly seeking second or even third opinions, to justify their personal concerns.

This depreciating trust in the doctor has made it very difficult for any doctor to respond appropriately, without seeming to over-react or to be too dismissive or insensitive. This might be misconstrued as tainted with ignoble intentions.

Conversely, the most glib or flamboyant physician may be the one that the seeking patient finally accepts. Sometimes, it is the doctor who pronounces the best prognosis or most grandiose reassurances, that wins the patient over. Not surprisingly, many a patient may be shortchanged, and be mistakenly reassured, with less-than-expected consequences.

To be sure, patients do have a right to seek a corroborative or dissenting opinion, but this should not be at the expense of the physician, who in a great majority of cases, will give his utmost best, with the patient's ultimate interest at heart. But alas, a cynical attitude has now permeated our modern society such that doubt has become the first response to any health pronouncements which is unexpected.

The growing acceptance of poorly defined and inadequately proven alternative healing practices has also made this scepticism that much harder to break. There is no easy way to re-establish this evaporating trust, this special patient-doctor relationship.

What now for the modern day physician? He now stands accused of breaching the Hippocratic Oath, one which he has not sworn or taken; perhaps, be even ignorant of. The Hippocratic Oath in western medicine was thought to be last taken by Scottish medical students in 1973. The question then, is should doctors be bound by this antiquarian oath written so long ago around 430 B.C. ?

Undoubtedly, the name of Hippocrates has always stood for an ethical ideal - that of a compassionate, discreet and selfless doctor. Although, the Hippocratic oath can no longer be regarded as the final repository of all medical wisdom, there is still much to be learnt from the spirit with which it was written. Thus, it has rightly continued to shape and to influence modern medical practices throughout the centuries.

With all these challenges, it behooves the physician to become more aware of his responsibilities and his duties. Also, he cannot divorce himself from the changing facade of patient expectations, whether he agrees with them or otherwise.

It is timely to reflect upon the Hippocratic Oath even as some of its tenets have been replaced and updated in the International Code of Medical Ethics and the Geneva Declaration. I believe the spirit of the Hippocratic tradition still lives on in all of us as medical practitioners.

For Malaysian doctors we have our own Code of Medical Ethics, which is currently undergoing a timely revision to keep up with the newer ethical concerns and challenges of modern society.

It is the continued respect and application of this ethical thrust that the modern day physician has to grapple with, in his day-to-day dealings with a changing and more informed patient population. If one pays particular attention and care to the sensitivities and concerns of each and every individual patient, I believe, it is possible to enjoy a more meaningful patient-doctor relationship. But this is simpler said than done.

The patient on the other hand, should be mindful that, the doctor is also human and can err or even make poor judgments sometimes, maybe even become angry, rarely. Hopefully all these unpleasant encounters will be rarities that they have been. The patient should also play his role to assist the physician in formulating the best partnership for maintenance of his health.

In this day and age, if any patient cannot agreeably interact with his physician, he can always find another to match his temperament and expectations. That is his right.

Furthermore, in non-emergency or non-life-threatening situations, the physician may also decide that his patient's interest be best served, if he opts out, and let another more congenial doctor take over. For it is certainly true that we cannot force everyone to like us, all the time. While we accept that the practice of medicine is patient-centred, it is worth considering that the doctor too, has his rights.

As a trained and well-apprenticed professional, the doctor has the right to be respected for his clinical acumen, his judgment, his therapeutic decisions and his fees, for all of which, they are his just due.

However, the Hippocratic tradition should still be as relevant in helping him steer clear of any unwarranted misadventure.

The patient-doctor relationship has changed somewhat, and both sides must make efforts to readjust their positions. A newer more tolerant partnership should be forged for the betterment of health for the patient and the nation as a whole.

Meanwhile, the medical profession must continue to improve and re-mould itself in the inspired tradition of Hippocrates, so as to be capable of not only providing excellent medical services and technologically-driven expertise, but also offering a more caring, yet affordable and patient-centred one.

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