‘Physician heal thyself’ hard-hitting speech, the 41st president Dr. Jayaratne spoke of ethical values, private practice, the physician-pharma link and much more

‘Physician heal thyself’

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In a wide-ranging and hard-hitting speech, the 41st president Dr. Jayaratne spoke of ethical values, private practice, the physician-pharma link and much more
Simple, significant and powerful were the messages amidst humorous quips and video cartoons, when an eminent Physician took the very heart and brain from within a doctor, examined them thoroughly by turning the searchlight inward and gently guided them in the right direction.
“It would be wise to analyse the situations that cause patients to be dissatisfied. Sometimes this may be due to unavoidable circumstances that lead to pain, suffering or loss of a patient. But often it is due to mishandling of or poor or complete lack of communication with the patient,” Dr. S.D. Jayaratne told a distinguished gathering on February 12 at the Cinnamon Grand Hotel in Colombo.

Inducted as the 41st President of the Ceylon College of Physicians (CCP) on the 50th anniversary of this august body, Dr. Jayaratne brought forth laughter from the audience when he quipped that the “grand introduction” he got from Immediate Past President Dr. Nihal Gunathilaka made him wonder whether “I am at my own funeral”.

In a wide-ranging and hard-hitting speech, Dr. Jayaratne spoke of ethical values, private practice, the physician-pharma link and much more.
He called on his colleagues to reflect on the past, while looking ahead with optimism and readiness to face challenges, as the CCP reaches its golden anniversary with the theme, ‘Celebrating our past, Igniting our future’.


Newly-inducted President Dr. S.D. Jayaratne addresses the distinguished gathering

“We must improve our communication skills to prevent misunderstandings. We can do many things as professionals to improve the quality of care, while building patients’ trust. If you are keeping your patients waiting, have your staff explain to them the reason why. If necessary, apologise. Treat them with respect,” he urged, adding that physicians should involve patients in decision-making about their health.
Empathy is very important, he said, explaining that it is the ability to understand the feelings of another. It is not sympathy. “You have to be able to put yourself in another person’s shoes, see their point of view. For this, you must have patience, and a good listening ear. Sadly, this is something that is dwindling in the modern set-up, with the commercialisation of medical practice and more reliance on technology, rather than face-to-face conversations and history-taking.”

He said that computers and the internet have equipped patients with knowledge to make informed decisions about their health, while demanding that doctors keep abreast of the latest treatment options.

Moving onto professionalism, Dr. Jayaratne pointed out that although it has many definitions, the important attributes are specialised knowledge, competency, accountability, self-regulation and vitally, honesty and integrity. “In my opinion, when private practice enters the front-door, professionalism tends to disappear from the back-door.”

With strong trends towards sub-specialisation in postgraduate education, he questioned whether it has led to an improvement in the quality of health care or a fragmentation of the system. It appears to have led to a less holistic approach to health care. It is also more costly and not widely accessible to the wider population. This approach to treatment confuses the patient and for different ailments, the patient sees multiple specialists who draw up multiple plans of care. This often results in less commitment to patients from multiple health care providers, poly-pharmacy and unnecessary costs for repeated investigations. Often, it does not change the ultimate outcome.

“As our patients, without being referred, go directly to consult a specialist, the ‘gatekeeper’ is the receptionist at the private hospital or channelling centre,” he said, highlighting a common scenario. “Mokakda lede,” the patient will be asked and if the reply is “oluwe lede” he/she gets referred to the neurologist even though the headache may be due to a febrile illness. “Ganu leda” are referred to the gynaecologist, said Dr. Jayaratne, citing the case of a woman with shoulder pain being sent to the gynaecologist, as her relative had told the receptionist “ganukenekge ledak”. The best part is that the woman’s shoulder pain was treated by the gynaecologist!

“Internal medicine has been called the ‘cornerstone’ of every national healthcare system. In the face of so many sub-specialties, the lines among each of them and internal medicine are increasingly blurred,” he pointed out, urging that the role of the internist be re-defined. “I think we as internists need to act as the co-ordinators of care, so that patient management occurs smoothly and efficiently. Follow-up with sub-specialists need to be streamlined and more focused on specific diseases that need very specific diagnostic and treatment procedures. This would save a lot of time, money and effort.”

Balance professional well-being with the interests of patients and the public
Dealing with ‘ethical issues’ and private practice, this Physician and Academic pointed out that private medicine encourages doctors to make decisions on the basis of profits, rather than need.This is a poor driver of clinical decision-making. Professionalism has often been compromised and unethical behaviour promoted due to the avarice for money, said Dr. S.D. Jayaratne, explaining that private hospitals implement systems that focus first on balance sheets and not patient welfare. It is well-known that some hospitals pay commissions to doctors who order tests or admit patients. Indeed, some doctors gleefully accept this unethical practice without any remorse. This means “the business of medicine and the practice of medicine are at odds”.
Cartoon: Arrow through patient’s head: Ordering unnecessary tests
He lamented that sometimes physicians exaggerate the disease condition to patients and convince them to play along because seeing more patients translates to more profit. However, there is less time spent with each patient, which is dangerous. This also means that public-sector patients are neglected and the free services that they are entitled to often delayed or postponed. Patients are unnecessarily pushed towards consulting specialists, as it is more profitable for hospitals, but more costly for patients. As someone once said, “If there be an excess supply of doctors and they are paid a fee-for-service, there would not be one womb or appendix left in the population!”

He raised the issue of a wide variation in practice standards and fees. There are many unethical practices, misinformation and misleading of the public and the CCP should stand strongly for the ethical practice of medicine. It is wise for doctors to take the initiative and formulate the necessary regulatory policies within the professional community, rather than awaiting a point-of-no-return situation – where the government dictates the terms of service, according to pressure from the public.

Touching on another controversial topic, Dr. Jayaratne looked closely at the relationship between the pharmaceutical industry and the healthcare service. “This debate has been raging for quite awhile now. There are arguments against the undue influence that big pharma companies wield over the profession. However, at the same time, the financial support from these companies make a vast amount of valuable work possible, which would otherwise be out of our grasp. Events such as educational programmes would incur a burdensome cost if not for their support.”

Reiterating that there are codes of conduct for pharmaceutical companies developed by the industry, he said that most if not all such codes prohibit companies from giving doctors inducements to prescribe their products. Many medical professional organizations in developed countries have their own codes and guidelines on interacting with pharmaceutical companies. The WHO has published criteria for ‘medicinal drug promotion’ and a ‘Code of Pharmaceutical Marketing Practice’.

Drug companies come in various shapes and sizes; some are fiercer than others, and the relationship among doctors, academic institutions, pharmaceutical companies and medical journals will always be complex and interdependent. But, we should not forget that this relationship has produced some remarkable collaborations and enabled the discovery and development of drugs, he said, adding that the recent acrimonious friction between doctors and the Health Ministry has highlighted these issues. Funding of continued medical education (CME) is mostly by the pharmaceutical companies at present in Sri Lanka. Governments in developed countries have resources to allocate funds for CME. This is a distant dream in our country with the government already constrained and overburdened by the provision of a free health service.

The CCP must push for policies that regularize the use of such resources. It may be more prudent to channel these resources towards professional bodies and organizations rather than individual practitioners. In this way, professionals can better maintain ethical practice, with no undue incentives offered directly to the individual. There can also be more transparency. “Our advocacy must always be grounded in our ultimate goals of improving medical care and the health of patients and the public — not any short-term gain for individual doctors or medical institutions.”

Dr. Jayaratne added: “Trust is important in an increasingly transparent world. If we are dominated by the profit motive alone, independence of thought and conscience may be lost irrevocably. The profession and professionalism will be compromised, perhaps terminally.
“The essence of professionalism is its integrity — sense of being beholden to use its knowledge for the greater good of humanity and in service of truth. As long as we as a profession hold on to this essence of professionalism — even, and especially, in an age of globalisation — we will survive and flourish, and we will fulfil our role in serving the patients of this country. I acknowledge that it is challenging to balance professional well-being with the interests of patients and the public; but we dare not abandon these aspirations.”
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