By Lasantha Pethiyagoda –

Prof (Emeritus) Lasantha Pethiyagoda

Sri Lankan health-care professionals are often idolized, especially in recent times, as heroes when the Covid pandemic’s far-reaching impacts are felt. The common narrative is that since they save lives, they are the givers of life. Sri Lanka being a largely poor country with a desperate and struggling poor population, a seriously sick person is generally at the mercy of all-powerful doctors who take on the role of deity.

Thus, patients and their families can find themselves on the receiving end of curt communications or seemingly uncaring attitudes if not downright rudeness and arrogance. This is understandably disappointing. A worried, scared patient looks to the doctor not just as the person who will take the lead in uncertain situations, but as someone who can understand their feelings and emotions.

According to the curriculum at medical school, doctors are trained to provide care and act with genuine empathy. The bad news is the training doesn’t always make a difference in the long run: a “hidden curriculum” of medical education can explain this.

It would seem that there are two kinds of medical students. The first are young people who compete for the prizes every year at school, who go to selective private schools and gain entry to medicine with remarkably high entry scores. They are highly motivated and come from families which are fanatical about their child’s academic success and their career choice, and who have often paid a great deal of money to have their child coached privately to within an inch of their life from early childhood (if indeed they had a childhood).

They grow up in a bubble with little exposure to the world of the people who will be their patients in the future, possibly commuting in chauffeur driven luxury to school and back. In recent decades children from a newly rich family background are overrepresented in this group. As medical students they continue to excel as they will in certain specialties, but not in others. They will probably make poor employees in government clinics.

Their skillset is accurately learning vast amounts of highly technical material which they can regurgitate on demand, the task of imitating required behaviours such as demonstrating ‘empathy’ to their examiners is a simple matter for these youngsters. After passing the relevant exam they will discard this ‘empathy’ in a jiffy. There is no “hidden curriculum”. Accordingly, this group could be the majority of medical students. It is irrelevant whether they are male or female, but with sufficient financial backing.

The second kind of medical student has a more ‘normal’ background and at least some life experience similar to their patients. They have to battle more to get the marks and to pass exams than the first group, but they have some innate intuitive empathy (which is not enhanced by empathy training). Consequently, their skillset is wider than the first group and they tend to gravitate towards clinical specialties or general practice that serve the most needy. They are better (much better) at problem-solving and applying their knowledge in clinical settings as they see their kin in the patients before them.

This type of student is more often found in admissions to Medicine from rural or under-privileged areas rather than the traditional private or city schools, but my impression is that this difference is becoming less than in earlier decades.

Early generations of doctors, like those of the British tradition, were taught about the ‘art’ of medicine as well as the science. This largely occurred after finishing medical school and was learnt at the bedside while working as interns with senior doctors. A good doctor was just as well versed in the art as in the science. In recent decades this teaching of the ‘art’ seems to be disappearing, with training of junior doctors becoming secondary to the service demands of hospital administrators (now themselves medical people) and the advent of competition with private practice while being employed in public health services. Even if there is empathy training, imitating empathetic behaviour is not the same as having empathy.

An important topic, but not as simple as it seems. Empathy and compassion can be emotionally draining, especially if the doctor has no skills or support at home or social network to recharge. The result is early burn-out resulting in behavioural lack of compassion and abandoning ethics in place of survival. If a doctor is too empathetic, it can distract from the practice of sound medical science and render the doctor less able to help the patient.

If the doctor is too arrogant or distanced, the patient is more likely to withhold information and not cooperate with optimal treatment. Both reduce the quality of care and outcome for the patient. Students need to be taught how to achieve a sustainable balance: enough empathy to be caring; not so much that it clouds medical judgment.

They also need to be taught how to prevent and recognise ‘compassion fatigue’ before it leads to burnout and wholesale abandonment of care. Perhaps the primary driver for emulating the senior doctors is that they have survived in the game long enough to become senior doctors, and passing post-graduate exams for the title “consultant” with the attendant lucre.

Sri Lanka is at a cross-roads in several ways. It is spiraling downwards in terms of economic health, with moral values and ethical standards in professions and society in general accompanying the desperation that results from economic depression. People are increasingly underfed, under-nourished, over-worked and constantly stressed out. An ideal set of conditions for escalating health problems, with drug abuse, alcoholism and risky behaviour all complicating health outcomes.

One business that thrives under these conditions is the private supply of health services in cleaner, newer, more sophisticated settings than the public health system. A patient, unlike a consumer of goods and most other services, does not choose to be sick. A practitioner must choose between ethical conduct consistent with the noble profession of healing, or maximizing of profits at every opportunity.

There is a moral dilemma for young doctors. Do as everyone else seems to be doing, and make your money, build grand mansions, buy luxury cars and send the kids to exclusive schools or serve the poor with genuine compassion and empathy and be happy that you have accrued merit where it will count in your conscience for the rest of your life?