18 August, 2022

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Should Doctors Make Money Or Serve The Poor Sick People?

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?

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Latest comments

  • 7
    0

    “Should Doctors Make Money Or Serve The Poor Sick People?”

    They can do both.

    But the unfortunate truth is, many don’t become doctors to serve/cure/save the sick ……… or the poor.

    It’s the case all over the world.

    • 1
      0

      NF,

      There are a increasing portion of medical graduates/engineers after obtaining their degree certificates shamelessly leave for greener pastures. Many of them move to Australia WHILE others to any other geographical destinations. Not many of them would contribute to srilanken development either, becuase they settle in outside of the country.
      .
      Not even today, these graduates are entitled to any kind obligations that they have to serve at least 5 years before leaving the country. Srilanka is a poor country and they maintain free education with much more difficulties than appeared to be. So, I think it is high time any powerful govt to implement hard regulations regarding ones leaving the country without having served the public sector. In European countries, if they would leave any other geographical locations, after completing their due services, they have to pay it once or within a short period. Burseries that they enjoyed during their education are tax payers funds.
      :
      In our hell, where NO LAWs are effective, any idiots could make use of the FREE EDUCATION and leave the country, with thousands of AL qualified stay away from University education for not having placements for their choices of studies.
      This should change at least for the benefits of the future generations. Dons and buffaloes in UNIVERSITY ADMINISTRATION in our hell should pay their due attention at least today. Thank you

  • 2
    0

    Thanks for a very intelligent article.

  • 4
    0

    Gone are the days of the mystic doctor.
    Nowadays, men of other professions make more money. They live in bigger bungalows; travel in chauffeur driven cars, have an extravagant life.
    .
    In my opinion, when we introduced Private Practice, we let slip service to the sick and the poor.

    • 0
      0

      “Gone are the days of the mystic doctor.”.
      .
      Are u sure ?.
      .
      Eliantha white (49 ) found dead by Covid but was held until his death as under the title ” royal doctor ” for no reason. It was revealed his knowledge is similar that of Dhammika paniya maker/ who twisted masses including srilanken Mbbs holders remember? .
      .
      And the man who enjoyed greener pastures for such a long time / 15 long years having misled the donkey nation and is believed to be brainwashed by Ghanakka or the like mystic women.
      .
      Thanakola eaters dominated srilanka attack Ghabakka but not yet Gotabaya😎😎😎😎😎😎😎😎😎😎

  • 4
    0

    Lasantha I have been in North America, UK, Lanka and now in India. Only in our part of the world people expect doctors to provide services without expecting payment, if possible free at cost. Is it because of some kind of Social medicine?? Not really. Many countries where social medicine is provided , governments adequately pays to compensate so that higher quality of care is assured. Medicine is considered just like any other services in these countries but may stand out because of ” human touch”. They have licensing boards which specify and monitor conduct and care. Patients are free to complain any of their concerns. Whereas in Lanka medical council dictates public and government even on foreign policy. In contrary only in India public manhandles doctors at will..

    • 2
      0

      Chiv,
      .
      but you have not been in to NON-ENGLISH speaking world – I mean to Germany, France, Switzerland, The Netherlands and several other smaller nations across europe.
      .
      In Germany, it is an obligation to have a health insurance for anyone who work in Germany.
      Medical doctors are respected but not held like GODS as is the case in Uk and North america. They can t earn as much as they are allowed as is the case in UK for example. Many incl. americans and the english dream of German Health care systems.
      I dont think it is much different in France and several other grand nations in EU. Where there HI is made a must – the public health is kept above.
      The less fortunate ones are offered free also their lives would not be left tobe in risks. I know it very well how those obdachlose (roofless people) are treated by non-gov organisations in high winter times, not allowing any single person be dead by winter freezing temperature. Carritas voluntary services and various other religious bodies protect those people.

      • 4
        0

        LM I totally agree. The Scandinavian and some European countries have the best health care services available today. Most do not treat health care services or doctors any different from others. Hence they expect higher standards in general and their quality of life is rated high. I agree we as doctors should strive to give the best csre possible to our patients but the same should be applied with others too ( polticians ???) With universal coding systems payments for services are now being regulated. So there is limitation to payment but I too agree attitude and behavior are debatable.

        • 0
          0

          And Chive,
          .
          With us becoming older, dental hygiene is considered to be one of our higher expectations. This is common to anyone where would be geographically no matter we are rich or poor.
          teeth resetting with their aging is a real big problem in UK than in Germany. I dont think it is better in the US without proper health care systems for all all equally. It is common to everyone, with the age, People loosing their normal teeth become shy to pay a smile
          as had been before. Many where health insurances cover their huge costs for teeth repair and setting live long really.
          That has become a social issue with the time. It is natural that our teeth would become weak and losses being made with us becoming older. However, proper care by dental doctors is guranteed with a health insurance in Germany and other neigbouring countries than in UK and America. Germans in general are perfectionists. They may still be treating foreigners not that hospitably. HOwever their systems being introduced to their people or others are comparatively well structured.

  • 2
    0

    Medicine is huge business. Its commerciality is meant to prop up the Western dollar to keep Western countries afloat. It has produced good innovations, but like all Capitalistic inventions, it has to continuously keep up the innovations through experimentation with patients. Alas, no more is it to cure. For every 70 patients, there are another 30 who suffer the birth pangs of medical innovation. And the medical innovation is not for cure, but to push the frontiers of ever-worsening commercial creations of other sorts, like environmental toxicity. Doctors in the US are paid hugely to keep the enterprise going.

    Our famous Motherland, thus following the Western model of all things commercial, and in fact trying to take over from them, has created this bunch of Medical Professionals to have the same….Look! That’s all! Can you believe it?

    • 1
      0

      RTF,
      .
      May I add someting to it please,
      Medicine is a business where there are no health insurances are there. Medical doctors and even specialits/consulatants cant earn exceeding their limits in Germany, France, Switzerland and the like countries. Most of them are just medical graduates so as the other graudates. Their tax system would not allow them to become business men like in our hell – srilanka. Each time back in my home country, I have to exchange arguments with our medical graduates. Most of them though mostly not having obtained PG qualifications behave like they should be respected above any other professionals. Needless to say, how GMOA and that Padadaseniya reacted – making them as the experts in COVID containment program- …. Padadadeniya has PG qualifcation in Paediatric Neurology but not in Contagious medicine/Community disese control/Human virology

      And for your info, I have cousins living in CA. I think all of them are over 65. They stayed back in that country after they obtained their university education. But I am talking about the average ameicans, that struggle with the high costs in health in that country. Obama care was about to introduce a health insurance to all. I have no doubt, he understood that the health care systems being found in rich countries in europe can be a role model for them as well. America is a population of 320 millions of people (3/4 of europe). However, that Trump the clown in all times destroyed everything after becoming the successor to Obama.

      • 0
        0

        leelagemalli,

        Yes, the commercialized side of medicine is mostly from the USA. Yet the doctors in US are of a far more compassionate nature than our Lankan doctors. Big law-suits can be taken against them for malpractice, and so that drops down their any hubris quite a bit…..don’t know if it is that, or they are naturally like that compared to the Lankan pompous gene.

        • 0
          0

          …….drops down any hubris*……

  • 2
    0

    Mr Pethiyagoda

    In general, wealthy parents are able to guide their children on a career path, medicine or in some other profession, from an early age & support them throughout their education, often enrolling them in foreign universities. Obviously they have an advantage over the less privileged & no surprise they do well, often, easily finding employment abroad. The ‘second kind’, as you categorise, seem to be from the outstations, many who manage to get into university with bare minimum qualification, & in your opinion, seem to ”… 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….” I am sure the GMOA & its President, belong to this second category, if so, what do you say about all those strikes demanding privileges? These doctors had their medical training funded by the people, yet, forget their moral duty to pay their debt to society. Then there are the unfortunate from the so called ‘Colombo’ schools, some who even had better marks than the ‘second’ category but were unable to get admission. The only opportunity for them was paying for their education privately but wasn’t it the GMOA mafia that opposed it, fearing competition? Didn’t the same gang even objected to the Indian govt. donating ambulances, the only significant public service by the previous regime?

    Cont

    .

  • 1
    0

    Cont

    In UK, a senior nurse or a plumber earns more than a junior doctor. A nurse has the same respect as a doctor & a senior doctors’ earning are the same as in other professions & everybody pays tax on their earnings. As long as doctors in SL are considered privileged & considered a lucrative profession, for most, the motive for taking up medicine is purely for financial gain, so empathy goes out of the window. Of course, there are a few honourable doctors & I raise my hat to them but, by large, most are driven by greed. To your question, ‘Make Money Or Serve The Poor Sick People?’, the simple answer is in the Hippocratic oath

    • 1
      0

      Raj you seems to know the reality and I will not further discuss on this matter. Thanks for saving my time. As in many things Lankan medical system too is unique where the public have kept doctors on pedestals, like most they too have close nexus to politicians .They dictate terms on non medical matters and public is at their mercy, so much so to call or threaten with strikes and paralyze system. I have not come across such system in any part of the world including India.

      • 1
        0

        See today news. GMOA strike an act of sabotage says Health Ministry. Apparently GMOA launched 24 hour strike in 5 districts and threatening to extend island wide tomorrow, if their demands are not met.

    • 1
      0

      Raj-UK,
      .
      It is just at the begining only.
      :
      Assitenzarzt (junior doctors) in Germany earn more with them becoming experiencd month to month.
      .
      But private practices or the like culutre is not in Germany. I dont think it is also available in france

  • 0
    0

    Lasantha has given his opinion about this complex and important topic at basic level. In Sri Lanka doctors do not engage with patients and families at same level. They were illusion ed as if they were given divine power to control people’s lives. Part of the society accept it as normal behavior.
    Doctor should earn money by ethical practice and that is part of the practicing a profession.
    To start
    they can limit the number of patient see in private practice so that they can spare enough time for individual patient. They should give time for patient to ask question irrespective of validity of the question. Arrogance by any by a doctor should be investigated by medical council and there should be avenue to report bad behavior by general public body manged by Sri Lanka medical council so that minor oppense could be investigated and doctor can be counseled.

  • 0
    1

    COVID-19 is an infectious respiratory illness caused by a coronavirus skipping medical care because of the cost, shocking and unacceptable that medical bills strike more fear in the hearts, Many people infected with the coronavirus do not feel sick FEEL LESS SICK MORE THAN VISITING THE DOCTORS. but they can still transmit the coronavirus to other people AND TO THE HEALTH CARE STAFF

  • 3
    1

    Thanks for the article. Good to raise these ethical questions particularly under present Covid pandemic. My university experience and social contacts show more than 80% of medical students and doctors come from ordinary families. People who came from upper strata perhaps were more empathetic because of their upbringing. There can be some changes in recent times due to commercialization and competition in the profession. Under the circumstances of private hospitals, GMOA has several ‘trade union’ issues although their behaviour at times being controversial.

    • 0
      0

      Laksiri,
      if all what you say is the facts, that is the reason SRILANKEN medical professionals to become inhuman as of today. One of my friends, a german national got sick after entering the country, with fever and degue may be the etiological reasons. However, what he shared us on his return was unbelievable because most medical doctors dont want to speak with a foreigner just because they shy to speak in English. Not just the patient but entire family of that foreigner was there, being down with all anxities causing the young man in early 30 ties had permament fever for a week or so. I think level of medicine and the quality of medical services fallen into as of today is no different to that of rural india. Only competent medical graduates in india earn respect while all others are believed to be low-quality products from their local universities.

  • 0
    0

    We find good and bad people in All Walks of Life and mostly in Developing and
    under developed world , depending on their power of purchase of goods and
    services . The main difference I notice with my experience is that Developed
    countries Let the People hold the real Power in their hands in the name of
    Real Democracy . And this process allows people to get the best of services from
    All walks of Life . The aim of the rulers is , to deliver more and more better
    services while that is exactly what the general public want from them . It is
    only based on this result , governments are coming and going . The people of
    third world , in majority of the case , the system is Abused and People Do not
    Care . In the name of democracy , the values of Democracy itself gets destroyed
    in many ways while the very public , the guardians of the process watch on
    with no help from anyone . Sufferings go on and on , no end in sight ! This article
    sheds the limelight on just one such suffering by the public . One must ask the
    majority who used their power to bring in their rulers , whether the situation is
    under their control ! Are they the Kings ?

  • 0
    0

    The article is a a fair reflection of reality.
    The medical profession has been transformed from a community service, to a career, to a business and at times daylight robbery.
    All of this happened in a little over half a century. Thanks to private medicine as part of the economic package of JRJ.

    *
    Mrs Thatcher made clear what she intended when under her passengers, patients and clients, all became ‘customers’ overnight.

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