E. M. Wijerama Endowment Lecture delivered by Dr. Ruvaiz Haniffa on October 25, 2019 at the Lionel Memorial Auditorium of the Sri Lanka Medical Association
As we pass through our professional lives we are confronted by experiences – some good some bad. These experiences mould us in to the professionals we are. In the fullness of time we pass on these experiences to the next generation of Sri Lankan medical professionals. In doing so have we adequately reflected upon what we are passing on as individuals and collectively as a profession?
Being in the medical profession Knowledge and Skills with regards to our profession to a very large extent is dictated to us by our Western colleagues. In terms of attitude, what we acquire and then pass on is to a very large extent determined by indigenous or local factors. That’s what makes us Sri Lankan doctors practicing western medicine.
Attitude by definition is the settled way of thinking or feeling about something.At the core of this lies the question who or what are we as medical professionals?
The physician of yore, and down the ages, had the ‘lives of men’ in their hands. In most early civilisations, illness was attributed to the vengeance of Gods. Sinners were punished with illness. In our own culture, viral infections were called “Deiyange Leda” (illnesses from the Gods). Hence, those who had the skill of ‘curing’ illnesses had to intercede with the Gods. The physician, therefore, also became the priest - the intermediary between God and Man. The ‘sorcerers’, ‘exorcists’ and ‘witch doctors’ sought to ‘speak’ with the Gods to plead for cures for the physically and mentally sick.
With the advent of modern science and dependence on the scientific method to determine causality of disease and illness, the aura began to fade. It was discovered that disease and illness was not ‘God-sent’ after all. There was no real need for an intermediary to intervene between God and Man to cure illness. What was needed was a mere human with knowledge and skills to identify the causation and invent or discover remedies. The so-called Bio Medical Model. The model and the science behind it have allowed today’s doctors to have mastered the science of medicine and in my opinion, it has caused a serious erosion of the art of medicine which in turn has led to increase in the arrogance of today’s medical practitioner.
We are now faced with a state of ‘cognitive dissonance’. Parallel to being ‘God-like’ and ‘playing God’.
Centuries of being intermediary between God and Man has made the physician what he/she is today. Assertive behaviour is inherent in the ‘professional medical culture’ that encourages arrogance. Many doctors tend to believe that they have an entitlement to be arrogant as they claim to be ‘top of the pile’ amongst the professions. This arrogance seems to be generated from several presumptions. Firstly, it comes from the fact that the best performers in the biology stream at the GCE A/Ls are admitted to faculties of medicine. Hence, they think they are intellectually superior to those in other professions. Secondly, it is the inherent patriarchal antecedents of the medical profession from the earliest of times. So much so that ‘arrogant behaviour’ is learnt during training - passed from the professor to student and from the consultant to the subservient medical officer. This creates an unhealthy narcissistic personality from the medical student right up to the Consultant.
The arrogance is indeed exacting a high price on the profession.
The Medical establishment has become a major threat to health, not through negligence or drug reactions alone but due to arrogance of the profession. Medicine has assumed the authority to label one man’s complaint a legitimate illness, to declare a second man sick though he himself does not know it, and to refuse a third the recognition or acknowledgement of his pain. In urban elite set ups this power expands to bureaucratic, rude, inhuman approach. Here medicine is exercised by specialists who control large populations by means of institutions. The total control of health matters by the medical community alone is dangerous.
During the past few years the medical profession has attracted more criticism than usual. Some has been justified. In an era of sound-bites and newspaper agendas driven by tabloid headlines, the lives of peace-loving majorities are inevitably obscured by attention seeking acts of minorities. The news media acts like a distorting mirror, exaggerating the bad behaviour of a few while minimizing the quietism or indifference of the many. This outstanding feature of modern society has been successfully exploited by interested parties on all sides. A few doctors have behaved badly; some have been incompetent or rude, libidinous, dishonourable, even dangerous. That it is a small minority that behaves in this way tends to get overlooked: the entire profession, is discredited. That was from an Editorial in The Journal Clinical Medicine, in its September/October 2001 issue written by Sir Raymond Hoffenberg, former President of the Royal College of Physicians. He goes on in the editorial to sum up this arrogant behaviour in one sentence – ‘Leave it to me, I’m your doctor!’. Some may argue that this statement is not arrogance but that it is a statement of self-confidence.
In relation to the difference between arrogance and self confidence I wish to quote from my own speciality of Family Medicine. Prof Marion Stuart, Professor Emeritus in Family Medicine at the Robert Wood Johnson Medical School, New Brunswick, New Jersey, in the USA and co-author of the book The 15 minute Hour: Therapeutic Talk in Primary Care has this to say of the difference between arrogance and self-confidence. Arrogance she says is to do with the doctor’s judgement of other people being inferior to them and Self-confidence is to do with the doctor’s assessment of his/her own competence in terms of his/her experience and wisdom as to what he/she can or can’t do. She further poses the question ‘Could the self confidence that comes from being accomplished and successful make someone arrogant?’ Typically, not. She further questions how can someone who has done the hard work and has gone into medicine because they care about people, and are interested in helping people’s lives and make the world a better place behaves in an arrogant manner?
How many of our doctors have both the humility and the confidence to tell a patient “I don’t know”? They fear that it will put off the patient – especially if it is in the private sector. A doctor can always say “I don’t know, but I’ll find out, or find someone who does”. That will raise the patient’s belief in the doctor and mitigate most fears. His humility will be reassuring. Patients will realise that the doctor is not “all knowing” and begin to see the doctor in a more realistic, human light. But the perceptions of the doctors are usually, just the opposite.
The trait of arrogance develops or resides within a person at a much earlier stage than at the point of becoming a doctor. Prof. Stuart postulates that it arises from one of two pathways;
1. The ‘I am indeed better’ pathway
2. ‘I made it, so why can’t I pathway’
In the ‘I am indeed better pathway’ doctors assume that they are top of the professional pile for numerous reasons. This they assume confers upon them certain privileges as opposed to obligations and duties. This causes them to have a sheltered and protected existence with no perception of the real world, making them a so-called elite group among fellow citizens from which the doctors apportion to themselves the right to be superior.
In the ‘I made it, so why can’t I’ pathway in contrast - a deprived person who has worked hard to pull himself up by the bootstraps may then look down on others who don’t have the same perseverance or initiative to take charge of their life and create similar success.
Modern medicine is poisoned by professional arrogance. We have ample evidence for this. Hence, please do not become alarmed that my statement is not evidence based. The antidote is professional humility. This too is evidence based and we should indeed be alarmed that we as a profession and as individuals are not acting on the available evidence.
Jack Coulehan, of the Centre for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University, State University of New York, proposed four attributes that 21st century physicians should strive for. They are: (i) Unpretentious openness, (ii) Avoidance of arrogance, (iii) Honest self-disclosure and (iv) Modulation of self-interest.
On the day I was elected as President of the SLMA on December 15, 2017 in my acceptance speech I noted that our profession would face challenges which could have an impact on how we practice medicine in Sri Lanka. Also in my message as President to the SLMA Website I wrote ‘Our founders deemed it fit to adopt ‘Lankadipassa Kiccesu Ma Pamajii’ (to act without delay for the betterment of our nation) as our motto, fully cognizant of the leadership role the SLMA is expected to play as the leading medical organisation in the country representing all grades and all specialties of doctors from both the state and private sectors.
It would be fair to say that we as a medical profession are at cross roads in terms of how we practice medicine and how we interact within and without the profession on matters and issues concerning the medical profession and medical professionals. The immediate cause of this, in my opinion is that, we as a profession are having a crisis of identity.
Identity is all about sameness and difference. This leads to concepts of our identity and their identity. The basis for this dichotomy is the Western ideological concept which celebrates the dignity and equality of the individual- principles such as one man one vote, equality before the law and human rights. All these hinges on the autonomous individual with his/her personal identity. From this individualistic origin, the notion of identity is transferred to collectivities, delimited by various shared features (predetermined and adopted) that claim a selfhood worth sustaining and ‘defending’. This results in collective or group identity inevitability leading to inequality in the face of postulated equality.
In an article titled Against Identity Politics: The New Tribalism and Crisis of Democracy in the September/October 2018 issue of the journal Foreign Affairs Francis Fukuyama, of Stanford University, states ‘Most economist assume that human beings are motivated by the desire for material resources or goods. This concept of human behaviour has deep roots in Western political thought and forms the basis of most contemporary social science. But it leaves out a factor that classical philosophers realized was crucially important: the craving for dignity. Socrates believed that such a need formed an integral ‘third part’ of the human soul, one that coexisted with a ‘desiring part’ and a ‘calculating part’. In Plato’s Republic, he termed this the thymos, which English translations render poorly as ‘spirit’. Thymos is expressed in two forms. The first is what I call ‘megalothymia’: a desire to be recognized as superior. Pre-democratic societies rested on hierarchies, and their belief in the inherent superiority of a certain class of people-nobles, aristocrats, royals- was fundamental to social order. The problem with megalothymia is that for every person recognized as superior, far more people are seen as inferior and receive no public recognition of their human worth. A powerful feeling of resentment arises when one is disrespected. And equally powerful feeling-what I call ‘isothymia’- makes people want to be seen as just as good as everyone else.
In the same article Fukuyama further states (and I have para phrased here a bit) ‘the medical profession needs to protect marginalized and excluded groups, but they also need to achieve common goals through deliberation and consensus. The shift of focus in the agendas of various fragmented groups within the medical profession in Sri Lanka towards protection of narrow group identities ultimately threatens that process. The remedy is not to abandon the idea of identity, which is central to the way that modern people think about themselves and their surrounding societies; it is to define larger and more integrative national medical identities that take in to account the de facto diversity of the entire Sri Lankan medical profession/professionals’.
People will never stop thinking about themselves and their societies in terms of identities. But peoples’ identities are neither fixed nor necessarily given at birth. Identities can be used to divide, but it can also be used to unify. That, in the end, will be the remedy for the identity crisis of the Sri Lankan medical profession/professionals’.
It is obvious that we as a profession/professionals are moving towards the opposing dystopias of hypercentralization and endless fragmentation. As the apex national professional medical body the SLMA needs to play a role to steer the profession/professionals towards a utopia rather than a dystopia. We need to act together without delay for the betterment of the profession and keep true to our motto.
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