Words of Wisdom

I want to give this writer a standing ovation.

Patients and doctors must be loyal to each other

I REFER to the letter, 'Fees aside, pick the right hospital and doctor' by Ms Virginia Goh Min Wen and Dr Victor Teoh (ST, Sept 22).

It is obviously prudent in matters of health, to choose a hospital not based on the cost of treatment but the clinical outcome or effectiveness of therapy.

At the same time, it is not only the skills of the specialist or the quality of the equipment in a hospital that determines good clinical outcome.

Most of all, a patient needs a doctor who will act continually in his best interest.

Patients need doctors who are loyal and place their welfare as their first consideration, even at times at the expense of subjugation of the doctor's personal interest.

Patients, like all humans, have multiple and often varying interests.

Doctors, like all professionals, have multiple interests and commitments.

Some personal interests of doctors which may come into conflict with their professional obligation and thus the patient's welfare and interests include accumulation of wealth, fame, academic position or rank, or even the promotion of scientific innovation.

In today's medical-commercial complex, doctors can inadvertently be drawn to promote the interests of the pharmaceutical industry, companies that produce medical devices and equipment, insurance companies and even hospital bottom lines.

When conflicts of interest arise, there may be, in extreme cases, neglect of professional duties but more often a compromise of the independence of clinical judgment.

In a medical encounter, it is not only the knowledge and skills of the doctor that are important in the clinical outcome but also the independence and quality of the clinical judgment.

The judgment may be tainted so as not to serve the patient's best interest.

The clinical judgment can be compared to the plan and strategy of the diagnosis and therapy.

Thus, even with careful and expert execution, an inappropriate plan and strategy will not lead to a good outcome.

In addition, it is important for patients and the public to know that in the rapidly changing knowledge and technology of modern medicine, medical uncertainties are a common feature of medical practice.

New therapies and technology may not be fully validated.

Protocols of therapy continue to change and many areas of disease and treatment are still unknown.

Every patient brings his own special features to the illness and therapy.

There are large grey areas in medicine where the doctor must exercise clinical judgment.

Independent and good clinical judgment, based on scientific facts, clinical skills and experience and based on the particular patient's context, needs to exercised to serve the best interest of the patient.

To act in the best interest of his patient, the doctor must not only be up to date in his knowledge and skills on the diagnosis and various treatment options, but must also have a good knowledge of his patient and his interests.

Equally important, the doctor must have knowledge of himself and his motivation.

Unfortunately, in the hospital setting when a patient seeks a specialist consultation, the clinical encounter is transient and between strangers.

Many times, patients hardly remember the name of the specialist they consult, let alone the medical information exchanged.

The specialist who sees several patients a day remembers them as diagnostic labels in medical notes.

Specialisation in medicine no doubt increases expertise and more proficient practice.

At the same time, it runs the risk of compartmentalising the patient to organs and waters down the quality of the doctor-patient relationship.

For patients to benefit from a good clinical outcome, optimally utilising medical facilities at affordable cost, a collaborative effort is required between the generalist family physician who knows the patient well and the specialist who has the special skills to carry out the treatment.

It is not always easy for anyone, let alone the patient, to judge whether his doctor is acting in his best interest and welfare.

However, some professional behaviours are surrogate markers to show the doctor is acting in the patient's best interest.

A doctor who spends time and effort giving medical information and options to empower the patient to participate effectively in medical decision making, tells of his concern for the patient's interest.

A doctor who acts in the best interest of his patients not only keeps up to date with his skills and knowledge, but also fills in any gaps by not hesitating to consult his colleagues and getting a second opinion.

One's medical colleagues often have a better insight of their another's clinical competence and patient-centeredness of practice.

Thus the value of a medical referral to a specialist by the family physician.

Unfortunately, in today's society, the climate for and culture of having a regular primary or family physician is not strong.

For patients and their families to run around by themselves seeking the right hospital, right doctor and right specialist for the patient's illness is a common phenomenon locally termed 'hospital (or doctor) hopping'.

Information from books and the Internet leaves many gaps.

Hospital and doctor hopping is nearly always detrimental to the patient's welfare, whether in acute illness or chronic disease care.

It also erodes loyalty and continuity of care.

Nor is it cost-efficient.

The simple formula in choosing the right doctor for the patient, for a good clinical outcome at affordable cost, is for patients and doctors to be loyal to each other and communicate effectively.

The challenge for policymakers and the medical leadership is to build a climate, culture and system which will ensure and promote this loyalty and communication.

Dr T. Thirumoorthy