This letter refers to the letter from Muttu, appeared on Tuesday, October 5, 1999 StarOnline. As a medical student and future medical practitioner, I cannot agree enough with Muttu that communication is probably the most important tool in practising medicine. However, I would have to say that I do not agree to all the points put forward by Muttu.
First and foremost, I agree that preventative medicine plays an important role in modern medicine. How effective it is, however, no one can answer that question. We certainly know that smoking cessation to a major extend is helpful to many disease process. As the question of diet and exercise and lifestyle modification in the treatment of coronary heart disease, blood pressure control and cholesterol control, the evidence is not clear. Furthermore, changing the lifestyle and eating habit is a major change that may not be well tolerated by a lot of patients. How could we convince our patients and tell them that by changing your lifestyle and eating habit, there is a 10% reduction in your cholesterol level and hence reduce your risk of heart attack by 1%? What does all those figure means?
Muttu put up a list of complaints made from patients and concluded that most complaints are not about clinical competency but about information giving. i am very suspicious about that statement. First of all, where did Muttu come up with the list of complains? From his head or from some research done? If it comes from a research paper, what population did they research on? Is the diagnosis checked by another physician? Secondly, some of the complaints are not exactly valid. I would assume that Muttu is a medical professional and he should know that there is no way that a doctor could tell all the side effects of a medication to the patient. Some of the side effects happen in one in a million chance. What should we do? Give them a list of 100 side effects that may occur when they take the medication? Muttu also put prognosis not explain as a complaint. I do not understand what does that mean exactly. A patient with a Duke C colonic cancer has a 5-year survival rate of 50%. Does that statement help? There is no way that a medical professional can predict how well a patient will be after treatment. There are so many biological variances that we simply could not say for sure. All we could say is on average, what sort of survival we are looking at. I have to stress that this statement is often wrongly taken by the patient to mean their life span. Thirdly, it is quite clear that patients is not likely to be able to judge a doctor's clinical competency unless they are medical professionals. Hence, of course they will complain about information giving, either too many decision they need to make (and hence to them, the doctor is useless because he cannot make the decision) or too little information.
Muttu stated that medical schools hardly pay attention to communication. I have to say that I do not know about local medical schools, but in my medical school, we spend 4 years in the hospital (third year onwards) learning communication with patients, with specialist, with nurses and other allied medical professionals. Furthermore, I think the hypothetical question "what would happen if I had a fall?" is a relevant question for a pregnant women. The consulting doctor can definitely give some advices on the falling issue which is as important as, if not more, the side effects of medication taken!
When Muttu argued that well informed patients would never risk self-medication, he assumed that all patients are well educated and can understand all the information given by the doctor. This is simply not correct! A lot of patients are not compliant to drug regime and many of them self-medicate and only after self-medication fails, they decide to go see a doctor.
Communication marks the difference between a good and not-so-good doctors, or does it? I think a good doctor is much more than communication! It requires knowledge, intellegence, suspicion, clinical experience, communication skill, practical skills, attitude towards patient etc. Assuming that all graduates have the same degree of knowledge and skill is not correct. There is a very common say in Australia that I would like to share with Muttu. What do you call a graduate with a first class honours in medicine? A doctor! What do you call a graduate who spent 10 years instead of 6, with 10 supplementary pass? A doctor!
The graduation day of a doctor marks the beginning of medical education, NOT the end! A system at which continuous medical education (CME) is compulsory for registration might be helpful. I should point out that it is not possible for a doctor to be able to answer all questions put forward by the patient. The volume of medical journals doubles every 3-5 years, the amount of information available on the internet is ever increasing. A doctor should not only be able to keep up to date, but also be able to examine those informations careful and being critical about the information published.
In my opinion, the behaviour of a doctor can be predicted by the reason they go into a medical school. I think the process of medical student selection should be changed. It should not be assume that students with many A's or highest aggregates will become a good doctor. As I have stated above, good doctor is more than getting a lot of A's. The most important thing, in my opinion, is the attitude towards medicine. If you survey all medical students, a lot of them put money as a primary factor that brings them to the medical school. Is this the student's fault? NO! NOT AT ALL! It is the society's attitude towards medicine as a whole! When I got into medical school, a lot of people congradulated me and said that: " Wow, studying medicine, very good, you can earn a lot of money in the future!" I certain have heard a lot of parents say to their children that they must study heard and get into medicine to earn a lot of money. There are quite a few medical students in my class who come from Malaysia told me that they do not wish to pursue futher studies. Instead, they want to go back and become a GP and earn a lot of money.
What worries me more is not the prioritisation of money but the attitude towards medical education. I certain have heard people state that there is no need to study too hard and to obtain all the knowledge, as far as you can pass and get out of the medical school with a certificate, you could become a millionaire in no time. When I decided to spend extra hours doing an honours project concurrent with my fourth year medical education at the beginning of this year, instead of receiving encouragement from fellow students from the same country, I was told that the three month summer holiday is more important and it does not make any difference in the future as far as monetary term in concerned. One will hope that the more commitment and the more time that one spent in studying, the more rewards that one will receive from all areas. This is however not true. In reality, if I decided to do a PHD in the future, while I am still struggling to finance my PHD study, some of my colleuges will already become a millionaire. When I finish my PHD, I probably need to start from the beginning and my colleuges are far ahead of me.
In conclusion, there are a lot of factors that are important in medical practice, not solely communication, neither is it knowledge nor clinical competency. The world is changing rapidly. More and more are expected from a doctor and medical students have to cope with this challenge. A postitive attitude towards medicine is probably the most important thing in deciding who are the so-called "good doctors". Hence, the society and the university have to change to nurture positive attitudes among medical students and those who are going to enrol in a medical school. Children should not be instilled the idea that medicine is a gold mine at which you will become rich in no time once you get into it. They should be encourage to do medicine with a positive attitude for patient care. Let's look forward to the new millenium and build a caring society together.
Yee, Kwang Chien
University of Tasmania,
Australia.