Public Health: Doctors losing out to pharma & tech companies
Commercial and political interests have overshadowed medicine and doctors’ autonomy has been eroded significantly
Miyamoto Musashi, the Japanese swordsman, philosopher and strategist born in the 16th century, refined a two-sword technique, naming it "NitoIchi Ryu."
This is the teaching of the school founded by this great Samurai. He stresses the correct choice of using the long and short swords. The best use of the short or companion sword is in a confined space or when engaged in hand-tohand combat. The long sword can be used judiciously in all situations.
Using this analogy in the fight against disease, the short or companion sword for the physician is symbolised by the stethoscope and the doctor's clinical skills. The long sword can be compared with costly and state of the art lab investigations. The increasing use of this long sword, with good intentions no doubt, is alienating the patients and escalating the cost of medical care.
Young doctors out of medical schools are fascinated by technology or the long glittery sword. Rightly so, the marvels of modern medicine are often miraculous. However, for majority of human ills and ailments, the short sword, wielded with the art of medicine offers much better outcomes and improves the doctor-patient relationship. It is also cost-effective.
This reality hit me several years ago when the long sword was not very long. As a young doctor in the military posted in a remote field station in the north-east, I would see patients, mostly young soldiers, in the morning before rushing to nearby military hospital to learn from 'interesting cases' from specialist doctors.
While taking a leisurely stroll one evening in civilian clothes, I saw a queue in front of my office. I enquired from the last man in the queue the reason. I was informed that "doctor sahib" was seeing patients. I was surprised. I told him that the doctor comes in the morning not in the evening. I was informed in hushed tones that the doctor who comes in the morning is no good while the one who comes in the evening is excellent. Highly curious by now, I tiptoed to the window and looked inside. It was a humbling experience.
My medical assistant was attending to the patients and talking to them in their mother tongue. He was explaining to them my illegible notes. In the remote area, away from family and friends, the medical assistant was the friend, philosopher and guide. My technical knowledge or the "long sword" was no match for his "short sword".
While I was using the long sword in the morning, he was complementing it with the short sword in the evening. I realised that to become a consummate physician, I should not abandon the use of the short sword in my eagerness to master the potentials of long one.
The "consummate doctor" is rare in the current environment. This doctor is equally skilled in making a diagnosis as in customising treatment to each patient's and family's needs, understanding that the human connection is vital to establish rapport and contributes to compliance and cure.
‘History taking’ was an art which refined communication skills. This combined with examining the patient in person cemented the doctor-patient relationship. The practice of medicine was then patient-centric. With technological advances, the length of the long sword is ever increasing, making it unwieldy.
While these advances make real time diagnosis feasible, the modern physician is losing touch with the patient, with adverse impact on the doctor-patient relationship.
Like swordsmanship of a past era, medicine too started as an art. In both, the encounters were close and intimate. The short sword dominated both in combat and in medicine.
The "art of combat" gave way to the "science of combat" escalating to nuclear, chemical and biological warfare. Combat became blunt and artless, resulting in more collateral damages. In all modern wars, civilian casualties are colossal. The nuclear holocaust of Hiroshima and Nagasaki which ended the Second World War stands testimony to the potential for catastrophe when the long sword grows unchecked and assumes nuclear properties.
Moderation by artful use of the short sword is needed to save humanity from extinction. Easier said than done. The arms race has moulded both the short and long swords into a single sword of Damocles hanging over us threatening extinction of life on earth. Powerful and invisible forces have drastically curbed the autonomy of the simple soldier. He no longer has the option of choosing the swords. Commercial interests, political influence and the arms trade have destroyed the art of war. Similar crises of identify is facing medicine today. It is one of the oldest arts but the youngest science, softer than the hard sciences, rich in possibility and promise, says Siddhartha Mukherjee in his book, 'The Laws of MedicineField Notes from an Uncertain Science'. Regrettably, it too is becoming increasingly commercialised. Like in combat, so in medicine, commercial interests, political influence and pharmaceutical companies are increasingly restricting the autonomy of doctors. Diseases and pandemics are seen as opportunities to follow Winston Churchill's dictum, "Never let a good crisis go to waste."
The world is facing a double challenge today. Arms race and pharma race. Both need speed-breakers and traffic signals. Humanity should introspect in advance rather than after a catastrophe like the nuclear holocaust in Japan which made Albert Einstein regret his suggestions on atomic research, with the words, "Woe is me".
The world is facing a dilemma due to the break neck speed at which technology has progressed. It is not "Doctors' Dilemma" like in an era when medicine was still an art. Autonomy and decision making of doctors have diluted long ago. The already complex field of medicine has become more complex to the point of being incomprehensible. The level of noise can make complex decisions difficult if not impossible. It has become "People's Dilemma".
The present mRNA technology for vaccines is remarkable and has the potential of being a game changer in our fight against disease and pandemics. But like all powerful technologies, it should be used with caution. There are some reports of vaccines manufactured by this technology causing myocarditis (an inflammation of heart muscle), particularly in young people.
One of the inventors of this technology has expressed a word of caution in mass scale use of this technology. Regrettably, the scientific community has become polarised on the issue at a time when all opposing views should be carefully examined and debated.
In the heady excitement of the new technology the scientific and political consensus is moving at breakneck speed ignoring all speed-breakers and traffic signals like a reckless teenager driving his first car. One only can pray that there is no crash down the road.
(The writer is Professor & Head, Community Medicine and Clinical Epidemiologist at Dr DY Patil medical college, Pune. Views are personal)