Zambezia (1981), IX (i).DOCTOR'S DILEMMA*J. E. P. THOMASDepartment of Medicine, University of ZimbabweTHE PUBLIC IMAGE of a doctor is an amalgam of what patients think about doctors,what doctors, as patients, think about themselves, and what both parties believe isthe Ideal. Patients throughout the ages have grumbled about doctors; Plato, forexample, had a double criticism: that doctors treated slaves as carefully as theytreated free men or philosphers, and treated patients, including sick philosophers,like slaves. An ambivalent attitude towards doctors was shown in Eccleslasticus2.000 years ago: 'Honour a physician with the honour due unto Mm for the uses youmay have of him, for the Lord hath created Mm. For of the Most High coraethhealing' (thus almost deifying doctors and treating them with respect, as anexpedient, since they may be needed any time); and a few lines later we arereminded of the dangers of being a patient 'He that sinneth before his maker, lethim fall into the hand of the physician.' (Ecclus, 38: 1-2, 15.)There is little consensus today about what the doctor-patient relationship is, orshould be. Some feel it should be a mystical bond of healing accompanied byexalted human sentiments, whilst others feel that it should be an efficient technicalservice like calling in the mechanic or the plumber. It is my belief that the doctor-patient relationship has suffered in recent years. Among the many reasons wouldbe rapid changes to which many, particularly the elderly, would have difficulty inadjusting, a failure of communication which has left the patient at a loss to knowwhere he/she fits into the new system, and a social change which demands rightsand privileges and brooks no failure or delay.1DILEMMAI propose to discuss some of the changes and problems which confront thedoctor thus constituting the Doctor's Dilemma. I hope that by drawing attention tothese problems the lay public will have a better understanding of the situation andthat better doctor-patient relationships may thereby be restored:1. Should the emphasis be on preventive or curative medicine?2. Should we rely on a single doctor or on a health team?3. Is specialization a good or bad development?4. Should a doctor be predominantly an artist or a scientist?5. Should a doctor be emotionally involved with his patients?*An inaugural lecture delivered before the University of Zimbabwe on 23 October 1980,1 H, Osmon4 "God and the doctor', New England Journal of Medicine (Jan.-Iune 1980), CCCII,1920 DOCTOR'S DILEMMA6. Should treatment be at home, clinic or hospital? If hospital, whatkind of hospital?7. How do we solve the problems of medical manpower?8. How do we supply cost-effective treatment to the greatest numberof the population?9. Do we support science or pseudoscience?10. Are we training committed or committeed doctors?1. Should the emphasis be on preventive or curative medicine? With theirusual good sense the Greeks believed that Aesculapius (God of Healing) had twodaughters called Panacea (Goddess of Healing) and Hygeia( Goddess of Health orHygiene). Like many fathers, the god hoped that his daughters would live togetherharmoniously. In fact, however, they often competed rather than co-operated.Thus, if Hygeia was wholly successful in promoting good health, what would beleft for Panacea to heal? On the other hand, if Panacea dominated medical andpopular thinking, who would listen to the valuable but trite stricturesŠ'Eat less,drink less, smoke less, fornicate less, avoid excess, exercise prudently; or fall intothe hands of my sister Panacea and her physicians'Šof Hygeia?2. Should we rely on a single doctor or on a health team? In the past thegeneral practitioner alone would visit the patient at home, spending time talking tothe patient and his family, offer a diagnosis, do some simple tests himself, make up aprescription, arrange a follow-up, attend to the social needs of the patient and act asguide and counsellor.With rapid change and increasing demands it has become difficult for the doctorto make house-calls that waste time in a car. He may try the art of bedsidediagnosis, but all too often early disease will only be discovered by fancy tests andx-rays, both of which need expensive equipment manned by skilled personnel.Prescribing has become increasingly complicated and fraught with hazard. Withless time available, counselling is apt to be neglected and social problems ignored.These many facets may require the combined skills of specialists, generalpractitioners, medical officers of health, hospital nurses, district nurses, radiolo-gists and radiographers, pathologists and laboratory technicians, speech,occupational or physiotherapists, pharmacists, almoners and various socialworkers. The health team, like a chain, is as strong as its weakest link.Communication between members of the team is essential, but gets difficult withthe increasing size of the teams. Thus a busker playing a one-man band outside astation can play simple tunes very well, but the best music comes from a fullorchestra controlled and co-ordinated by a good conductor.3. Is specialization a good or bad development? There is no doubt thatspecialization has been a two-edged sword. Two well-known definitions are that'A "specialist" is a doctor who knows more and more about less and less untilultimately he knows everything about nothing', and 'A "general practitioner" is aJ. E. P. THOMAS21doctor who knows less and less about more and more until ultimately he knowsnothing about everything'.The good points about specialization include the rapid advance of knowledgeand expertise in certain fields. The bad points include the lack of a doctor for thewhole family, since the patient is bound to be the wrong age, or the wrong sex, or tohave come with the wrong organ. Referral from one specialist to another sets off avery expensive chain reaction, which takes much longer.Teaching by specialists tends to give students an unbalanced concept ofmedicine. Specialization is a field in which Parkinson's Law flourishes. ProfessorLouw, in an oration at the Academic Festival of the Medical Faculty of theUniversity of Cape Town to mark its 150th anniversary, quoted an Americaneducator who likened the modern medical curriculum to a smorgasbord or abuffet of educational facilities. The teacher will function as a dietician to help thestudent select a nutritious diet. The curriculum will thus be a la carte rather thantable d'hote.24. Should a doctor he predominantly an artist or a scientist? The supremeartist is the charlatan. The extreme scientist is the backroom boffin. The ancientGreeks, besides their gods and goddesses, recognized medical philosophers calleddogmatists (clinicians) or empiricists. The dogmatist held that true medicineshould be a science resembling geometry derived from known and stated principles.The empiricists treated the sick according to their experience. Some medicalscientists today still scorn clinicians and yet when they or their family are ill theycall in the practical clinician rather than their fellow scientistThe decline of the art of medicine is lamented by S. J. Reiser:In the framework of modern clinical medicine, reverence for objectiveevidence has led to a continual and serious decline in trainingphysicians to take histories or listen to patients; such data, objective incontent, personal biased, is viewed as inferior.. . His skill in physicalexamination has declined, and his own sense perceptions and clinicaljudgements have been devaluedŠin deference to objective data sensedand generated by machines and interpreted by technicians andspecialists.3There has been public disenchantment with the poor practical returns of moneyspent on research. No cure has been found for diseases such as the common cold,coronary artery disease or cancer. Research doctors seem to end up as specialistsrather than family doctors and their expensive expertise seems to centre roundcostly equipment and ever-increasing health costs. The disillusionment showsitself in remarks such as 'medical research is occupational therapy for maladjusteddoctors'.2J, J. Louw, 'Whither medica! education*, South African Medical Journal (Jan.-June 1980),LVII, 269.3 S. J. Reiser, 'Humanism and fact-finding in medicine', New England Journal of Medicine (July-Dec. 1978), CCXCIX, 952.22 DOCTOR'S DILEMMAThe public has often chosen to forget the tremendous advances of the past fiftyyears, resulting from medical research and enabling prevention to replace the needfor cure: vaccination for polio, diphtheria, whooping cough, measles, tetanus andsmallpox, for example. The advent of the antibiotics and many other discoveries,which have allowed man to live longer, have drawn attention to less curablediseases such as coronaries and cancer. That the science of medicine is waning ispointed out by J. B. Wyngarden in his Presidential Address to the Association ofAmerican Physicians, entitled, 'The clinical investigator as an endangeredspecies' .4 In America and Britain,5 it is pointed out that one of the modem shortagesis in the field of clinical research investigators.5. Should a doctor be emotionally involved with his patients? The extremeof emotional involvement is the doctor treating his own family. The extreme ofunbiased wisdom is the judge with emotionless countenance, framed by a wig,pronouncing a learned judgement In my introduction I referred to those who liketheir doctor to be emotionally involved and those who merely want a businesslikeservice. Emotionalism undoubtedly colours and impairs judgement Unduecoldness seems to give an impression of not caring. On an emotional level the age-old axiom still holds: 'You can make your mistress your patient but beware if youmake your patient your mistress.'6. Should treatment be at home, clinic or hospital? If hospital, what kindof hospital? Bed rest is less favoured than in the past The evils of bed rest weresummarized by the late Richard Asher:Look at a patient lying long in bed. What a pathetic picture he makes!The blood clotting in Ms veins, the lime draining from his bones, thescybala stacking up in his colon, the flesh rotting from his seat, theurine leaking from his distended bladder, and the spirit evaporatingfrom his soul.6Home-visiting brings the family doctor into contact with the whole family and thepatient's environment The patient is at ease 'playing on the home-ground' andgreater privacy is assured.Clinics improve the turnover and efficiency of the doctor and it can be arguedthat any patient sick enough not to be at the clinic should be in hospital. However: ifa hospital is required, do you envisage a cottage hospital such as Tannoch Braewith attention from Doctors Cameron and Finlay, or do you see yourself in BlairGeneral Hospital with Doctors Gillespie and Kildare?7. How do we solve the problems of medical manpower? These problemsinclude:4 J. B. Wyngaarden, 'The clinical investigator as an endangered species', New England Journal ofMedicine (July-Dec. 1979), CCCI, 1254-9.5 Editorial, 'MDs or PhDs in medical research', British Medical Journal (Jan.-June 1980),CCLXXX, 274.6 R. A. J. Asher, 'The dangers of going to bed', British Medical Journal (1947), ii, 967.J. E, P. THOMAS23(i) The unequal distribution of doctors. Doctors throughout theworld tend to gravitate towards the cities. Specialists tend to needbig cities and big hospitals for their survival. Yet the majority ofthe population does not live in urban areas. How then can healthcare be provided for the rural areas?(ii) Who should be the primary care provider. Is this best done by adoctor or by paramedical personnel? If paramedical personnel,what kind? For example, by medical assistants, advancedclinical nurses, pharmacists, or others?(iii) The distribution of facilities. Should care be spread widely orshould there be improved transport facilities to move patients tocentral units?8. How do we supply cost-effective treatment? Should the doctor haveunlimited money for research and be allowed to prescribe whatever drug he likes?Should there be some system of rationing? For example, there can be 'implicitrationing' whereby districts or institutions are given a sum of money to spend asthey think fit, or 'explicit rationing' whereby dictatorial instructions, subject topublic and political pressures, exclude certain drags or procedures with lowbenefits and stipulate what proportion of the budget is to be spent on preventive andcurative services or on primary, secondary and tertiary care respectively.9. Do we support science or pseudoscience? A move from orthodox toalternative medicine is shown by the following editorial in The British MedicalJournal entitled, 'The flight from science':Nowadays most G.P.sŠcertainly those in the bigger citiesŠhave afew patients who are being treated by alternative medicine: meditation,yoga, acupuncture, moxibustion, ginseng, and a whole galaxy ofdiets , . .Outside medicine, the public mood has swung away from un-questioning admiration of science and technology that reached its peakat the time of the NASA flights to the moon. Nuclear power is nowseen as a threat, not a hope for the future. The motor car is evil; jetaircraft are noisy, polluting and unsafe. Science fiction illustrates thetrend: authors such as Arthur Clarke and Isaac Asimov, whoseinventiveness was firmly based on orthodox physics, have beenovertaken by writers and film makers primarily concerned with doom,disaster, and the paranormal. Astrology is taken more seriously nowthan at any time this century,7An American book, Wholislic Dimensions in Healing,® suggests that peopleare looking for alternatives to what some perceive to be a dinosaur (the modernmedical system). The subject matter of the book includes homeopathy, naturopathy,chiropractic, applied kinesiology, nutrition and herbs, oriental medicine and1978).7 Editorial, 'The flight from science', British Medical Journal (Jan.-June 1980), CCLXXX, I.1L. J. Kaslof (ed.), Wholistic Dimensions in Healing: A Resource Guide (New York, Doubleday,24 DOCTOR'S DILEMMAacupuncture, whole-plant substances, aerion-therapy, radiesthesia, psionic medi-cine, astrology, iridology, psychic and spiritual healing, psychophysical approaches(shiatsu, polarity therapy and rolfing). Also, various mystical cults and witchcraftseem to have-been revived.JO. Are we training committed or committeed doctors? Doctors have notbeen immune to a modern disease. Already too busy to be able to spend time talkingto their patients, they are called upon to serve on a plethora of committees. In allwalks of life individuals are no longer allowed to make decisions. Consensus has tobe obtained from committees, which proliferate into subcommittees wheneverdifficult decisions arise, all in the name of democracy. Committees have beendefined as 'bodies of people who take minutes and waste hours'. 'The bestcommittee is one composed of two members when one is absent'ANSWERS1. Should the emphasis be on preventive or curative medicine? Undoubt-edly prevention is better than cure. Prevention can usually be undertaken byparamedical personnel and is thus relatively cheap. An example of the stage ofexpensive half-truth to the cheap state of whole truth is as follows:PolioHalf Truth:Whole Truth:FaithHopeCharityRespirator (Iron Lung)PhysiotherapyTendon transplants; Gadgets (calipers;wheelchairs; special cars)Polio vaccineHowever, until Hygeia is wholly successful there will still be a need for Panacea.Also, preventive medicine improves survival, so family planning becomesincreasingly important as a form of preventive medicine.2. Should we rely on a single doctor or on a health team? For most simplehealth needs one can still depend on the local medical assistant or advanced clinicalnurse, in the case of the districts, or on the local G.P., in the case of the towns andcities. With complex problems it becomes increasingly important to make full useof the diverse talents and facilities available, which one practitioner alone is unableto provide. Doctors form a relatively small proportion of the health team, but sincethey usually lead the team they must remain of high calibre.3. Is specialization a good or bad development? Specialists have beenmisused at the expense of the G.P. who is himself a specialist of sorts.Specialization in itself is admirable and desirable if used at the right time, in theright place and in the right proportions. The main need in developing countries andin fact all countries, is for generalists rather than specialists. Specialists areJ. E. P. THOMAS25required in a small percentage of cases. 'G.P.s are the backbone of the professionand must be.brought to the front'4. Should a doctor be predominantly an artist or a scientist? Desparauxmight well be describing the back-room boffin in his poem written in 1711:Brimful of learningSee that pedant stride,Bristling with horrid GreekAnd puffed with pride.A thousand authorsHe in vain has readAnd with their maximsStuffed his empty headAnd thinks thatWithout Aristotle's ruleReason is blindAnd common sense a fool.Or, as Bertrand Russell puts it, we are faced with the paradoxical fact thateducation has become one of the chief obstacles to intelligence and freedom ofthoughtA good doctor is both artist and scientist, using his experience to improve his artand keeping up to date with the science of medicine by reading, by postgraduateeducation and by research. Not all research has to be expensive. Practical, low-technology research is cheap and will answer many problems, improve efficiencyand ultimately save lives and money.5. Should a doctor be emotionally involved with his patients? Here againthe ideal doctor manages to strike the golden mean. He must show the patient thathe really cares and yet he must not let emotions colour his decisions.6. Should treatment be at home, clinic or hospital? If hospital, what kindof hospital? Ambulant treatment should be used wherever possible. Clinicsprovide a useful stepping stone for the Health Team. When hospital is required, thepersonal touch of the family doctor in a small hospital or G.P. unit is preferred inthe majority of cases, providing that the G.P. has clearcut guidelines as to whenreferral to specialists is necessary. For the small percentage of cases requiring hightechnology services, such as neurosurgery, thoracic surgery or plastic surgery,complicated obstetrics, renal failure, or coronary thrombosis, a large modernhospital with advanced facilities, intensive care units, and junior staff available at amoment's notice becomes essential.However much faith one has in Dr Cameron or Dr Finlay, it would be a mistaketo ask them to do some cardiac surgery at Tannoch Brae. Far rather Drs Gillespie,Kildare and the team at Blair General Hospital.26 DOCTOR'S DILEMMA7. How do we solve the problems of medical manpower? Where practicalwe should use paramedical personnel in primary care and preventive medicine. Forexample, medical assistants, advanced clinical nurses and health assistants.Pharmacists will have some role to play in primary care, but an even greater role ineducating patients and doctors in how to take medicine and in indicating whichmedicines may interactWhere doctors are necessary in rural areas a scheme of National Service couldbe introduced, initially for Government Cadets bonded to Government for fouryears and then possibly for all newly qualified doctors. With two years'postgraduate training for the job and two years in the district, I believe we will havea new breed of doctor (or more accurately the rebirth of an old breed). I believe ourtraining in Zimbabwe should be table d'hote rather than a la carte or a messysmorgasbord. Our young doctors should be good all-rounders who can cope withwork in a district, and may hopefully decide to become country G.P.s. Some willdecide to specialize, and since two years in general practice is needed forregistration in most countries, these requirements will have been met, the doctorwill have found in which fields Ms strength lies, and he will make a better and moreunderstanding specialist8. How do we supply cost-effective treatment to the greatest number of thepopulation? As far as drags are concerned, I prefer control by implicit rather thanexplicit rationing. One can control prescription by limiting drugs to those in aNational Formulary. Alternatively one can circulate schemes of practical cost-effective treatment for common disorders to doctors and paramedical personnel inGovernment service, suggesting possible therapy. This would mean that therapystarted in central hospitals could be continued in the smaller hopitals and clinics towhich patients are discharged.As for hospitals, it is cheaper to treat as many patients as possible in the districtsand keep the number of patients referred to expensive central hopitals to aminimum. This requires the re-establishment of an efficient peripheral service.In regard to primary care, re-admissions should be avoided by an efficienthanding over of care to the original primary-care centre or doctor, whether this bethe specialist handing back a case to his G.P. or the hospital handing the patientback to a primary-care clinic. A discharge clinic and chronic disease register maywell help in this respect9. Do we support science or pseudoscience? Orthodox medicine must notdespise alternative forms of medicine, but subject these alternatives to the samecontrolled trials and experiments on which orthodox medicine has been built Untilthese alternatives have been subjected to the fire and crucible, I believe thatGovernment and Medical Aid Societies should recognize only orthodox medicine.In my personal opinion it was a retrograde step when Medical Aid Societiesaccepted the payment of chiropractors' bills. Whilst I have a healthy respect for themanipulative skills of chiropractors, I find dangerous the concept that disease,J. E. P. THOMAS27whether it be meningitis, diabetes or cancer, is due to displaced vertebrae.Once alternative forms of medicine, or pseudoscience, gain a foothold it will beimpossible to draw the line between which should be recognized and which shouldnot. It is hard enough to decide about the acceptability of the training in differentschools of orthodox medicine, without introducing further imponderables such asfaith healers, herbalists and astrologists.10. Are we training committed or committeed doctors? I could not helpgetting a dig at my pet hate, namely committees. Communication is becomingincreasingly necessary and may well need to take the form of committee meetings.Committees are often used as stalling devices or as the means of postponingawkward decisions. Under such circumstances family planning to avoid thepropagation of numerous subcommittees is desirable!CONCLUSIONThe dogmatists held that medicine should be a science resembling geometry.Let me conclude by putting my concepts of medicine into geometric form:PREVENTIVE SERVICECURATIVE SERVICEM.O.H.Health OfficersDistrict NursesHealth AssistantsVillage Health WorkersG.P.Advanced Clinical NursesMedical AssistantsHOSPITALSTOTAL HEALTHGeneral HospitalDistrict HospitalRural Clinics28DOCTOR'S DILEMMAAt present the body and mind are catered for by orthodox medicine. Thespiritual beliefs of the patient are very important, but difficult to cater for when theydiffer so widely; it is debatable whether those catering for the spiritual needs of thepatient should be financed by the taxpayer. If body, mind and spirit are workingharmoniously with each other and with the environment one is at ease; but if anyfacet is disordered or out of step with the others there is a state of disease.