Prof Panduka Karunanayake
MBBS (NCMC), MD (Colombo), FRCP (London), FCCP, PgDip Appl Sociol (Colombo)
President CCP 2018
Facing the Next Fifty Years
At fifty years, the Ceylon College of Physicians has a lot to celebrate, and it’s with great pride and satisfaction that today we wear our College lapel pins and ties. But a golden jubilee is also a time to reflect and plan.
As our College enters the next fifty years of its existence, what must occupy our minds? In these few pages, let me share my thoughts on this – not with finality, but with a view to stimulating thought and, if appropriate, urging action.
A Changing World
It’s a good habit to start from the general before proceeding to the particular, because then we don’t miss important issues that might be lurking in the shadows of the background.
The major challenges that the world faces today and will demand increasing attention tomorrow are climate change, environmental degradation & distress, biodiversity- & resource-depletion, overpopulation, untrammelled consumerism, increasing socioeconomic inequity, and violence. It appears that for providing solutions to these, the global elite are banking on highly technological tools such as information & communication technology, robotics & artificial intelligence, and molecular biology & biotechnology. Their faith seems to be in geoengineering, fusion energy, surveillance society, high throughput technology, etc. Emphasis is placed on individualism over collectivism: security over peace, rights over duties, individuality over egalitarianism, certification over education, and rule of law over justice.
These issues will affect humanity’s future health and healthcare too, both globally and locally, because health is inextricably intertwined with our physical, biological and social environments and healthcare with our general societal response. The future physician must be conversant and must engage with these broader issues too, in order to be able to deal with healthcare, even at day-to-day, mundane levels. Otherwise, their frustrations about ‘the bad system’ will be even greater than ours.
From Changing Disease Profile to Changing Tool Kits
Within our own lifetime we have seen how diseases have changed: rheumatic valvar heart disease in the young has been replaced by triple vessel disease in the middle-aged, amebic liver abscess in toddy consumers by hepatic veno-occlusive disease in stem cell transplant recipients, post-streptococcal glomerulonephritis in adolescents by chronic kidney disease in farmers, type 3 lepra reactions by drug-induced eosinophilia with systemic syndrome, non-A-non-B hepatitis by Zika virus and so on. With changing lifestyle, such changes are inevitable.
But these have always been diagnosed in the same way, with the same tool kit: history, physical examination and ancillary investigations that included carefully selected laboratory, radiological and physiological tests – all yielding a small number of discrete, relevant data for interpretation inside one physician’s brain, leading to a diagnosis. Their treatment also used one tool kit: manipulating individual, discrete receptors and enzymes, etc. using specific molecules, each on the basis of its pharmacokinetics & pharmacodynamics.
In the future even these tool kits will change – a change that follows a paradigm shift and becomes visible only after a few centuries. Paracelsus first questioned the humoral theory in the fifteenth century, but Pasteur finally laid it to rest only in the nineteenth. Harvey, Sydenham, Laennec, Osler and others laid the foundation for today’s tool kit, beginning from the seventeenth century and reaching into the twentieth. These changes are slow and almost imperceptible – and we too are in the throes of one.
On the day our College celebrates its centenary, the number of discrete data that go into the tool kits will be too many for one brain – any brain – to interpret. A disease will be defined according to bioinformatics and complexity science. A diagnosis will be a bioinformatics-based prognosis. And treatment will be based on chaos theory and predictive medicine, and will use robotics and custom-tailored, ‘precision’ molecules whose use will be monitored and adjusted in real-time using artificial intelligence.
But of course, the fire in the hearth will heat up only very slowly, and we ourselves will have enough time to leave the kitchen without getting burnt. But our successors must be geared to face those hot temperatures – and we must plan for them, and now.
The Human Touch
Does this mean that by the time of our centenary, the physician would have been replaced by a touch-screen and a digital interphase, or a robot? No.
While the changes of the future are indeed mindboggling, they can still be neatly stacked into three compartments: the world, the people, and technology. We are a profession that brings these three together
- a profession that knows the world and its people, its health and disease, its remedies and artisans, it strengths and frailties, and its joys and tears, while possessing mastery over the As long as there is the need for the human touch, the understanding eye and the caring face, there will be a need for something that the screen and interphase cannot provide. The connection of a human being with a human being is a human affair – even more so in the midst of the pain, confusion and bewilderment that illness brings.
Let me use a metaphor. Palliative care physicians have been aptly described as friends with platform tickets who accompany their patients to the train station: the patient boards the train and leaves, and the palliative care physician waves him goodbye and comes back to the town. The rest of us physicians are the friends in the town itself, walking with the many patients through the streets that mark the various diseases, illnesses and sicknesses. These streets are lined with shops and restaurants, and our task is guiding them to buy their wares and eat their food wisely – advising on how to stay in the indoors of good health, hoping to put off the train journey meaningfully. Technology is represented by what is sold in the shops and restaurants. The way of the world is represented by the layout of the streets and map. These may change, but a friend in need – the friend who knows the map and the wares – is a friend indeed.
The key to maintaining that friendship is in maintaining the patient’s trust. Trust is a matter of mutual respect and understanding. Such things, through all centuries, will not change.
The Generalist-Specialist Balance
It’s nice to thrill a bon vivant palate, but the wise chef doesn’t neglect the balanced diet. One of the most immediate and important challenges for our College is to achieve the right generalist-specialist balance in patient care and in our professional pow-wow.
Sri Lanka’s post-colonial condition has engendered and institutionalized a preference for the expensive high- tech over low-cost technology, the urban wants over rural needs, the latest innovation over time-tested practices, and the finer specialist’s attention over generalist care. The generalist’s wide-angle lens is necessary not only to ensure that healthcare is cost-beneficial and fair at population level, but also that it’s balanced, harmonious and palatable at individual level. The finer specialist’s in-depth focus helps delve into the intricate and the intractable, so that our fellow human beings at the edges of the possible get the best possible fruits of our collective knowhow. We must therefore promote the generalist-specialist distinction and harness it to get the right balance. Within the profession, we must cultivate consensus-building, cooperation and collegiality.
Our College is in the unique, priceless position to do this. We are all in the College because of our M.D. in General Medicine (or equivalent), with all its shared moments, poignant memories and collective crusades. All of us, whether generalist or specialist, still love to share with each other stories about how we suffered through our on-calls, never-ending clinics, case books, thousands of data interpretations & grey cases, getting ambushed in the long and short cases, and the deceptively gentle vivas. We began that long journey to specialization with the College MCQ course and finished it, after pocketing the M.D. (Colombo), by getting College membership. The College is our common ancestral home, and the M.D. in General Medicine our common professional birth certificate.
In 1996 the theme for the College’s annual academic sessions was “The generalist and the specialist: Duel or duet?” That prescient theme has remained with us to date. The task of keeping us all together is neither new nor one that ever finishes – it’s a work-in-progress.
The Threat of Pseudoscience
Our technology may have become cutting-edge, but our patients and the people are becoming more confused, disappointed, dismissive and distanced. This is not because they have rejected science: indeed, nowadays even non-science is packaged in scientific jargon, to create the pseudoscience of nutraceuticals, ‘natural remedies’ and so on. The people’s greater attraction is not to what science can offer but to what pseudoscience claims to offer. It makes people feel both safe, because it’s ‘natural’, and happy, because it’s ‘scientific’ – although it delivers probably neither.
Why is this happening? Are we bureaucratic or inaccessible? Are we incomprehensible? Is our science no longer affordable? Is our technology unacceptably frightening, intrusive or invasive? Is the world becoming increasingly superstitious and folkish?
To understand this, we must understand people better – not just understand technology well. If we don’t, we will be more compelled to wrap our science and the non-science together, and fall right into the trap of pseudoscience. A profession must take pride in its scientific basis. A profession that forfeits science to populism loses its scientific legitimacy and, hence, its professional identity and worth.
The medical profession – and physicians in particular – took the lead in embracing science and establishing the modern professions. Let us not take part in a sordid return-journey. Let us stand up for science, and call a spade a spade.
Facing the Future
In summary, medicine – and even pseudoscience – will become increasingly technological. But while we continue to understand and master the technology (which will make forays into hitherto untouched methods, such as complex mathematics and bioinformatics), we must make the extra effort to understand the humanistic, anthropological, sociological, legal, economic and political economic aspects of our work. We must equip the future physician with mastery of the human and the societal aspects of healing, and not merely the technological.
And we must not just understand it – we must shape it too. We as a profession and a college must be more involved in that process – benignly, proactively and effectively. Our College must become a greater advocate of the health of our compatriots and the care of the sick who come within our purview, while maintaining a keen and informed eye on the wider world. I think that the medical exhibition we held this year to celebrate our golden anniversary was an excellent launch pad for this.
And we must do all this firmly from the pedestal of science, with the right generalist-specialist balance. The future physician must be both a professional and a public intellectual – because the future needs such physicians to not only advise individuals but also to guide society.
In the coming fifty years, the College should take the quantum leap from being a profession that effectively cares for its patients to being, in addition, a social movement that effectively shapes the field itself. Otherwise, the forces that we fail to understand or act on will shape the way we care for our patients, or even determine whether or not we get to care for them in the first place. If that happens, not only would we lose our professional identity, but our society will go back from science to pseudoscience, and lose all the great benefits that our profession has been fortunate enough to serve them with.
The future is challenging and fascinating, and it’s already starting. Let’s predict the future – let’s invent it!