A Personal view of the Perks, Privileges,and Practices of the Noble Profession

By Dr. Nihal D Amerasekera

Although I do not recall pledging my allegiance to the Hippocratic Oath of 275 AD I treasure its values and hold it sacred. This binding document still remains relevant to practicing doctors today. The professionals of today have tweaked it to suit themselves while working within the rules of the General Medical Council and the laws of the land.

Reliving memories is a soothing balm. I remember as if it were yesterday when as a first-year medical student,taking my mother to Dr.Rustomjee as a private patient. Amid the splendour of his sprawling house was a small but elegant consulting room. I believe he was an ENT Surgeon. After the consultation, he looked quizzically at me and asked: “what are you doing young man”. As I squirmed in my seat trying to engage my vocal cords my mother proudly announced: “he is a first-year medical student”. Later my mother told me she wasn’t charged a fee. I was astonished by his professional etiquette and unfailing generosity to a student and a complete stranger. This became a life-changing experience as you would see from my narrative. My respect for the profession grew beyond measure for this simple act of professional courtesy.

In later years taking my family to the doctors remained a mixed bag. Many were polite and respectful, some charged and other waived their fees. As there was no medical insurance then,patients paid the fees directly to the doctor.We chose to go privately.Paying for the service was never a cause for complaint. The ethics of charging fees from colleagues and their families have changed since my childhood. During my years in Practice in the UK,I made the decision never to charge doctors and their immediate families. A local GP sent me her daughter as a private patient for an early pregnancy scan.When I didn't bill herI received a call from her father asking me to charge a fee as the insurance would pay. This does muddy the water. I didn’t want to charge and move down that slippery slope.

It is an age-old Sri Lankan tradition to accompany friends and relatives on their trips to the doctors.There was a batch-mate who worked for a well-known consultant to whom I wanted to take a relative. I spoke to my friend who most rudely brushed me aside.Such rebuffs were rare and I felt that was tremendously unkind.I wish he told me so more politely.Many have approached the consultant direct and he has obliged. Showing anger was not part of my normal repertoire of behaviours and neither was swearing.I did lick my wounds and swallow my pride. This upset me enough to remember it for more than 40 years.I hasten to add we still remain friends and consider such setbacks a part of the rich tapestry of life. 

As a doctor in the Blood Bank there were many professional colleagues who came to me for favours.They needed blood for their kith and kin prior to surgery. Many such professional favours were done with pleasure all through my long career. I felt that was my duty as a fellow professional. When I wanted a favour, Sanath Lamabadusuriya went out of his way to help me despite his busy schedule. He holds the mantle of Professor with great dignity. Revo Drahaman has been a great help to keep my family in Sri Lanka healthy.Never has he chargeda fee. His charming ways and modesty remains unchanged since those days in the Faculty.During my mother’s final illness  I was fortunate to have Harsha Samarajiwa to look after her. He waived his fee. Harsha is the most perfect of physicians for his refined civility and kindness. I recall the agonising pain and anguish I felt when I heard my father had a carcinoma of the sigmoid colon. This is every expats’ nightmare. I had known Dayasiri Fernando from the Faculty days and we also met in London. He was then an eminent colo-rectal surgeon in Colombo. When I sent him a letter he promptly did the investigations and proceeded to surgery. I remember Dayasiri with great affection and esteem for his thoughtful kindness at a most difficult time in my life.

Teaching medicine and passing on the skills is a part of the Hippocratic oath. Our time in the Faculty was the golden era of medical education in Sri Lanka.The physicians and surgeons took on the task of tutoring students seriously and gave of their best. It is also true some were insufferably arrogant. But we benefited enormously from their tutelage and guidance. The ethos has changed worldwide since those halcyon days. Nowadays, there area myriad of different pressures on doctors. In society now, it is money that counts. I have no knowledge of the current state of the Health Service in Sri Lanka. Do Consultants’ commitment to Private Practice affect the care of the non-paying patients and teaching? Many doctors from my era who remained in Sri Lanka practiced their profession with great diligence, decorum and dignity. Those who rose to the dizzy heights of professors and lecturers have continued the devotion and dedication of their predecessors. As they too retire I hope the next generation will maintain those fine traditions to keep the Nation in good health.

During my medical student days and later it was taken as our special privilege to take a patient or present ourselves to the consultants, bypassing the queue. Once I went to Dr. Pararajasekaram’s clinic in the Eye Hospital. The place was heaving with people. Proudly wearing my stethoscope round my neck, I ignored the queue with an easy conscience and went straight up to Dr.P. I said I was a medical student and would like to see him. He was furious that I broke the queue. Dr. P barked at me “I don’t care who you are. You have got to join the queue.” Although it upset me deeply at the time I do appreciate his willingness to break with an outdated tradition. Many of the patients have come from faraway and have been there since the break of dawn. It was totally wrong of me not to take my turn in the queue.I do admire and support his egalitarian attitude.

When Ceylon/Sri Lanka had just the one medical school, doctors were a small group.They knew each other.A strong cohesion remained among the medics. At times the bond seemed tribal especially when in the GMOA. When the second medical school opened in Peradeniya this unity was somewhat diluted. From 1970-74,I crisscrossed the country on my official travels for the Central Blood Bank.I regarded these journeys as my adventures to see the unsophisticated charm of my homeland at government expense. Once I went on a trip to Welimada. I had booked a room for the night in the rest house.When I arrived there in the late afternoon I was met by the DMO,Dr. Vernon Abeynaike. He was a final year student when I entered the faculty.I knew him only by sight. After the usual pleasantries, he asked me to stay with him. He spoke to the Rest House keeper and got my booking canceled. Vernon and his wife made me feel at home in their lovely and spacious DMO’s bungalow.He was delightful companyand had a fine repertoire of amusing anecdotes. After a delicious dinner we chatted well into the night. I have remembered this act of kindness to a “stranger” with much gratitude. Later, Vernon became a successful GP in Mt Lavinia. I was deeply saddened to see his obituary in May 2013. I will always remember Vernon for his generosity, humility and decency.

On these official journeys, I met with many doctors from many different era.What amazes me is  how happy and welcoming they were to make friends with me. I wonder if this spirit of friendship still exists. On one of those memorable adventures, I went to Rikillagaskada when Sanath de Tissera was the DMO. It was then a rural outpost far away from civilisation. The road ended at the hospital!!I was treated most lavishly by Sanath and Kanthi. We spoke of our times together in Nugegoda, the agony and the ecstasy in the Faculty, the mutual friends and the fun we’ve had.  Sanath and I have been close. I was sad to leave them.It would be remiss of me not to mention a visit to my friend Bernard Randeniya alias Claude Bernard. He was DMO Rattota near Matale. His bungalow was in an idyllic setting surrounded by lush green mountains and a fast flowing stream. I stayed a weekend with him when I was treated most lavishly. His wife Rangani was such a fine cook. We had so much in common to reminisce and relive. They were delightful company, warm and affectionate. I just cannot believe they are both no more. Despite the passage of years, the aching sadness of their demise has never really left me. On my many trips for the Blood Transfusion service whenever I visited Kandy, Galle or Matara the house officers welcomed me generously.They found a place for me to sleep in their quarters. Often, I never knew them personally but there was a certain closeness that came via the profession.They made it an occasion to greet me, enjoy a drink and share their food. Even now when I think of those years I feel a warm glow run through me. Perhaps it is a mixture of that legendary Sri Lankan hospitality and doctors’ unity at work!!

The insurgency of 1971 was an event remembered for the violence, uncertainty and distress generated by misguided youth. It was a tough time for our fledgling democracy. People were frightened to leave their houses and the roads were deserted. There was a shortage of blood in the National Blood Transfusion Service. With travel restrictions in place within the country,special permits were required to move around. There were road blocks,road checks, arrests and incarcerations. I feel hugely privileged to have played a meagre part in travelling to the affected areas to collect blood. I made a trip to Hambantota as the young insurgents in the prison camps were keen to donate blood. Many of the insurgents seemed to be brainwashed.Their personal storiescut through the turmoil and turbulence of the time. They complained of poverty, lack of jobs and of a government that didn’t care. They wanted to establish a utopian socialist state not realising this was an impossible dream.What concerned me most was their lack of remorse. The insurgents donated blood with great pride and in large numbers. The Army Major incharge of the area visited the camp.He was a big burly man with a luxuriant moustache. He asked me to stay in the security of the Hambantota Rest House which had been commandeered by the Armed forces. The Army Major was a total stranger to me but he made certain I was comfortable and well looked after. We were surrounded by the detritus of ‘war’. Despite the confusion, constant roar of jeeps and the clicking of boots I was wined and dined in the finest place in town.That was true Sri Lankan hospitality. They appreciated my commitment to provide a service during a difficult time. Built on a hill by the sea the Rest House is a stunning old building steeped in history and full of mystical charm. I was given the finest room overlooking the turquoise sea and the golden sandy beach. These are the memories that make me feel proud I worked for 7 years in Sri Lanka to pay at least a small part of my dues to a country that has given me so much.

Although my memory fails me I presume we have had an initiation and an introduction to the Hippocratic Oath. Pledging an oath is an invaluable experience for doctors. I find the oath inspirational. It is a moral compass. The medical profession too is a cross-section of society with its share of the good, bad and the ugly.In the UK the GMC has been proactive to eliminate doctors who cross the fine red line. We too have our quota of lounge lizards, lotharios and unscrupulous doctors.They are a curse on the noble profession. Of this, I will say no more. Despite the bad apples, I remain optimistic about the ethics of the profession and the ability of the GMC to keep it clean. The world depends on the medics to keep us healthy.We need rules to live by and work responsibly.

When I first became a consultant, I wasn’t aware of the attitudes, ethos and the unwritten codes of Private Practice. Doctors were attracted to the Private Hospitals like moths around a flame. Once a senior Chest Physician sent me a patient with bronchogenic carcinoma, for imaging. He was terminally ill. I just couldn’t get myself to send him a bill. The Chest Physician knew I was new to the job. He took me to his office and spoke to me about Private Practice. The rules, ethics, manners and the nuances he mentioned are a fine charter for the practice of private medicine. Amongst other things, PP does require an easy conscience!! Sadly,much of this is passed down from word of mouth and is not written down. It is true this is all common-sense but is easily lost and forgotten in the greed and cut-throat world of private practice. His advice was well taken and has stood me in good stead in later years. Despite my indulgence in private practice, a bit of me always thought medical care should be given free.

In the UK I have never experienced the professional unity that I found working in Sri Lanka. As the numbers of medical schools and doctors have increased I wonder if the intensity of that unity and harmony still exists.Egos, competition for private practice and professional rivalry must get in the way of unity. We must not allow unity to hinder the accountability of doctors. Self-doubt is not something that comes naturally to the medical profession.They don’t take kindly to requests for a second opinion. Doctors do have the right to disagree with the diagnosis and treatment of others. The search for a second opinion has become common place now.  Patients’ welfare is paramount and must remain our overriding goal. There is a moral obligation to bring to the attention of the relevant authority information on malpractice at the expense of friendship and goodwill.

Charging fees from fellow professionals is common place in the UK. I am reliably informed that is the case in Sri Lanka too. There are exceptions. I remember being seen by an ENT surgeon in a private hospital in the UK. He was friendly with a fine bedside manner. After the consultation, he waived his fees and asked the hospital not to charge me.When I asked him why? He said Dr. Amerasekera you wouldn’t charge me, would you? I was proud to announce with honesty, I would not.

Despite that endless search for the Fountain of Youth,age has caught up with me.Being a patient, literally, the tables have been turned. When I visit my GP, I wait my turn to be seen.I am not shy to announce I am a doctor. When they know I’ve worked in the National Health Service I get recognition for the thirty years of toil. I often get a call at home from my GP asking me to which hospital I want to be referred, a luxury not offered to many.At the Royal Free hospital, the consultants have treated me with civility and courtesy. So, the age of professional etiquette is not dead. Long may it survive the rigors of modern living.

If medicine doesn’t remind us of the fragility of life, nothing will. For many of us doctoring has come to an end.Visions of our long and distinguished careers remain as an indelible memory. The Hippocratic oath will prevail as the moral standard to show how well we have done our duty and how well we have cared for our patients. This we will carry with us to the end.Although it is easy to develop an appetite for life’s pleasures, we cannot take with us our material wealth.The part we have played in healing, relieving pain and suffering will live long after we are gone to swirl in the ether forevermore. It may even give us hope for a better life next time around!!