Doctors’ ethics and “industrial action”

By Nihal D. Amerasekera

Hippocrates is often called the father of modern medicine. He wanted the medical practitioners to maintain ethical standards. He wrote down the ethical guidelines between the 5^th and 3^rd Century BC.  Although the world has changed much since the days of Hippocrates his oath has remained a beacon for doctors until the present day.

The earliest reference to certification of doctors in England goes back to 1411 but the body called the General Medical Council was born in 1858. The General Medical Council (GMC) regulates British doctors through the Medical Act. The Council comprises doctors and lay people. It registers doctors for UK practice, sets professional standards, regulates basic medical education, and manages doctors' fitness to practice.

We have the medical trade unions like the British Medical Association and the GMOA who represent the doctors when there is a conflict between the profession and the government.

Mostly, conflicts between doctors and the government arise due to pay or conditions of service or both.

The provision of healthcare in a country like the UK is a joint venture between the Government, hospital, doctor and the patient. So the responsibility for healthcare has multiple limbs. If the relations between any of the partners in this contract breaks down, the patient suffers. If the government fails to meet its contract with the doctor then it makes strike action more ethically justifiable. Society must be willing to support the doctors by paying them a proper wage. Here we assume the doctors are reasonable in their demands. As the Journal of Medical Ethics points out  “Little harm can accrue from shattering a somewhat antiquated myth of sainthood and injecting a good dose of realism”

On the other hand doctors have a duty of care to their patients. If a patient dies as a direct consequence of strike action is it morally justified? Does that amount to medical negligence when the GMC can take appropriate action? Should the striking doctors make contingency plans for medical emergencies or is that the responsibility of the hospital and the government?

If the doctors strike purely to improve patient care in their refusal to put patients lives at risk. Does it make strike action justifiable?

The doctors too have lives to lead with professional and family commitments. They have bills to pay and have a right to a decent wage and a reasonable quality of life. Their long years of study and onerous routines must be adequately remunerated.

Provision of free healthcare is an enormous burden to any government. In their attempts to economise the government will inevitably try to slash healthcare costs and doctors pay will not be exempt from the cuts. This will result in conflict and recurrent disputes.

As you see there are more questions than answers. I would ask for your opinion on this ethical dilemma that would be a recurrent problem to the medical profession worldwide.

Should doctors go on strike?

Creative Spot - By Mahendra (Speedy) Gonsalkorale

Sanasen Nalawenna Sudo

Originally sung by Athula Adhikari, this is one of my all time favourites. In this version by Speedy, he has done a wonderful job. I am sure all of you out there will enjoy.

Lucky

SLMA Foundation Sessions 2015 - EM Wjerama Endowment Oration by Dr. Sunil Seneviratne Epa

I am pleased to publish the 2015 EM Wijerama Endowment Oration which was delivered by Dr. Sunil Seneviratne Epa at the recently held Foundation Sessions of the Sri Lanka Medical Association (SLMA) in Anuradhapura. This posting is mainly for the benefit of members of our batch who are based overseas.

Dr. Sunil Seneviratne Epa is a Consultant Physician who owns the Matara Nursing Home which is a leading private hospital in Matara in Southern Sri Lanka. Most of you may not know him as he had been a few years junior to us in the Colombo Medical Faculty. He had however served the Colombo Medical Faculty as a Lecturer before he set up his own practice in Matara. Dr. Seneviratne Epa has a special interest in this subject. He believes in the Medico Spiritual Health model which has now been accepted by the Ministry of Health in Sri Lanka. This means that doctors would now accept that religious activities such as pirith chanting will have an effect on healing. Hospitals would now recognise the spiritual needs of the patients and provide appropriate facilities. Dr. Seneviratne Epa is a Past President of the SLMA.

I have "cut and pasted" the full oration from the Sunday Times of 15 November 2015.

Sunday Times 2

Emotional and spiritual intelligence and its relevance to medicine

By Dr. Sunil Seneviratne Epa

People with spiritual intelligence are calm, peaceful and compassionate. Such people have less stress and conflict both at work and at home. They have better health and better output of work at work places

Albert Einstein said, “The intuitive mind is a sacred gift, and rational mind a faithful servant. We have created a society that honours the servant, and forgotten the gift”. My speech today is on this intuitive mind. Purpose of my lecture is to show you the vast potential of this intuitive mind and how best we can put it to good use. Emotional and Spiritual Intelligence is a function of this intuitive mind. Some people refer to this intuitive mind, as subconscious mind. According to some classifications, as much as 88 percent of our mind is subconscious. What is Intelligence? A simple way to understand this abstract term is to think of it as an ability to apply skills. We now have a definition of Intelligence which is as follows.

“Intelligence is the ability to apply appropriate skills at right time for right purpose.” We have four types of intelligence: Physical, cognitive, emotional and spiritual. If we are to place them in a pyramid, Physical intelligence is at the bottom and is the most basic level. Next is the Cognitive and above that is Emotional, and Spiritual intelligence is at the peak and is the highest form.

Traditionally, the Cognitive intelligence or Intelligence Quotient (IQ) is what we have been referring to as intelligence, at least up to few decades ago. However, this trend is now fast changing. Over the years, we have realised that after reaching a certain level of IQ, there is no direct correlation between IQ level and the actual achievements or success in life. The concept of Emotional intelligence or EQ emerged as an explanation to this observation. Emotional Intelligence basically means how skilled you are, in handling emotions, your own or other peoples’ emotions. EQ is defined as follows.

Dr. Sunil Seneviratne Epa

“Ability to make healthy choices based on the ability to recognise, understand and manage your own feelings and feelings of the others”. Daniel Goleman described EQ as a combination of four different skills under two groups. a) Ability to recognise your own emotions (Recognition) and control them (Impulse control). b) Ability to recognise other peoples’ emotions (Empathy) and ability to manage them (soft skills or social skills). One may be good at one skill but may be poor in another. So, if we are to improve our EQ we need to know in which respect we are weaker. EQ can be enhanced by training and as a result it is now a big industry in the US. Studies have shown EQ level is directly related to success in business. Being a good doctor too means having good EQ. Empathy or the ability to understand another person’s emotions is a valued trait for success in medical profession too. We are dealing with a special category of people with emotional needs. Leadership training essentially means developing good EQ. You may have heard of gut feeling. This is the feeling based on perception rather than on rational thinking. This is a function of EQ. A surgeon may use his gut feeling whether to operate or not, on a bad patient.

Conventional thinking has been, that emotions are produced by what are called emotional peptides in the brain. So it was a chemistry that we talked of. There is, however, now newer evidence that these peptides, once get attached to the cells, cause a vibration in the cell membranes, producing energy waves with different frequencies. So we are now talking of physics of emotions, producing measurable energy waves with different frequencies. This brings us to a totally new topic — Cell vibrations. In fact the body is a bundle of energy in constant vibration producing measurable energy frequencies. Nikola Tesla, who is considered to be the father of electromagnetic engineering, said: “Everything is vibration and everything is energy”. Different emotions have different vibration frequencies ranging from 20 to 700 plus Hertz. Negative emotions such as fear and anger have lower frequencies while positive emotions such as peace and joy have the highest frequency.

Empathy is the ability to perceive another person’s emotions. The secret of empathy may lie in the energy waves of emotions. So it looks, we now have a scientific basis for explaining empathy – the ability to perceive another person’s emotions. How strange? You may have heard of people who can read other peoples’ minds. This may be the secret of that, too. These emotional vibrations producing energy waves may explain the mechanism of transfer of merit or blessings on to another person by us performing spiritual activities. This is totally a new dimension connecting spirituality with science. Isn’t that strange again?

Spiritual Intelligence (SQ) is a kind of extension of EQ and is the highest form of human intelligence. We have a definition of Spiritual Intelligence too. “It is the ability or the skill to behave with compassion and wisdom while maintaining inner and outer peace regardless of circumstances”.

When people were asked to name a person with these qualities utmost, majority of them thought of their respective religious leaders. I think this is how, the term “spiritual” came to be coined with this highest form of intelligence. This inner peace component is what distinguishes SQ from EQ. In EQ we are not talking so much about inner peace. A sales man with high EQ may recognise an angry customer and may respond appropriately to calm him down and may succeed in maintaining outer peace. But he may not feel inner peace in himself during this process.

As one progresses from EQ to SQ , the person becomes skilled in maintaining inner peace too. How do you recognise people with high SQ? Essentially, they are calm, peaceful, compassionate people. Such people have less stress and conflict both at work and at home. They have better health and better output of work at work places. SQ too can be enhanced by way of training.

We can learn compassion by following the teachings of our religious leaders. Wisdom is a state of heightened inner awareness or tranquility of mind. It is something you need to develop and acquire on your own. Meditation is one way of doing that. There is now enough scientific evidence to suggest that meditation calms down the conscious brain and reduces ego. It is the ego that makes us lose our inner peace in conflict situations. Functional MRI Scan of brain during meditation has shown that activity of the conscious brain and of the limbic system is reduced during meditation. Wisdom dawns as ego becomes thinner.

The ultimate aim of any human being should be to reach the peak of intelligence pyramid or to acquire SQ before death. How do we do that? All we need to do is to change the way we think of our own minds. Let me conclude by repeating what Einstein said,
“The intuitive mind is a sacred gift and rational mind a faithful servant. We have created a society that honours the servant and forgotten the gift”.

I leave you pondering how apt it is, what Einstein said over 100 years ago, in our present context today.

SLMANA (Eastern Region) Dinner Dance

SLMANA (Eastern Region) had held their Dinner Dance recently in NYC. I have received these pictures from Srianee (Bunter) Fernando Dias. Thank you Srianee for sharing the photos.

Creative Spot - By Mahendra (Speedy) Gonsalkorale

Composed and sung by Mahendra based on a poem by Magadalena Podobinska.

A.R.K. (Russel) Paul - An Appreciation

By Sanath P. Lamabadusuriya

Russel was the eldest in a family of four boys and two or three girls Their father was Professor R.H. Paul who was the Professor of Electrical Engineering in the University of Peradeniya and he became the Dean later. Russel entered Royal College (RC) in 1952 and was senior to me by two years, but later I caught him up and we entered the University together. His younger brother Hillary, was a good athlete at RC and he excelled in the long jump and triple jump. I think he captained the athletics team and he was one year senior to me, but I caught him up later. Unfortunately Hillary died of a malignancy prematurely. Keith was one or two years junior to me and was an excellent ruggerite and he captained the RC rugby team. Beverly the youngest of the boys, played cricket for RC

Russel excelled in the Freshers Athletics Meet when he entered the University of Colombo in 1961, by winning four events. He was an excellent student and he came second in the order of merit at the Final MBBS examination in March 1967 ( I topped the batch). I really came to know him during the internship at GHC, where we  worked together as Interns in the Professorial Medical Unit with Prof. K Rajasuriya, Dr, Oliver Peiris and Dr. David Chanmugam. We shared a room in the Main Quarters for one whole year. During our free time we played poker together with others such as Neil Fonseka, "Sodium" Karunaratna, Marius Cooray, C. Balakrishnan (who opened batting for the Ceylon Cricket Team), Michael Satchithanandan, Ajith de Silva, Sathanandan et al. He continued his internship with Dr, L.D.C. Austin at the GHC.

Later both of us went to Chest Hospital Welisara for the post-internship appointments. On 1st April 1969 I joined the Faculty of Medicine, Colombo as a Lecturer in Paediatrics. Soon after, Russel returned to GHC as a Registrar in the Professorial Medical Unit with Prof. K. Rajasuriya. In 1970 both of us spent many hours in the nights studying for the MD examination. In December 1970 we sat for the MD examination. Russel passed and I failed (the exam was only in adult medicine and there was no paediatric component). In 1971 both of us sat for the MRCP Part 1 examInation which was conducted for the first time in Sri Lanka. Both of us passed. The next morning, I managed to recollect the whole paper consisting of 60 True/False type MCQ's , five responses in each (total of 300 questions).  As there was no question bank at that time, this document turned out to be extremely valuable for future candidates. The billiards marker in the students Common Room in the Colombo Medical Faculty, cyclostyled this document, sold it and made a fortune!

Russel was romantically involved with one of our batch mates, Dawne de Silva whom he later married. In 1971, Russsel and Dawne decided to emigrate to the US. When I asked him why he was doing so, he told me that his father was a University Academic all his life and after retirement, was living in a rented flat at Duplication Road (R. A. de Mel Mawatha). Therefore, he did not want to end up like his father.  Dawne was quite affluent but Russel did not want to live off her. That was typical of Russel.

They had two children - a daughter and a son.. Unfortunately, the daughter was brain-damaged at birth and became mentally handicapped and hyperactive. Whenever they came on holiday to Sri Lanka, we used to meet up and socialise. As one of his children was an asthmatic, he used to bring all the necessary drugs, scalp vein needles and syringes which he used to leave behind for my use at Karapitiya.

In the  1970's or early 1980's one of Russel's sisters was abducted near the Eye Hospital Junction and was raped. A notorious criminal Gonawela Sunil, was convicted for the crime and sent to prison . Later, he was released on a presidential pardon given by J.R.Jayewardene. After he was released, he was gunned down by the JVP.

Russel became a specialist in Gastroenterological Oncology and settled down in Philadelphia later. I visited the US with my family in 1988 and was planning to visit Russel and his family. But I had to change my plans and we did not travel to Philadelphia. I last spoke to Russel from Indra Anandasabapathy's home in Staten Island, New York. Russel told me about the problems he was going through. Dawne had developed Ankylosing Spondylitis and was bed ridden latterly. Their daughter was a teenager by then, but was fed and washed by Russel as she was handicapped. Russel had avoided socialising with friends gradually because it was difficult for him  to manage his daughter, So, gradually Russel became isolated.

In 1990 or 1991, when I was working at the Ruhuna Medical Faculty, I was shocked to read about the murder/suicide of Russel's family in the front page of the "Daily News". Russel had apparently injected some drug IV to his family members and committed suicide by injecting himself. I am sure that it was a joint decision taken by Russel together with Dawne.The coroner did not disclose details of the drug used as others may have followed.

Knowing Russel, he would have calculated the individual doses to a decimal point, taking the body weights into account. I think it came to a breaking point when he could not manage his family by himself. I am sure  this tragic event would not have happened if Russel and his family lived in Sri Lanka because of the extended family support found here.

Thus ended the life of a wonderful human being and a close friend.

Untold Stories

This was posted as a comment by Sanath Lamabadusuriya under the Appreciation on Prof. Rajasuriya written some time ago by ND (Nihal) Amerasekera. I decided to publish it as a separate post because of two reasons. Firstly, it is quite some time now since ND's Appreciation on KR was posted and it is unlikely that the majority of viewers would go back to read comments under old posts. Secondly and more importantly, it is much more than a mere comment and in my opinion, an interesting story yet unheard by many. I for one, had not heard it before. So, I have posted it as an "Untold Story" on this blog.

Sanath writes....

I did my internship in the Medical Professorial Unit at the General Hospital, Colombo (GHC) from May to November 1967. My co-house officer was Russel Paul, who was my room mate as well, at the Main Quarters for one whole year. In the post internship year, Russel and I were together again at Chest Hospital, Welisara. I joined the University as a Lecturer in Paediatrics on 1st April 1969 and Russel came back to GHC as a Registrar in the Professorial Medical Unit. We used to do joint studies until he emigrated to the US some time later. As you can appreciate, we were indeed very close to each other.

Dr Oliver Peiris was a Senior Lecturer in the Prof unit and David Chanmugam was in the female ward. The Registrars were, H.B. Karunaratne,  P.H. Billimoria and Soma de Silva. Mr. L.H. Mettananda (former Principal of Ananda College) was a patient during this time and he was terminally ill with cirrhosis of the liver. One day, KR. asked me who was on call for the next weekend and when I replied that I was on call, KR was happy. It was probably because Russel was a Catholic and I was a Buddhist. He told me that if Mettananda dies, not to mention cirrhosis of the liver as the cause of death in the death certificate. So I mentioned "Liver Failure" as the cause of death.

Towards the end of the internship, KR called me to a side and showed me a letter. He said that PH  Billimoria had applied for a Commonwealth Scholarship and had requested for a reference. He had mentioned in the reference "PHB came to work with me on such and such a date as a Reader and he worked with me until such and such a date". I told KR that it was  grossly unfair by PHB because he was the hardest working registrar out of the three. Nevertheless, PHB proceeded to UK to be trained in Neurology. He returned about 2 years later after over staying for about a week. When he reported for work at the Ministry of Health, the Director of Health Services happened to be KR.  PHB was served with a vacation of post notice. Although PHB protested, it was not withdrawn and PHB continued his journey "Down Under" where he is still domiciled. Dr George Ratnavale  retired or resigned soon after and J.B. Peiris who returned at about that time was appointed as Neurologist GHC.

My second half of the internship was with Dr. P. R. Anthonis, Senior Surgeon, GHC. Both KR and PRA were excellent clinicians and what I learned from  both of them during my internship, helped me to mould my future.

I returned to Sri Lanka after post graduate study leave on the 1st of January 1975 and reported for work on the 2nd of January. When I visited the Colombo Medical Faculty, I was happy to see KR's silver coloured Borgwaard Issabella car parked in the quadrangle at the  usual place close to the canteen. I proceeded upstairs and met the Dean, Prof  S, R. Kottegoda and when I told him that I was going to meet KR, he told me that KR had collapsed that morning in the MD examination hall, and had been admitted to GHC. KR died the same day  and I regretted very much that I did not meet  him after being  away for 3  years. Later, I heard that KR was eager to see me when he had come to know that I was returning to the country because not many were returning home during those difficult days.