Doctors need to go beyond medical skills to offer the wisdom of their experience
By Lee Wei Ling
In his maiden article for Think-Tank, a weekly column in The Straits Times rotated among eight leading figures in Singapore's tertiary and research institutions, Professor Su Guaning, the president of Nanyang Technological University, wrote: 'We need to train more doctors to be not just specialists, diagnosticians and therapists based on clinical reasoning and evidence-based medicine, but also be overall managers.
'As medicine and technology play ever more intertwined roles in patient care, the doctor of tomorrow will also need to be knowledgeable about the latest advances in medical technology.'
I agree wholeheartedly about doctors needing to play the role of overall managers - but it is not just about keeping up to date with medical science and technology.
The latter has already been ensured by the Singapore Medical Council's requirement that each doctor fulfils a certain quantum of Continuing Medical Education (CME) points. This system is easy to police and implement.
However, just as important but less easy to assess is the ability of a doctor to analyse the problems a patient, his family and sometimes even the community, face. This requires the ability to see the forest as well as the trees and to have enough life experience to advise a fellow human being.
My Nigerian patient's sad story might serve as an example.
The patient was four years old when I saw her in 2006. She was apparently normal at birth and did not have any significant illness until she developed a kind of epilepsy (spasms), which is usually associated with severe brain damage. She had been extensively investigated and was still under the care of a paediatric neurologist in a reputable medical institution in Atlanta in the United States.
She neither understood what was said to her nor did she try to communicate by speech or by gesture. Her father and grandmother who had accompanied her to see me said that she could not indicate her needs, not even by taking her parents to the object she wanted.
She simply cried when she was hungry. She did not recognise her parents or anyone else. She walked around my room aimlessly, climbed onto my examination couch then jumped off it, exhibiting normal strength and agility as well as restlessness and hyperactivity. There was no response when I called her, nor did she respond to the calls of her father and grandmother.
In fact, she seemed more aware of the objects in my room and seemed oblivious to the human beings there. She made no eye contact with any of us. I needed no IQ test or any other psychological test to know that she had profound mental retardation and was autistic.
The father was 40 years old, a stockbroker in Nigeria. His mother was 55 years old. The patient's mother was in Atlanta looking after her one-month-old baby. The patient also had a two-year-old sister. There was no family history of mental retardation or epilepsy.
I read the medical records that the father had brought along from Atlanta. The young girl had been extensively and comprehensively investigated, and all appropriate anti-epileptic drugs had been tried with minimal improvement.
I asked the father: 'Do you think I can perform a miracle?' He nodded his head. I told him there was nothing more I or any other doctor in the world could do.
The father began to tear, and said that if that was the case, he would leave her with her mother and her two siblings in Atlanta, where she could get the best treatment, and he would return to Nigeria to work to support the family.
I advised otherwise, telling him that he would ruin the lives of his wife and two normal children as well as his own, without any benefit to the patient.
I asked him if no one had told him of his daughter's hopeless prognosis. He shook his head. I told him that she would never be independent and it is likely that even normal activities such as dressing herself would be beyond her.
The best thing he could do was to keep the family together. If he needed to work in Nigeria to support them, then the entire family should return to Nigeria. The grandmother understood what I meant and urged her son to take my advice.
I spent 45 minutes counselling him and waited until he had regained emotional control before sending the patient for a blood test to determine whether she was on the appropriate dose of the anti-epileptic drug. I asked the father to return the next day.
He came back the next day, calm and collected, and said that he would follow my advice. The result of the child's blood test indicated that the dose of the anti-epileptic drug was appropriate. Yet, while she was in my clinic, I had observed her jerk and flex her body as she woke up from her nap. The grandmother said that this was her usual seizure. It confirmed my diagnosis that her epileptic syndrome was one usually associated with severe mental retardation.
I counselled the father not to neglect the rest of his family and gave him my e-mail address so that he could contact me if he had any questions.
This was a difficult problem. There was very little I could do for the patient, but there was something I could do to save the entire family from unnecessary suffering. It was not knowledge of medical technology that I needed in this instance, although there are cases where that would be relevant. Medical technology in Atlanta would have been at least as good if not better than what we had in Singapore in 2006.
It was wisdom, common sense or perhaps just years of experience that enabled me to give practical but important advice.
Primum non nocere - 'First, do no harm' - doctors are enjoined by the Hippocratic Oath. Sometimes 'do no harm' means 'do nothing'. We must heal, when we can; comfort, when we can't - and be wise enough to know which would be the best course of action in each particular case.