Surgery and its future
 

Speech delivered by the Chief Guest Prof. Dayasiri Fernando at the Induction of the President Dr. M. Ganeshanathan 29th President of The College of Surgeons of Sri Lanka.

Traditionally, the induction of the President of the College is a momentous event in its calendar. It is a great day for the College. It is also a great day to the new president and his family. It is also a great day to me to be thus honoured, especially at a time when there are more years behind me than ahead of me. So Mr. President, I am truly delighted to be with you in celebration. May I warmly congratulate you and wish you all the guidance from above for a very fruitful tenure as the President of the College of Surgeons.

Many years ago John Hunter, anticipated that a time would come when surgery, gaining much from the general advance of knowledge might be tendered both knifeless and bloodless. This was stated by Lord Moynihan, when he delivered the 199th birth anniversary oration of John Hunter. It was also the centenary of the birth of Lister. From all those who have ever served the cause of surgery, Hunter and Lister stand a part by reason of the immeasurable gifts which they have conferred in their fellow men. Mr. President, today you are taking over office at a time when Hunter's ideal is being achieved with a rapid build up of technology, from which our predecessors were completely debarred. Surgery is continuing to grow. Today the skills of the hands are being replaced by intricate technology of the machine. The complicated surgeries which took many hours to perform are becoming relatively simple procedures. As such, the need to reach out to our colleagues throughout the world and achieve greater collaboration is increasingly important. Therefore, it becomes our responsibility as a College to ensure that the young surgeons we produce are mentally and socially adequately equipped to meet this need.

At the same time the mind of the patient is changing. Many years ago, when we were students, the doctor, especially the surgeon was god to the patient. He was one who can do no harm to him. He was looked at with veneration for the wonders he performed with his hands and the healing knife. Patients accepted the words of the surgeon as gospel. Today, the patient is different, he thinks differently and has a different image of those who deliver healthcare to him and his family. He is more educated about healthcare and healthcare procedures. He has easy access to information of all types by merely pressing a computer key. He is able to critically evaluate the performance of the surgeon using this knowledge. In addition, he gets information about the work of the surgeon from those who work with him, especially the junior doctors and the hospital support staff. He also has the assistance of the legal profession.

Therefore, Mr. President, I think an occasion like this serves two useful purposes. To think a while and look at ourselves from the point of view of the patient and re-dedicate ourselves, renewing our wows, to the ideals for which we committed ourselves when we started our lives as surgeons. So many I ask two simple questions - "How does the patient see us?" "What do they expect from us?" This evening, I'll share with you some of the answers on these questions, from a recent study. Foremost in their minds was professional competence and professional confidence. We as surgeons know and think of ourselves as knowledgeable and competent professional with a distinct understanding of what is right for our patients and what is not. We know this with complete confidence and rarely if ever do we find the need to question it. But the patient or his relatives can question. To them, we must be able and willing to demonstrate that we deliver care of the highest quality and that we are quite willing to be accountable. The patients expect this from us and that accountability applies directly to the vulnerable state of the patient whom we treat. They expect the surgeon to be calm and confidant in himself, and not temperamental. At the same time, they also expect the surgeon to have a touch of humility and reach out and harness the help of other experts if the need arises, in the best interests of the patients. We are often accused of not willing to do this and when we do this, of promoting our friends. A recent newspaper article referred to this in rather strong words. Is this true? We should be careful not to be guilty of this.

The patients want the surgeon to have good communication skills. They prefer a surgeon who would interact honestly and sincerely, taking time to discuss his problems and not one who is rushed for time because of the number of patients he has too see within a short time in his practice. Majority of the patients have complained that "the doctor has no time and he is very busy". It is true we are happy when we are busy but the patient demands time. Without an exception they have said that the doctor is no respecter of time. They have complained that they are kept waiting and waiting for long periods of time for the arrival of the doctor. Sometimes, the doctor never comes and this is announced by the receptionist in a matter-of-fact way. In a recent article titled 'The Owl and The Pussy-Cat', a very strong view was expressed by the writer. I most humbly admit that to a certain extent I am also guilty of this, but I always make it a point to apologize when I get late. I think this makes a big difference.

Another concern expressed was about the way decisions are made and conveyed to the patient. They have said that the doctor talks very lightly about surgery. He is rather insensitive about the state of mind of the patient who is facing a difficult moment in life with anxiety. It is our duty to help the patient to decide especially when many options are considered. In difficult moments dialogue with the relations is important, and this can be difficult with a well informed internet society. "How can the doctor speak to my relatives when he has no time for me" is another comment that has been made. Remember, it is the lack of this that leads to litigation and our medical defence society will vouch for this.

Another strong comment was about the way fees are charged. They have said that "With the rapidly developing market economy, the doctors are also, becoming market orientated", We may agree that other professionals charge high fees, but that is not what is expected of a divine calling. We must not be mercenary. When it comes to money, the best of people do the worst of things. We have to remember that our relationship with our patients is a covenant of faith, not a business contract. An article of trust, not simply a fee for service.

At the same time the patients wanted to be assured of adequate care especially in crisis. They wanted to see the doctor more frequently when their patients are critically ill, situations which shatters their morale. This brings to my mind Prof. R. A. Navaratna, an unique and great surgeon to whom I am ever greatful. If I may be permitted to use the words of one of our past presidents, Dr. S. J. Steven, "Prof. Navaratna is the one who taught to use the scalpel. It was he who taught me the way of the surgeon." When I was his intern, he used to do three ward rounds everyday, seeing every patient. Later on he did two ward rounds and telephone the wards in the night. So even if the worst happened the relatives knew that everything possible was done.

Another interesting observation was that a surgeon must have a good personality. Patients expect the doctor to be well dressed and well groomed and the lady doctors to be preferably in saree, and of course must smile. These observations were also disclosed in a study conducted by medical students of the University of Sri Jayawardenapura on dress code for a doctor, just before I retired. So we have to maintain our looks.

So the main expectations of the patients can be summarised in the words of the late doctor P. A. P. Joseph as "ability, availability and amiability".

Now in retrospect, let us look at ourselves. I think this is an appropriate and solemn occasion to renew our vows to ourselves as surgeons and rededicate ourselves to the highest ideals for which we stand.

Talking about renewal of vows, ladies and gentlemen, in recent years their is an emerging trend which is fast becoming a fad among couples celebrating their wedding anniversaries to renew their marriage vows. They do this at a solemn church ceremony in the presence of their family and friends. Recently, two family members of mine were preparing to celebrate their silver wedding. Their young son asked "ammi, have you forgotten you are married? Is it necessary to renew your vows?" Should we ask ourselves the same question? Whatever the answer may be, I think an occasion is a time for quite reflection. While we are doing this thinking of patients 'expectations', there is another important group of people on whom we should focus our attention. They are our students and trainees.

All surgeons are teachers and trainers. All throughout lives we have to transfer knowledge and skills, unselfishly, to those who are working with us as our juniors. Should we teach our trainees only surgery? Let's look at this a little more; should we not teach them the importance of interpersonal relationships? Should we not go beyond knowledge and skills and teach them something more? Should we not infuse into these young minds that the surgeon is no longer the key player in a one man show, but a leader of a team giving direction to every segment of his team. Should we not teach them to be professionals? Should we not teach them to be sensitive to the needs of the patients? Should we not teach them values and attitudes? Should we not do this with our lives as the example and being role models? The answer to all this is a definite yes. Lack of this has resulted in much criticism by public. A few months ago at the general assembly of the church, several speakers spoke at length about the crumbling standards of the medical profession. They used the words "Dysfunctional doctor". Is this true? Is there a dysfunctional doctor? If so, who should be blamed? Where is the fault? Is it not with dysfunctional teachers?

Mr. President, I think as a responsible College, we should not only focus our attention on the trainees but on the trainers as well. Training the trainer workshops should be more frequent, including a wider spectrum of topics to cover the expectations of the patient. Then hopefully the trainer would be inspired to deliver to those who learn from them, not only Knowledge, but more importantly values and attitudes, that would contribute to the making of a complete surgeon.

Finally it is important for us to remember that a surgeon stands out different from the rest in the medical community, in that he learns the skills of surgery not from the text books, not from the lectures, but under the personal supervision of the teacher. Or in other words 'at the foot of the master'. It is the teacher who shows him how to operate.

It is the teacher who shows him the finer movements of his hands in using the scalpel, the scissors and other instruments. It is he who teaches the students the intricacies of the finer work, such as in dissection, anatomising and restructuring.

As such we should have within ourselves a deep seated sense of debt and gratitude to those who taught us these skills. It is a binding obligation.

This gratitude should not be confined to mere words spoken on public occasions like this but more importantly, by living up to the expectations of the teachers.

Mr. President, may I conclude by thanking you once again for inviting me to be the chief guest this evening. I am deeply conscious of the great honour you have conferred on me. With the abundance of good wishes from all of us here, may you be blessed with vision an courage to steer the affairs of this College from strength to strength.