Why all medicine men should watch Munnabhai M.B.B.S

Shuvendu Sen in The Times of India

It does not have the somber ambiance of The Doctor, where a brash MD himself succumbs to throat cancer and is hushed to humility. It does not carry the macabre interaction of a supposedly psychologically disturbed man and a tyrannical nurse as seen in One Flew Over the Cuckoo’s Nest. Neither does it inspire an awakening as Philadelphia did through a gay lawyer fighting AIDS.

Munnabhai MBBS is anything but the tempting medical plot hashing out tears, tension and hope. It walks clear of such obvious seductions. Truth be told, the movie is as loud as it can get, carries all the ingredients of Bollywood absurdity and harps on emotions, raw and running. But take a moment to peer beneath the rubble and you would smell a treasure. A rare treasure’s takes on a mission that has degenerated into a profession soaked with cynicism and slit throat parlance. And I am no film reviewer.

Let us take an earthly stand. When was the last time, we physicians have put our right hands up and taken the oath that we would take care of patients over and above vested interests? When was the last time, save glorious exceptions, we have crossed the borders of our financial gains and taken a bow for the penniless sufferer? When was the last time we thanked the hospital sweeper for his services to patient care? For that matter, when was the last time a medical book was written to highlight the absolute necessity to reach out to a stage four cancer patient other than through mindless chemotherapy and pain medications? Fact remains that medicine, like none other profession has become the yardstick of a cultivated upper lip vocation, to pursue and prevail. In our pursuit for perfection we have lost the imperfect patient.

And the fact that Munna bhai, despite all his convivial and genteel mindset, was a full blown quack, a rank outsider, drenched in liquor, roadside patois and all that was coarse and callous, made the white coat adorned messiahs look even more like bloodless bodies. Harsh words, but if anything had been flushed down the drain in the practice of medicine, it had to be empathy and emotions. Formless jottings have replaced tender words. Machines have superseded probing minds. An impatient doctor sits across the floor, rummaging the symptoms, inaccessible to the sufferer.

But of course, Munnabhai M.B.B.S has its own share of absolute lunacy. The frequent fist fights, the semi clad on-campus dance and the lugubrious antics are a far cry from the austere charm and book like precision of its western counterparts. But there’s a reason why British Medical Journal took a note of this movie. One suspects the makers of this movie played the human mind well.

Sometimes the finest sustains longer when drowned under the gross. The fine trickle beneath the plunging waves has always made its presence felt. Cure has always been the visible highpoint of medicine. It is the unseen, unspoken care that needs visibility. Munna bhai was all about that care.

What Does it Mean to be a Physician?

Whitcomb, Michael E. MD

 Extraordinary changes have occurred during the past few decades in the design and conduct of the medical school curriculum. To a great extent, this reflects a commitment by medical school deans and faculties to better prepare their students for the challenges they will face throughout their professional careers. The changes that have been adopted are truly impressive, yet there is still more to be accomplished. I have suggested on several occasions that in order for the medical education community to be clear about the kind of changes that are needed, the community needs to define more clearly the purpose of the educational program.^1,2 And I have suggested that in order to reach agreement on that purpose, the community must first answer a fundamental question: What does it mean to be a physician?

This approach reflects my belief that one of the primary purposes of the educational program is for students to learn, in depth, what it means to be a physician. After all, the title is bestowed upon them when they graduate from medical school, even though they are not yet prepared for the actual practice of medicine. Even so, shouldn’t they have an understanding of what it means to be a physician when they receive the title? In posing the question I am not seeking a formal definition of the term physician that one might find in a dictionary. My intent, instead, is to seek agreement within the medical education community on the attributes—that is, the personal qualities—that a physician should possess if he or she is to be capable of meeting the public’s expectations of a doctor.

Some have suggested that possessing a body of knowledge and a set of skills that can be applied in the practice of medicine defines what it means to be a physician. Now, there is no question that certain knowledge and certain skills are essential elements of being a physician. But it is also clear that the knowledge and skills required vary depending upon the particular career path a physician has chosen. So, while it is essential for physicians to be knowledgeable and skillful in order to engage in the practice of medicine, it is not possible to define what it means to be a physician by identifying a body of knowledge and a set of skills that all physicians must possess. On the other hand, there is a specific set of personal attributes that I maintain all physicians should possess if they are to meet the public’s expectations, and that it is those attributes that define the essence of what it means to be a physician.

First, a physician must be caring. One of the most famous quotes in the annals of American medicine comes from the address Francis Peabody gave to Harvard medical students in 1925.³ In that address, Peabody stated, “The secret of the care of the patient is in caring for the patient.” There are many texts that describe in eloquent terms the value that patients place on being truly cared for by a physician. But in modern times, members of the medical profession have too often equated caring with treatment, and have tended at times to limit their role to providing treatment leading to a cure. Unfortunately, this approach has too often meant that physicians ignored the importance of a caring manner, no matter what the treatment options were. Worse, once a patient could no longer be cured, too many physicians believed that there was nothing more to be done and attended in only a minimum way to the patient’s needs. In fact, it is now clear that caring for patients becomes more critical in situations in which the patient understands that treatment will no longer be useful and cure is no longer possible.

A few years ago, the Hastings Center initiated a project to define the goals of medicine.⁴ One of the four major goals that evolved from the project was called The Care and Cure of Those with a Malady, and the Care of Those Who Cannot be Cured. It is essential, therefore, that physicians understand clearly that to serve the goals of medicine, they have a responsibility to continue to care for their patients when they can no longer prescribe a particular form of treatment or offer the likelihood of a cure. If they do not continue to provide care under those circumstances—that is, by being caring—their patients will sense that they have been abandoned by their doctor at a critical time. Clearly, the essence of what it means to be a physician requires that a physician not allow this to occur.

Second, physicians must be inquisitive. Medicine has a long tradition of celebrating all that the members of the profession know about mechanisms of disease and the diagnosis and management of various clinical maladies. Indeed, admission to the study of medicine and advancement throughout the various stages of one’s career are often based solely on what one knows. But the fact is that there is a great deal about medicine that is not known, and there is a great deal that individual physicians do not know about what is known.

Given that, the value of physicians’ being inquisitive about medicine is clear. This attribute contributes in an important way to the quality of care provided by physicians by ensuring that they continue to acquire the knowledge and skills they will need to meet their professional responsibilities as the nature of medicine changes during their careers. But it is also important to recognize that this attribute contributes in a more immediate way to the quality of the care provided to individual patients.

In his new book, How Doctors Think, Jerome Groopman⁵ emphasizes that most of the diagnostic errors made by physicians result from cognitive mistakes. He points out that because of the uncertainty inherent in the practice of medicine, there is a tendency for physicians when encountering a patient to lock in too soon on a particular diagnosis or a particular approach to treatment. By doing so, the physician runs the risk of overlooking clues suggesting that the working diagnosis may not be correct. Even though a patient may present with the classic manifestations of a particular malady, the true physician will always pause before making a diagnosis and embarking on a course of therapy by asking himself or herself, What is there about this patient’s presentation that I don’t understand? Or, importantly, What is there about this patient that I should know before proceeding?

And finally, physicians must be civic minded. This is a confusing concept to grasp, because in modern times the civic responsibility of the individual physician tends to be obscure. Over the years, this responsibility has come to be viewed as an element of professionalism that is somehow embedded, at least implicitly, within the context of the social contract that defines the medical profession’s responsibility to the society as a whole—a responsibility manifested largely by how professional organizations relate to the public. But Bill Sullivan⁶suggests in Work and Integrity: The Crisis and Promise of Professionalism in America that it is critically important that individual physicians become more personally involved in meeting medicine’s responsibility to society. In his view, they must concern themselves with ensuring that the professional organizations to which they belong are focused on serving the interests of the public, rather than simply serving the interests of the organization’s members. But the civic mindedness of physicians should go beyond that to include consciously contributing in a variety of ways to the betterment of the communities in which they live by participating in community organizations and bringing their special talents to bear in volunteer efforts specifically aimed at improving the health of the public.

So, I suggest that although a physician who is not caring, inquisitive, and civic minded may be a highly skilled technician involved in the practice of medicine, such an individual will not truly reflect the essence of what it means to be a physician. Given this, it is essential that as medical schools continue to modify their educational programs, they ensure that those programs reflect a commitment to ensuring that their graduates be caring, inquisitive, and civic-minded physicians. Deans and faculties of medical schools must understand clearly that while their graduates will spend their residencies acquiring much of the knowledge and many of the skills they will need for the practice of their chosen specialties, it is in medical school that they must learn the essential attributes of a true physician.

Medical Errors - Eighth Leading Cause of Death in the US

According to the Institute of Medicine, between 690,000 and 748,000 patients are affected by medical errors in the US every year and between 44,000 and 98,000 die from them. Even this low ball estimate makes medical mistakes the eighth leading cause of death worse than breast cancer, AIDS and motor vehicles accidents. It also makes medicine far more error prone than high-risk fields. For commercial aviation to take the same toll in the US as medical errors do, a full-up 747 would have to crash every three days, killing everyone on board.

More troubling is the medical profession's traditional response to these disturbing statistics, which has largely involved evasion, obfuscation, minimisation, defensiveness and denial....

"Observing more senior physicians, students learn that their mentors and supervisors believe in, practice and reward the concealment of errors. They learn to talk about unanticipated outcomes until a mistake morphs into a complication. Above all they learn not to tell the patient anything."  - Nancy Berlinger in After Harm.

Extracted from Being Wrong by Kathryn Schulz