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| Tuesday, 22 July 2003 |
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Empowerment is the key The Moving Finger by Lionel Wijesiri The era of doctor-knows-best medicine is fading. The ever-increasing power of consumer lobbies has not spared the medical profession. And nor it should. There is a clearer view now of the doctor-patient relationship as a partnership, where each party has coexisting rights and obligations. The doctor's duty of care can be negotiated, according to the patients' beliefs. This is arguably a far superior model of care, but it does deprive the medical profession of some of the power and influence it once wielded, which some doctors find difficult to adapt to. The whole point of medicine is said to be the empowerment of patients to take control, and to make appropriate decisions on questions affecting their health and their life. How can this concept be consistent with the medical profession's denial of this fundamental right? Empowerment is a strong word in the medical field. Traditionally, it has always been that only doctors be empowered to handle patients' health. However, with today's changes in the healthcare industry, doctors have been forced to cut down on treatment time, while patients are forced to stay mum. As a result, patients have never been truly empowered with the ability to monitor and manage their condition effectively. Doctors on the other hand have never had sufficient time or resources to give patients this empowerment. One-way traffic 'One-Way' is defined by the Oxford Dictionary as "moving or allowing movement in one direction only". It is an apt description of the status of patient education in Sri Lanka as it was conceived and practised in the past. Not only then: the underlying assumption in most books and articles on the subject today is still that patient education is one-way traffic: from physician to patient. The public (actual and future patients) is there to receive the blessings of health education from above. Of course, education is based on the principle of knowledge being handed down from those who know a lot to those who know less or are ignorant. The problem is not that some will teach and some will learn, but that the process is regarded by most by health professionals and policy makers as one-way traffic. Experts are conscious of the problems. Health care literature is productive on the need for attitude change, backed by academic and field research demonstrating widely acknowledged deficiencies. Again and again health professionals are given the results of surveys of patients' attitudes and are advised to improve their communications. Volumes are written on how to deal more effectively with patients' complaints. Yet all of this aims mainly at improving the educational skills of health professionals, not those of patients. The impression persists that patients are only recipients, not contributors to health education. Health care professionals tend to prefer a passive laity to one that sets out to meddle with experts by attempting to contribute actively to joint decisions. Indeed, the word activist embodies the establishment's fear of the troublemaker and kindles equivocal emotions in those whose attitudes and practices are being questioned. In health care, the educated patient will inevitably be more active than the established system has reckoned or foreseen. Once-upon-a-time, health was a privilege. More recently, it was pronounced a right: one that patients may or may not be able to exercise fully under a variety of national systems. Now, health is fast approaching the status of a necessity in the developing world. Increasing longevity, greater social mobility, the progressive disappearance of support from the extended family - these trends speak for themselves. As health becomes a necessity, so does health education. The two go hand in hand. The span of education ranges from the promotion of healthier lifestyles and an understanding of risk factors for the prevention of many infectious and chronic diseases, to providing knowledge about their disease to sufferers, their families and their carers. Among what I consider a typical response, a patient I met at the General Hospital commented: "I need to know what the drugs I actually am on do, as in what prevents it, what to know if I have an attack, which one do I need, not just to be told it, but I need to know why. It helps me to understand." What empowers? On the health benefits of empowerment there is no dispute. The sensible medical professionals accept that the more empowered people are - the more affluent they are, the better they are educated and the more they are in control of their lives - the longer and healthier their lives. But what empowers? Can a doctor cajole or coerce a patient to feel free and in charge? On the face of it, such attempts are doomed to fail, even if the patients succeed in tricking others into believing they're in control and coping well. Similarly, coercing patients into pretending that they are happy could also increase their sense of helplessness and hopelessness. An immense amount is at stake in discovering the secret to empowerment: But although the medical world knows empowerment somehow relates to socio-economic factors such as affluence and education, it can only guess at the actual mechanisms or underlying factors at work. And yet, despite the stakes, a few of those who would reform health care in Sri Lanka have promised to implement the empowerment of patients. After all, it serves not much purpose in the Government's spending money on patients' behalf, without giving the patients the power to spend on their own behalf, despite the success that this approach has had elsewhere in the world. |
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