• Medical profession has fragmented owing to increased specialization 
   
• Focus should shift from diseases to patients  
   
• We are at crossroads as a profession 
   
• We have lost our dignity to care for other people  
   
• Our identity should be used to unite and not divide ourselves 
   
• Although SL boasts of a free healthcare system, 40% of per capita income goes to health  
   
• Need to improve quality of primary curative care  
   
• Doctors based in outstation hospitals don’t work the eight hours they are required to 
   
• There are no good or bad doctors. There are only doctors with equal qualifications  

Dr. Ruvaiz Haniffa is the 125th President of the Sri Lanka Medical Association (SLMA) which is the apex medical professional association of Sri  Lanka. It is the oldest professional medical association in Asia and Australasia which brings together medical professionals of all grades and branches. Dr. Haniffa is a Consultant Family Physician and Head of the Family Medicine Unit of the Colombo University Medical Faculty. In an interview with Daily Mirror, Dr. Haniffa spoke about universal health coverage, loopholes in our healthcare system and various breaches of ethics.

Excerpts: 

We have an undisputed role as guardians of the academic, professional, moral and ethical affairs of the medical profession. But we are not punitive. We work through committees. We have a council elected by members. We have standing committees

 Q  What is the difference between the Sri Lanka Medical Association (SLMA), the Government Medical Officers’ Association (GMOA) and the Sri Lanka Medical Council (SLMC)? 

The SLMC is a statutory body established by the Health Ministry to govern the academic and professional standards, the ethical conduct of doctors and any other matter related to the profession. It is the body that licenses the practice of medicine in Sri Lanka. Hence, it is regulatory. 

Then, doctors need to get together for their interests, for continuing medical education (CME) and so forth. The SLMA is one such organization open to all doctors in this country. They can be specialists, non-specialists, government doctors or in private practice or in the university. They can even be university students. Our membership is open to all medical professionals. We are an apolitical, non-trade union, professional and academic body. 

Other organizations are specific. For instance, to be a member of the GMOA, you need to be working in the Health Ministry. I am from the Colombo University. Although I am in government service, I can’t become a member of the GMOA because I am not attached to the Health Ministry. We have the Faculty of Medicine Teachers’ Association at the university. That’s a trade union which lobbies for salary hikes and profession related trade issues. 

Other than trade unions, you have specialists’ professional bodies. If you’re a surgeon, you become a member of the College  of Surgeons. There are 52 such organizations in Sri Lanka. Due to increased specialization, the medical profession has fragmented. There are both good and bad things in fragmentation. We offer an umbrella for all doctors under these 52 organizations. 

We have an undisputed role as guardians of the academic, professional, moral and ethical affairs of the medical profession. But we are not punitive. We work through committees. We have a council elected by members. We have standing committees. Then we have the Sri Lanka Clinical Trial Registry. Without registering with us, one cannot do a clinical trial in the country. This is recognized by the World Health Organization (WHO). 

We organize a ‘Run and Walk’ every year. This time, the theme was ‘Eat Wise, Drop a Size.’ A lot of people are overweight and use drugs for diabetes, hypertension and similar maladies. As a practising doctor, I can say that one cannot treat ailments by taking drugs. You need to have a lifestyle modification. One way is to have the ideal weight. You need not diet but eat wise. 

We also have the Annual International Congress and this year’s theme was ‘Shifting focus from diseases to patients.’ There is no point in treating diseases. You must treat people. For instance, when treating diabetes, for many doctors it doesn’t matter who has diabetes. In the long-run it does. So you need to treat the patient. He or she might have some other issue along with diabetes. If you don’t take that into account, treatment won’t be effective. So this is why we thought that the focus should shift from diseases to patients. 

The SLMA has been around for 131 years. But the challenge is, will we be there for another 131 years if we go on like this? We are at crossroads as a profession. Where are we heading to? We have divided ourselves into 52 groups and each demands a separate identity. When I introduced myself, I told you that I was a family physician. I didn’t say I was a doctor. I am conscious of my identity and I want to project that. This identity has started to divide us. We are fragmenting. In my profession, I can treat you, your father and even your grandfather. I am a general practitioner. But if I’m an obstetrician, can I treat Mr. Perera who comes to me? No, I can’t. So where is ‘medicine’ in medicine? I am not saying it’s bad, but we need to get back to how we treat patients. I am an expert in family medicine, but can I care for people? You can’t care for people if you don’t know the art of caring. We should know how to talk and conduct ourselves. We have lost dignity in the profession. We are affluent. As a doctor, you can amass a lot of wealth. But what we have lost is our dignity to care for people. Our identity should be used to unite ourselves, not to divide. 

This year, the WHO’s health day theme was ‘Universal Health Coverage: Everyone, Everywhere.’ It is a concept where you want everyone to have access to basic healthcare. We want to promote this concept in Sri  Lanka. 

 Q  Sri Lanka provides basic, free healthcare. What more should be done to achieve universal health coverage? 

Although Sri Lanka has a free healthcare system, 40% of per capita income goes to health. So, to achieve universal healthcare, you need to give a basic, essential package of care. This will include fasting blood sugar and lipid profile. This cost will be borne by the State. The investigation cost will go down. When it comes to drugs, for instance anti-diabetes, you have to go to a big hospital. So your transportation cost will reduce when it is made available at the primary medical care unit. 
We need to improve the quality of primary curative care which includes the vaccines given. When it comes to a cough or a cold, the focus is on how to treat. The key is to train doctors. The centre has to improve. You need the help of Provincial Councillors, MPs and other eminent personalities as this is a policy decision. You need that political and bureaucratic assistance. 

 Q  What loopholes have you observed in our healthcare system? 

The biggest loophole is the bypassing phenomenon. For instance, Ragama has a top-class centre. But people don’t go there. They bypass that centre and come to Colombo and then the hospital is overcrowded. That has a knock-on effect. Doctors want to come to Colombo too. For instance, those who pass out from the Eastern University don’t want to stay there for various reasons like having better schools for their children. This is while they’ve been provided with all facilities to work in that hospital. 

So, if you can stop the bypassing phenomenon and provide care at the local hospital, that would be the best for the system. There won’t be a wastage of money. All resources will be utilized. 

The other loophole is maldistribution of medical officers. Most of them are in big hospitals. Doctors based in outstation hospitals don’t work the eight hours they are required to. Even at the Colombo OPD, you just work for two hours or so. There should be someone to monitor and look into the working hours of doctors. 

 Q  What breaches of ethics have you observed in the medical profession today? 

The biggest misunderstanding and potential cause for negligence happen because the medical officer doesn’t take time to sit down and explain what is going on with the ailing patient. The doctor might know what is going on, but not share that information with the patient in a patient-centred way. So the patient goes from pillar to post trying to figure out what’s going on. This lack of communication leads to a lot of ethical issues. 

 Q  When is a doctor liable for medical negligence? 

Negligence has to be proven in a court. According to medical ethics, we have to act in the interests of patients. We have to do no harm. If you’re not skilled enough, you are at a high probability of inflicting harm on patients and being negligent. So number one is to have a good, skilled doctor out there. You need to have a very good regulatory training system. That is the role of the Sri Lanka Medical Council. It will have to investigate these things. This is within the profession. There are categories where the doctor is barred from practice for six months, for life or the doctor might be sent for retraining. Beyond that it’s a litigation issue. 
The negligence can be something as easy as not being able to read and diagnose an ECG. That is being very negligent. Part of our role through the continuous medical education is to see such things don’t take place. The primary interest is the public. But as a profession, we want to improve our standards to provide a better care to the public. 

 Q  There is concern over certain doctors promoting particular pharmaceutical products in return for benefits offered by corporates. What are your thoughts on this? 

As a doctor, I am approached by agents of these companies. I do meet them. That is the reality. But it is up to me to see how I ethically conduct myself. We have given ethical guidelines on how to deal with the pharmaceutical industry. To be fair by the pharmaceutical industry, they too have prepared guidelines on what they can do and shouldn’t do with us. But some people from both parties misuse this system. They get undue benefits from each other. This happens. So you have to prevent unethical practice by doctors and the pharmaceutical industry. 

We have an undisputed role as guardians of the academic, professional, moral and ethical affairs of the medical profession. But we are not punitive. We work through committees. We have a council elected by members. We have standing committees

 Q  When it comes to private practice, people claim that doctors are money-minded and that they don’t spend sufficient time with patients. How does the SLMA try to assure that doctors fulfil their duties? 

Doctors are spread all over the country. If you really analyze the situation, overcrowding and the fact that doctors don’t have time is with the busy doctor who has more patients. Why are patients going to particular doctors? Because they feel they provide good care. If they think they can get that care in 10 seconds as opposed to an equally-qualified doctor who will give you 45 minutes, it’s a patient’s perception of the problem. As far as I am concerned, there are no good or bad doctors. There are doctors with equal qualifications. This is what the SLMC assures. If people consult popular or unpopular doctors, that categorization is not by the profession. It is by the public perception. So where you make the difference is probably how you talk -- the soft skills in the doctor. It is like voting for what you like. 

We know that there is overcrowding and doctors are seeing patients late at night. But if there was no demand, doctors wouldn’t do that. So it’s demand-driven because you must understand that doctors are also practising a profession. What we as an association can say is do it ethically. We can only say, but we cannot enforce. 

 Q  Do you think euthanasia should be legalized in Sri  Lanka? 

We have a committee on palliative care -- end of life care. Currently, the end of life care does not mean euthanasia itself. Euthanasia is medically assisted termination of life. That includes a lot of medical and social issues, religious beliefs, values and so forth. Euthanasia is a western concept. I know we practise western medicine, but we do it in an Asian culture. In our opinion, we have to take the cultural factor into consideration before recommending anything. You might also ask about abortion. 

 Q  I was coming to that…

Even there you find a termination of life. In such an instance, it has to be contextual -- in Sri Lanka what do we do? As a profession, we can make recommendations. Again, the ultimate decision has to be made by parliamentarians who reflect the public opinion. The doctors’ opinion is also reflected there. We do a lot of work on ‘end of life care.’ We want to improve the quality of it in Sri  Lanka.