When does charity acquire its true purpose in medical training?
What do we exactly mean by charity?
As a nation of Christians, that question need not even be asked. Well, I ask myself the question anyway because in meetings and visits of the training program accreditation committees of the different specialty societies, someone always brings up the question: “ Do you have charity patients?”.
What exactly are charity patients and how is charity given?
In straight language, charity patients are sick people who are poor – or poor people who are sick – and cannot afford to pay for tests or treatment, much less the doctors’ professional fees. The hospital wholly or partially subsidizes their care because either the hospital is owned and run by the government (in which case these poor citizens are supposed to experience the existence of a government), or the privately-owned hospital needs the patient volume to keeps its training program accreditation secure. The former is about good governance and winning elections; the latter is about meeting minimum requirements. In both cases, the poor patients submit themselves to the hands of doctors in training who need “to be exposed to various cases” before they graduate.
Within the period of their training, the doctors hopefully progress from being untrained to partially-trained to fully-trained in the field of specialization of their choice, measured – as the accreditation committees would seem to indicate – by the number of cases that they treat on their own, i.e., without interference from their superiors or consultants. As in every learning process, this usually means gaining wisdom and experience from encounters that call for good judgment but which, as a matter of course, frequently falls short of expectations. Indeed, wisdom is expected to emanate from mishaps of judgment. In the traditional sense, the more encounters that challenge the doctor’s judgment, the better the outcome of his training. In all this, the backbone – as the training program would like us to think – is the ‘charity patient’.
Having ‘charity patients’ thus represents the ‘ideal set-up’ by which doctors in training can have a wider latitude for learning. That actually also means a higher threshold for tolerating medical errors. The implicit paradigm here is that a ‘charity patient’, by the indigent nature of his condition, can hope to receive a standard of medical care only up to the extent that he is able to afford, and only to the limit that a trainee-doctor is capable of providing. In a government hospital where there are many of his non-paying kind, he is a statistic that comes and goes through human traffic, remembered only for the interest that his case might generate for training purposes. In a private hospital required to maintain a minimum number of beds for poor people with ‘interesting’ diseases, he is an oddity on which tests are done and treatment protocols are applied. In both places, he is a disease.
His is one more case that the doctor-trainee can learn or gain confidence from; or one more case too many that the doctor-trainee can excel in and, in time, be renowned for.
So, come to think of it, who is really giving charity to whom?
Whoever coined the term “charity patients’ might have done so with real service in mind once upon a time. But training programs and accreditation committees that are asking for – nay, requiring! – ‘charity patients’ must begin to listen to themselves say it aloud…and to realize how pejorative and obscene ‘charity’ has become! They must seriously examine the wide disconnect between what a good training program really needs and what they are asking for so that they would realize that the term “ charity patient” entrenches the status quo : a third-world paradigm that exploits poverty, relegates patients to numbers and cases, draws doctor-trainees away from establishing a more meaningful and interactive relationship with the patients, and ill-prepares them for the delivery of holistic care in private practice after their training.
I may sound a bit too harsh, but I hope people in charge of evolving a relevant and meaningful training program do give it some thought. It is about time that we notice the warp that we have been in, see beyond the boundaries of tradition, and change the patterns of our thinking. Is what we are asking for aligned with what we are really after? The practice of medicine is rapidly changing, and so are our patients. Patients are now more aware of their rights, and if they are not, they soon will be. As more doctors leave the country, less students take up medicine, more poor people learn to question and demand, and more rich people ask for what the poor people are having, the playing field will even out, training will no longer depend on other people’s poverty, and charity will apply to all people rich and poor.
Where patients abound, the wealth of opportunity for learning astounds. Every patient is a source of knowledge, just as every interaction between two individuals is a potential source of wisdom. But the patient doesn’t have to be poor and indigent to provide the trainee the learning opportunity. The opportunity is not premised on his poverty or helplessness; it rests mainly on the ability of the trainee to communicate with him and engage him in an interaction that acknowledges his role in the management of his health.
If the trainee cannot learn to do this with patients who are well-to-do (private patients, we call them) then he is not ready for a medical career in the real world where he cannot make medical decisions unilaterally, where he is required to temper his clinical judgment with the decisions and wishes of his patients. If in private practice, the best physician is the one who deals with his patients holistically, why don’t we then prepare our trainees for the future by focusing on the quality of their diagnostic and treatment skills, honed not by the passivity and submissiveness of their patients but by the ability to communicate and engage them in a real partnership. Indeed, how else can training be best acquired than by a physician-patient partnership that assures continuity of care? Where, in all this, do ‘charity patients’ become essential?
If in every worthy endeavor we measure success by the quality of the outcomes, what are we measuring by the quantity of ‘charity patients’ that the residency training programs require? The free treatment that is dispensed by the trainees or the “free training” that the poor patients provide them? Shouldn’t we instead be training our sight on bigger measures of quality that aligns higher learning with sophistication of thought and elegance of behavior, engages trainees and patients in the healing process, and prepares graduates of our specialty training programs to face their own humanity?
I really hope that the specialty societies begin to look at the changing world of health care and medical practice with a lot more foresight. I hope that new leaders would emerge who can begin to challenge the reasons why we do what we do. We cannot be doing more of the same every year and expect changes to happen – certainly not the ones that we dream of or the kind that we wish to lead!
The fragmentation of medical care into organ systems and body parts, into mind and body, is not separate from the compartmentalization of our view of the world into the rich and the poor, the intelligent and the ignorant, the active-inquisitive and the passive- submissive. I wish that the medical profession would find integration, coordination and wisdom amid the unfortunate changes that we ourselves are responsible for. May we continue to be charitable, but no longer for utilitarian purposes, so that we, too, can experience charity the way real charity alleviates the problems of the world.
In time.
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