Take care!

Based on the Presidential Address to the Ceylon College of Physicians, delivered at the ceremonial induction held at the BMICH.

As we all entered the New Year, the Ceylon College of Physicians, one of the pioneering and premier professional organisations of medical specialists in Sri Lanka entered the second 50 years of its existence. Its achievements at this point are many and enormously important – but so too are its future challenges. This is, therefore, a time for both celebration and reflection.

The College was inaugurated in 1967 by eleven pioneering consultants, who met at the consultants’ lounge in the General (now National) Hospital Colombo and resolved “…to promote an academic postgraduate medical college for physicians, paediatricians, and psychiatrists.” At that time our doctors received their specialist training in the UK, from where they obtained world-renowned qualifications such as MRCP (London) or FRCS (England). These pioneers were responding to the need to create a process that would enable our country to train its own specialists, which would be both contextually more appropriate and economically more viable, without compromising on the internationally recognized standards that the country already possessed.

This was necessarily a task for many sectors to take up in unison: the healthcare sector, the academia and the profession. Perhaps the best possible start was provided in 1959, when Prof K Rajasuriya commenced the MD (Ceylon) postgraduate degree, which quickly established itself internationally: in the words of Lord Rosenheim, chief examiner of the MRCP (Lon) and external examiner at the MD (Cey): “Your degree of MD is awarded on the results of a very searching examination, the standards not differing from the London Membership [MRCP]. We place Australia, New Zealand and Ceylon on the top bracket. I hold your MD in very high esteem.”

The College was founded in 1967, with Dr E.M. Wijerama as the founder-president and Prof Rajasuriya himself as the president who followed him. From then on through the 1970s was the trying, tentative gestation period of creating the local training process that everyone wanted, with the College itself playing a pivotal role and providing the input from the profession. It was eventually born in 1980, with the establishment of the Postgraduate Institute of Medicine (PGIM).

Today the pioneers’ dream is fulfilled – our country now produces an adequate number of specialists, not only in the speciality of Medicine but also in just about every medical speciality. The PGIM has become a robust, highly cost-effective institution that produces our specialists in the required quantity and quality.

The contribution of the College to this process has been crucial and essential. It was part of the initial process of conceptualization – a crucible of disparate ideas from diverse sectors that helped bring forth a composite, harmonious whole. It has provided the academic training programmes for trainees, as well as continuing professional development (CPD) for practising specialists. When the finer specialities emerged, the College encouraged and nurtured them, and we now have a healthy plethora of these with their own vibrant colleges and professional organisations, producing a close-knit family with the College as the overall, much-loved umbrella. Throughout, it has continued to maintain close links with overseas professional colleges, both in the UK and elsewhere; our outlook is, therefore, both locally situated and globally informed.

The backbone of our College has always been the generations of dedicated members who have given their time, energy and priceless intellectual input to our numerous projects. They have worked tirelessly, voluntarily and often at their own expense. They are conscious of how much they have benefitted as individual citizens from the nation’s collective gifts of education, training and professional status. And, having not squandered away those gifts nor emigrated, they are now determined to give back to the profession and the nation, both individually and collectively. The College is a collectivity that we all value and are proud of – a lasting legacy of professional excellence and dedication.

Facing the future

But the global human society is in transition. We all face enormous challenges that would haunt future generations: climate change, environmental degradation, increasing and ageing population, unplanned urbanization, untrammelled consumerism, increasing socio-economic inequity, increasing violence and wars, and more disease emergence.

How much longer can ‘business-as-usual’ continue before humanity loses everything it has gained, including its many health-related successes? Lester Brown, one-time vice-president of Exxon and later founder of World watch Institute, warned: “Socialism collapsed because it did not allow the market to tell the economic truth, and capitalism may collapse because it does not allow the market to tell the ecological truth.”

These broader social issues will affect our health and disease too because human health is inextricably intertwined with not only our biological environment but also our physical and social environments. This understanding was crucial to medicine’s shift in the 1970s from the biomedical model to the biopsychosocial model, first articulated by psychiatrist George Engel. They will also affect our health-seeking behaviour and health systems because these are integral parts of our general human and societal responses. This understanding was crucial to our shift from a narrow, health sector-limited societal response to a broader, multi-sectoral approach, first articulated in 1974 by Canadian Health Minister Marc Lalonde as the Health Field Concept.

But not only these issues, even the ‘solutions’ offered for them by the global elite could themselves become problems. Such ‘innovations’ are often mass-produced commodities that swamp over the lives of people everywhere, leading to the McDonaldisation of healthcare. Instead, solutions need to be both effective and appropriate to the contexts that people live their lives in, what they find able to afford, understand and accept. Professionals both understand the science and look after the people in their own settings – they are therefore in the right place to decide on the appropriateness of solutions.

As the pace of all this change quickens, the challenge of understanding, responding and adapting to it will become harder. For the medical profession, it is no longer enough that we understand science and technology well – we must also understand the human mind and society better. And our awareness has to extend beyond our own immediate surroundings into what is happening in the far corners of the world today because globalization enables them to affect our own corner of the world tomorrow. What is more, it is not enough that we merely understand it – we must also be able to predict, advocate and give directions to that change, at least for the benefit of our own part of the world.

Thanks to our College and other colleges and organisations like it, in Sri Lanka the medical profession has successfully made the quantum leap from a collection of individual doctors to a collective profession. We must now make the leap from a profession that prescribes remedies to sicknesses to an intellectual force that understands the local and global undercurrents that create sickness.

It is opportune for us to reflect on what Rudolf Virchow, one of the most brilliant of modern physicians, said about medicine in the nineteenth century: “Medicine is a social science, and politics is nothing else but medicine on a larger scale.” (Here, of course, the word ‘politics’ is used in the broad sense, as in Aristotle’s Politics.)

Our strategies

As a responsible and important group of citizens, the medical profession must evolve into a proactive group that understands these undercurrents and advice and advocates to our society what our response should be. We need to evolve from a profession of service-providers into being, in addition, a force of public intellectuals.

Our strength is science – the approach to understanding our world that gives it its reliability and validity and yields and guides effective responses. We need to expand our scientific know-how from the natural sciences to the social sciences; from the physical, chemical and biological sciences to the psychological, social and environmental sciences.

Our guide is professionalism – the contract we have with the society that gives us our legitimacy, dignity and independence, in return for our social conscience, disinterested service and responsiveness.

Our toolkit is knowledge – not only the declarative and procedural knowledge that we acquire in our training but also the conditional knowledge that comes from reflective practice and from exploring the humanities.

Hence our theme for the College this year: ‘Inventing the future: with science – professionalism – knowledge.’

The College invites not only its own members, but also all medical professionals and, indeed, the wider society to join it in an effort to get ready for the future. Join us and support us in this broad, collective and multi-sectoral effort as we face our common future – a future we can successfully negotiate only if we work together. As computer scientist Alan Kay said: “The best way to predict the future is to invent it.”