15 - 21 August 2002
Issue No. 599
|Published in Cairo by AL-AHRAM established in 1875||Recommend this page|
Fathi Iskandar:Through a lifetime in surgery, he has been faithful to himself -- and to the demands of his profession
The importance of being earnest
The first person to greet us when we arrived at Fathi Iskandar's flat is his wife Reine. Diminutive, yet blessed with an expansive personality, she seems like a more extroverted expression of many aspects of her husband. This is no mere coincidence. Like her husband, Reine is a doctor too. But her chosen discipline is anesthesiology, not surgery. At medical school, she was Iskandar's student; they later married. Fifty years on, her admiration for him remains just as intense.
Click to view caption
Then 'the doctor' himself enters. Tall and swarthy, in the typical way of 'Saidis' (Upper Egyptians), his tan contrasts strangely with his neatly brushed silvery hair, which endows the 72-year old surgeon with an appropriately distinguished air. Where his wife is expressive, Iskandar himself is courteous, yet reserved. Not that he is unwilling to communicate. Yet he is reluctant to personalise issues, constantly steering the conversation away from "his self" -- as if any form of media exposure is somehow antithetical to his work as a doctor. Indeed, he has only agreed to be interviewed on condition that we will concentrate on general questions about the condition of the medical profession in Egypt. Yet, inevitably, what he has to say on these subjects is grounded in a lifetime's experience.
Ice cold drinks are served for the guests, accompanied by shredded coconut biscuits, while Iskandar takes a cup of coffee, in observance of his daily ritual. Air conditioning combines with electric fans in a largely successful attempt to ward off the extraordinary heat outside -- the coolness of the room enhanced by its sheer white walls and understated elegance.
Iskandar is one of our country's leading surgeons, and professor emeritus at Cairo University's Faculty of Medicine. Like many of his generation, he combines scientific, academic and managerial roles in a way that makes him particularly well qualified to judge the condition of Egypt's health service in general, and the practice of general surgery in particular.
He was director of the Qasr Al-Aini University Hospital from 1969 to 1975, at a time when that institution was still in the vanguard of medical prowess in the Arab world. With the advent of the "open door" economic policy in the late 1970s, Iskandar moved on to establish one of the country's major private hospitals, Al-Salam Hospital in Mohandisseen, which he currently chairs.
Today, Qasr Al-Aini mirrors the multitude of problems afflicting both medical education, and the profession itself. The list of problems plaguing the health sector seems endless. Above all, Iskandar cites an educational system overburdened by too many students, to the detriment of the basic learning and training processes required for any doctor. Meanwhile, the public health sector, which caters for the majority of Egyptians, is coming under mounting financial pressure.
Iskandar's experience is not limited to our national hospital administration system. He has also travelled in the Arab world, studying our neighbours' systems of healthcare management. His diagnosis is simple, and his initial perspective, naturally enough, that of a practitioner. A health system must "encourage young doctors to progress, rather than intimidate them". He bemoans the lack of clear job-descriptions to define who should be doing what, and the widening scientific gap between Egypt and the advanced medical centres in the West, which did not exist some 30 years ago.
Al-Salam is to some extent free of these problems, being what is known as an "investment hospital", set up under the 1974 foreign investment and free zones law. As its chair, Iskandar sees such hospitals filling a gap, by providing a high standard of medical treatment, as well as the scientific and technological systems which enable doctors to progress in their specialisations. However, he is the first to acknowledge that the medical system is split in two. On the one hand, expensive treatment in "investment hospitals" for the privileged few, and on the other, government hospitals which, while not absolutely starved of human resources, nevertheless suffer from antiquated management methods, and an overwhelming level of demand.
"Private hospitals do a lot of work in the field of medical practice," says Iskandar. "But they offer their services at a cost which is beyond the reach of most Egyptians." There is no obvious solution to this dilemma: modern medicine is an inherently expensive business. "The only way out would be to expand the medical insurance network. The government could continue to pay part of the bill, but we need private insurance too. The government cannot afford to pay for everything. Today, the state insurance system actually owns hospitals -- that is not its role! Instead, it should seek to collaborate with different hospitals according to the way in which they are managed. Using appropriate criteria, it could then decide where a particular operation or treatment should be carried out, and pay the resulting bills."
Where does Egypt stand today in the field of general surgery? "We are doing well in this respect, but the gap is widening rapidly, in equipment, training and assessment, between Cairo and the Western centres."
Iskandar made his mark as a surgeon performing operations on the biliary system, pancreas and colon, as well as on the parotid salivary glands. Many of these operations relate to diseases which are prevalent in Egypt, such as bilharzia, which affects the spleen and liver, and can lead to varices in the lower oesophagus and stomach. In the late 1970s, along with the late Professor Abu Shadi El-Ruby and Professor Maged Barsoum, Iskandar set up Qasr Al-Aini's first unit for the injection of varices, with funding from the Academy for Scientific Research. Since then, injection of the varices has become a standard procedure in treating this type of internal bleeding.
Iskandar also established the first hepato-biliary-pancreatic specific unit within Qasr Al-Aini's General Surgery Department. He has carried out extensive research in this field, on which he has authored several articles in international journals.
Over the years, he has earned himself a reputation as a doctor for whom system and method are all-important. Patients, as well as colleagues, speak of his characteristic thoroughness, of 'never taking matters for granted' or resorting to quick diagnosis based on superficial observation. When a new patient is admitted, Iskandar takes time to listen to what he has to say, to study his history, and perform a thorough physical examination, whatever may be the source of the referral, prefering to arrive at his own diagnosis independently. Only then will he determine what he believes to be the best treatment.
"Experience has shown that if you reach a diagnosis very quickly, it will probably be wrong," he explains. "Being 'fast' to diagnose is just a way of showing off. Different patients have different needs. An educated patient may express himself articulately, but with someone who is less well educated, the physician or surgeon will need to spend more time listening if he is to understand that person's complaint."
In our age of extreme specialisation, how does he view his role as a surgeon? "We had a professor at medical school, Mustafa El- Sherbini, who would tell us that 'a surgeon is a practising physician,'" Iskandar replies. "By this he meant that a surgeon's task is not simply to implement his technique, divorced from other medical considerations pertaining to the patient. Rather, he must weigh up all relevant aspects before commencing his work. This is what we call 'pre-operative assessment'. And after the surgery, he must adopt the same approach, which is what we call 'post-operative management'. All of this is no less important than the surgery itself, and makes a great difference to the end-result of an operation. A surgeon must start from the beginning. For him to isolate himself and not do so would be a very bad mistake. In that case, the end-results will not be what he wants."
True to this teaching, in 1967 Iskandar headed a unit within Qasr Al-Aini's Emergency Department which was dedicated to the reception of emergency cases. Once the emergency was contained, the patient recieved elective treatment.
Our conversation turned to the younger generations of doctors -- those whom he has taught, or who work alongside him as 'scholars' while perfecting their scientific and professional training. For Iskandar, the main problem faced by the up and coming surgeon today is time, -- that is to say, money. "Most of them do not devote sufficient time to their work." Poor salaries and financial pressures force them to take jobs in more than one hospital at a time, unlike Iskandar and his contemporaries, who enjoyed the luxury of focus and single-mindedness.
What makes a good doctor? Iskandar is adamant that honesty is an important part of competence. "Some people are afraid, when you ask them about something, to say that they do not know. But admitting one's limitations is the fine line separating a good doctor from a bad one. This, along with good learning and good training."
Next October will mark the golden jubilee of his graduation class -- the class of 1952. He is still in touch with many of his former colleagues, and constantly remembers his professors, whom he can name by heart: Shafik Shalabi, Ismail El-Siba'i, Mustafa El-Sherbini and Ibrahim Badran.
I ask him what he has learned from his 50 years as a surgeon.
"The importance of treating all people equally, regardless of their social and material standing, or their education," he replies. "If in illness and pain all human beings are equal, then they must be treated as such, without distinction, and under all circumstances."
This knowledge has guided him in all his life's dealings, and forms the fundamental ethic of the medical profession, without which a doctor cannot be true to his vocation.
It is often said that doctors make good writers, because their work compels them to subject human nature to close scrutiny. How people react to pain, illness and their relief -- these are their constant study. The examples of Somerset Maugham and Youssef Idriss spring to mind. Does Iskandar agree? "Very much so". Though not a writer himself in any literary sense, his long practice has brought him an understanding of people, and "an ease in communicating with them".
The drinks are finished, the coconut biscuits all gone. Rising to leave, we pause in front of a white canvas that occupies a special place in the home. It bears a collage of photographs assembled by Reine -- a present from the family on his 70th birthday. Snapshots of his engagement and wedding. The happy couple standing together in white coats. With their two daughters: here, children; there, grown women, with their own children in tow. (One is now a pediatrician, the other studied business administration.) For Iskandar, his four grandchildren are the 'non-professional aspect' of his life which gives him the greatest sense of fulfillment. These images of the inner circle are followed by photographs of his professors, of his own students -- and of the patriarch himself, standing among the nurses and staff who worked with him at Qasr Al-Aini. He demonstrated his trust in them each day by delegating them tasks, while always being present should they need him. Wherever he goes, his relationship with those who work with him forges a family-like atmosphere, grounded in mutual care and love.
Fathi Iskandar was heart broken the day that the old Qasr Al-Aini Hospital, that venerable institution by the Nile, which had stood for almost 100 years, was pulled down to make way for its new more modern successor.
The trust he inspires in family and friends is tangible, not only in medical matters, but in all aspects of their life. His strong faith forms the pendant to his painstaking approach as a man of science. Should a patient be terminally ill, he will be candid with his family members, but never with the patient himself. Those whom he tends are the full recipients of his empathy, and all know that his concern for their humanity goes far beyond their status as 'patients'.
Every day, he rises and goes to his hospital in Mohandessin, to perform operations and tend to its management. And almost every day, on his way out, he calls on Onsi Sawiris, a close friend whose office is located in the same building where the Iskandars live. Their friendship has been etched over the years -- they have known each other since their youth -- unwavering in its constancy. Friendship for Iskandar is the ultimate relationship, "where you can be totally open with
Letter from the Editor
|WEEKLY ONLINE: www.ahram.org.eg/weekly
Updated every Saturday at 11.00 GMT, 2pm local time