Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa S, B.A.M.S
A wise physician should choose his patients wisely. He should have clarity so as to which patients he should be treating and whom he shall be rejecting. He should know his limitations.
All Acharyas have described ‘rejectable patients’ – the ones whom the physicians should not be treating. In this article we will study ‘Tyajya Rogis’ i.e. patients who are worth rejecting and the reasoning for the same as explained by Acharya Vagbhata in Ashtanga Hridaya Sutra Sthana, Chapter 1 (Ayushkamiya Adhyaya) – A.Hhr.Su.1/34.
Below mentioned patients should be rejected and not treated by a wise physician –
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Bhishak Dwishtam – the patient who is hated by the physician
There should be a reason why a physician should hate a patient. The patient should have been non-obedient, of bad manners and ill-behaviour and mis-conduct, who has bad reputation and hated by many people, including his family and friends, is untrustworthy, is a criminal or habitual offender and is wanted by the law or government and many other reasons why a physician thinks that it is not wise to treat the patient. Such patients will neither obey the physician’s instructions nor follow the advice. All these would bring insult and loss of name and fame to the physician.
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Bhupaihi Dwishtam – the patient who is hated by the king
These persons may be ‘wanted’ criminals or outlaws or traitors or law-breakers or obsessive offenders. They may also be the ‘abandoned’, not allowed to live in the city or country. Basically these are the people who are unwanted, untrustable or punishable persons. The word Bhupa means king. The meaning may also be extended to include the heads of the state or country, city or village-heads or Government officials who occupy positions of importance and decision-making. When such patients are treated, the physician may invite the wrath of the king or country.
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Tesham Dwisham – the patient who hates the physician or king
These people are obvious threats for the physician or king, state, country or government. The person who hates the physician may hurt the physician physically, emotionally or bring bad-repute in his profession. Such patients will also not be obedient and submissive to the instructions of the physician, even if they visit one. This will lead to failure of treatment and bring bad name for the physician. Similarly, the person who hates the king will be considered a traitor or outlaw. If treated, they might not even show gratitude nor change themselves. In fact they might bounce and pounce back to damage the reputation of the king and the country as they are committed or obsessed with the same.
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Dwisham – patients who hate themselves
These are the most helpless species. They question their own existence and importance in the world. They feel everything including themselves, and their health to be insignificant – ‘I hate myself’ type of people. When a person does not love himself or herself, hates themselves, does not feel the importance of their health and cannot be convinced over even a few talks or positive motivational sessions, there is nothing much a physician can do to bring them on the ‘healing track’.
On the other hand, we need to understand that these patients should not be treated when they are in a state of self-hatred and given up all hopes or a mindset to think positively. If they can be edited out after many sessions of counseling or psychotherapy (sattvavajaya chikitsa, dhi-dhairya-atmadi vijnanam), they shall be treated if the physician is convinced that the patient would religiously follow his or her instructions.
We need to remember that the patient (rogi, atura) is also an essential component of chatushpada (four limbs of treatment) and he too has his share of responsibilities if the treatment needs to hit ‘success’. If the patient does not volunteer into the treatment process, there is nothing much the physician, medicine or caregivers can do about it.
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Hinopakaranam – the patient who is not well equipped
One of the important qualities of an ideal patient is ‘adhyo rogi’ which actually means ‘being wealthy’. The meaning should not be limited to ‘being wealthy’. It also described ‘being well equipped in all possible ways’ and also ‘being prepared to undergo treatments of any kind as advised by the doctor’. Nowadays we see that the front office of well equipped hospitals would like to see your insurance papers before even considering your admission into the hospital to ensure that you can afford the stay and treatment and all expenses that would come your way while in their jurisdiction. Upakarana or equipment also includes having a good quantum of friends, family members or people of good will to be with you and take care of you, until and after discharge.
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Vyaghram – the patient who is always busy in his own activities and not giving attention towards health or treatment
Here, there is an element of negligence. If it is topped up with ignorance, it becomes a difficult combo to handle. The priorities of these people will be something else and ‘health’ always comes last in the list of priorities.
Example – a businessman who is totally focussed towards his meetings and deals will not commit himself or herself to the business of health. ‘We will see when it is badly needed, not for now!’ type or ‘Do I have to get admitted now itself, can’t it wait, doctor? Can I take the treatment after a couple of months? I am too busy with my business appointments and travels’ type of persons. They will neglect their health issues when they are at a budding level and allow them to progress to a point of ‘difficult to cure’ or ‘impossible to treat’ status.
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Avidheyam – the patient who is not obedient
Disobedient patients are the greatest obstacles in the journey of healing. They do not follow any instructions given to them regarding treatment, medicines or lifestyle changes. Bhisak Vashya – being submissive to the physician and following his instructions is an important quality of Rogi (the patient). He or she should possess this quality mandatorily for the successful execution of treatment.
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Gata Ayusham – patient whose life-span seems to have come to an end
Acharya Charaka has dedicated an entire section of Charaka Samhita for describing various kinds of Arishta Lakshanas – ‘signs of impending death’. In the presence of Arishta Lakshanas, the physician should reject the patient. This would prevent the patient from becoming a victim of bad reputation and from losing everything – name, fame and wealth. So, a person showing signs of impending death shall be rejected. This includes all critically ill patients and those who are surviving on life-support, whom the life itself has abandoned and the physician finds no sign of making them live more. They too have a right to live but life itself is not sustainable. Physicians may continue treating them with an undertaken consent of family members.
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Chanda – patients having evil minds and are violent and destructive in nature
These persons need rehabilitation and counseling rather than medicinal treatment or therapies, which also comes under treatment. From this, we can understand that some aspects considered by Acharya Vagbhata in this context of ‘patients unfit for treatment’ explains the strict inclusion of ‘medicinal and therapeutic part of treatment’ in the discussion and might have omitted certain aspects of treatments. On the other side, we should also see the time period when these treatises were written and the administrative rights and decisions at that time. Treating certain patients was under the control of laws and regulations of the state and orders of heads of the country (king) or state. If the patients who are Chanda are treated, they may yet again prove dangerous and destructive for the state, which might also get bad repute to the physician. Seeing from today’s context, these people should be counselled and subjected to intense psychotherapies in specialized institutions and monitored until they are rehabilitated.
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Shokatura – patients who are in deep grief
The same hypothetical discussion we had in the context of Chanda is also applicable here. The mind is an important component which needs to be addressed not only in mental disorders but also in psycho-somatic disorders. According to Ayurveda, physical and mental disorders will have an impact on each other at some point of time and the same is accepted by modern medicine too. Persons suffering from severe mental illnesses are seen not to respond to any kind of medicines or therapies even in today’s context. The idea is to subject these people to intense sattvavajaya chikitsa (psychotherapy) initially and then treat their health issues once the grief factor is deleted out of the equation. But we may get a doubt that science sattvavajaya is also a form of chikitsa (treatment) and might fit in the treatment protocol of Shokatura, why did Acharya consider these patients to be rejectable? Maybe Acharya was pointing towards a more comprehensive approach and calling for a serious attention of ‘mind factor’ along with other medicines and therapies, in a different setup rather than a simple conventional medicinal approach. We need to see the hidden inclusive rule in the exclusions. Shokatura needs help and support from physicians, family and friends, a combination of daiva vyapashraya, yukti vyapashraya and sattvavaja chikitsa and they need to be differently planned and methodically executed.
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Bhiru – patients who are in a state of immense fear or panic
The same hypothetical discussion made in the context of Chanda and Shokatura is also applicable for Bhiru. These people need serious help to pull them out of the whirlpool of fear and panic in which they are deeply stuck.
Note – In case of Chanda, Shokatura and Bhiru – ‘rejectable’ means they should not be initially treated with medicines or therapies like Panchakarma therapies and ‘temporarily rejected’ until their mind is brought to a state of balance and the patient is under the control of the physician and his instructions so as to volunteer willingly into the treatment process. Else, all the efforts of the physician will become futile. The idea is ‘not to reject the patient always and by all means’. The instructions by Acharyas should be contextually understood and not merely on the meanings of their words. We also need to see in some of the contexts, the time period in which these instructions were laid on in the treatises by these wise men. Ayurveda is always a compassionate medical science and believes in treating every patient equally. At the same time, the idea was to save the skin of the physician and create a sense of responsibility and thought of skilfully shortlisting the patients that he wants to consult and is capable of doing the same. Being an important component of the society and a ‘life saving entity’ the respect of the physician should be guarded and that comes when he practices within the walls of meaningful restrictions, rules, laws and regulations – applicable to the time period in which he is living.
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Krutaghnam – patients who are ungrateful
These persons behave as if they have done favour to the doctor by visiting him or her and it is because of them that the physician is making a living. They appear un-social and do not display any social manners like a ‘thank you’ or even a social smile. Basically they are arrogant people with plenty of bad attitudes. They have never learnt to respect anyone or haven’t shown gratitude to anyone. Though helping out every single life is the responsibility of the physician and also his dharma, ungrateful persons would definitely disturb the balance of physicians. The healing process is a happy partnership and an ideal combination and synchronization of physician, patient, medicines (diet, therapies, lifestyle changes) and attendants. The synchrony, good-will, positive vibe and eagerness of providing best service will be put into dysrhythm when ungratefulness is displayed by the patient.
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Vaidya Maninam – the patient who considers himself / herself (equivalent) as a physician (in terms of deciding and selecting herbs, therapies, diet and activities)
These are the most dangerous persons whom the physician might encounter every-now-and-then or might not like to encounter at all. These over-smart persons assume or strongly believe that they know everything and for them the physician or his opinion comes only second to what they have. These people cross-check the wisdom of physicians with theirs. That is the reason they visit clinics and hospitals. They also try to prove a point that they know better than the physician and narrate everything they know about ingredients of health-service. They even carry evaluation meters into the consultation chambers and rate the doctors they visit. They are also dangerous to themselves. In spite of consulting the physician just for fun or as a game, they clearly know they are going to swallow pills, eat stuff and live according to their knowledge. They will never follow anything the doctor tells them to do. They are also doctors for their family members and friends and keep sharing their knowledge on social media as well. People often mis-diagnose them as doctors. There are hell lot of people who believe in such persons in comparison to a qualified doctor. These disguised doctors are called as chadma-chara vaidyas in Ayurveda i.e. non-physicians who are in the mask and disguise of a doctor. It is wise for a qualified doctor to surrender to the knowledge of such so-called-doctors and leave them be!
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