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=== Introduction ===

== Introduction ==

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As the name suggests, the chapter deals with the four minor but equally important components of healthcare management.(''Khud'', or minor/short, ''Chatu'' , or four, and ''Pada'', or components/parts].By using the term ''Chatushpada'' i.e. four equivalent components, it is indicated that contribution from all four factors is equally important for successful management of health and disease, although the physician plays the most important role. Incorporating the best qualities of each component (i.e., Physician, patient, medicine and care-taking attendant) assures success in treatment. If any of these components does not play its role properly, then it may lead to inadequate management of diseases. This chapter describes the qualities expected in an ideal physician, as well as his/her roles and responsibilities required to fulfill the job as a medical practitioner. [[Ayurveda]] provides for a holistic healthcare management framework, addressing all key aspects of management. This is evident in the fact that the role of patients is also factored in medical management and a patient is also expected to have certain qualities for good outcome of treatment. It is observed that happiness, optimism and satisfaction of patient enhances the chances of cure in any hospital. There is a synergistic relationship between the healthcare provider and the beneficiary. But the role of the physician and the attendant in providing compassionate service to the patient is critical to the treatment process.

As the name suggests, the chapter deals with the four minor but equally important components of healthcare management.(''Khud'', or minor/short, ''Chatu'' , or four, and ''Pada'', or components/parts].By using the term ''Chatushpada'' i.e. four equivalent components, it is indicated that contribution from all four factors is equally important for successful management of health and disease, although the physician plays the most important role. Incorporating the best qualities of each component (i.e., Physician, patient, medicine and care-taking attendant) assures success in treatment. If any of these components does not play its role properly, then it may lead to inadequate management of diseases. This chapter describes the qualities expected in an ideal physician, as well as his/her roles and responsibilities required to fulfill the job as a medical practitioner. [[Ayurveda]] provides for a holistic healthcare management framework, addressing all key aspects of management. This is evident in the fact that the role of patients is also factored in medical management and a patient is also expected to have certain qualities for good outcome of treatment. It is observed that happiness, optimism and satisfaction of patient enhances the chances of cure in any hospital. There is a synergistic relationship between the healthcare provider and the beneficiary. But the role of the physician and the attendant in providing compassionate service to the patient is critical to the treatment process.

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===Sanskrit text, Transliteration and English Translation===

==Sanskrit text, Transliteration and English Translation==

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Now (I) shall expound the ''Khuddakachatushpada'' (chapter on four components of healthcare in brief) as propounded by Lord Atreya.[1-2]

Now (I) shall expound the ''Khuddakachatushpada'' (chapter on four components of healthcare in brief) as propounded by Lord Atreya.[1-2]

==== Four components of Healthcare ====

=== Four components of Healthcare ===

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Physician, medicine, attendant (nursing staff) and the patient, these are four components  which, all in their best of qualities are responsible for the complete cure of disease. [3]

Physician, medicine, attendant (nursing staff) and the patient, these are four components  which, all in their best of qualities are responsible for the complete cure of disease. [3]

==== Definitions of disease, health, happiness and unhappiness ====

=== Definitions of disease, health, happiness and unhappiness ===

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Disequilibrium of ''dhatus'' is disease and their equilibrium is health. Health is termed as happiness, while disorder as unhappiness. [4]

Disequilibrium of ''dhatus'' is disease and their equilibrium is health. Health is termed as happiness, while disorder as unhappiness. [4]

==== Definition of ''chikitsa'' (therapeutics/management of disease) ====

=== Definition of ''chikitsa'' (therapeutics/management of disease) ===

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Employment of all the excellent four – physician etc. – in case of disorder of ''dhatu'' with the objective of (re-establishing) their equilibrium is called “Therapeutics”. [5]

Employment of all the excellent four – physician etc. – in case of disorder of ''dhatu'' with the objective of (re-establishing) their equilibrium is called “Therapeutics”. [5]

==== Qualities of the best ''vaidya'' (knowledgeable physician) ====

=== Qualities of the best ''vaidya'' (knowledgeable physician) ===

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A ''vaidya'' should possess the qualities such as proficiency in theoretical knowledge (that is learnt), extensive practical experience, dexterity and purity (of body and mind). [6]

A ''vaidya'' should possess the qualities such as proficiency in theoretical knowledge (that is learnt), extensive practical experience, dexterity and purity (of body and mind). [6]

==== Qualities of ''dravya'' (medicine) ====

=== Qualities of ''dravya'' (medicine) ===

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Abundance (in availability), efficacy (with good pharmacological properties), various pharmaceutical forms and intact qualities of drugs – these are four qualities of the ideal medicine. [7]

Abundance (in availability), efficacy (with good pharmacological properties), various pharmaceutical forms and intact qualities of drugs – these are four qualities of the ideal medicine. [7]

==== Qualities of best attendant (caretaker/nursing staff) ====

=== Qualities of best attendant (caretaker/nursing staff) ===

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Knowledge of taking care of patient (nursing) as well as preparation, dispensing and administration of medicines and healthy recipes, dexterity, affectionate towards patient and purity of body and mind – these are four qualities of attendant. [8]

Knowledge of taking care of patient (nursing) as well as preparation, dispensing and administration of medicines and healthy recipes, dexterity, affectionate towards patient and purity of body and mind – these are four qualities of attendant. [8]

==== Qualities of best patient ====

=== Qualities of best patient ===

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Good memory (to remember treatment guidelines), obedience (to follow given instructions), fearlessness (courage to face adversities of disease) and ability to provide all information about the disease – these are the qualities of patient. [9]

Good memory (to remember treatment guidelines), obedience (to follow given instructions), fearlessness (courage to face adversities of disease) and ability to provide all information about the disease – these are the qualities of patient. [9]

==== Importance and role of physician ====

=== Importance and role of physician ===

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Such a person regarding himself as a physician cures by chance a patient whose lifespan is certain (who was destined to survive) but kills hundreds having uncertain lifespan. [17]

Such a person regarding himself as a physician cures by chance a patient whose lifespan is certain (who was destined to survive) but kills hundreds having uncertain lifespan. [17]

==== Qualities of ''pranabhisara'' (life saviour) physician ====

=== Qualities of ''pranabhisara'' (life saviour) physician ===

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Hence, a physician possessing four qualities -  indulgence in scientific knowledge, clear understanding, right application, and practical experience - is known as the one who promotes life i.e. ''pranabhisara''. [18]

Hence, a physician possessing four qualities -  indulgence in scientific knowledge, clear understanding, right application, and practical experience - is known as the one who promotes life i.e. ''pranabhisara''. [18]

==== Qualities of a royal physician ====

=== Qualities of a royal physician ===

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The physician, who possesses knowledge of etiology, symptomatology, therapeutics and prevention of diseases, is the best among physicians and is fit for becoming a  royal physician. [19]

The physician, who possesses knowledge of etiology, symptomatology, therapeutics and prevention of diseases, is the best among physicians and is fit for becoming a  royal physician. [19]

==== Qualities of ideal ''vaidya'' ====

=== Qualities of ideal ''vaidya'' ===

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Learning, wisdom, practical knowledge, experience, accomplishments, and continual guidance from eminent mentors – of these, even one quality is sufficient to add significance to the degree of ''vaidya''. The one, who possesses all the auspicious qualities like learning etc., deserves to hold the honourable degree of ''vaidya'' who showers happiness on all living beings. [20-23]

Learning, wisdom, practical knowledge, experience, accomplishments, and continual guidance from eminent mentors – of these, even one quality is sufficient to add significance to the degree of ''vaidya''. The one, who possesses all the auspicious qualities like learning etc., deserves to hold the honourable degree of ''vaidya'' who showers happiness on all living beings. [20-23]

==== Importance of scientific studies ====

=== Importance of scientific studies ===

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Scientific scriptures provide light for illumination (to remove darkness of ignorance or to know things) and one’s own intellect is like eyes. The physician who uses both (scientific knowledge and own intellect) properly, does not commit mistakes during treatment because in treatment, the other three components are dependent on the physician. Hence the physician should make all efforts to enrich his qualities. [24-25]

Scientific scriptures provide light for illumination (to remove darkness of ignorance or to know things) and one’s own intellect is like eyes. The physician who uses both (scientific knowledge and own intellect) properly, does not commit mistakes during treatment because in treatment, the other three components are dependent on the physician. Hence the physician should make all efforts to enrich his qualities. [24-25]

==== Ideal attitude of physician towards patients ====

=== Ideal attitude of physician towards patients ===

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Friendliness, compassion towards the diseased, attachment to the remediable and indifference to those who are moving towards the end (death) – this is the fourfold attitude of an ideal physician.[26]

Friendliness, compassion towards the diseased, attachment to the remediable and indifference to those who are moving towards the end (death) – this is the fourfold attitude of an ideal physician.[26]

==== Summary ====

=== Summary ===

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Thus ends the ninth chapter on small quadruple in ''Shlokasthana'' (i.e., [[Sutra Sthana]]) in the treatise composed by Agnivesha and redacted by Charak.

Thus ends the ninth chapter on small quadruple in ''Shlokasthana'' (i.e., [[Sutra Sthana]]) in the treatise composed by Agnivesha and redacted by Charak.

=== ''Tattva Vimarsha'' / Fundamental Principles ===

== ''Tattva Vimarsha'' (Fundamental Principles) ==

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* Four components i.e. Physician, Medicine, Caretaker/nursing staff and patient are essential pillars for any healthcare system.[3]

* Four components i.e. Physician, Medicine, Caretaker/nursing staff and patient are essential pillars for any healthcare system.[3]

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=== ''Vidhi Vimarsha'' / Applied Inferences ===

== ''Vidhi Vimarsha'' (Applied Inferences) ==

    

    

'''Chart 1: Four components of healthcare'''

'''Chart 1: Four components of healthcare'''

Of the four components of healthcare management, the role of the physician is of utmost importance because he/she is the person who is responsible for the planning of medicine, management of disease and the patient, and for all the instructions to the nursing staff. To establish a new healthcare facility, physicians should be appointed first. Then all necessary medicines (or ingredients required to formulate Ayurvedic preparations), including emergency medicines should be made available. Finally, able nursing staff should be appointed. If all these prerequisites are planned and provided for, then patients will come. Instead if one believes that physicians, medicines and nursing staff could be acquired once patients start coming, it would be wrong thinking.[3]

Of the four components of healthcare management, the role of the physician is of utmost importance because he/she is the person who is responsible for the planning of medicine, management of disease and the patient, and for all the instructions to the nursing staff. To establish a new healthcare facility, physicians should be appointed first. Then all necessary medicines (or ingredients required to formulate Ayurvedic preparations), including emergency medicines should be made available. Finally, able nursing staff should be appointed. If all these prerequisites are planned and provided for, then patients will come. Instead if one believes that physicians, medicines and nursing staff could be acquired once patients start coming, it would be wrong thinking.[3]

==== Disease and health ====

=== Disease and health ===

''Dhatu'' is a collective term signifying all the constituents of a body that sustain its existence.  Seven ''dhatu'' (''rasa, rakta, mamsa,'' ''meda, asthi, majja'' and ''shukra''), ''upadhatu'' like ''raja'' etc , three ''doshas'' (''vata, pitta'' and ''kapha'') and ''mala'' like ''pureesha'' etc. Perfect health is achieved when all the seven ''dhatu'' , three ''doshas, upadhatu'', and ''mala'' function properly (i.e. are in equilibrium or harmony). Health is not mere the absence of disease. Certain diseases like ''tilakalaka'' (moles) do not cause any physical discomfort or pain, but they hurt the mind of that person. Therefore here it is specifically mentioned that ''vikara'' (disease) is termed as ''dukkha'' (unhappiness or source of unhappiness).  Any disequilibrium of ''dhatu'' and ''dosha'' (according to the time of the day, stage of digestion etc.) that does not affect the happiness of a person cannot be considered a disorder. Establishment of equilibrium of ''dhatu'' is the objective of ''chikitsa''. [4]

''Dhatu'' is a collective term signifying all the constituents of a body that sustain its existence.  Seven ''dhatu'' (''rasa, rakta, mamsa,'' ''meda, asthi, majja'' and ''shukra''), ''upadhatu'' like ''raja'' etc , three ''doshas'' (''vata, pitta'' and ''kapha'') and ''mala'' like ''pureesha'' etc. Perfect health is achieved when all the seven ''dhatu'' , three ''doshas, upadhatu'', and ''mala'' function properly (i.e. are in equilibrium or harmony). Health is not mere the absence of disease. Certain diseases like ''tilakalaka'' (moles) do not cause any physical discomfort or pain, but they hurt the mind of that person. Therefore here it is specifically mentioned that ''vikara'' (disease) is termed as ''dukkha'' (unhappiness or source of unhappiness).  Any disequilibrium of ''dhatu'' and ''dosha'' (according to the time of the day, stage of digestion etc.) that does not affect the happiness of a person cannot be considered a disorder. Establishment of equilibrium of ''dhatu'' is the objective of ''chikitsa''. [4]

==== Therapeutics ====

=== Therapeutics ===

The process of re-establishing the equilibrium of ''dhatu'' and ''dosha'' by a qualified physician is known as ''chikitsa'' (therapeutics). Thus a physician and his team work together towards curing the pathology and bringing back homeostasis of the ''dhatu'' and ''dosha''. For example for treating ''kamala roga'' (jaundice), if ''virechana'' therapy is advised by the physician, if the potency of prescribed drugs is correct, if the nursing staff is trained to do the procedure, and if the patient is not afraid of the course of treatment prescribed,  then an equilibrium of ''dosha'' and ''dhatu'' could be realized. [5]

The process of re-establishing the equilibrium of ''dhatu'' and ''dosha'' by a qualified physician is known as ''chikitsa'' (therapeutics). Thus a physician and his team work together towards curing the pathology and bringing back homeostasis of the ''dhatu'' and ''dosha''. For example for treating ''kamala roga'' (jaundice), if ''virechana'' therapy is advised by the physician, if the potency of prescribed drugs is correct, if the nursing staff is trained to do the procedure, and if the patient is not afraid of the course of treatment prescribed,  then an equilibrium of ''dosha'' and ''dhatu'' could be realized. [5]

====Physician ====

=== Physician ===

''Shruta'' (listening or being a listener) has been mentioned as the first and foremost quality of a physician, implying that it is critical for an aspiring practitioners to listen attentively to the teacher, and understanding the exact meaning of the topic being taught. In ancient India,  knowledge passed down from generation to generation by oral tradition. Therefore this quality is specifically termed as ''shruta'' ( knowledge acquired by listening). ''Paryavadatatvam'' means divine knowledge acquired from authentic ''guru'' (mentors) and passed down from generation to generation in the purest form, without a shade of misunderstanding. ''Dakshyam'' means skillfulness or dexterity, ever-alertness and also sincerity. ''Shaucham'' indicates clarity and cleanliness of thoughts, mind and body to get or receive the maximum understanding of a subject.

''Shruta'' (listening or being a listener) has been mentioned as the first and foremost quality of a physician, implying that it is critical for an aspiring practitioners to listen attentively to the teacher, and understanding the exact meaning of the topic being taught. In ancient India,  knowledge passed down from generation to generation by oral tradition. Therefore this quality is specifically termed as ''shruta'' ( knowledge acquired by listening). ''Paryavadatatvam'' means divine knowledge acquired from authentic ''guru'' (mentors) and passed down from generation to generation in the purest form, without a shade of misunderstanding. ''Dakshyam'' means skillfulness or dexterity, ever-alertness and also sincerity. ''Shaucham'' indicates clarity and cleanliness of thoughts, mind and body to get or receive the maximum understanding of a subject.

Today, the qualities of an ideal physician include possession of relevant knowledge, professionalism, strong credentials, good reputation, sincerity, empathy, responsiveness, humility, strong communication skills, timeliness/punctuality, and thoroughness. All these qualities are addressed in ''Shrute paryavadatatvam, bahusho drrushtakarmata,'' ''dakshyam'' and ''Shaucham.'' [6]

Today, the qualities of an ideal physician include possession of relevant knowledge, professionalism, strong credentials, good reputation, sincerity, empathy, responsiveness, humility, strong communication skills, timeliness/punctuality, and thoroughness. All these qualities are addressed in ''Shrute paryavadatatvam, bahusho drrushtakarmata,'' ''dakshyam'' and ''Shaucham.'' [6]

==== Medicines ====

=== Medicines ===

''Bahuta'' means that the drug should be available in abundance or wherever the patient needs it. ''Yogyatvam'' means drugs should have adequate potency to cure diseases. Also it should be appropriate for the patient. ''Anekavidhakalpana'' means a single drug could be prepared in different forms, such as decoctions, tablets, medically fermented preparations, etc. This is necessary because certain formulations of a good drug may not be suitable for certain diseases or conditions of diseases or for certain patients. If a drug can be used in multiple formulations, then it gets wide applicability. Various available forms might be palatable to the patients as per their need in today’s era. ''Sampat'' means intact qualities of drugs i.e. drugs should not lose the potency due to time factor or contamination, adulteration or affected by insects or moisture etc.  [7]

''Bahuta'' means that the drug should be available in abundance or wherever the patient needs it. ''Yogyatvam'' means drugs should have adequate potency to cure diseases. Also it should be appropriate for the patient. ''Anekavidhakalpana'' means a single drug could be prepared in different forms, such as decoctions, tablets, medically fermented preparations, etc. This is necessary because certain formulations of a good drug may not be suitable for certain diseases or conditions of diseases or for certain patients. If a drug can be used in multiple formulations, then it gets wide applicability. Various available forms might be palatable to the patients as per their need in today’s era. ''Sampat'' means intact qualities of drugs i.e. drugs should not lose the potency due to time factor or contamination, adulteration or affected by insects or moisture etc.  [7]

==== Nursing staff/ attendant/caretaker ====

=== Nursing staff/ attendant/caretaker ===

Among the qualities of nursing staff, ''Upacharajnata'' means knowledge of preparing different forms of medicine, healthy recipes, dispensing, administration of various purification procedures etc. The staff should be skilled to handle a situation, compassionate towards the patient, possess hygiene, and should be able to understand the prescription of the physician. In modern era, an ideal attendant (nurse) should possess the relevant knowledge , skills and credentials required for nursing, with excellent communication skills, empathy for patients and their families, flexible working, attentiveness, responsiveness, and problem-solving skills. These characteristics have been examined further in the fifteenth chapter of the [[Sutra Sthana]], titled [[Upakalpaniya Adhyaya]]. [8]

Among the qualities of nursing staff, ''Upacharajnata'' means knowledge of preparing different forms of medicine, healthy recipes, dispensing, administration of various purification procedures etc. The staff should be skilled to handle a situation, compassionate towards the patient, possess hygiene, and should be able to understand the prescription of the physician. In modern era, an ideal attendant (nurse) should possess the relevant knowledge , skills and credentials required for nursing, with excellent communication skills, empathy for patients and their families, flexible working, attentiveness, responsiveness, and problem-solving skills. These characteristics have been examined further in the fifteenth chapter of the [[Sutra Sthana]], titled [[Upakalpaniya Adhyaya]]. [8]

==== Patient ====

=== Patient ===

The patient should follow the instructions of the doctor, be intelligent enough to understand his disease, and should be able to express his condition openly with the physician.  ''Smriti'' (memory) is an important character of the patient for him/her to explain the course of disease. ''Nirdeshakaritvam'' (ability to follow instructions) is also an important characteristic, because some drug must be taken at specific time. If the patient does not follow the physician’s instructions, adverse reactions may occur and desired effects cannot be obtained. ''Rogaṇam jnapakatvam'' (information about the disease) is important. If patient is unable to pinpoint the location of pain or other symptoms properly,  then diagnosis of disease would be difficult or not accurate. He should openly convey all the details about his ailment to the physician. If he does not do this, the physician may not be able to properly decide the line of treatment. He should not have fear. He should trust his physician and be ready to undergo any treatment prescribed. If he is scared and not ready for surgery or [[Panchakarma]], for instance, it will be difficult for the physician to manage as there may not be a suitable alternative always. Depression and anxiety in patients are the foremost factors that worsen disease conditions[Cha.Su.25/40]. [9]

The patient should follow the instructions of the doctor, be intelligent enough to understand his disease, and should be able to express his condition openly with the physician.  ''Smriti'' (memory) is an important character of the patient for him/her to explain the course of disease. ''Nirdeshakaritvam'' (ability to follow instructions) is also an important characteristic, because some drug must be taken at specific time. If the patient does not follow the physician’s instructions, adverse reactions may occur and desired effects cannot be obtained. ''Rogaṇam jnapakatvam'' (information about the disease) is important. If patient is unable to pinpoint the location of pain or other symptoms properly,  then diagnosis of disease would be difficult or not accurate. He should openly convey all the details about his ailment to the physician. If he does not do this, the physician may not be able to properly decide the line of treatment. He should not have fear. He should trust his physician and be ready to undergo any treatment prescribed. If he is scared and not ready for surgery or [[Panchakarma]], for instance, it will be difficult for the physician to manage as there may not be a suitable alternative always. Depression and anxiety in patients are the foremost factors that worsen disease conditions[Cha.Su.25/40]. [9]

==== Good clinical practice ====

=== Good clinical practice ===

Research has shown that patients who feel that their physician has made a genuine empathetic connection - an attempt to understand how they feel and how their condition is affecting their everyday life - will actually experience a reduction in pain. A ''vaidya'' should be a friend of the whole society. The society can be divided into apparently healthy persons and the ailing community and the ''vaidya'' should have compassion towards the ailing. The patients can be divided into curable and incurable. The ''vaidya'' should devote himself to the curable. For the patients who are incurable, he/she should have the approach of ''upeksha'' which means to observe or monitor closely. Many of these patients may not respond to the treatment and approach death (terminal patients). He/she should have a sense of detachment towards such patients. If the ''vaidya'' is too attached to the patient, he is likely not going to pay proper attention to the patients who are curable , and may neglect them as a result.

Research has shown that patients who feel that their physician has made a genuine empathetic connection - an attempt to understand how they feel and how their condition is affecting their everyday life - will actually experience a reduction in pain. A ''vaidya'' should be a friend of the whole society. The society can be divided into apparently healthy persons and the ailing community and the ''vaidya'' should have compassion towards the ailing. The patients can be divided into curable and incurable. The ''vaidya'' should devote himself to the curable. For the patients who are incurable, he/she should have the approach of ''upeksha'' which means to observe or monitor closely. Many of these patients may not respond to the treatment and approach death (terminal patients). He/she should have a sense of detachment towards such patients. If the ''vaidya'' is too attached to the patient, he is likely not going to pay proper attention to the patients who are curable , and may neglect them as a result.

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=== Further reading ===

== Further reading ==

#Kushwahavd. Harish Chandra Singh. 2011. The Caraka Samhita. Reprint edition. Varanasi. Chaukhambha Orientalia.

#Kushwahavd. Harish Chandra Singh. 2011. The Caraka Samhita. Reprint edition. Varanasi. Chaukhambha Orientalia.