Published in IJCP November 2023
Viewpoint
Doctors’ Pride and Ethics: Time to Introspect
November 13, 2023 | Aleya Anitha
Medicolegal Nephrology
     


https://doi.org/10.59793/ijcp.v34i6.716

Abstract

A doctor’s role in society is unique. Over years, medical science has advanced; publics’ expectations have changed; recent pandemic challenged it. Doctors’ face is blemished by accusations. An online survey was done to analyze the change in the attitude and respect of the public towards doctors. For this a questionnaire was forwarded through WhatsApp contacts. Data was extracted to an excel sheet and analyzed. The cohort (n = 328) included both doctors (34.1%) and non-doctors (65.9%). Non-doctors comprised of the general public (47.3%) and people who worked with doctors (18.6%). Overall, 93.3% of those surveyed agreed that “doctors deserve respect”. More doctors (89.3%) as compared to non-doctors (39.4%) (p < 0.001) perceived a reduction in respect towards doctors. On an objective scale (0-10), respect had reduced from an average of 8.55 to 6.76 over 10 years; doctors felt steeper reduction (8.68 to 5.42 [p < 0.05] than non-doctors [8.48 to 7.46 [p < 0.05]). Among doctors, 64.3% opined that “doctors’ profession should be considered as service”, while 49.1% agreed that “doctors’ profession can be a business model”. A portion of the public, agreed that medications (61.3%) and investigations (56.1%) were prescribed/advised only when necessary. An important reason for reduction in respect was the perception that the “medical profession is run as a business model” (16.8%). Respondents other than doctors, when given an opportunity, wanted to practice ethically (19.4%).

Keywords: Medical profession, business model, service model, ethics, leadership, introspection

Doctors, the “guardian of health”, don a unique role in society; their profession has been tagged “noble”. Over the years the medical profession has evolved. It has witnessed several scientific advances, identification of newer diseases, newer branches of speciality services, better treatment modalities, revision in health care policies, to name a few. Health care information available on social media, is easily accessible but rarely authentic. Science and its practitioners have limitations; however, the public’s expectations from doctors have increased disproportionately. Instances of aggression, accusations and litigations have tainted the profession.

The thoughtful practitioner, tries to protect “Self”, before following the traditional teachings of “Patient First”; this is countered by rants of needless investigations, interventions and medications.

However, the public cannot be criticized, for not under­standing. Doctors are faced with dilemma of “service” versus “business” model and haunted by a sense of betrayal or loss of charisma and hence this study was undertaken.

MATERIALS AND METHODS

An online survey analyzing the change in public’s opinion about doctors, ethics of medical practice and their respect towards this profession over the years was done.

A questionnaire was forwarded through WhatsApp contacts and groups. Open-end questions in search of “reason behind change in level of respect if any” and “what non-doctors, would want to do if they had an opportunity to step into a doctor’s shoe”, were asked. Open-ended questions had received more than one response covering different aspects.

All responses were extracted onto an excel sheet, grouped under appropriate common headings and analyzed. Questions, that had responses graded between strongly agreed to strongly disagreed, were simplified during analysis; agreed and strongly agreed were clubbed under “Agreed”, and similarly, disagreed and strongly disagreed were clubbed as “Disagreed”, while “Neutral” were retained as such.

RESULTS

There were 328 respondents (Fig. 1). Their average age was 41.3 ± 13.26 years. Among them, 50.6% were males and 34.1% were doctors. Out of 216 (65.9%) who were non-doctors, 61 (18.6%) were working with doctors and 155 (47.3%) were general public.

Figure 1. Change in the respect towards doctors over 10 years.

Among all respondents, 46.3% had visited or interacted with at least 5 doctors for themselves or for their close family members’ health; 48.8% agreed that doctors are trained for at least 5 years before they are permitted to start practicing medicine. Approximately 93.3% and 91.5% of all respondents, considered that, “doctors deserve respect” and “doctors are knowledgeable”, respectively.

Respect towards doctors in the community was felt to be decreasing by 56.4% of all respondents. Around 89.3% of doctors as compared to 39.4% of non-doctors felt so (p < 0.01) (Fig. 1). When respect was assessed objectively on a linear scale from 0 to 10, reduction in the score was from 8.55 to 6.76 over 10 years. Doctors perceived the reduction to be much steeper than non-doctors (Fig. 1). Change in respect, assessed by subjective response and objectively on a scoring system correlated well (r = 0.754).

Out of all respondents, 78.7% felt that “doctors’ profession should be considered as service”; (Fig. 2) the general public (87.1%) as compared to doctors (64.3%) (p < 0.001) was more likely to consider that doctors’ profession should be a service. Forty-six percent of all respondents agreed that “doctors’ profession can be run on business model”.

Figure 2. Opinions and thoughts about medical profession.

Around 49.1% of doctors as compared to 48.4% of general public (p = 0.78) agreed that doctors’ profession can be run on business model. Medical profession being a business model was considered as a reason for change in respect by 20% of general public. If given an opportunity, 10.3% and 5.2% of the general public would serve poor/needy/do free service and would stop greed, respectively.

Among all responders, some agreed that doctors prescribe/advise medications (70.7%), investigations (68.3%) and interventions & procedures (71.3%) “Only when necessary” (Fig. 2). Doctors (78.6%, 80.4% and 83%) and general public (61.3%, 56.1% and 59.4%) also agreed upon doctors prescribing/advising medications, investigations and intervention/procedures, respectively (Fig. 2). While 1.9% of general public considered unethical practice as a reason for change in respect; if given a chance, 19.4% of general public wanted to practice ethically.

Around 97.3% of doctors as compared to 88.4% of general public (p < 0.01) agreed that patients should trust doctors (Fig. 2); 95.5% of general public agreed that each patient is different and same medications will have different effect in different individuals, and 94.8% of general public agreed that some patients cannot be saved at times, even when treated by best of doctors. Lack of trust was blamed as the reason for change in respect by 3.2% of general public, and when given an opportunity only 4.5% of the general public wanted to build trust.

Around 96.4% of doctors agreed that “doctors should focus on preventing diseases also” (Fig. 2); if given an opportunity, 0.6% and 1.3% of the general public would do prevention and patient education, respectively.

Limitation of information available in the social media, and role of the doctor in personalizing treatment was accepted by 96.1% of general public (Fig. 2). Though only 5.2% of general public considered that internet and social media was a cause for change in respect towards doctors; 29.5% of doctors felt so.

Analyzing factors that were indicated as reasons for change in the respect, the coronavirus disease 2019 (COVID-19) pandemic improved the respect towards doctors: while greed, business model, internet and social media, lack of trust and unethical practice were reasons for reduction in respect towards doctors (Fig. 3).

Figure 3. Reasons for change in respect and its magnitude.

DISCUSSION

Doctor’s Life Drill

Doctors in India are trained for 4.5 years, with an additional 1 year of internship, where they rotate among departments of medicine including pediatrics, surgery, obstetrics and gynecology and community health. During this period, they work day/night shifts and on holidays too. They miss many meals and several nights sleep. Many years are spent in post-graduation training, to finally become a specialist.

Doctors are first human beings, with families, emotions, personal challenges in life and individual abilities/limitations. As professionals they are bound by legal corpus (medical ethics) mostly written.1 They also follow many unwritten rules, for example – “Do not drink water in front of a dialysis patient as you may tempt them to breach fluid restrictions”.

Patients visit doctors for ailments, but their approach to doctors, depends on multiple factors like legitimacy and understanding of their problems, affordability, previous experience with doctors, trust and respect towards doctors, peer and media influence.

Due to the large patient load, outpatient consultations typically last for 10 to 15 minutes, sometimes shorter, during which, doctors must understand the reason for consultation, go through old medical history/investigations, do a thorough examination, write a note of all the findings in a logical manner, convey the diagnosis and treatment plan and hand over a detailed advice and prescription. If it is the first consultation, an impression, trust and rapport are also built. Inpatient consultations can begin in an emergency room, intensive care unit or a ward. Here, the priority is to pick up diagnosis faster, facilitate quick recovery and discharge in a reasonably stable condition. Investigations requested help narrow down differential diagnoses and monitor recovery. The sicker the patient, more the investigations; this rationale is to prevent loss of time in sequential investigations.

Terms Associated with a Doctor

Here are a few terms that adorn the life of a medical professional, and their dictionary meaning.

“Respect” – a feeling of deep admiration for someone or something elicited by their abilities, qualities or achievements.

“Pride” – a feeling of deep pleasure or satisfaction derived from one’s own achievements, the achievements of those with whom one is closely associated or from qualities or possessions that are widely admired.

“Ethics” – moral principles that govern a person’s behavior or the conducting of an activity.

“Trust” – firm belief in the reliability, truth or ability of someone or something.

Respect and Trust

In India, doctors were respected and trusted, as the unfeigned advocates of patients. This resonated in the phrase “Vaidhyo Narayano Harihi”, which translates to “Doctor is God”. It indeed described a doctor who impersonated compassion, empathy, knowledge and selflessness. Undeterred devotion towards doctors, continued till a few decades ago. The family physician was a friend, philosopher and guide.

Moving fast forward to present situation, the medical profession has progressed by leaps and bounds. It has spread its roots to many specialties and sub­specialties and experiences are now shared across continents. Medical profession falls under the ambit of the Consumer Protection Act. Doctors are indicted on counts of corruption, professional negligence and immoral financial gains.2 Many cases are won against doctors. This sets a bad precedent as all members of this profession will be seen through this lens. In the present study, we found that there was a reduction in the respect towards doctors, over the last 10 years, and it was significant. Doctors perceived it more than others (Fig. 1). There were many reasons for the change in the respect towards this noble profession (Fig. 3).

Trust reposed in a doctor is associated with better health care seeking, adherence to advice and follow-up, which in turn translates to improved long-term outcomes.3 It is important to remember that trust is fragile, difficult to earn and easy to lose.2 Systems trust (trust in the medical profession/health care system) does not equate to interpersonal trust (trust between doctor-patient).2 Ideally both should coexist, align parallel and run like wheels of a cart, with the focus fixed on patient’s well-being. Dualities in the medical practice prevents trust from building. Building back trust is not only the need of the hour, but what doctors owe to their patients.2

Conversely, unrealistic expectations are also harmful. In this study, we found that 5.4% of doctors perceived that unrealistic expectation was the reason for change in respect (Fig. 2). About 88.4% of general public agreed that patients should trust the doctors fully and follow them correctly for better patient outcomes. Around 96.8% of the general public agreed that “Doctors are human beings and are limited in their abilities”; while 94.8% of the general public agreed that “Some patients cannot be saved at times, even when treated by best of doctors”.

Service versus Business Models are Conflicting

Doctors are taught that the medical profession is “Service” and hence a noble one. Intrusion of business concerns into medical practice, has its repercussions. There are several angles to it. While individual doctor works on “service model”, Health Care Industry (HCI) in India, comprising hospitals, medical devices and equipment, health insurance, clinical trials, telemedicine and medical tourism is a “business”.4 HCI is one of the largest sectors of the Indian economy in terms of revenue and employment; with a growth rate of about 22%.4 Indian government encourages Foreign Direct Investment (FDI), and its policies have been liberalized.4 There are several benefits of FDI. Government enjoys lesser burden on its finances, while there is better quality of health care/choices for nationals of the host country, who can afford private health services. But it may also worsen inequality. There can be brain drain from public sector to multinationals.5

HCI offers incentives (financially or non-financially) and sometimes disincentives to doctors in the name of maintaining consistency in their services towards patients.6 Such incentives will be speculated as unholy by the general public. Financial investment in HCI fetches consistent returns that are uncorrelated with stock market. It can influence pricing of the end products, be it medications or services. In addition, health care system in India is one of the most privatized systems in the world, at about 80%.7,8 This business model has promoted “materialistic approach” which some medical practitioners have embraced without remorse. Internet and its various apps run business; they provide easily accessible services; their authenticity and moral binding are questionable.9

Accepting large corporate donations for any reasons, can be ethically worrisome; such criticism needs ethical justification, lest, character of such organization will be questioned.10 Pharmaceutical industry being a business, promotes its sales by influencing prescription habits of physicians. Promotion is done by various methods such as sponsoring research, conferences, providing travel grants/accommodation to physicians. Attending company sponsored continuing medical education (CME) or accepting facilities from them are known to increase physicians’ prescription of sponsor’s medications.11 Receiving sizable gifts from pharmaceutical industry is punishable.11 It is important to remember that sponsorship is not just about ethics, it affects pricing of drugs.11 National Medical Commission (NMC), which superseded the Medical Council of India (MCI), has forbidden sponsorship of medical conferences.12

In a business model, physician has been demoted to a “Provider”.13 In Indian dialect, any part of the medical profession run as a business is adjudged as ruled by Goddess Lakshmi, instead of Goddess Saraswati. Unsurprisingly, public considers business model as one of the main reasons for reduction in respect towards doctors (Fig. 1).

Oath and Ethical Conflicts

“Hippocrates oath” was written over 2,500 years ago. There are several translations and newer versions. Oath was intended to create virtuous physicians.13 It binds doctors to ethical practice, to keep patients before self, and to ensure equal treatment for all. Some physicians, adhere to it, even when it may be self-destructive.14 “Patients first” is ingrained into medical students; their care gets an “interruptive priority”. That cannot happen 24/7/365 for years; after all well-being of oneself and family is also crucial.14 Such burdensome demands contribute to physician burn out.14

Quotes from the Hippocrates Oath15 – “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.” “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”- Swearing by this Oath, doctors are bound to provide “the best treatment” in any given situation for each of their patients.

In our study, we found that 61.3%, 56.1% and 59.4% of general public agreed that doctors prescribe medications, advice investigations and interventions ONLY when necessary, which implies, that about 38% to 44% did not agree (Fig. 2). About 19.4% of general public conveyed their intention to practice ethically, if they could step into the shoes of a doctor. While general public, lacking medical knowledge should be prohibited from questioning the sincerity of doctors; as professionals, this allegation needs introspection.

Physicians are bound to face several ethical conflicts in one’s career; some genuine and some not. Common among such dilemmas are best versus affordable treatment; convincing a doubting patient while being wary of possible litigation; differing in one’s advice when patient has consulted many doctors from the same specialty; defending a well-meaning colleague who discussed one-sided opinion, while the best option would be slightly different; just to name a few. Handling dilemmas may be a challenge. Administering oath is not sufficient. Ethics should be taught as a part of medical school curriculum, with an aim to develop ethically sensitive individuals, who can anticipate, identify and solve ethical dilemma. Ethical abilities should be assessed just like other subjects.16

Prevention

Doctors have taken an oath to prevent diseases.15 Hippocrates oath – “I will prevent disease whenever I can, for prevention is preferable to cure”. All levels of prevention are important. Preventive medicine in its true sense is cost-effective, and constructively preserves quality of life. For a society, focus is on promoting healthy lifestyles, early detection and treatment of communicable and noncommunicable diseases. Prevention at individual level depends on their risk factors. Addiction of any kind, and poor self-care should be demoted; health education in school curriculum and social media is inexpensive.

Preventive health care sector in India is also a business; projected to reach 197 billion US Dollars by 2025, growing at a compound annual growth rate (CAGR) of 22%.17 India’s National Health Policy (2017) emphasizes greater investment in preventative and primary health care and aims to increase government spending on health to 2.5% of GDP by 2025.4 There are several companies providing preventive health care, which includes an array of experts like fitness maestros and dieticians; gadgets such as fitness trackers and health-monitoring devices.

While business focuses on financial growth, these is a need for a) well-meaning physicians to avoid wasteful expenditures, and b) public that trusts the profession. In our study, 88.4% of general public agreed that doctors should focus on preventing diseases also (Fig. 2). Effective prevention needs to be considered closely.

Internet and Social Media

Internet in India is cheap, easily available and its outreach has steadily expanded. Around 4.5% of all internet searches are related to health, and it is gradually increasing.18 Information available in the internet is uploaded by many individuals; it comprises both authentic and nonauthentic contents. Few minutes of browsing provides a sense of control to patients/care takers. Patients with thus obtained “instant wisdom” approach doctors, in a manner comparable to a child getting home from kindergarten and asking parents, if they know alphabets. Browsed information may not be applicable to individual patients and obviously cannot equate to years of practical experience of professionals, who will understand the problem, examine patient, and provide personalized advice. In our cohort, 29.5% of doctors considered internet and social media as the reason for reduction in respect (Fig. 2).

Regardless, internet and social media are here to stay. Artificial intelligence and machine learning (AI and ML) are at the helm. Such encounters are bound to increase. Doctors must accommodate patients with (mis)information from internet. On a positive note, we can use social media to spread authentic health-related information widely.18

Pandemic

The pandemic has taught us many lessons; many lives were lost with innumerable left in doom. People learnt the importance of unity, sharing and helping one another. Government changed its priorities, tailored health care policies, fast tracked research, shared necessary information across countries, declined patents on life-saving drugs, hastened production of necessary medications, showed magnanimity in providing vaccines across borders. People from many walks of life took to frontline, medical fraternity stood guard, accepting its professional risk. Business and money took a back seat. Public recognized the service rendered and respect towards doctors increased (Fig. 3).

STRENGTH

There were open-ended questions permitting the responders to convey their thoughts without being guided by limited options. It included subjective scoring system and an objective question asking for change in the respect which correlated (r = 0.754). There was representation from doctor community, those working with doctors and general public. The differences in their views were well perceived.

LIMITATIONS

This was a small cohort; it has the inherent bias of an online survey. This study was influenced by the COVID-19 pandemic where doctor community was both praised and criminalized.

CONCLUSION

Certainly, there is a change in the respect towards doctors. It has left a negative impact on the profession. It is time for us to introspect. Change for the better, will happen, when a true leader, one who becomes the voice of profession and its individual professionals; one who becomes the moral advocate of patients that trust us, takes the forefront. Unregulated business practice, malpractice and corruption can be removed only when well-meaning doctors lead; not self-centered proxy leaders.19 It is time for medical profession to clean up its white coat, the symbol of purity, that is tarnished now.

REFERENCES

  1. Singh MM, Garg US, Arora P. Laws Applicable to medical practice and hospitals in India. Int J Res Foundation Hosp Healthc Admin. 2013;1(1):19-24.
  2. Kane S, Calnan M. Erosion of trust in the medical profession in India: time for doctors to act. Int J Health Policy Manag. 2017;6(1):5-8.
  3. Gopichandran V, Chetlapalli SK. Factors influencing trust in doctors: a community segmentation strategy for quality improvement in healthcare. BMJ Open. 2013;3:e004115.
  4. pdf. Available from: https://www.niti.gov.in/sites/default/files/2021-03/InvestmentOpportunities_HealthcareSector_0.pdf. Accessed November 3, 2023.
  5. Can FDI improve the resilience of health systems? Available from: https://www.oecd.org/investment/Can-FDI-improve-the-resilience-of-health-systems.pdf. Accessed November 3, 2023.
  6. Lee TH. Financial versus non-financial incentives for improving patient experience. J Patient Exp. 2015;2(1):4-6.
  7. Private Healthcare Sector – A Vibrant Force in Indian Healthcare Industry. IIHMR Delhi. Available from: https://www.iihmrdelhi.edu.in/uploads/articles/pdf/private-health-care-sector.pdf. Accessed November 3, 2023.
  8. Kapur R. The Public Health System in India. Acta Scientific Nutritional Health. 2019;3(11):130-3.
  9. Roy B, Kumar A, Kumar A, Gowda KR. Ethical conflicts among the leading medical and healthcare leaders. Asia Pacific J Health Manag. 2022;17(1):i1491.
  10. Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8(4):354-8.
  11. Nagral J, Roy N. The Medical Council of India guidelines on industry-physician relationship: breaking the conspiracy of silence. Natl Med J India. 2010;23(2):69-71.
  12. getDocument (nmc.org.in). Available from: https://www.nmc.org.in/MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNews/NMC%20RMP%20REGULATIONS%202022%20Draft%20Final%20YM.pdf. Accessed November 3, 2023.
  13. Clark SA. The Impact of the Hippocratic Oath in 2018: The Conflict of the Ideal of the Physician, the Knowledgeable Humanitarian, Versus the Corporate Medical Allegiance to Financial Models Contributes to Burnout. Cureus. 2018;10(7):e3076.
  14. Chesanow N. Does the Hippocratic Oath promote burnout? Medscape. Mar 29, 2017.
  15. Hippocratic Oath - Wikipedia, Available from: https://en.wikipedia.org/wiki/Hippocratic_Oath. Accessed September 25, 2023.
  16. Eckles RE, Meslin EM, Gaffney M, Helft PR. Medical ethics education: where are we? Where should we be going? A review. Acad Med. 2005;80(12):1143-52.
  17. The rise of preventive healthcare in India. TOI. January 3, 2023. Available from: https://timesofindia.indiatimes.com/blogs/voices/the-rise-of-preventive-healthcare-in-india/. Accessed November 3, 2023.
  18. Renganathan L, Ray S, Nagpal D. Use of internet for accessing healthcare information among patients in an outpatient department of a tertiary care center. J Marine Med Soc. 2017;19(1):15-7.
  19. Kumar R. The leadership crisis of medical profession in India: ongoing impact on the health system. J Family Med Prim Care. 2015;4(2):159-61.