Indian
background: personal view of my experience in India
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The
issue of ethicality for me, as for many doctors in India, started
before joining medical college. In my time and until
today, the issue of admission to higher education by merit as judged
purely by school final examinations and entrance
tests versus the need for social justice to correct the vestigial
effects of historical wrongs remains a highly volatile,
emotionally-charged ethical dilemma. Once we joined medical college,
we saw that the professionalism was
often tainted by the general corruption and laissez-fare attitude of
which it is often accused.
We
overcame these
issues due to four main factors:
a)
We were really passionate about being doctors;
b)
the subjects were really tough, so there was not much time to think
about anything else;
c)
some highly ethical, professional teachers had a disproportionately
positive impact on our thoughts; and
d)
most of us were only passive players in any unethical and
unprofessional behaviour (at that time, that made it
okay).
My
own brief period of post-graduate training in India was a mixed
experience - for me because of where I worked, my
training was directly related to my effort, with the occasional
heartache when some VIP’s son (it was usually the
son)
forcefully robbed me of my opportunity. Many of my colleagues
completed their post-graduate training with limited
skills; some of them could afford (the time, money and connections)
to gain it in the real world after they finished
their training and become better doctors; the normal reality of life
engulfed the rest and they entered a self- perpetuating
cycle
of talent deficit. In the years as a young doctor in India, and then
later as an experienced surgeon who
practised in India for a brief period, I saw repeated examples of
unsupported doctors driven to displaying unprofessional
and unethical behaviour which were adversely affecting the patient’s
clinical care amidst a few individual
islands and beacons of high moral behaviour. To avoid being
misunderstood or misquoted, let me make it very
clear - my view is that the doctors in India want to deliver the
highest quality of clinical care and they want to apply
ethical methods. The social construct and systems often try to push
them away from ethicality; some doctors manage
admirably to resist this.
Broad
UK contextual principles
The
UK is indeed a very ethical and professional atmosphere for doctors.
Generally, expressed behaviours are a function
of societal standards and expectations. The UK has a high degree of
expression of the whole spectrum of the domains
of human action - a high level of personal free choice which is
tempered with a high level of societal ethics; and
a high level of legal control should the personal free action cross
ethical boundaries. To phrase it differently, people
can do what they want, they do that with consideration for the rest
of the society and when they cross boundaries
there are laws and rules in abundance which are generally enforced
effectively. This was not achieved easily.
Broad
context for doctors
There
are broader factors that act as the foundation for professionalism
and ethicality. As soon as we begin working in
the UK, we realise that the bulk of healthcare is delivered by the
government through the NHS (though there is increasing
privatisation at this time).We learn that the rich and poor can get
the same access and treatment, which is
more or less of the same standard, across the country. Healthcare has
no relationship with the ability to pay – it is
free at the point of care. An overwhelming majority of doctors are
employed by the NHS on national contracts and
there is no difference in pay, and thus earnings, for doctors from
various specialties working in any part of the country.
Private care exists for people with money or private health
insurance; but it is usually to jump any queues and
get some frills but the care quality is in substance the same. The
system generally removes any financial or professional
reasons that might trigger unprofessional or unethical behaviour.
Specific
context for doctors
Doctors
are held to higher standards of behaviour; these are regularly
reviewed and set out in the UK regulator’s (General
Medical Council’s) Good Medical Practice guide. Doctors’ annual
appraisals are related closely to the domains
defined in the GMC’s GMP guide. There is a specific area in annual
appraisals titled ‘probity’ which is taken
very seriously. Further, a doctor’s personal health problems have
to be declared and their impact on effective
functioning
assessed. The GMC’s GMP is applicable not just within a doctors’
professional and clinical domains it is
applicable to behaviour standards in a doctor’s personal life as
well. If a UK doctor’s drunken behaviour during
private
holidays affected any member of the public the GMC wants to know
about it and will investigate it to see if
there were any patterns that might impinge on patient care. If a
doctor attends a court of law on a completely private
matter such as speeding on the road or a financial irregularity the
GMC wants to know about it and is likely
to sanction in parallel for any major convictions in court. A
registered doctor is expected to have a higher standard
of behaviour compared to the average member of the public and when it
slips the regulator will not hesitate
to act against that doctor. The GMC even has guidance on how doctors
should interact in the social media even
when doctors interact with social media on non-clinical matters.
Voluntary compliance is the norm. Breaches are
quite a few but these are resolved through either local or social
pressure. A word from the senior, a call from the
medical director or a well meaning assertive/aggressive warning from
people in the social media is usually enough
for doctors to pull back and fall in line. Doctors have to reflect on
their developmental Continuing Medical
Education/Continuing
Professional Development (CME/CPD) activity, doctors have to reflect
on the complaints they face.
Currently, doctors are required to have regular 360 degree feedback
administered by an independent party, funded
usually by their employers - this feedback is obtained from randomly
chosen colleagues including other doctors of various grades, nurses,
managers and others. If this feedback shows a need for improvement
that has to
be undertaken. The UK regulator has recently introduced revalidation
for doctors where annual appraisals form the
core element of the decision to revalidate a doctor every five years
and allow them to practise. All the above descriptions
form a part of the appraisal revalidation process.
The
evolution of current practices
This
is an interesting exercise in conducting large scale change. It was a
slow, incremental multi-channel process that took
many years and many stages. CME/CPD requirements were defined by the
Royal Colleges in the early 1990s. Clinical
audits were introduced in a big way in the early 1990s, 360 degree
appraisals were introduced as a part of progression
for trainees in the early 2000s; reflective practice was introduced
in medical schools in the early 2000s. Cross
pollination of these practices between specialties and grades were
encouraged. Formal annual appraisals were
introduced with it being mandatory for trainees. Soon annual
appraisals became an essential part of senior doctors’
career job planning and career progress with many elements already
having been brought together. Now all
these have been pulled together into a comprehensive
appraisal-revalidation system which is mandatory.
In
the late 1990s, the Bristol enquiry into paediatric cardiac surgery
deaths on how a department’s poor performance went
unrecognised over a period of time; in the early 2000s, the Shipman
enquiry on how a doctor could escape any official
scrutiny over many years of criminality; and currently the Francis
report on how a whole local system focused on
the wrong things causing patient harm without being challenged by
clinicians were major national external stressors
that have pushed the medical profession to re-focus on the patient
and start taking responsibility.
Some
counter points
Is
the NHS system perfect? Certainly not. Will it catch the bad doctors?
Probably not. The scientific evidence for many
of these methods is arguable. Many doctors opposed it actively all
along and resist it passively even now. Some
use it as a purely tick box exercise so that they will have a licence
to practise their jobs. No one can be sure if these
improve clinical quality for the patient.
What
it does seem to have done is to increase the professionalism and
ethicality of doctors. When anyone suspects a
breach of professionalism and ethicality by doctors anyone is
entitled to report the doctor to the GMC. The GMC does
a full investigation only for a small number of the cases reported to
them. During the investigations the GMC looks
for reflection, maintenance of clinical skills, and development of
insight. If the GMC is satisfied with these then
it decides on minimum sanctions or on no sanctions at all. If it is
not satisfied, the sanctions can be very severe,
including erasure. The GMC, backed by the law, is a powerful force
for doctors to seek a higher degree of professionalism
and ethicality.
In
practice, a large number of doctors who are international medical
graduates (IMG) and who are from black and minority
ethnic (BME) origins believe the system may be broadly very fair for
the UK local graduates, but for IMGs and
BME doctors there is evidence of a higher rate of reporting to the
GMC and a perception of a higher chance of sanctions
and a higher severity of sanctions. This is seen by many IMG and BME
doctors as somewhat defeating the otherwise
worthy ideals that in general work well. It
is not as though there are no other sub-radar ethical problems:
defensive practice, higher levels of service
utilisation
with its implications of unnecessary interventions, racial divisions
(in jobs, exams, pay grades, bonuses) and
others.
Transferable
lessons
The
principles underpinning UK medical practice are universal and hence
transferable. The core principles are:
a)
expecting
a higher standard of behaviour from doctors in the practice of their
profession and in their personal lives;
b)
having
a strong, progressive regulator backed by law; and
c)
encouraging
and supporting doctors at every opportunity to be ethical and
professional, but with the clear
d)
understanding
that any breaches will involve facing the full impact of regulatory
and legal enforcement without fear or favour.
The
practice of these principles is not easily transferable since the
context and environment is very different in India.
As
very junior surgical trainees in India we used to ask patients to buy
a variety of drugs, sutures and allied implements for their care - we
would also make a judgement on the economic capacity of the patient,
and on that basis ask them to buy a certain amount more than what
would actually be needed for their care, sometimes upto double their
actual requirement. We then used to store this in our individual
cupboards and use the surplus for the care for other patients.
Sometimes, we told the patients that this is what we were doing,
sometimes we did not – either deliberately or simply due to lack of
time. Essentially all of us were running our own individual small
scale charity process. We saw this as completely ethical, moral and
professional. We were saving lives, we were curing patients.
In
the UK, this will be misrepresentation, lying, theft, financial
misdemeanour, etc, all of which obviously are offences with the
potential to end careers.
In
India unnecessary investigations could have a financial motive
(essentially fraud), in the UK it is mostly simply a matter of high
utilisation (hence an issue of lack of operational standards). In
India, talking to the next of kin of ill patients is normal accepted
practice; in the UK, speaking to the next of kin without specific
consent is sanctionable under the Data Protection Act and is a clear
breach of right of privacy.
Creating
an Indian system
A
two-channelled approach may be needed in India. The first channel is
to enable a higher standard of positive behaviours from doctors.
My
personal suggestion is for doctors to create and maintain their own
personal-professional portfolios. These portfolios could be reviewed
by either employers or peers (individuals or professional bodies)
every two years; and voluntarily submitted to the state medical
councils every four years. In return these doctors could get the
status of updated/enhanced registrations. Over a period of time, the
medical councils and professional bodies can work together to make
the portfolio very robust (perhaps in 20 years’ time the whole
process can include a 5 yearly voluntary written knowledge test). A
higher degree of respect, recognition and remuneration for doctors
who have updated/enhanced registration could be an incentive to
encourage the uptake.
The
second channel would be to reduce the incidence and severity of
negative behaviours in doctors. Pro-active, transparent, supportive
intervention by the relevant professional society and the state
medical council will be crucial. However, when those interventions
fail a strict regulatory and legal approach will be needed.
A
time defined, long term, incremental protocol, with specific measures
that must be achieved, should be mandated with implementation
commencing urgently.
I
am hoping that these words make meaning and help thought in creating workable
recommendations to enhance the ethics and professionalism of doctors
in India. This will be essential for the future of the doctor-patient
relationship and to enhance the reputation of doctors in/from India.
©M HEMADRI
Follow me on Twitter @HemadriTweets
Note:
This was originally written at the request of Prof Rajan Madhok as a part of background documentation for a conference in Kolkata in January 2014
The Global Indian Doctor: Workshop on promoting professionalism and ethics
The Global Indian Doctor: Workshop on promoting professionalism and ethics
http://leadershipforhealth.com/wp-content/uploads/2014/02/Event-report.pdf
The article was republished in Sushrutha (Volume 7 Issue 3), BAPIO's magazine published on the occasion of their annual conference 2015.
