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.
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.
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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
The article was republished in Sushrutha (Volume 7 Issue 3), BAPIO's magazine published on the occasion of their annual conference 2015.