Introduction
Over the four- and- a- half- year span of medical training, students are extensively grilled on how to diagnose diseases and treat patients. The rules of conduct, which should guide his behaviour when interacting with his own professional colleagues, is hardly ever touched upon in the medical curriculum. These rules and laws actually offer a framework within which the future doctor can act. Many students and practitioners are genuinely surprised to know that rules actually exist. Some know that some sort of ethical conduct is expected of them, but are not very clear on the subject. This essay is an attempt at starting a discussion on the ethics of relationships between doctors.

Forms of professional relationship
The doctor has to play many roles in his professional life. He is both student and teacher during different periods of his career, a patient himself when ill, or a doctor to another professional colleague. More pertinently, throughout his career, he has to regularly interact with colleagues in his speciality and those in different branches of medicine. The forms of professional relationship between two doctors may thus be summarised as follows:

• between student and teacher;
• between doctors (including specialists) in the same discipline;
• between general practitioner (GP) and consultant;
• between two doctors in differing specialities;
• between the doctor and his doctor-patient.

Principles governing the relationship between doctors
It is necessary to clear a general misconception that medicine and ethics are two independent and divergent subjects, or that ethics is merely an adjunct to medical activity. The two are irrevocably harnessed together, and this marriage has been recognised since before the days of Caraka, Susruta and Hippocrates. After all, medical ethics are those obligations of a moral nature which govern the practice of medicine (1). In turn, the practice of medicine, in any field, in any discipline, has been succinctly described as ‘a long, continuous sequence of ethical moments (2).

The set of moral principles that must guide members of the medical profession in their dealings with each other, is termed medical etiquette. The basis of a good relationship between doctors lies in mutual respect and understanding. A feeling of loyal camaraderie is essential, not only for the sake of the profession, but also for the welfare of patients.

Rules or codes of medical ethics are good templates to work. on. In this essay, only those comments and rules that apply specifically to the relationship between doctors will be covered. On this matter, the Medical Council of India (3) declared the following clauses in its code of medical ethics.

• I will give to my teachers the respect and gratitude which is their due.
• I will maintain by all means in my power, the honour and noble traditions of the medical profession.
• My colleagues will be my brothers.

In the same vein, theInternational Code of Ethics(3) states the following:

• A doctor ought to behave towards his colleagues as he would have them behave towards him.
• A doctor must not entice patients away from his colleagues.

Some rules are clear and precise. However, there is scope for debate and controversy in many of the complex situations of our modern competitive life styles. Some of these controversial areas will be dealt with individually, with frequent references to the Indian code of medical ethics. Situations as they exist today will be touched upon and attempts to achieve the ideal will be suggested.

Student and teacher
One of the tenets of the Hippocratic oath states that it is a physician’s duty to teach his students all he knows, freely and without thought for remuneration. At an undergraduate level, the physician, (and I use this term in the broad sense which encompasses doctors in all disciplines of medicine), is teaching his future colleagues.

The onus of guiding and shaping a young mind should never be taken lightly. As stated by Dr F. Udwadia, "good teaching, though concentrating on essentials, must question dogma, must arouse and encourage an attitude of inquiry and a thirst for knowledge and serve as a stimulus for further study. Above all, teaching must be imbued with an ethical slant." (4) The professionally sound and ethically upright teacher is in the best position to appear as a role model for his impressionable pupils.

The ideal is sometimes very far from reality. Full time teachers are often dull, uninteresting and are themselves bored with the monotony of their teaching careers. That they are underpaid and live in relatively modest conditions as compared to those of their colleagues in private practice, does nothing to improve their psyche. The cream of the medical profession is often enticed into making their way onto foreign shores, or onto the more lucrative avenue of private practice. Teaching jobs are often manned by professionals who start working as a stop-gap arrangement and then just carry on, with very few being truly motivated to take on the vocation of being a teacher. Many teachers view their work as ‘just another job’. Many of the truly gifted teachers may not be motivated enough to take on the job, because of its limited returns. Some of these same full-time teachers resort to coaching classes to boost their income. This is unethical and is a source of corruption with all the undercurrents of nepotism and misconduct. Students at the undergraduate level are striving not just for the pass class. They know, and the teacher knows, that marks matter tremendously for entrance. into the post graduate training programme. One does not require much imagination to understand the implications of coaching classes run by potential examiners or by influential staff members.

The Government has got to realise that teachers, at all levels (and this definitely includes school teachers), are in the best position to mould young minds. In order to recruit good and gifted teachers, it is necessary to provide them with salaries and amenities which are realistic and at least on par with the earnings of those in practice.

For those already in the teaching profession, it is imperative to see that high standards of teaching are maintained and improved upon with constant seminars and workshops for the teachers. Teaching aids, computers, Internet facilities and availability of the latest journals and literature on the subject are not just a luxury, but a necessity in the fast changing world of medicine.

At the post graduate level, it is the duty of the teacher to train the young doctor so that he learns to perform according to accepted international standards.

At present, clinics are held often at erratic intervals and the science of medicine is elaborated upon. Ethical issues may be touched upon in passing, but ethical dilemmas are rarely the subject for detailed discussion. More often than not, the teachers themselves scoff at and ridicule the behaviour and practice of their own contemporaries. To exercise restraint and maintain the dignity of their profession is something which many teachers, themselves, need to learn. Students are shrewd and discerning and can easily read between the lines when such comments are made. The effect of snide remarks on their minds is usually the exact opposite of what the teacher hoped to achieve.

Conducting coaching classes at the post graduate level too is unethical and opens up immense possibilities for corruption and exploitation. (3)

At an interpersonal level, sharing of knowledge and dissemination of scientific information are very necessary in our profession. For the advancement of his profession and for his own sake, a physician would do well to affiliate himself with medical societies and scientific meetings and contribute his time, energy and means, so that these societies may represent and uphold the ideals of the profession. There is no age bar to the process of learning and it does not matter whom one learns from. It should not be surprising that one day the student may indeed be teaching his own professor in the course of conferences, seminars and workshops. The physician who feels ‘he knows it all and has seen it all’ is dangerous. Sooner or later he is going to harm some of his patients because of his inability to keep up with the times and learn about recent advances and techniques.

Professional services of physicians to each other
A physician should consider it a privilege to render service to his colleagues and their immediate dependants. The Indian code of ethics urges a physician to ‘cheerfully render professional services to his physician-colleagues and their immediate family members without seeking monetary compensation.’ However, there is no rule that a physician should not charge another colleague for his services. (3) When called from a distance to attend to, or advise, a colleague, he should be reimbursed for travelling and other incidental expenses. Unfortunately, many doctors who themselves require specialised or professional help from their colleagues cheat on them by seeking free treatment for themselves, their families and also for friends and distant relatives. This is unfair to the treating colleague, who gives of his best, without receiving compensation for his time and efforts. In this context, the terms ‘immediate family’ and ‘dependants' require definition. The immediate family consists of parents, spouse and children. Dependants include non-earning members of the family dependent upon the doctor for their survival.

Duties of the physician profession at large
Doctors may criticise one another, but only face-to-face and in complete confidence. To criticise a colleague in front of a patient is both damming and dangerous and can never be justified.

It is equally important that the utmost care and tact be maintained when listening to patients complaining about how they have been treated or handled by other doctors. A patient who dislikes or develops a grouse against a doctor based on some real or imagined mistake can be extremely disparaging and indiscreet in his manner of speech. The mature doctor would do well to refrain from listening to this tirade against a colleague. If, however, he cannot restrain the agitated patient, he must studiously refrain from making any comment that could possibly be construed as acceptance of the patient’s criticism. Professional loyalty demands understanding and mutual respect for your colleagues.

On the other hand a doctor is urged to expose incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession without fear or favour as these are against the best interests of patients. The accused doctor may be an alcoholic or a drug addict or a debauched person. Such matters may have to be considered by medical tribunals or by specially appointed ethics committees if they are not alreadysub judice. This cannot be considered as license for witch hunting or slander. The responsibility is grave but must be followed through with courage and honesty.

Ethics of employment obtaining assistance of non-medical men
In the matter of employment of personnel who would be required to render professional skill and discretion, the physician is morally obliged to recruit qualified attendants who are registered and enlisted under the law in force at that time. Those who are deficient in character or education should not be allowed to attend, treat or perform operations upon patients, as this is dangerous to public health. By enlisting non-medical men for medical tasks, the physician denies his colleagues jobs and, at the same time, does a grave disservice to his patients. If however the clinician does employ assistants to help him, the ultimate responsibility in the event of any mishap rests solely with the doctor.

A doctor asked whether he could utilise the services of a clinical laboratory which was not being operated under the supervision of a qualified pathologist but was run by a science graduate who had no medical qualifications. The reply of the Maharashtra Medial Council was as follows, "The medical practitioner should not co- operate with the clinical laboratory conducted by a B. Sc. who neither has medical qualifications nor works under the supervision of a medical man. Such a person, by himself, is not competent to assess the results obtained and as he is not directly under the control of the medical council, a report submitted by him, if incorrect, will reflect upon the medical practitioner who acts on the report." (3)

The burgeoning home industry of small laboratories run by laboratory technicians or by mere science students or less, is on the rise. There are, at present no curbs on this sort of activity. The truth is, they prosper and multiply because they are patronised by members of our own profession, who find such laboratories cheaper than those run by professionally qualified pathologists and microbiologists. The danger to patients from this selfish measure can be considerable. In addition, injustice is done to our own qualified colleagues.

There is also a proliferation of diagnostic and imaging centres, which are run as businesses, manned by smart but ill-qualified personnel. The public may not be in a position to understand the threats this may pose to their health. It is necessary for our profession and the medical councils to take cognisance of these centres and force them to run with some form of a license under the guidance and direction of a fully qualified doctor. They, too, along with the pathology and microbiology laboratories, must be subject to reviews and surprise checks similar to those for blood banks.

The practice of doctors running drug shops, dispensing drugs and appliances prescribed by other physicians also needs correction. This is the prerogative of the qualified pharmacist. A physician should not run a shop for the sale of medicine or for dispensing prescriptions prescribed by doctors other than himself or for sale of medical or surgical appliances. This does not mean he cannot prescribe or supply drugs, remedies or appliance for his own patients, so long as there is no exploitation of the patient.

Advertising
The physician who sets up practice and announces his presence with an unusually large signboard is probably not breaking the law, but he is certainly acting unethically. A doctor’s signboard cannot have the status of a glossy hoarding. Both signboard and the doctor’s prescription pad should proclaim nothing more than the physician’s name, qualifications, titles and speciality. It is improper to affix a signboard on a chemist’s shop or in places where he does not reside or work.

Advertising lowers the dignity of the profession and entices or lures patients on the basis of glamour rather than competence.

The Maharashtra Medical Council is aware of a growing menace of doctors who seek self-glorification and who market themselves in newspapers, magazines and on television. Doctors, surgeons and many quacks have been known to make tall claims of successful. and fantastic surgeries, guaranteed cures for obesity, cancer, AIDS and other diseases. Such individuals cannot wait for their work to speak for itself. Instead, they indulge in talk shows, consultancy columns in newspapers and advertisements of their arrivals and departures in various cities.

The Maharashtra Medical Council is now taking cognisance of doctors who advertise for various drugs, toothpaste products or remedies on TV and is also proceeding against doctors who place huge advertisements in newspapers for slimming programs and other quick money making programmes. Self promotion in any form is a punishable offence under the rules laid down by the Medical Council of India and the state councils. These also bar doctors from publishing their photographs.

Unless the Councils force the medical profession to realise that such conduct will debar doctors from medical practice, this cheap exhibition is likely to worsen.

A physician cannot claim to be a specialist unless he has put in a number of years of study and experience in the speciality, or he has the appropriate University qualification. Once he becomes a specialist, he cannot and should not work outside his speciality even for his friends. The ramifications of this statement are far reaching. Cross practice of allopathy and other disciplines of medicine like Homeopathy, Unani or Ayurvedic Medicine is wrong and it behooves the clinician to restrict his practice to the discipline he is specifically trained for. Dabbling in other sciences is unethical and potentially dangerous. On a similar note, the anaesthetist, for instance, should not do general practice nor should the neurosurgeon dabble in conditions that fall within the domain of the neurologist. There is, however, scope for debate on this issue when considering physicians who practice in rural areas, where they are forced to offer services on many fronts, because of the non-availability of qualified or specialist help. The rules have to be viewed in the context of the circumstances and the intentions of the physician.

An institution run by a clinician for a particular purpose, such as a maternity home or sanatorium or home for the blind or aged, may be advertised in the lay press, but such advertisements should not contain anything more than the name of the institution, types of patients admitted, facilities offered and the residential fees. The names of the superintendent or the doctors attending should not appear in the advertisement.

The code of ethics forbids cheap exhibition by doctors in the form of interviews and articles published for the purpose of advertising themselves or soliciting practice.

The doctor is permitted to write to the press under his own name, on matters of public health or hygiene, or to deliver public lectures or give talks on the radio or television on subjects of public interest. He is also permitted to make a formal announcement in the press regarding the following:

• starting practice
• change of type of practice
• change of address
• temporary absence from duty
• resumption of practice
• succeeding to another practice

On a more pragmatic note, the Indian code of ethics categorically states that the ‘solicitation of patients directly or indirectly be a physician, by groups of physicians or by institutions or organisations is unethical.’ The physician who advertises his skills, achievements, qualifications lowers his own dignity and that of the profession.

No physician should use touts or agents for procuring patients. He should neither pay, nor receive a commission for referring patients.

Etiquette of inter - professional relationships
The British Medical Association (2) and the Medical Council of India (3) state that ‘a practitioner in whatsoever form of practice, should take positive steps to satisfy himself that a patient who applies for treatment or advice is not already under the active care of another practitioner before he accepts him.’ Furthermore ‘a practitioner should not accept as a patient any patient whom he has attended as a consulting practitioner, or as a deputy for a colleague.’ Implementing this directive is not an easy task in a country like ours where private practice is rampant and where patients often switch doctors at will. Patients literally go shopping from clinic to clinic, or from hospital to hospital for doctor's opinions. Unscrupulous doctors readily accept any and every patient, often with full knowledge that the patient is under the care of a colleague. Such a commercial approach to patient care reduces the profession to a business venture.

Ethics in consultations
Consultations are a time-honoured custom and they should be encouraged in cases of serious illnesses, especially in doubtful or difficult conditions. In every consultation the benefit to the patient is of the first importance. The rights of the patient to ask for a second opinion should be respected. As in most situations the attending practitioner is the best judge but his vanity should not prevent him from refusing to recommend it, or to refuse to accede to the patient’s request for consultation with some other doctor. No medical practitioner can claim to be a specialist in every branch of medicine.

The following suggestions made by the Maharashtra Medical Council in its Code of Medical Ethics tersely state the important circumstances under which a practitioner should ask for a consultation:

• in serious illness,
• in doubtful conditions,
• in operations of a mutilating or destructive nature upon an unborn child,
• in operations which may vitally affect the intellectual or generative function of the patient. (3)

The attending doctor may certainly suggest the names of the consultants of his choice but even then, in the event of a difference of opinion between him and patient or his relatives of the patient, the choice of the latter should prevail.

In the event of irreconcilable difference of opinion between the two doctors, the circumstances should be impartially and frankly explained to the patient concerned. It is now up to the patient to decide which of these he will follow or, indeed, whether he will seek further advice from a new consultant.

There are points on the proper etiquette of consultation laid down in the International Code of Ethics which are summarised as follows:

• The attendance of the practitioner should cease when the consultation is concluded, unless the patient has dispensed with the services of his first doctor and engaged those of another.
• In no case should the consultant treat the patient alone or hand him over to his assistant or admit him to a nursing home or hospital without the knowledge of the the referring physician or injure the latter’s position in any respect. (Emergencies form an exception to this rule. In such an event, the consultant should inform the referring physician at the first opportunity after the crisis has been tided over.)
• When a consultant sees a patient in his rooms at the request of a medical practitioner, it is his duty to write to the latter, stating his opinion on the case and the line of treatment he thinks should be adopted. He should not see this patient again without a fresh note from the first doctor.
• A doctor called upon in an emergency must treat the patient, but after the crisis, the consultant must retire in favour of the original attendant of the patient.

Fees - insofar as they concern our colleagues

A practitioner’s fee should be commensurate with the services rendered and the patient’s ability to pay. They must be reasonable. It is advised that the fee be on par with those charged by his colleagues. The Medical Council of India code of medical ethics further states that remuneration received for medical services should be in the form and amount specifically announced to the patient at the time the service is rendered. It is unethical to enter into a contract of ‘no cure no payment’.

The practice of splitting fees must be condemned as infamous conduct. A medical man is a professional. He is not doing business. Splitting of fees stinks of commercialism.

Dichotomy or splitting of fees is illegal. When a practitioner consults a specialist in the interests of his patient, he is not acting as a business agent. The practitioner has no right to demand or expect a cut from the specialist for calling him in. The specialist in turn can charge the patient the appropriate fee for his consultation visit.

Conclusion
The Code of Medical Ethics offers this advice: "To other members of the profession you owe a duty as a colleague. You should never do or say anything that may make the position of your colleague awkward." There is a vast body of literature on ethical issues written by medical men, lay public and by those who understand the law. One sardonic statement, obviously written by someone who had clashed with the medical profession reads as follows: "There are three subjects on which the medical profession in general, is woefully weak. They are manners, morals and medicine."

Ironically the author of that comment, was himself a doctor. There are many people in different walks of life who share this view.

On introspection, there is no doubt that from time to time doctors do forget their moral obligations to each other. Our colleagues and the layman are quick to notice these deviations. If we aspire to retrieve the situation, we need to look back at our graduation day and have another close and honest look at the oath we swore when we so proudly assumed the prefix ‘Doctor’.

References
1. Dunstan CR, Dunstan GR: The artifice of ethics. London: SCM Press, 1974.

2. William AR, Thomson A: A dictionary of medical ethics and practice. London: John Wright & Sons Ltd, 1977.

3. Mehta HS, Taraporevala VJ: Medical law and ethics in India. Bombay: The Bombay Samachar Private Ltd., 1963.

4. Udwadia FE: Ethical problems in medical education. Issues in Medical Ethics 1997; 5: 37-39.

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