Indian Journal of Medical Ethics

DISCUSSION

Improving the ethics of medical practice: a family physician's viewpoint

A B Merchant

Based on my experience of 20 years in urban general practice I would like to present the following thoughts regarding the declining ethical values in medical practice. I will initially make some general points and then focus on family practice. I believe that the root cause of differing standards of medical practice can often be traced back to the criteria for selection of medical practice as a career. A young student selects the medical profession for various reasons, which ultimately influence his or her attitude towards medical practice. These reasons include: aptitude, dedication and capability; parental pressure, sensing a money-making opportunity and wanting 'family business' to continue. Only a person falling in the first category, who has chosen to become a doctor out of a certain commitment to serve society, is able to enjoy his life, work with dedication and emerge wiser towards the end of his career. He or she may contribute substantially to society (irrespective of his 'achievements') Any other person without dedication and aptitude is not able to achieve the 'target' and may develop resentment towards life and society. He may use his position to gain power, status or money. Unfortunately a significant number of doctors in today's society are from the latter group

Our colleagues should realise that looking at their practice only from the money-making angle, in the long term makes them lose both money and skills. I believe that excessively money-minded individuals often lose sight of the core issue, which in our case is the treatment of patients. No doubt money is important in today's world, but doctors should not expect to earn like industrialists who can employ many people and run their production three shifts per day. We should focus on our main objective, our patients' interest, which will not only earn love and respect for us but will eventually become financially rewarding as well.

On a more pro-active level, we could take the initiative in promoting interaction with society. For example doctors from a locality should also form groups which, acting as 'watchdogs', assist law-enforcing and medical authorities. Medical councils should encourage ethical values and enforce carefully thought-out and frequently up-dated rules, so that the medical community on the whole continues to be respected by society. We must actively vote for the right candidates in medical council elections On the other hand, society should discourage 'ambulance-chasing' lawyers and 'trial-by-press' against doctors. Demoralised doctors may not be in the interests of society. High-school curricula should contain a small chapter in the civics textbook on how to select and deal with professionals. Students should be made to realise that intrinsic values should be given emphasis while selecting professionals, not their 'appearance'. Society should not always expect doctors to act as selfless, dedicated souls. Unless proper fees are paid, doctors will either indulge in malpractices or remain relatively poor - and neither situation will be healthy for society. A ban on advertising by doctors should continue, because otherwise a doctor's worth will always be decided by marketing men. At the same time, media persons should reduce the publication of unnecessary articles written by publicity-hungry doctors.

From the specific viewpoint of general practice, I would like to share my own experiences, which I believe have helped me practice ethically and at the same time be content with what I am doing.

General practitioners (GPs) should always try to purposefully interact with patients of all age-groups. The relationships which they build over time will be useful and will bring long-lasting satisfaction to him. The goodwill which they so gather, should be used for guiding their patients towards the path of recovery from their illness. They must always put across the pros and cons of a particular treatment to their patients. A consenting patient will then be more co-operative while undergoing treatment. Patients who do not want to listen to professional advice may not come again, but a practice built up in a straightforward way later brings rich dividends in the form of satisfaction and respect.

GPs must always charge and get appropriate fees, but in certain cases may give credit facilities. A carefully given credit facility is usually not misused. Moreover, the same patient may not hesitate to come if he has fallen ill but has no money at that time.

GPs should be very careful in issuing various certificates and one of the reasons for our low credibility is the practice of easily issuing certificates on demand. GPs should not give injections except when unavoidable. However, using injections such as placebos should be allowed in certain situations. No drug should be used indiscriminately (for example, appropriate antibiotics should be prescribed only for documented or strongly suspected bacterial infections). The GP's prescription should be precise, clearly written and properly explained to the patient.

GPs should always refer their patients to a competent diagnostic centre. I have come across X-ray clinic where reports are regularly written by technicians. I have also come across a pathologist who would always print 'QNS' (quantity not sufficient) across the specific gravity column of the routine urine examination report, irrespective of the amount of urine given by the patient, and another pathologist who would never give RBC indices even when a complete haemogram was ordered.

I strongly believe that general practitioners must continuously update their knowledge. In the field of medicine, concepts, clinical course, treatment, etc., keep changing even as new diseases like AIDS come up. GPs who have to cover a wide range of topics are therefore very precariously placed. They must keep abreast of these changes because they are the first doctor to whom the patient comes, and if they do not suspect a potentially dangerous disease in time, it may be too late for the patient.

General Practitioners should always keep a small percentage of their earnings aside for buying medical books. They also should not be ashamed to open and refer to them in the presence of the patient, in case of any doubt. They should also attend various updating programmes where lecturers are consultants who speak from their experience. They should avoid attending updating programmes which are in fact 'social events' combined with entertainment programmes (complete with lucky draws). Sponsors of scientific programmes should provide relevant study material as gifts instead of other useful things (which GPs will be inclined to buy anyway). Alternatively, GPs in small effective groups should make their own study programme, invite experienced specialists and gain knowledge out of them. GPs should always use the opportunity of visiting their patients in the hospital to study their cases.

A patient should be referred only if it is beyond the capacity (skill/facility) of the GP to treat. The referral should be made as transparent as possible, giving the patient a right to go to the specialist of his choice. If the GP has referred a patient to a consultant, then track should be kept on the patient's progress. He should insist on being informed prior to taking any major decision and should make it very clear to the attending consultant that appropriate treatment for his patient is all that he wants from him. Concessions should be demanded and obtained for poor patients.

In the ultimate analysis, a doctor who can take care of both the emotional and medical aspects of his patients is best suited to join general practice. Also, the only way to improve medical ethics would be to improve the ethics of society itself. I remember a stock-broker becoming a hero overnight for making an illegal fortune out of the stock-market a few years ago. In a society that worships such people, it may be a long time before we can expect the ethics of medical practice to improve.

Dr A B Merchant, B-55 Rigved, 344 Veer Savarkar Marg, Dadar, Mumbai 400 028.