Throughout the data, we found that the perceptions of young doctors demonstrated a low medical professionalism. Occasional self-comparison with the doctors in previous generation implied a decline in the spirit of serving humanity. The findings are based on analysis of the reporting of participants and observations of researchers in data collection. Overall, sixty participants were interviewed with equal representation of all three selected regional hospitals. The characteristics of participants are presented in Table 2.
Our analysis demonstrated the following categories of medical professionalism linked with how professional, young doctors think they are and how their attitudes diverge away from standards of professionalism, the structure, process and outcome factors affecting their medical professionalism in public hospitals in Pakistan.
Table 2: Characteristics of participants
Characteristics
|
Punjab
|
Sindh
|
Azad Jammu & Kashmir
|
Age
24 to 32 years
33 to 40 years
|
10
10
|
10
10
|
10
10
|
Gender
Male
Female
|
10
10
|
10
10
|
10
10
|
Highest qualification1
MBBS
FCPS1
FCPS2
Diploma
Others
|
4
4
4
4
4
|
4
4
4
4
4
|
4
4
4
4
4
|
Service level
House officer
Medical officer
PG trainee
Senior registrar
Specialist
|
4
4
4
4
4
|
4
4
4
4
4
|
4
4
4
4
4
|
Service length 2
Less than 7 years
7 to 12 years
|
12
8
|
9
11
|
13
7
|
Department
Outpatient
In-admission
Emergency and accidents
|
7
6
7
|
8
6
6
|
7
7
6
|
1 Qualified in Pakistan are selected. Doctor of Physiotherapy (DPT) and Bachelor of Dental Surgery (BDS) are not recruited.
2 Average age of completing MBBS (MD) is 23 to 25. This experience includes one year of house job.
Flexibility, tolerance and low medical professionalism
The study participants showed characteristics such as rigidity of opinion, inflexibility, and non-acceptance of contrasting perspectives. Some of the doctors became angry during the interview about the subject matter of the research and regarded it as a strategy to make doctors furious. The statement of one respondent may be useful at this point to further clarify the scenario: “I don’t understand why you’re carrying out such research. This is not your field – you’re not a medical doctor. A doctor of medicine can ask us such questions.” Another respondent said: “Because of this type of research, doctors are unable to perform well on duty.” No demonstration of acceptability was recorded in such cases. Constructive criticism should also be welcomed by professionals.
One study participant said about the need of tolerance: “I think to some extent tolerance is good, but it becomes negative if we use it everywhere like we will forget to even react on situations where reaction is actually needed. So, it has less to do with our field.”
The young doctors believed that they are superior and there should be no collaboration with experts of other fields. Only a medical doctor has the capacity to work with public health related matters. There is no need for the inclusion of a professionalism and humanity course in the medical school curriculum. The majority of respondents thought that social science topics are irrelevant to medicine and are merely common-sense things that they already know. Individually, doctors reported that they are highly professional, but some others demonstrate unprofessional behaviour. These reported characteristics include using social media applications during duty hours, ridiculing patients, substance use such as cigarettes in the office and inappropriate salaries.
Perceived superiority and paternalistic approach
We found that the perceived inferiority over all other professions and patients were highly prevalent among the participants and leads to the demonstration of false pride. Most of the participants reported that the tolerance and acceptability have less to do with medical professionalism. A doctor said: “A doctor is a ‘doctor’.” All participants (n=60) believed that their knowledge of medicine has equipped doctors with a superior position over their patients and other professions. The belief that patients know nothing was common among all the participants. One female doctor said: “A down-to-earth approach wouldn’t work for patients in Pakistan. Patients don’t mind the harsh conversation by the doctors, rather they think that a doctor who snubs is a competent doctor”. Another respondent said: “Patients know nothing irrespective of the fact that he is educated or not – obviously one would not become a doctor by googling diseases and symptoms”. This statement reveals a sense of superiority over patients and other human beings. The doctors demonstrated a lack of any perceived need to establish congruence with patients.
Training under positivism
Almost all the participants vested medical professionalism in themselves and reported other doctors as having distorted professional ethics. The training under positivist school of thought does not leave any room for subjective human nature. This is depicted in the words of our participants who believe that humanities, ethics and professionalism are common sense phenomenon and since medical doctors pass through the toughest educational screening and training, they do not need to learn these skills. There was reporting about clash of opinion and patty issues among the doctors, which reveals lack of acceptance of other viewpoints and rigidity perhaps linked with medical school training under scientific knowledge trends.
Seriousness towards duty
For example, we were told that medical doctors use mobile phones while seeing patients. This is a common practice among doctors in Pakistan, which affects the quality of attention they give to patients. Furthermore, smoking and substance use by male doctors has also been reported by female as well as male doctors.
Ridiculing the patient
There was reporting of sub-standard incidents of laughing at in which senior doctors discuss critical patients in debriefings to house officers. Making fun of those who are in pain and dependent for help on the doctors on duty does not imply medical professionalism. The words of a house officer doctor clarify this finding: “I became a doctor to serve mankind and I have tried my best to do my duty honestly. I feel depressed when I see my colleague house officers ridiculing old patients admitted in critical condition. None of the house officers want any patient to expire on their bed so they refer patients to other public hospitals without treating. Even it was depressing for me when I heard MO making fun of old patients in pain. (Probe: What did MO say while making fun? If you can recall?) Yes, he came in and asked his house officers: How many elderly patients do you kill today? And it was happening everyday as fun routine in meeting of house officers with MO.”
Inadequate role models
During the first sessions, the doctors gave socially desirable answers, such as: “We’re very professional and none of the doctors show aggressive behaviour on duty”. However, later on, the respondents emphasised that aggression is a basic part of human nature. In conflict situations, both parties are justified in demonstrating aggressive behaviour. Participants reported that the seniors and colleagues who are rude and critical and create conflict are just following human nature. None of the participants mentioned the need for anger and conflict management. Mistreatment by seniors and a high workload were reported by a few respondents. The seniors should set good examples for the young doctors to follow, said one respondent: “When they are not coming on time and insult patient on single question, how can young doctors follow their trends? They have clashes with others. They criticize each other on disease management strategies – even wouldn’t agree on the doze of anaesthesia.”
Intermediary non-medical staff
Several practical issues have been reported about working in healthcare teams, and non-cooperation of paramedical and nursing staff. The treatment errors are linked with the non-cooperation from non-medical staff, especially nursing assistants, during the execution of medical procedures: “The government initiatives have made the nurses superior to the doctors by giving them job security and reasonable salaries that exceed what is paid to the doctors. So now the nurses clash with doctors – even during operations they do not cooperate with us… Like during surgery that I asked for retractor from nursing staff, she didn’t respond so I asked again she kept standing silently and then I had to go further away and get it myself.”
Due to the status of the job and facilities in the public sector, nursing staff often clash with doctors. Technically, the doctor is head of a healthcare team, but the situation is different in public hospitals in Pakistan. Female doctors expressed their fear of abuse from nurses in case failure in making them happy and provoking anger on petty issues: “In gynae wards, it is very important for all house officers to have good ‘Hello’ or ‘Hi’ with nurses, because if you annoy them and cross them, they will not do anything for you so we call them nicely as baaji jee (in Urdu) meaning elder respectable sister.”
Another female trainee doctor said: “We have to call the nurse in a low and sweet tone so she may give us the thing that we need. All of the senior doctors even call the nurse as nurse ‘jee’” (in Urdu, jee is used with names to show extreme respect). Participants told that the patients also complain about the non-cooperation by the nurses. One of the doctors reported that she has heard a nurse putting off the patient by saying: “I’m busy now – come tomorrow. I will tell you how to use insulin, diet chart and check blood sugar…”
Ethical medical practice
There was incongruence in the perceptions of doctors on what describes ethical medical practice. The majority asserted the importance of technical aspects of medical care. We found few responses in favour of service for humanity, sacrifice and honesty. Only one male trainee doctor spoke about what professionalism is: “A good doctor sacrifices his sleep and appetite so that his patient could sleep well”. Overall, only two doctors said that they are serving humanity and emphasised that the purpose of joining this profession was not the monetary benefits: “How can people expect from doctors to think of serving humanity when they are having financial problems at home. Their families also need money for survival and a good quality of life. Doctors should be highly paid, because they have worked harder than people in any other profession. For following standards of what is right and wrong, there has to be overall workplace environment that would allow us do that.”
Need for accountability and training
The respondents agreed that a mechanism for accountability is required in hospitals but emphasised the need to appoint a medical doctor with expertise in evaluation. This suggested that medical doctors would not like to be watched by a person with a non-medical background. Few mentioned about low professionalism in general but at the same time reported that training on the non-technical aspects (i.e. interpersonal communication and professionalism) in their degree programmes is not needed. They still viewed it as irrelevant content.
‘Teach-ableness’ of doctors
While disagreement with experts of other fields, it is observed that that doctors are not teachable and lack acceptability for other viewpoints. Something is seriously lacking in the training at medical schools. This can be understood clearly in the words of a respondent of this study who said: “How can a social worker or a lawyer tell a doctor what to do in healthcare practice? The other professions are adopted by people of average intellectual and mental abilities. A doctor is a ‘doctor’. If something must be done about society or there is any kind of program evaluation, healthcare should be assessed by a medical doctor. There is no need for social scientists and humanities in here.”
These statements demonstrate the irrational sense of personal value and false pride that doctors have in medical profession. However, it can be understood only when contextualized in South- Asian society. This implies that the doctors are not teachable and have no skills of tolerance and acceptability.
Work in interprofessional collaborations and conflict management
There was no tendency for working in interprofessional collaborations as doctors felt that they do not need and trust services from experts of other fields since those are opted by low performing students. This attitude is not professional in nature.
The findings also implied that there are clashes of opinions within the team of doctors over prescribed treatment and procedures. The effectiveness of teamwork in healthcare is associated with patient outcomes. Respondents justified to be in conflicting situations frequently with other doctors and healthcare providers. A female doctor said: “It is normal and healthy to get into arguments and conflict.” Another said: “We cannot avoid getting into conflict because it is natural and has no harm”. Low concern about learning conflict management skills was found.