Throughout the data, we found that the perceptions of young doctors demonstrated poor medical professionalism. Occasional self-comparison with doctors in previous generations implied a decline in the spirit of serving humanity. The findings are based on an analysis of the statements of participants and observations made by researchers during data collection. Overall, sixty participants were interviewed, with equal representation from each of the three selected regional hospitals. The social demographic characteristics of participants are presented in Table 2. Our data analysis indicates the following themes and categories relating to the perspectives of young doctors on medical professionalism, how their attitudes diverge from standards of professionalism, and the contextual factors affecting their medical professionalism in the public hospitals of Pakistan.
Flexibility, tolerance, and poor medical professionalism
The study participants demonstrated 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, regarding 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.”
One study participant said about the need for 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 in situations where a reaction is actually needed. So, it has little to do with our field.
The young doctors believed that they are superior and that there should be no collaboration with experts in 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. For example, a male medical officer said:
Everybody knows that medicine is difficult to study and only exceptional students are selected for medical colleges and universities. Other subjects are also useful for weak students, but medical science is at the top of the hierarchy of various study disciplines. Social sciences and arts are something we already know, and we do not need to study them as additional courses and I do not think ethics has much to do with our field. Healing or the patient is the most important.
Similarly, a male house officer said:
It is of no use to teach humanities. Then there is no point in teaching humanities to medical students. This skill will not be used anywhere. It is useless for us to waste time studying irrelevant subjects. Already medical students have more useful books to study extensively. Why waste time on a skill which is never going to be used in practice?
Individually, doctors reported that they themselves are highly professional, but that some other doctors demonstrate unprofessional behaviour. These reported characteristics include using social media applications during duty hours, ridiculing patients, and substance use such as smoking cigarettes.
Perceived superiority and a paternalistic approach
We found that the perceived inferiority of other professions and patients were widely prevalent among the participants and led to the demonstration of false pride. Most participants reported that tolerance and acceptability have little to do with medical professionalism. One doctor said: “A doctor is a ‘doctor’.” All the participants 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 with 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 claimed medical professionalism in themselves while reporting other doctors as having distorted professional ethics. Their training under the 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 phenomena and since medical doctors pass through the toughest educational screening and training, they do not need to learn these skills. There was reporting about clashes of opinion and petty issues among the doctors, which reveals rigidity and a lack of acceptance of other viewpoints, perhaps linked to their medical school training under scientific knowledge trends.
Taking their duty seriously
As one example, we were told that medical doctors use their 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 was also reported by both female and male doctors.
Ridiculing the patient
There was reporting of sub-standard incidents of laughing at patients in which senior doctors discuss critical patients in debriefings with house officers. Making fun of people who are in pain and dependent for help on the doctors on duty does not imply medical professionalism. The words of one house officer 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 in their bed so they refer patients to other public hospitals without treating them. 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 did you kill today?” And it was happening every day as a fun routine in meetings of house officers with MO.
Inadequate role models
During the first few sessions, the doctors gave socially desirable answers, such as: “We’re very professional and none of the doctors show aggressive behaviour on duty.” However, other 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 their superiors and colleagues who are rude and critical and create conflict are just following human nature. None of the participants mentioned the need for anger or conflict management. Mistreatment by superiors and a high workload were reported by a few respondents. The senior staff should set good examples for young doctors to follow, said one respondent:
When they are not coming on time and insult patients on a single question, how can young doctors follow their trends? They have clashes with others. They criticise each other on disease management strategies – they couldn’t even agree on the dose of anaesthesia.
Intermediary non-medical staff
Several practical issues were reported in relation to working in healthcare teams, and non-cooperation by paramedical and nursing staff. Treatment errors are linked with the non-cooperation of non-medical staff, especially nursing assistants, during the execution of medical procedures:
The government initiatives have made nurses superior to doctors by giving them job security and reasonable salaries that exceed what is paid to doctors. So now the nurses clash with doctors – even during operations they do not cooperate with us… Like during surgery when I asked for a 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 their job and the 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 if they fail to make them happy and concern about provoking anger on petty issues:
In gynae wards, it is very important for all house officers to have a good “Hello” or “Hi” with nurses, because if you annoy them and cross them, they will not do anything for you so we address 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 address the nurse as nurse jee” (in Urdu, jee is used with names to show extreme respect). Participants reported that patients also complain about the non-cooperation of nurses. One of the doctors reported that she has heard a nurse putting off a 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 inconsistency in the perceptions of doctors about what describes ethical medical practice. The majority asserted the importance of the technical aspects of medical care. We found few responses in favour of service to humanity, sacrifice, or honesty. Only one male trainee doctor spoke about what professionalism is: “A good doctor sacrifices his sleep and appetite so that his patient can sleep well.” Overall, only two doctors said that they are serving humanity and emphasised that the purpose of joining this profession was not the financial benefits:
How can people expect 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 an overall workplace environment that will 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 judged by a person with a non-medical background. Few mentioned issues of poor professionalism in general, but at the same time reported that training in the non-technical aspects of care (i.e. interpersonal communication and professionalism) in their degree programmes is not needed. They still viewed it as irrelevant content.
‘Teachable-ness’ of doctors
When disagreement with experts in other fields occurs, it is observed that doctors are not teachable and lack the ability to accept other viewpoints. Something is seriously lacking in their training at medical school. This can be understood clearly in the words of one respondent in 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 programme evaluation, healthcare should be assessed by a medical doctor. There is no need for social scientists and humanities here.
These statements demonstrate the irrational sense of personal value and false pride that doctors have in the medical profession. However, it can be understood only when contextualised within South Asian society. This attitude implies that doctors are not teachable and have no skills relating to tolerance or acceptance.
Work in interprofessional collaborations and conflict management
There was no tendency to work in interprofessional collaborations because doctors felt that they did not need or trust the services of experts in other fields because such fields are chosen by low-performing students. This attitude is not professional in nature. The findings also implied that there are clashes of opinion within teams of doctors over prescribed treatments and procedures. The effectiveness of teamwork in healthcare is associated with patient outcomes. Respondents justified frequently being in conflict situations with other doctors and healthcare providers. One 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 does no harm.” Little concern about learning conflict management skills was found.