Towards Understanding Accountability for Physicians Practice in India

doi:10.21203/rs.3.rs-2111918/v1

The lack of accountability is considered to be a major cause of the crisis in health care in India. Physicians as key stakeholders in the health care delivery system have traditionally been accountable for health concerns at the doctor-patient interface. Following social and organizational dynamics, the interpretations of accountability have broadened and shifted in recent literature, expanding accountability to the community, national and global levels and to social domains. The objective of this study is to provide a comprehensive framework of accountability in medical practice that can be used as a vehicle for further contextualized research and policy input. Through literature review, this paper is presented in two parts. First, a description of accountability of a physician inclusive of the social domains is extracted by posing three pertinent questions: who is accountable? accountability to whom? and accountability for what? which addresses the roles, relationships with other stakeholders and domains of accountability. Second, a framework of accountability of a physician is designed and presented to illustrate the professional and social domains. This study revealed a shift from individual physician’s accountability to collective accountability involving multiple stakeholders through complex reciprocal and multi-layered mechanisms inclusive of the social dimensions. We propose a comprehensive framework of accountability of the physician to include the social domains that is multidimensional and integrative of all stakeholders. We discuss the utility of the framework in the Indian health care system and how this can facilitate further research in understanding the social dimensions of all stakeholders.

Framework

Physician

Accountability

Social domains

In the last decade there has been massive erosion of trust with significant deterioration of the doctor-patient relationship globally. This loss of confidence has been attributed to multiple societal factors such as publicity regarding physician abuses of the medical system, changes in consumer expectations, and increasing demands for involvement in decision-making and open and transparent communication in care [1, 2]. Similar changes have been observed in India. [3, 4, 5, 6]. In the recent past, despite governmental efforts to reform the healthcare system, India has witnessed a dramatic rise in litigation and violence against doctors and health care workers with similar incidents documented globally [7, 8, 9]. This disturbing trend has been associated with a rising climate of hostility and mistrust in the health profession [2, 10]. Pressing concerns have emerged regarding the failures in the health system and health providers with large-scale dissatisfaction related to malpractices, unethical practices, overpricing, and violation of patients’ rights [11, 12]. Various studies show lack of trust to be intrinsically related to accountability and hence enhancing the latter could be a possible solution to address mistrust in medical practice [13, 14, 15]. A study in India presents lack of accountability as reason for consumer dissatisfaction in health care delivery [16].

Accountability in health care practice has been a subject of debates for decades and it essentially entails procedures and processes of answerability and justification for decisions and actions [17, 18, and 19]. These procedures and processes of physicians’ accountability have not been examined adequately in the Indian context. The crisis in the Indian health care system is characterized by high disease burden, low healthcare expenditure, shortage of healthcare staff and a lack of healthcare resources [20, 21]. At the same time; rising literacy and technology have caused increasing consumer expectations. This tension between supply and demand calls for greater accountability and transparency from health care providers and the health system. As context is critical in conceptualizing and practicing accountability, literature regarding accountability shows that it is a contested and multi-layered construct, which needs to be contextualized in order to be applicable. Hence a closer scrutiny of accountability is crucial.

This study attempts firstly to explore how accountability is framed and operationalized in the literature, and secondly how this exploration could lead to a framework that is relevant in the Indian context. The current paper will use this exploration to compose a conceptual framework which we believe to be applicable in the context of India. In the next phase, the applicability of the framework will be examined on the basis of empirical studies involving relevant Indian stakeholders.

When interpreting the term accountability in the health care practice, its meaning may be ambiguous and hence can be perceived in diverse ways by different stakeholders in the health delivery systems e.g., physicians, patients, public as well as policy makers based on priorities and expectations [17]. For any health system to work effectively and for progressive reforms to take place, all stakeholders should have clarity regarding what accountability entails and the expectations from health care professionals especially the physicians.

Search Strategy

A search for literature on the topic was done using the electronic databases PubMed and Google Scholar. The search strategy was limited to the studies from 1976 to Mar 2021. The key words social accountability OR accountability AND doctor OR physician were used. In addition, we searched the reference lists in the selected relevant articles.

Study Selection

A total of 22150 hits related to the topic were found during the search. From the titles and abstract list, 101 studies which were related to the purpose of the review were screened for relevance on abstracts and titles. Articles were excluded if (a) the key words were not included in the title and/or abstract, (b) they only addressed specific accountability improvement strategies, measurements of accountability, perceptions/attitudes regarding accountability, role of culture on accountability c) accountability was linked with specific medical disciplines only, (d) they were not available in full text versions (e) they were published in non-English language without English translations. A total of 33 articles were reviewed and included in the study [Appendix 1].

Data analysis

The studies were examined for accountability of health care providers and their relationship to patients, peers and various other stakeholders. Additionally, studies in which concepts on accountability were discussed in the context of medical schools, health and community were also analyzed. We analyzed the papers based on the thematic analysis approach as proposed by Braun and Clarke [22].

Thirty three studies from peer-reviewed journals were included in the review. The majority of the studies were from Canada, USA, Great Britain, and Australia. Articles that were included were about accountability with respect to health care practice (n = 16), health care systems (n = 4), health care delivery [n = 7], and medical schools [n = 6]. Three key themes emerged from the analysis, evolving around the following questions: [1]. who is accountable? [2]. to whom? and [3].for what? are presented in Table 1. The discussions of the results for these three questions are elaborated below.

Table 1

Articles selected for review and categorized year-wise from 1985–2020
	Author(s) & Country	Who is accountable?	To whom? Stakeholders	For what?
1.	Stacey, M. (1985). Medical ethics and medical practice: a social science view. Journal of Medical Ethics, 11(1), 14–18. https://doi.org/10.1136/jme.11.1.14 UK	Doctors *GMC	Patient Public Colleagues Law	Neglect or disregard of professional responsibilities to patients for their care and treatment. Abuse of professional privileges or skills. Personal behavior: conduct derogatory to the reputation of the medical profession. Advertising, canvassing and related professional offences Protection of public
2.	Charles Boelen and Jeffern E Heck. Defining and Measuring the Social Accountability of Medical Schools, Geneva, World Health Organization, 1995.	Medical Schools	Community	Education directed towards community priority health needs
3.	Emanuel, E. J., & Emanuel, L. L. (1996). What is accountability in health care? Annals of Internal Medicine, 124(2), 229–239. https://doi.org/10.7326/0003-4819-124-2-199601150-00007 USA	Individual patients; Individual physicians; non-physician health care providers, hospitals; managed care plans; professional associations; employers, private payers, the government; investors and lenders of capital; and lawyers and courts, pharmaceutical companies		Professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion, and com- munity benefit
4.	Daniels, N. (1999). Decisions about access to health care and accountability for reasonableness. Journal of Urban Health, 76(2), 176–191. https://doi.org/10.1007/BF02344674 USA	Insurers Health plans Physician Employers	Public - Insured and Noninsured patient	Access to health care Coverage decisions Physician incentives
5.	Davies, H. T. O., & Shields, A. V. (1999). Public trust and accountability for clinical performance: Lessons from the national press reportage of the Bristol hearing. Journal of Evaluation in Clinical Practice, 5(3), 335–342. https://doi.org/10.1046/j.1365-2753.1999.00200.x UK	Doctors *GMC	Public Media	Clinical performance and accountability for that performance. Clinical governance – Quality of care, public trust, public access to individual performance data, Professional self-regulation
6.	Goold SD, Lipkin M (1999). The doctor-patient relationship: Challenges, opportunities, and strategies. J Gen Intern Med.14 (1 SUPPL.): 26–33. USA	Doctor Managed care organizations & Administrators	Patient	Professional standards, Public trust, Enhance knowledge & Skills, Protection and advocate of patient interests, Quality care Administrators - Financial stewardship, openness, honesty, privacy & Confidentiality
7.	Allen, P. (2000). Clinical governance in primary care. Accountability for clinical governance: Developing collective responsibility for quality in primary care. British Medical Journal, 321(7261), 608–611. https://doi.org/10.1136/bmj.321.7261.608 UK	Individual clinicians Groups of professionals, such as primary care groups and trusts	Patients Local Communities **NHS Peers Regulatory bodies Colleagues in practice Primary care group/trust	Quality and standard of care Clinical Governance – fiscal, process, program, and priorities Legal & Professional
8.	Donaldson, L. J. (2001). Professional accountability in a changing world. Postgraduate Medical Journal, 77(904), 65–67. https://doi.org/10.1136/pmj.77.904.65 UK	Clinicians Health professionals **NHS Organizations	Patients, Professional Code, Service directorates, General Public, Patient advocates, Patient representative organizations, Employers, Professional regulatory bodies, Courts, Inquiries, Elected politicians, Media,	Self-budgets Quality service provision Good practice Competence &Conduct Effectiveness Professional development & high standards Teamwork Developing service Management of change Quality care Accessible care Participation in Clinical governance Delivering corporate goals Assessing risks & avoiding failure
9.	Brinkerhoff, D. (2003). Accountability and Health Systems: Overview, Framework, and Strategies Prepared by: Accountability and Health Systems: Overview, Framework, and Strategies. 1–45. http://www.who.int/management/partnerships/accountability/AccountabilityHealthSystemsOverview.pdf. USA	Ministry of Health Agencies of Restraint and Enforcement Funding Agencies Parliament Local Government Officials Non-governmental Organizations Health Councils and Hospital Boards Professional Associations Unions Health Care Providers International Donors	Health service users/Patients Policy makers Citizens	Financial, Performance, Political/Democratic Accountability
10.	O’Neill, O. (2004). Accountability, trust and informed consent in medical practice and research. Clinical Medicine, Journal of the Royal College of Physicians of London, 4(3), 269–276. https://doi.org/10.7861/clinmedicine.4-3-269. UK	Professionals –Doctors & Scientists Institutions Professional bodies Civil servants Politicians Regulators Funders Public bodies	Patients Research subjects Public	Performance Accountability, Performance Corporate governance & democratic Accountability, Professional and standards Environmental or health incidents and disasters Research Consent in research & Public health
11.	Checkland, K., Marshall, M., & Harrison, S. (2004). Re-thinking accountability: Trust versus confidence in medical practice. Quality and Safety in Health Care, 13(2), 130–135. https://doi.org/10.1136/qshc.2003.009720 UK	Medical Practitioners	Government Patients & their advocates, Employers Professional regulatory bodies Court Elected Politicians Public be said to be arguable such as the media) Commission for Healthcare Improvement GMC	Efficient use of resource Qualitative performance Quality care Prudent use of public money Improvement of public health
12.	Fleet, L. J., Kirby, F., Cutler, S., Dunikowski, L., Nasmith, L., & Shaughnessy, R. (2008). Continuing professional development and social accountability: A review of the literature. Journal of Interprofessional Care, 22(SUPPL. 1), 15–29. https://doi.org/10.1080/13561820802028360 Canada	Health Professionals	Patients Community Managers Policymakers	***Socially accountable CPD -Personal, social, and political aspects of health care
13.	Fu Furler, J. S., & Palmer, V. J. (2010). The ethics of everyday practice in primary medical care: Responding to social health inequities. Philosophy, Ethics, and Humanities in Medicine, 5(1), 1–8. https://doi.org/10.1186/1747-5341-5-6. Australia	Family Physician Professional associations	Socially disadvantaged people in society Patients	Access to care Responding and active engagement with social health inequities
14.	Forster, A. J., Turnbull, J., McGuire, S., Ho, M. L., & Worthington, J. R. (2011). Improving patient safety and physician in accountability using the hospital credentialing process. Open Medicine, 5(2), 79–86. Canada	Physician Hospital Administrators	Patient Public	Patient safety Individual Performance & Behavior Patient complaints Health outcomes
15.	Zelisko, D., Baumann, A., Gamble, B., Laporte, A., & Deber, R. B. (2014). Ensuring accountability through health professional regulatory bodies: The case of conflict of interest. Healthcare Policy, 10, 110–120. https://doi.org/10.12927/hcpol.2014.23850. Canada	Health Professional Regulatory bodies	Public	Professionalisms & Self -regulation Standards of Professional ethics Practice Conflict of interest
16.	Baumann, A., Norman, P., Blythe, J., Kratina, S., & Deber, R. B. (2014). Accountability: The challenge for medical and nursing regulators. Healthcare Policy, 10, 121–131. https://doi.org/10.12927/hcpol.2014.23911 .Canada	Health Professional Regulatory bodies	Public, Government and their members	Licensing registration Providing support & better practice Transparency and privacy of physician
17.	Rudolf, M. C. J., Reis, S., Gibbs, T. J., Murdoch Eaton, D., Stone, D., Grady, M., Berlin, A., Blair, M., Essa-Hadad, J., Spitzer-Shohat, S., & Weingarten, M. (2014). How can medical schools contribute to bringing about health equity? Israel Journal of Health Policy Research, 3(1), 1–6. https://doi.org/10.1186/2045-4015-3-17. Israel	Medical Schools	Community Public Governments Health care organizations	Service, research, and education to community health needs Health equity Political advocacy
18.	Cochran, J., Kaplan, G. S., & Nesse, R. E. (2014). Physician leadership in changing times. Healthcare, 2(1), 19–21. https://doi.org/10.1016/j.hjdsi.2014.01.001 USA	Physicians Hospital Payers	Patients	Shaping health care system Patient advocates Leadership Fair distribution of limited health care resources
19.	Preston, R., Larkins, S., Taylor, J., & Judd, J. (2016). From personal to global: Understandings of social accountability from stakeholders at four medical schools. Medical Teacher, 38(10), 987–994. https://doi.org/10.3109/0142159X.2015.1114596 Australia	Medical schools	Local Communities	Community health needs Socially accountable medical education
20.	Buchman, S., Woollard, R., Meili, R., & Goel, R. (2016). Practicing social accountability from theory to action. Canadian Family Physician, 62(1), 15–18. Canada	Family physicians	Individual, Community Health system Societies	Equitable access, patient-centeredness, Physician advocates Fairness and equity, Human rights, and dignity Primary care research Medical Education
21.	Lodenstein, Dieleman M, Gerretsen B, Broerse J.Health Policy and Planning, 2016, 1–16. doi: 10.1093/heapol/czw089	Health providers, Policy makers	Citizens	Health rights, Better health care
22.	Macpherson, CC., & Hill, J. (2017). Are physicians obliged to lead environmental sustainability efforts in health care organizations? AMA Journal of Ethics, 19(12), 1164–1173. https://doi.org/10.1001/journalofethics.2017.19.12.ecas2-1712. USA	Physician Health organizations	Patient Community Public	Protection of health through environment sustainable efforts
23.	Rosoff, P. M. (2017). Who should ration? AMA Journal of Ethics, 19(2), 164–173. https://doi.org/10.1001/journalofethics.2017.19.2.ecas4-1702 USA	Physician Health care system	Patient	Health care resource rationing
24.	Genovese, Umberto & Del Sordo, Sara & Pravettoni, Gabriella & Akulin, Igor Zoja, Riccardo Casali, Michelangelo (2017). A new paradigm on health care accountability to improve the quality of the system: Four parameters to achieve individual and collective accountability. Journal of Global Health. 7. 10.7189/jogh.07.010301. Italy	Health care systems Health care professionals	Patients	High quality treatments, reduce adverse events, transparency in health care systems
25.	Boelen C. Coordinating medical education and health care systems: the power of the social accountability approach (2018). Med Educ. 52(1):96–102. USA	Medical Schools	Community	Medical education training
26.	Rourke J. Social accountability: A framework for medical schools to improve the health of the populations they serve 2018. Acad Med. 93(8):1120–4. USA	Medical Schools	Community	Medical education training
27.	Gallagher, S., Little, M., & Hooker, C. (2019). Evidence, Emotion and Eminence: A Qualitative and Evaluative Analysis of Doctors’ Skills in Macroallocation. Health Care Analysis, 27(2), 93–109. https://doi.org/10.1007/s10728-018-0356-z. Australia	Doctors	Health system	Transparent and equitable Health care resource allocation
28.	Mannion, R., Davies, H., Powell, M., Blenkinsopp, J., Millar, R., McHale, J., & Snowden, N. (2019). Healthcare scandals and the failings of doctors: Do official inquiries hold the profession to account? Journal of Health Organization and Management, 33(2), 221–240. https://doi.org/10.1108/JHOM-04-2018-0126 UK	Individual Doctor NHS Health system	Patient	Quality and safety of care Professional wrongdoings
29.	Martinez-Bianchi, V., Frank, B., Edgoose, J., Michener, L., Weida, J., Rodriguez, M., Gottlieb, L., Reddick, B., Kelly, C., Yu, K., Davis, S., Carr, J., Lee, J. W., Smith, K. L., & New, R. (2019). Addressing family medicine’s capacity to improve health equity through collaboration, accountability, and coalition-building. Family Medicine, 51(2), 198–203. https://doi.org/10.22454/FamMed.2019.921819 USA	Family Physicians	Patient Families Community Population Marginalized people	Improving health equity Health advocate
30.	Asghari, S., Heeley, T., Walsh, A., Rourke, J., Bethune, C., & Graham, W. (2019). Rural360: incubating socially accountable research in the Canadian North. International Journal of Circumpolar Health, 78(1). https://doi.org/10.1080/22423982.2019.1633191 Canada	Rural Physicians	Communities	Accessible and contextually relevant healthcare and research
31.	Mohammadi, M., Bagheri, M., Jafari, P., & Bazrafkan, L. (2020). Motivating medical students for social accountability in medical schools. Journal of Advances in Medical Education & Professionalism, 8(2), 90–99. https://doi.org/10.30476/jamp.2020.84117.1128 Iran	Medical schools Physicians Medical students	Individual Family Community	Professional practice Health delivery, Prevention, Educational, Managerial and Treatment services Community needs
32.	Boroumand, S., Stein, M. J., Jay, M., Shen, J. W., Hirsh, M., & Dharamsi, S. (2020). Addressing the health advocate role in medical education. BMC Medical Education, 20(1), 28. https://doi.org/10.1186/s12909-020-1938-7 Canada	Medical Trainees Medical Schools	Community - Socially disadvantaged and marginalized	Health advocate for health equity
33.	Christina M. Cutter, Christopher Nelson, and Mahshid Abir. Population Health Management. 27 May 2020 ahead of print http://doi.org/10.1089/pop.2020.0096 USA	Hospitals Health system	Community Less resourced systems	Equitable organizational governance, Consumer safeguards, community engagement Protection of Less-Resourced Health Care Settings Transparency of Regional Health System Capacity
GMC - General Medical Council NHS-National Health Service **Socially accountable CPD - Socially Accountable Continued Professional development

Who Is Accountable?

As the included papers show (Appendix 1), the common stakeholder who the majority of the authors hold accountable in the health care system is the physician. However, this view has been contested by other authors who posited that the physician can no longer be seen as the only actor accountable in the health care system. Emanuel and Emanuel described an accountability ‘network’, consisting of 11 different actors [23]:

“Individual patients; individual physicians; nonphysician health care

providers such as nurses and physical therapists; hospitals; managed care

plans; professional associations; employers, … private payers, … the

government; investors and lenders of capital; and lawyers and courts …”

Daniels and Allen emphasized that when working in primary care groups, trusts or organizations, the physicians as well employers and administrators are held accountable for all aspects of health care delivery [24, 25]. According to Donaldson, health care organizations on their part have a responsibility to provide the environment, support, and systems where physicians can deliver high quality care and participate in clinical governance [19]. In a later publication, Genovese et al., builds on this by arguing that there is currently a shift from “individual” accountability” to a “collective” accountability where responsibilities of patient care, transparency and error prevention are shared among health care providers, health care institutions and the health system [26]. We consider these actors internal stakeholders in the health system in this study.

In collective accountability, stakeholders interact with each other over different domains and mechanisms of accountability that Genovese calls a “complex reciprocating matrix of accountability” to guide health reforms [26]. Brinkerhoff adds external stakeholders to the collective network, such as the Ministry of Health (MOH), agencies of restraint and enforcement, funding agencies, parliament, local government officials, non-governmental organizations (NGO), professional associations, unions and international donors [27]. These stakeholders are connected to each other through networks of “layered webs of accountability with varying degrees of autonomy and sources of control/oversight.” Interestingly, in this article the active role of the patient/health service user is emphasized. As an integral part of the health service, health service users have limited powers to demand accountability or impose sanctions; however they can hold politicians accountable by exercising their voting rights and health care providers through legal routes which include malpractice suits. Citizens as an active stakeholder in the community, through citizen voice and participation in health policies can hold political and governmental actors and public service providers accountable to the society for quality and equity in health services [28].

From the above, it is understood that a shift has taken place in the onus of accountability. Where before the physician was seen as the focal point in accountability in health care practice, the focus now is much more on ‘collective’ accountability’ involving internal and external stakeholders. Figure 1 depicts the network of stakeholders who are accountable and distinguishes those who actually provide healthcare as internal stakeholders and other regulatory and non-regulatory bodies as external stakeholders. This collective accountability entails mutual dependencies between multiple stakeholders, in layered webs of accountability with varying degrees of autonomy and sources of control/oversight.

Accountable To Whom?

Initial papers on accountability focused mainly on the locus of accountability of the physician within the physician-patient relationship [2, 29] While Genovese et al., refers to this as horizontal accountability which involves the physician-patient relationship, Allen describes answerability to colleagues, primary care group members and trust/organizations where the physician practices as horizontal accountability [25, 26]. These two loci of accountability of the physician have been distinguished by Emanuel and Emanuel in their models of accountability. The first was directed to the individual patient where patients are participant-recipients of care with the physicians providing professional service. The second locus of accountability was to their professional colleagues and the organizations that they serve [18]. Both the parties can be considered as internal stakeholders in the health care system.

However, the health care system has evolved and continues to evolve into complex organizations where multiple key players are accountable to one or more internal and external stakeholders [30]. Genovese et al., endorsed the collective nature of this accountability mechanism not only at the physician-patient interface, but included other groups of internal stakeholders in the health care system [27]. According to them, accountability is a reciprocal collective shared responsibility between all actors in the health care system. Medical schools, another internal stakeholder, also play an important role by directing medical education to groom physicians-in-training to provide accountable care [31, 32].

Allen, in addition to accountability to internal stakeholders, introduced accountability to external stakeholders such as regulatory bodies and local communities [25]. Regulatory bodies maintain standards of the profession through formal and informal mechanisms and hold their physicians accountable to the patient, public, non-professional bodies and the government (such as the Ministry of Health) and they in turn are answerable to the same stakeholders [28, 33]. Regarding accountability to the local community, Buchman et al., discussed the physician’s unique position in the society and defined accountability as “the social contract that medicine has with the society”[34]. Many authors argue that accountability to the community by physicians and in particular medical schools should include the vulnerable and socially disadvantaged people in the community especially in underserved regions, who are the victims of social inequities and may not have access to quality care [35, 36, 37].

Other external stakeholders such as the media, patient representatives and patient advocates play an important role in providing reciprocating check mechanisms [19, 38, 39] Adding to the complexity of this network, Daniels introduced yet another external stakeholder, the insurer, who constitutes the doctor-patient-insurer triangle relationship in the accountability link between the physician and the patient. Physicians are accountable to both the insured and non-insured patients through health plan coverage decisions of the insurers and insurer incentives offered to them [24].

In summary, the accountability of physicians to multiple stakeholders has shifted from a unidimensional relationship between the physician and the patient to a more complex network characterized by reciprocal and multi-layered mechanisms of accountability between internal and external stakeholders [Fig. 2].

Accountable for what?

Traditionally, accountability of physicians was discussed within the context of professional and ethical obligations to the patient and profession. Professional duties that the physicians were held responsible and accountable for were predominantly concerned with individual patient care. Stacey reiterated that physicians should not disregard or neglect their professional duties to their patients, abuse professional privileges or skills or engage in behavior that can bring disrepute to the profession [29]. Donaldson argued that physicians in addition to accountability for the quality of work were collectively accountable for the organization’s performance and provision of local services [19]. Physicians working in hospital settings were accountable to the administrators for patient complaints and documentation that can be monitored through various hospital credentialing processes [40]. According to Donaldson and Allen, legal and professional accountability alone does not suffice [19, 25]. Accountability in clinical governance by maintaining the highest standards, assessing risk, and avoiding failure, quality service provision and continuous and sustained quality improvement is of utmost importance to provide quality and safe care. Additionally, several authors highlight the importance of transparency and openness in patient care, in how health care resources are used and distributed, in adherence to ethical principles in research and how this informs public health policy [38, 26, 41, 42].

More recently, social dimensions have entered the ongoing debate regarding physician’s accountability. Adequacy of access, public health promotion, improving health inequalities, health advocacy, providing for contextually relevant care and community benefits extend the physician’s professional responsibilities into more social dimensions [23, 34, 35, 43, 44, 45, 46]. Catering to the needs of the socially disadvantaged is based on notions of justice and human rights, which covers the social dimension. Martinez-Bianchi et al., called on doctors to “play an active role as a ‘health advocate’ for the marginalized members of the society” [36]. It is in this capacity as advocates for patients and community that they can shape the healthcare system especially in resource limited settings where decisions regarding fair distribution of resources are warranted [47, 48]. Transformation of health care systems also requires research in community health. In this regard, Asghari et al., called on rural physicians to be socially accountable by ensuring accessible and contextually relevant research that can translate into evidence-based care or new models of practice [46].

With the advent of new health problems arising from the deleterious effects of climate change and the emergence of pandemics, additional obligations and accountability are placed on physicians and health organizations to address societal health. According to Macpherson and Hill, doctors should “use their influential position, expertise, and resources to protect patients, community, and the public from the consequences of environmental damage by promoting environmentally sustainable initiatives” [49].

As mentioned before, the physician is part of a larger network involving internal and external stakeholders, thus accountability extending to the social domain should also include this network. Following the Covid-19 pandemic, Cutter proposed rethinking of accountability for public health and advocated for active involvement in disaster preparedness measures within the total health care system [50]. Several authors, in line with WHO recommendations, state that medical schools should train physicians to become socially accountable by partnering with government and community [34, 37, 45, 51,532 Mohammadi et al., and Boroumand et al., specified that by training and involving medical students in health advocacy for health equity, they would be motivated to work towards addressing health disparities and ensuring an equitable health system [44, 45]. Fleet et al., and Rudolf et al., in addition, discussed the inclusion of political advocacy in the training of medical graduates [44, 53]. The authors argued that medical universities serve the community, and thus can sensitize policy makers to the health inequities that exist in the society which in turn can lead to health care reforms.

External stakeholders such as regulatory bodies/medical councils ensure that the guidelines and procedures are balanced to protect not only the profession but the public as well [29]. Rising litigation has forced the regulatory bodies to provide public access to individual performance data, answerability for issues regarding self-regulation and clinical performance and accountability of their physician members [2, 53]. According to Baumann et al., health professional regulatory bodies also have an additional duty to address financial conflict of interests thereby ensuring accountability to the public [53]. Further, insurers are important external stakeholders as well, who determine public and patient access to medical care through coverage decisions. According to Daniels, their decision making power with regards to coverage might violate the health care system’s social obligation in providing for the marginalized and disenfranchised, as stated above [24]. This in turn, may influence the physicians’ or organizations’ decision to collaborate with certain incentive schemes that are provided by the various insurers. Figure 3 depicts the three pillars of social domains of a physician’s accountability.

Summarizing, a shift has taken place in the notions of what physicians or other internal or external actors are accountable for. Whereas traditionally, physicians were held accountable for professional duties in the physician-patient relationship, accountability has extended to include answerability for the social aspects of health care. Scholars advocate for including social considerations in training and education, changing medical practice to prioritize the needs of the marginalized and take into consideration environmentally sustainable health care that is morally and socially just. Recognizing that the physician is an actor in a complex network of internal and external stakeholders, social accountability extends to the whole network and becomes a joint responsibility.

In this study, we set out to review notions of accountability in medical practice, with a focus on physician’s accountability. The analysis resulted in the emergence of three key themes: who is accountable, to whom and for what. The reviewed literature has shown that a shift has taken place in all three aspects of accountability. Firstly, a shift has taken place from individual accountability to collective accountability, meaning that a physician has become a part of a more comprehensive network, encompassing internal and external stakeholders, who are jointly accountable to other actors in the network. Secondly, physicians are no longer solely accountable to the individual patient; rather the locus of accountability has shifted towards reciprocal and multi-layered mechanisms of accountability between internal and external stakeholders. Thirdly, a shift has taken place in the notions of what physicians or other internal or external stakeholders are accountable for and social responsibilities have been added to professional accountability. This goes primarily for the physician, being the key actor in medical practice, but as emphasized before, this extends to all stakeholders in the network. This means that physicians are an integral part of a complex interdependent and interlinked multi-stakeholder environment in the health care delivery system in which domains of accountability are multidirectional and collective in nature. The physician’s accountability can no longer be restricted to the doctor-patient interface but has extended from the professional domain to include the social domain.

The amalgamation of these ideas has been diagrammatically represented in a conceptual framework of the physician’s professional and social accountability and the relationship with external and internal stakeholders [Fig. 4].

This integrated conceptual framework of accountability of a physician and multiple stakeholders with the social domains can be used as an analytic tool for assessment and measurement at the community, national and international levels. This aspect will be explored in subsequent papers in the Indian context. Additionally, the core social domains outlined in this framework can be used in the medical curriculum to develop educational materials to design loci and domains of accountability of a physician regarding professional development. The limitation of this conceptual framework is that the societal and environmental concerns need detailed exploration and further research. Since the health care system is dynamic and becoming more technology driven this concept may need upgrading over time with emerging new societal and environmental health concerns. This model can be used across all disciplines in health care and need not be restricted to the medical profession alone. Hence, there is a broad scope to integrate framework in other health professions and demonstrate relationships and linkages of this concept with other actors in the health system. Additionally, research on the enabling factors and barriers for accountability and the various individual social domains in this framework can provide further insights.

Applying this conceptual framework of accountability to India, the Ministry of Health and Family Welfare which includes the politicians and bureaucrats are responsible for designing and implementation of health policies and family planning along with the state governments. At the state level, implementation occurs through the district health department and the health care workforce that includes the physician at the primary, secondary and tertiary care levels. The beneficiaries are the consumers in the society i.e. the citizens of India [54]. Having described the Indian health care sector, we propose that this model of physician’s accountability can be operationalized to understand the domains of accountability of a physician vis-à-vis the internal and external stakeholders which will be explored in the Indian context in subsequent papers.

We commenced with the need to understand accountability of a physician in this paper as this was one of the reasons for mistrust in the medical profession and health care system. Through a detailed analysis of the literature of the relevant articles, we developed a conceptual framework of accountability of a physician which can be used in the local, national, and global context. This new understanding of accountability can be used for future research in countries where the health care system is similar to India. Additionally, it can be used as a tool to assess accountability of a physician in various professional and social domains. In the light of the strengths and limitations, we propose that our description and conceptual framework brings clarity to the notion of accountability of a physician and can serve as a model and framework for understanding and operationalizing this concept.

WHO – World Health Organization

NGO – Non Governmental organizations

MOH – Ministry of Health

GMC - General Medical Council

Ethics declarations

Conflict of interests

All the authors have no conflicts of interest.

Acknowledgements

We wish to acknowledge the help provided by Dr. Prakash P for designing the figures^.

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Appendix. Table 1: Articles selected for review and categorized year-wise from 1985-2020
	Author(s) & Country	Who is accountable?	To whom? Stakeholders	For what?
1.	Stacey, M. (1985). Medical ethics and medical practice: a social science view. Journal of Medical Ethics, 11(1), 14–18. https://doi.org/10.1136/jme.11.1.14 UK	Doctors *GMC	Patient Public Colleagues Law	Neglect or disregard of professional responsibilities to patients for their care and treatment. Abuse of professional privileges or skills. Personal behavior: conduct derogatory to the reputation of the medical profession. Advertising, canvassing and related professional offences Protection of public
2.	Charles Boelen and Jeffern E Heck. Defining and Measuring the Social Accountability of Medical Schools, Geneva, World Health Organization, 1995.	Medical Schools	Community	Education directed towards community priority health needs
3.	Emanuel, E. J., & Emanuel, L. L. (1996). What is accountability in health care? Annals of Internal Medicine, 124(2), 229–239. https://doi.org/10.7326/0003-4819-124-2-199601150-00007 USA	Individual patients; Individual physicians; non-physician health care providers, hospitals; managed care plans; professional associations; employers, private payers, the government; investors and lenders of capital; and lawyers and courts, pharmaceutical companies		Professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion, and com- munity benefit
4.	Daniels, N. (1999). Decisions about access to health care and accountability for reasonableness. Journal of Urban Health, 76(2), 176–191. https://doi.org/10.1007/BF02344674 USA	Insurers Health plans Physician Employers	Public - Insured and Noninsured patient	Access to health care Coverage decisions Physician incentives
5.	Davies, H. T. O., & Shields, A. V. (1999). Public trust and accountability for clinical performance: Lessons from the national press reportage of the Bristol hearing. Journal of Evaluation in Clinical Practice, 5(3), 335–342. https://doi.org/10.1046/j.1365-2753.1999.00200.x UK	Doctors *GMC	Public Media	Clinical performance and accountability for that performance. Clinical governance – Quality of care, public trust, public access to individual performance data, Professional self-regulation
6.	Goold SD, Lipkin M (1999). The doctor-patient relationship: Challenges, opportunities, and strategies. J Gen Intern Med.14 (1 SUPPL.): 26–33. USA	Doctor Managed care organizations & Administrators	Patient	Professional standards, Public trust, Enhance knowledge & Skills, Protection and advocate of patient interests, Quality care Administrators - Financial stewardship, openness, honesty, privacy & Confidentiality
7.	Allen, P. (2000). Clinical governance in primary care. Accountability for clinical governance: Developing collective responsibility for quality in primary care. British Medical Journal, 321(7261), 608–611. https://doi.org/10.1136/bmj.321.7261.608 UK	Individual clinicians Groups of professionals, such as primary care groups and trusts	Patients Local Communities **NHS Peers Regulatory bodies Colleagues in practice Primary care group/trust	Quality and standard of care Clinical Governance – fiscal, process, program, and priorities Legal & Professional
8.	Donaldson, L. J. (2001). Professional accountability in a changing world. Postgraduate Medical Journal, 77(904), 65–67. https://doi.org/10.1136/pmj.77.904.65 UK	Clinicians Health professionals **NHS Organizations	Patients, Professional Code, Service directorates, General Public, Patient advocates, Patient representative organizations, Employers, Professional regulatory bodies, Courts, Inquiries, Elected politicians, Media,	Self-budgets Quality service provision Good practice Competence &Conduct Effectiveness Professional development & high standards Teamwork Developing service Management of change Quality care Accessible care Participation in Clinical governance Delivering corporate goals Assessing risks & avoiding failure
9.	Brinkerhoff, D. (2003). Accountability and Health Systems: Overview, Framework, and Strategies Prepared by: Accountability and Health Systems: Overview, Framework, and Strategies. 1–45. http://www.who.int/management/partnerships/accountability/AccountabilityHealthSystemsOverview.pdf. USA	Ministry of Health Agencies of Restraint and Enforcement Funding Agencies Parliament Local Government Officials Non-governmental Organizations Health Councils and Hospital Boards Professional Associations Unions Health Care Providers International Donors	Health service users/Patients Policy makers Citizens	Financial, Performance, Political/Democratic Accountability
10.	O’Neill, O. (2004). Accountability, trust and informed consent in medical practice and research. Clinical Medicine, Journal of the Royal College of Physicians of London, 4(3), 269–276. https://doi.org/10.7861/clinmedicine.4-3-269. UK	Professionals –Doctors & Scientists Institutions Professional bodies Civil servants Politicians Regulators Funders Public bodies	Patients Research subjects Public	Performance Accountability, Performance Corporate governance & democratic Accountability, Professional and standards Environmental or health incidents and disasters Research Consent in research & Public health
11.	Checkland, K., Marshall, M., & Harrison, S. (2004). Re-thinking accountability: Trust versus confidence in medical practice. Quality and Safety in Health Care, 13(2), 130–135. https://doi.org/10.1136/qshc.2003.009720 UK	Medical Practitioners	Government Patients & their advocates, Employers Professional regulatory bodies Court Elected Politicians Public be said to be arguable such as the media) Commission for Healthcare Improvement GMC	Efficient use of resource Qualitative performance Quality care Prudent use of public money Improvement of public health
12.	Fleet, L. J., Kirby, F., Cutler, S., Dunikowski, L., Nasmith, L., & Shaughnessy, R. (2008). Continuing professional development and social accountability: A review of the literature. Journal of Interprofessional Care, 22(SUPPL. 1), 15–29. https://doi.org/10.1080/13561820802028360 Canada	Health Professionals	Patients Community Managers Policymakers	***Socially accountable CPD -Personal, social, and political aspects of health care
13.	Fu Furler, J. S., & Palmer, V. J. (2010). The ethics of everyday practice in primary medical care: Responding to social health inequities. Philosophy, Ethics, and Humanities in Medicine, 5(1), 1–8. https://doi.org/10.1186/1747-5341-5-6. Australia	Family Physician Professional associations	Socially disadvantaged people in society Patients	Access to care Responding and active engagement with social health inequities
14.	Forster, A. J., Turnbull, J., McGuire, S., Ho, M. L., & Worthington, J. R. (2011). Improving patient safety and physician in accountability using the hospital credentialing process. Open Medicine, 5(2), 79–86. Canada	Physician Hospital Administrators	Patient Public	Patient safety Individual Performance & Behavior Patient complaints Health outcomes
15.	Zelisko, D., Baumann, A., Gamble, B., Laporte, A., & Deber, R. B. (2014). Ensuring accountability through health professional regulatory bodies: The case of conflict of interest. Healthcare Policy, 10, 110–120. https://doi.org/10.12927/hcpol.2014.23850. Canada	Health Professional Regulatory bodies	Public	Professionalisms & Self -regulation Standards of Professional ethics Practice Conflict of interest
16.	Baumann, A., Norman, P., Blythe, J., Kratina, S., & Deber, R. B. (2014). Accountability: The challenge for medical and nursing regulators. Healthcare Policy, 10, 121–131. https://doi.org/10.12927/hcpol.2014.23911 .Canada	Health Professional Regulatory bodies	Public, Government and their members	Licensing registration Providing support & better practice Transparency and privacy of physician
17.	Rudolf, M. C. J., Reis, S., Gibbs, T. J., Murdoch Eaton, D., Stone, D., Grady, M., Berlin, A., Blair, M., Essa-Hadad, J., Spitzer-Shohat, S., & Weingarten, M. (2014). How can medical schools contribute to bringing about health equity? Israel Journal of Health Policy Research, 3(1), 1–6. https://doi.org/10.1186/2045-4015-3-17. Israel	Medical Schools	Community Public Governments Health care organizations	Service, research, and education to community health needs Health equity Political advocacy
18.	Cochran, J., Kaplan, G. S., & Nesse, R. E. (2014). Physician leadership in changing times. Healthcare, 2(1), 19–21. https://doi.org/10.1016/j.hjdsi.2014.01.001 USA	Physicians Hospital Payers	Patients	Shaping health care system Patient advocates Leadership Fair distribution of limited health care resources
19.	Preston, R., Larkins, S., Taylor, J., & Judd, J. (2016). From personal to global: Understandings of social accountability from stakeholders at four medical schools. Medical Teacher, 38(10), 987–994. https://doi.org/10.3109/0142159X.2015.1114596 Australia	Medical schools	Local Communities	Community health needs Socially accountable medical education
20.	Buchman, S., Woollard, R., Meili, R., & Goel, R. (2016). Practicing social accountability from theory to action. Canadian Family Physician, 62(1), 15–18. Canada	Family physicians	Individual, Community Health system Societies	Equitable access, patient-centeredness, Physician advocates Fairness and equity, Human rights, and dignity Primary care research Medical Education
21.	Lodenstein, Dieleman M, Gerretsen B, Broerse J.Health Policy and Planning, 2016, 1–16. doi: 10.1093/heapol/czw089	Health providers, Policy makers	Citizens	Health rights, Better health care
22.	Macpherson, CC., & Hill, J. (2017). Are physicians obliged to lead environmental sustainability efforts in health care organizations? AMA Journal of Ethics, 19(12), 1164–1173. https://doi.org/10.1001/journalofethics.2017.19.12.ecas2-1712. USA	Physician Health organizations	Patient Community Public	Protection of health through environment sustainable efforts
23.	Rosoff, P. M. (2017). Who should ration? AMA Journal of Ethics, 19(2), 164–173. https://doi.org/10.1001/journalofethics.2017.19.2.ecas4-1702 USA	Physician Health care system	Patient	Health care resource rationing
24.	Genovese, Umberto & Del Sordo, Sara & Pravettoni, Gabriella & Akulin, Igor Zoja, Riccardo Casali, Michelangelo (2017). A new paradigm on health care accountability to improve the quality of the system: Four parameters to achieve individual and collective accountability. Journal of Global Health. 7. 10.7189/jogh.07.010301. Italy	Health care systems Health care professionals	Patients	High quality treatments, reduce adverse events, transparency in health care systems
25.	Boelen C. Coordinating medical education and health care systems: the power of the social accountability approach (2018). Med Educ. 52(1):96–102. USA	Medical Schools	Community	Medical education training
26.	Rourke J. Social accountability: A framework for medical schools to improve the health of the populations they serve 2018. Acad Med. 93(8):1120–4. USA	Medical Schools	Community	Medical education training
27.	Gallagher, S., Little, M., & Hooker, C. (2019). Evidence, Emotion and Eminence: A Qualitative and Evaluative Analysis of Doctors’ Skills in Macroallocation. Health Care Analysis, 27(2), 93–109. https://doi.org/10.1007/s10728-018-0356-z. Australia	Doctors	Health system	Transparent and equitable Health care resource allocation
28.	Mannion, R., Davies, H., Powell, M., Blenkinsopp, J., Millar, R., McHale, J., & Snowden, N. (2019). Healthcare scandals and the failings of doctors: Do official inquiries hold the profession to account? Journal of Health Organization and Management, 33(2), 221–240. https://doi.org/10.1108/JHOM-04-2018-0126 UK	Individual Doctor NHS Health system	Patient	Quality and safety of care Professional wrongdoings
29.	Martinez-Bianchi, V., Frank, B., Edgoose, J., Michener, L., Weida, J., Rodriguez, M., Gottlieb, L., Reddick, B., Kelly, C., Yu, K., Davis, S., Carr, J., Lee, J. W., Smith, K. L., & New, R. (2019). Addressing family medicine’s capacity to improve health equity through collaboration, accountability, and coalition-building. Family Medicine, 51(2), 198–203. https://doi.org/10.22454/FamMed.2019.921819 USA	Family Physicians	Patient Families Community Population Marginalized people	Improving health equity Health advocate
30.	Asghari, S., Heeley, T., Walsh, A., Rourke, J., Bethune, C., & Graham, W. (2019). Rural360: incubating socially accountable research in the Canadian North. International Journal of Circumpolar Health, 78(1). https://doi.org/10.1080/22423982.2019.1633191 Canada	Rural Physicians	Communities	Accessible and contextually relevant healthcare and research
31.	Mohammadi, M., Bagheri, M., Jafari, P., & Bazrafkan, L. (2020). Motivating medical students for social accountability in medical schools. Journal of Advances in Medical Education & Professionalism, 8(2), 90–99. https://doi.org/10.30476/jamp.2020.84117.1128 Iran	Medical schools Physicians Medical students	Individual Family Community	Professional practice Health delivery, Prevention, Educational, Managerial and Treatment services Community needs
32.	Boroumand, S., Stein, M. J., Jay, M., Shen, J. W., Hirsh, M., & Dharamsi, S. (2020). Addressing the health advocate role in medical education. BMC Medical Education, 20(1), 28. https://doi.org/10.1186/s12909-020-1938-7 Canada	Medical Trainees Medical Schools	Community - Socially disadvantaged and marginalized	Health advocate for health equity
33.	Christina M. Cutter, Christopher Nelson, and Mahshid Abir. Population Health Management. 27 May 2020 ahead of print http://doi.org/10.1089/pop.2020.0096 USA	Hospitals Health system	Community Less resourced systems	Equitable organizational governance, Consumer safeguards, community engagement Protection of Less-Resourced Health Care Settings Transparency of Regional Health System Capacity
GMC - General Medical Council NHS-National Health Service **Socially accountable CPD - Socially Accountable Continued Professional development

No competing interests reported.

Towards Understanding Accountability for Physicians Practice in India

Status:

Journal Publication

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Abstract

Figures

Background

Method

Search Strategy

Study Selection

Data analysis

Results

Who Is Accountable?

Accountable To Whom?

Accountable for what?

Discussion

Conclusions

Abbreviations

Declarations

References

Appendix

Additional Declarations

Status:

Journal Publication

Version 1