A total of 72 physicians at PAHS were included randomly in study-1. All the respondents returned the questionnaires. However, some questionnaires consisted of non-response items. To preserve the sample size, pairwise deletion was done to analyze the data.
The majority of respondents were male 46 (66%) with a mean age of 29 ± 6 years. The mean years of clinical practice after MBBS was 4 ± 5.5 years (Table 1). If an ethical dilemma arose, 39 (55%) respondents would prefer to consult colleagues first. 46 (63.9%) doctors cited gaining knowledge regarding ethics through work experience (Table 2). The median score for the relevance of medical ethics in work practice was 8 with an IQR (InterQuartile Range) of 3 on a 10 point rating scale. Most respondents faced ethical issues at least once a month (Fig. 2). All respondents agreed that medical ethics should be a part of medical education.
Table 1
Participant Demographics for study 1.
Characteristics | Category | n (%) |
Due to missing data, not all category groups sum to 72 | | |
Age (years) | (N = 71) | |
| 20 to 25 | 14 (20) |
| 26 to 30 | 33 (46) |
| 31 to 35 | 17 (24) |
| ≥ 36 | 7 (10) |
Sex | (N = 70) | |
| Male | 46 (66) |
| Female | 24 (34) |
Qualification | (N = 72) | |
| MBBS | 47 (65) |
| MD/MS | 25 (35) |
Designation | (N = 72) | |
| Interns | 11 (15) |
| Medical officers | 36 (50) |
| Consultants | 25 (35) |
Department | (N = 72) | |
| Emergency | 17 (24) |
| Gynaecology/Obstetrics | 14 (19) |
| Medicine | 16 (22) |
| Orthopedics | 5 (7) |
| Pediatrics | 11 (15) |
| Surgery | 9 (13) |
MBBS from | (N = 70) | |
| Nepal | 26 (37) |
| Abroad | 44 (63) |
Years of Practice after MBBS | (N = 68) | |
| Less than 1 years | 23 (34) |
| Less than 5 years | 26 (38) |
| Less than 10 years | 10 (15) |
| More than 10 years | 9 (13) |
Table 2
Source of knowledge of medical ethics for study 1(n = 72)
Source | n (%) |
Work Experience | 46 (63.9%) |
Lectures During MBBS | 44 (61.1%) |
Books/Literature | 31 (43.1%) |
Seminar/Workshops/CME | 19 (26.4%) |
Lectures During PG | 11 (15.3%) |
The majority of the doctors were aware of the Hippocratic oath and Nepal Medical Council code of ethics (Table 3). There was no clinical ethics committee present in Patan Hospital at the time of the study. However, 40 (56%) of the respondents were unaware of it. 58 (81%) knew about the presence of a legal advisor in Patan Hospital. The median for the importance of an ethical committee in a hospital was rated at 9 out of 10 with an IQR of 3.
Table 3
Code of medical ethics heard and rating of knowledge for study 1(n = 71)
Code of Ethics | n (%) Heard | Median | 1st Quartile | 3rd Quartile | IQR |
Hippocratic Oath | 66 (93.0%) | 7 | 5 | 8 | 3 |
Nepal Medical Council Code of Ethics | 54 (76.1%) | 6 | 1 | 7 | 6 |
Declaration of Helsinki | 33 (46.5%) | 0 | 0 | 4 | 4 |
70 out of 72 participants who responded, 13 (18%) claimed to have used resources to complete the questionnaire. However, there was no significant difference (p = 0.990) observed in the knowledge score of those who had and had not used resources. Only 21 (30%) of the respondents considered the patients themselves to be the best judge while 50 (70%) of the clinicians thought that doctors are the most capable to judge what is good for the patient.
There was a positive correlation between knowledge (correlation coefficient = 0.218, p = 0.088) practice of medical ethics(correlation coefficient = 0.522, p = 0.000), attitude (correlation coefficient = 0.376, p = 0.002) and years of practice (Table 4 and Table 5). Although statistically insignificant, difference was observed in the knowledge of medical ethics between MBBS and MD/MS graduates (p = 0.050), between interns, medical officers and consultants (p = 0.144), between the different departments (p = 0.093) and between MBBS graduates from Nepal and abroad (p = 0.539).
Table 4
Assessment of knowledge, Practice, Attitude and combined KAP of medical ethics for study 1
| | Knowledge | Practice | Attitude | Combined KAP |
| | N | Mean ± S.D. (n = 22 questions) | p-value | N | Measure of Central Tendency ± Dispersion (n = 10 questions) | p-value | N | Median ± IQR (n = 10 questions) | p-value | N | Measure of Central Tendency ± Dispersion (n = 42 questions) | p-value |
Qualification | MBBS | 43 | 12.00 ± 2.96 | 0.050ᶜ | 46 | 5.50 ± 1.59ᵃ | < 0.001ᶜ | 46 | 6.00 ± 1.00 | 0.002ᶠ | 41 | 23.88 ± 4.35ᵃ | 0.001ᶜ |
MD/MS | 21 | 13.67 ± 3.45 | 24 | 7.38 ± 1.47ᵃ | 24 | 7.00 ± 1.00 | 19 | 28.42 ± 5.88ᵃ |
Designation | Intern | 10 | 11.80 ± 3.19 | 0.144ᵈ | 11 | 5.09 ± 1.87ᵃ | < 0.001ᵈ | 11 | 6.00 ± 2.00 | 0.005ᵉ | 10 | 22.70 ± 5.12ᵃ | 0.004ᵈ |
Medical Officer | 33 | 12.06 ± 2.94 | 35 | 5.63 ± 1.50ᵃ | 35 | 6.00 ± 1.00 | 31 | 24.26 ± 4.10ᵃ |
Consultant | 21 | 13.67 ± 3.45 | 24 | 7.38 ± 1.47ᵃ | 24 | 7.00 ± 1.00 | 19 | 28.42 ± 5.88ᵃ |
Department | Emergency | 17 | 11.94 ± 3.34 | 0.093ᵈ | 16 | 6.00 ± 1.75ᵇ | 0.300ᵉ | 15 | 7.00 ± 2.00 | 0.546ᵉ | 14 | 23.50 ± 7.50ᵇ | 0.472ᵉ |
Gynae/Obs | 12 | 11.58 ± 3.58 | 13 | 5.00 ± 2.50ᵇ | 14 | 7.00 ± 2.00 | 11 | 25.00 ± 10.00ᵇ |
Medicine | 14 | 11.79 ± 2.01 | 16 | 7.00 ± 2.50ᵇ | 16 | 6.00 ± 1.00 | 14 | 25.00 ± 7.25ᵇ |
Orthopedics | 3 | 13.00 ± 2.00 | 5 | 7.00 ± 2.50ᵇ | 5 | 7.00 ± 1.00 | 3 | 27.00 ± 0.00ᵇ |
Pediatrics | 11 | 15.00 ± 3.07 | 11 | 6.00 ± 3.00ᵇ | 11 | 7.00 ± 2.00 | 11 | 26.00 ± 8.00ᵇ |
Surgery | 7 | 13.14 ± 3.63 | 9 | 8.00 ± 3.00ᵇ | 9 | 7.00 ± 2.00 | 7 | 29.00 ± 8.00ᵇ |
MBBS completed from | Nepal | 24 | 12.92 ± 3.82 | 0.539ᶜ | 25 | 7.00 ± 3.00ᵇ | 0.302ᶠ | 25 | 7.00 ± 2.00 | 0.272ᶠ | 22 | 26.55 ± 5.68ᵃ | 0.190ᶜ |
Abroad | 38 | 12.39 ± 2.81 | 43 | 6.00 ± 2.00ᵇ | 43 | 7.00 ± 1.00 | 36 | 24.64 ± 5.07ᵃ |
N = Number of Doctors |
ᵃ Mean ± S.D. |
ᵇ Median ± IQR |
ᶜ Independent T-test |
ᵈ ANOVA |
ᵉ Kruskal-Wallis |
ᶠ Mann-Whitney U |
Table 5
Correlation of years of medical practice with KAP for study 1
| N | Rho (Correlation Coefficient) | p-value |
Knowledge | 64 | 0.218 | 0.088* |
Attitude | 66 | 0.522 | < 0.001* |
Practice | 66 | 0.376 | 0.002* |
Combined KAP | 58 | 0.347 | 0.008* |
*Spearman's |
A significant statistical difference favoring the group with greater years of practice was observed in the attitude (p = 0.002) and practice (p = 0.000), of medical ethics between MBBS and MD/MS graduates. Similar results were also observed among interns, medical officers, and consultants (p = 0.000). However, there was no significant difference in the practice of medical ethics between MBBS graduates from Nepal and abroad (p = 0.302). A statistically significant difference (p = 0.005) was also observed in the attitude between interns, medical officers, and consultants with the median score highest among the consultants. However, no significant difference was observed in the attitude regarding medical ethics among respondents of different departments (p = 0.546) and between MBBS graduates from Nepal and abroad (p = 0.272).
There was a positive and statistically significant correlation between knowledge and practice (correlation coefficient = 0.441, p = 0.000), knowledge and attitude (correlation coefficient = 0.611, p = 0.000) and practice and attitude (correlation coefficient = 0.554, p = 0.000).
A significant statistical difference (p = 0.001) was observed in the KAP of medical ethics between MBBS and MD/MS graduates with the mean score higher for MD/MS graduates. Similarly, a significant difference was observed (p = 0.004) in the KAP of medical ethics among interns, medical officers, and consultants. The mean score was highest for consultants (Table 4). A positive and statistically significant correlation was observed between KAP of medical ethics and years of practice (correlation coefficient = 0.347, p = 0.008). However, there was no significant difference in KAP of medical ethics among the various selected departments (p = 0.472) and between MBBS graduates from Nepal and abroad (p = 0.190) (Table 4).
Among the ethical issues, respondents scored well in obtaining informed consent; however, the majority scored poorly in issues concerning autonomy (Table 6).
Table 6
Number of Doctors with Correct answers in each Case Scenarios
S. No | Ethical Issue | Knowledge of presence of breach of ethics n (%) | Knowledge on principle of ethics involved n (%) | Practice n (%) | Attitude n (%) |
1 | Obtaining informed consent | 64 (88.89) | 54 (76.06) | 35 (48.61) | 68 (95.77) |
2 | Revealing diagnosis to patient | 64 (88.89) | 24 (34.29) | 8 (11.11) | 63 (87.50) |
3 | Revealing information to patient's relatives | 50 (70.42) | 57 (79.17) | 33 (45.83) | 59 (81.94) |
4 | Respecting autonomy of patient | 32 (44.44) | 23 (32.39) | 19 (26.39) | 36 (50.00) |
5 | Do not resuscitate | 37 (51.39) | 32 (45.07) | 21 (29.17) | 36 (50.00) |
6 | Euthanizing child | 53 (73.61) | 32 (45.07) | 16 (22.22) | 64 (88.89) |
7 | Withdrawal of treatment and autonomy | 44 (61.11) | 33 (46.48) | 29 (40.85) | 41 (56.94) |
8 | Reportable illness | 38 (53.52) | 31 (44.93) | 10 (14.08) | 22 (30.99) |
57 (80.28) | 26 (37.14) | - | - |
9 | Contraceptive and autonomy | 29 (40.28) | 40 (56.34) | 23 (31.94) | 31 (43.06) |
10 | Reporting colleague's error | 52 (72.22) | 29 (40.85) | 10 (13.89) | 59 (83.10) |
A total of 114 medical officers were included in our follow up study (study-2). The study was conducted in a 1:1 ratio among those who have had medical ethics lectures during their MBBS period apart from forensic medicine and those who have not had separate medical ethics lectures. Out of the total of 114 medical officers, 54 (47.36%) respondents had medical ethics lectures during their MBBS program (referred to as group 1 moving forward) and 60 (52.63%) respondents did not have medical ethics lectures (referred to as group 2 moving forward). Among group 1 who had medical ethics lectures during their MBBS program, the majority were those who had graduated from PAHS 37 (68.51%).
The majority of the respondents were male 67 (58.77%). The majority of respondents fell in the age group of 25–30 years (51.75%) followed by the age group of 20–25 years (47.36%). 75 (65.78%) of respondents completed their MBBS from Nepal, followed by Bangladesh 17 (14.91%), China 17 (14.91%) and Philippines 5 (4.3%). Majority of the doctors 54 (47.36%) had at least 6 months of practice after completion of MBBS followed by 39 (34.21%) doctors who had a practice of 6 months to 1 year and 21 (18.42%) doctors had a practice of more than a year (Table 7 and Table 8). Statistically significant negative correlation of years of medical practice with KAP of medical ethics was found in Study 2. We suspect it is due to the fact that our respondents did not have a long enough medical practice for the correlation to be of implicational value.
Table 7
Participants demographics for Study 2
Characteristics | Category | n (%) |
Age (years) | 20 to 25 | 54 (47.37%) |
| 26 to 30 | 59 (51.75%) |
| 31 to 35 | 1 (0.88%) |
Sex | Male | 67 (58.77) |
| Female | 47 (41.22) |
MBBS from | Nepal | 75 (65.78) |
| Abroad | 39 (34.21) |
Months of Practice after MBBS | < 5 | 55 |
| 6 to 11 | 39 |
| > 12 | 20 |
Table 8
Comparability of Group 1 and Group 2 in study 2
Characteristics | Shapiro-Wilk | P-value |
Age (years) | | |
Group 1 | < 0.001 | 0.913* |
Group 2 | < 0.001 |
Months of Practice after MBBS | | |
Group 1 | < 0.001 | < 0.001* |
Group 2 | < 0.001 |
*Mann-Whitney |
The source of knowledge of medical ethics among doctors was mainly from lectures during MBBS study 92 (80.70%) and work experience 69 (60.52%). All of the respondents thought that medical ethics should be a part of medical education.
Out of the 5 codes of ethics (Hippocratic Oath, Declaration of Helsinki, NMC code of ethics, AMA code of ethics, AMC code of ethics), the majority of the respondents knew about Hippocratic Oath 102 (89.47%) and NMC code of ethics 95 (83.33%). Among 114 respondents, 50% rated their knowledge regarding the Hippocratic Oath and NMC code of ethics above 7 in a scale of 1 to 10 (1 = lowest). In group 2 only 7 (11.66%) considered that the patients themselves are capable of judging what is best for them compared to 28 (51.85%) among those who received formal medical ethics training in group 1. Among group 1, 38 (70.37%) preferred to consult their colleagues if an ethical dilemma arose compared to 30 (50%) in group 2.
The median score for self-reported knowledge in group 1 was 7 compared to 5 in group 2. Out of the 22 questions asked to assess knowledge, the maximum number of questions answered correctly by medical officers in group 1 was 21 and the minimum was 9 with a median of 14. For medical officers in group 2, the maximum number of questions correctly answered was 16 with a minimum of 7 and a median of 12. There was a statistically significant difference (p = 0.000) observed in the knowledge between the two (Table 9).
Table 9
Comparison of KAP of medical ethics between Group 1 and Group 2 for study 2
| N | Measure of Central Tendency ± Dispersion | p-value |
Knowledge Score (Total question = 22) | Group 1 | 54 | 14.00 ± 4.00ᵃ | < 0.001ᶜ |
Group 2 | 60 | 12.00 ± 4.00ᵃ |
Practice Score (Total question = 10) | Group 1 | 54 | 6.00 ± 2.25ᵃ | < 0.001ᶜ |
Group 2 | 60 | 5.00 ± 2.00ᵃ |
Attitude Score (Total question = 10) | Group 1 | 54 | 7.00 ± 2.00ᵃ | 0.001ᶜ |
Group 2 | 60 | 6.00 ± 2.00ᵃ |
KAP Score (Total question = 42) | Group 1 | 54 | 27.09 ± 5.07ᵇ | < 0.001ᵈ |
Group 2 | 60 | 22.28 ± 4.09ᵇ |
ᵃ Mean ± S.D. |
ᵇ Median ± IQR |
ᶜ Mann-Whitney |
ᵈ Independent T-test |
Out of 10 questions asked to assess practice, in Group 1, the maximum number of questions answered correctly was 10 with a minimum of 7 and a median of 9. In Group 2, the maximum number of correctly answered questions was 10 with a minimum of 5 and a median of 9. A significant statistical difference (p = 0.030) was observed in the practice of medical ethics between Group 1 and Group 2 (Table 9).
Out of 10 questions asked to assess attitude, in Group 1, the maximum number of questions answered with the correct attitude was 9, with a minimum of 3 and a median of 7. In Group, the maximum number of questions answered with the correct attitude was 8, with a minimum of 3 and a median of 6. A significant difference (p = 0.001) was observed in the attitude between Group 1 and 2 (Table 9).
Out of 42 questions asked to assess knowledge, attitude, and practice of medical ethics, the maximum number of questions answered correctly by Group 1 was 39 with a minimum of 19 and a median of 39. In Group 2, the maximum number of correctly answered questions was 33 with a minimum of 15 and a median of 26. A significant statistical difference (p = 0.000) was observed in the KAP of medical ethics between Group 1 and Group 2 (Table 9).