Monday, July 27, 2009

Ethics, professionalism and the medical school(s)

We wade back into the issue of doctors' ethics with two letters to the Straits Times today - one by Bob Kamei from Duke-NUS and another by retired surgeon SC Ong. These letters confirm the growing concern about the standards of ethics and professionalism in our doctors.

Two issues come to mind.

Firstly, there appears to be an elitist attitude fostered in our school system that starts from a pretty young age, carries all the way to medical school, and through into the working life of doctors. The medical school need to do more to correct this aberration, even though they are essentially the inheritors of a problem that began quite a few years earlier. Parents need to do more...because generally elitist parental attitudes beget elitist expectations in their children.

Secondly, medical schools need to disabuse these students of the notion that they have 'earned' their place in society, and that somehow it is society that 'owes' them, rather than the converse. These students believe that as they have fought so hard to get into medical school, they should early on reap the rewards of their struggle. Medical schools should do more to correct this malignant attitude and to foster a greater sense of servanthood in the doctors we produce. This is not easy because of the very materialistic self-serving culture that pervades our society, but the medical school must not shirk from this responsibility.

On this latter point, I am continually disappointed in the medical school for her nominal efforts to discipline students' bad attitude and behaviour even when it is recognized. Why do you think the student's grow up into doctors who are quite happy to overlook each other's bad behaviour? I am quite sure the medical schools will protest their innocence, but we should ask these schools just how many students have they ever 'failed' from the course after they have entered the school? Almost none. Are there no students with demonstrable bad attitudes? No disciplinary problems? Were they all so correctable that almost all students who enter the school graduate as upright citizens who will go out to make exemplary doctors? Surely this has not been the case because otherwise we will not be having these discussions about falling standards of ethics and professionalism.

Unfortunately in recent times the student-teacher relationship has been subverted by populist measures to position the student as a consumer and the teacher, a service provider. This is unhealthy and untenable. Often careers of young medical teachers have been held to ransom by student's 'feedback scores etc. Such an environment does not make it easy, nor even possible to teach discipline and ethics.

I have said it before....if we want better doctors, we desperately need to reboot the system.

We claim it is a noble profession. We make graduands pledge to honor the profession and make it noble. But we lack the courage and fortitude to make it so.


Anonymous said...

The problem might be the prevalence of "relative morality" where there is no fixed set of values to judge behaviour.

It could also be due to "dumbing of the senses". Many years ago, a friend shared that she struggled constantly against the tendency to treat her patients as just another "case".

Because she had witnessed so many people dying, it was easy to take death as a matter of fact in life, and forget that each death is unique to the patient and his family and should be treated with sensitivity.

gigamole said...

Dumbing of the senses affects almost every doctor and to a large extent is a way of coping. But it should not be a reason to forget to be humane or ethical in our professional work.

I think the problem is not so much that of relative morality as you point out but more the gradual erosion of an ethical foundation that is more self serving than patient serving.

The mass media makes it so much worse by glorifying the exploits and lifestyles of the wealthy doctors and their indulgent lifestyles.

Robin said...

Compassion fatigue is a common sign in the doctors and nurses.
Increasing demand of patients are not helping the situation either.

But I agree that medical ethics has no direct co-relationship with compassion fatigue.

Imagine the surveyed subjects are HO, just fresh out of the school and they are already not making the right professional ethical decision.

Could it be the wrong emphasis placed during the selection interview at the point of admission? Or that students now are really different in terms of reality check and ethics?

So far no explanation from NUS mean.. would be nice to hear from John ..


gigamole said...

hehheh...I wouldn't hold my breath for that...

I think the survey had methodological problems with the sampling so the local vs foreign schooled students really represent students from different parts of the spectrum to begin with. Perhaps the environment just consolidated what was already there.

But my gut feel is that there is a real degeneration of the medical ethos. Multifactorial and complex forces at play. And the medical school environment certainly doesn't help.

Paul Ananth said...

Speaking as someone who has been involved in teaching students for a while, I cannot resist chiming in on this debate!

We try very hard in the older medical school to teach the students about the values and principles of medical professionalism. The trouble is that once the students hit the wards, those lessons are then promptly unlearned as they see their seniors (sadly including myself at times!) not listening to patients, rushing through clinics, behaving as though our time was all important and the patient's time is worthless, appearing to treat patients according to the size of their wallet or their genetic distance to those we are trying to impress.

Very quickly the students learn the real lessons of medical professionalism from us rather than from the Ethicists and the high powered role models who teach the pre-clinical classes.

Unless the entire system changes dramatically, I do not see how this can be solved easily.

gigamole said...


In a past generation, we had really towering icons in the clinics. Of course they had their politics, but they set really powerful examples of clinical professionalism for us that few have been able to match in recent times.

You shouldn't be too hard on yourself. We all have been busy, frazzled and short with patients. But this is really not about the occasional loss of composure, rather the devaluing of an ethos that places the patient in the centre of what we are doing.

Now it's just increasingly about wealth, fame..... and those dreaded publications.

By the way, your father was one of those I respected greatly. I hope he is well.

Robin said...

Paul, you are right.

I remember my old professor, who was extremely strict to his students, always failed half of his students during exam. He always remind us that if we are 99% accurate, we are killing 1 patient out of 100. And it is his duty to make sure only the best students will graduate from his class, or else his students will be a weapon to kill the patients.

We always laughed at him.. saying that he is giving excuse for being mean to the students and making our life a misery. Now I think otherwise.

If teachers are not teaching their students good ethics and not showing good ethics themselves, this is the cause of more suffering (especially now, it is a wake up call on the medical profession).

To be a doctor, their karma must be either the best or the worst. The Best... because they can help everyone in their life time, hopefully to reduce their suffering and pain. The Worst.. it can be emotional and physically straining if you are not up for it.

Hungry Doc said...

Dear Gigamole,

I've only just come across your blog and I've been reading it with great interest. I guess you could consider me a "junior" doctor. Not quite a house officer but not that far away from it that I cant remember what it means to be one.

Let me first say that I agree that there's a vast gulf between the ideal paragon of medical professionalism and the actuality of medical practice. Let me also say that I dont think this a new problem, whatever people might say. The unprofessional doctor exists everywhere i look, whether amongst the houseman, my peers or the consultants and even some of the professors. So does the professional/ethical doctor.

But since we were discussing medical schools and young doctors, let me just say this.

I have never thought of myself as elite, nor expected that society should raise me on a pedastal. I have never expected to be celebrated above my peers in secondary school or junior college, never demanded any higher reward than to have the gratitude of a life that i have bettered.

I've only looked forward to things that i think even you would agree, we should expect as a medical student and later as a junior doctor. Good clinical teaching, a mentor to look up to, words of praise for a job well done, words of gratitude for effort put in even when i'm at the limits of my physical energy. For my orders to be followed when i give as such, without having to nag, argue, cajole and debate with the various medical support staff involved.

I have my experience, found none of these in satisfactory quantity. Instead I feel consistently balked, questioned and stretched at every turn. And when I'm done at work i come home looking forward to quiet dinner and I flip open the newspaper and i find what?


The newspapers screaming about the unprofessionalism of young doctors. Bravo.

Let me say that my (local) house officers are in general hard working, knowledgable, diligent and yes, even compassionate where time allows. They work long after the prescribed hours, they do not leave work undone and they try their best to know their patients. Some have been known to buy patients conveniences and personal effects with their own money, not expecting to be repaid. They are harrassed, they are hungry and they are tired. They are tired of people telling them they are unethical, tired of people telling them that they are proud, tired of people telling them they dont know enough and they are tired of things that the MOH likes to do to them INCLUDING making them repeat housemanship just so that we can accomodate the duke students.

I note with great sadness that some of my best and most excellent, hardworking and compassionate housemen 4 months into their working life telling me that they want to leave hospital practice, that they feel abused and unappreciated. I concur.

I'm not sure what the medical profession has lost in the last 30 years that's made us junior doctors such a bunch of ungrateful ingrates, but i do know that the medical school starts with young people filled with a desire to do good and that somehow this changes as they go through 5 years of bonded medical school and housemanship.

I think it's time we gave a junior staff a break. It doesnt hurt to pat them on the back once in a while and say " I believe in you."

gigamole said...

Hi Angry Doc,

I really appreciate your defense of the younger doctors. Let me say very clearly that I never meant to apply my remarks across the board to all 'junior doctors'. It is very clear as I engage medical students and eventually see many of them professionally as colleagues, that they are at least a bimodal group. Most (happily they are still the majority!) are pretty motivated passionate (bless their souls) individuals who truly want to do their best in a profession they have chosen to serve in. And I know they will do great and make us all proud.

But there is an proportion in every cohort who seem to think that they inherit the world and that somehow the world owes them. These are what seem to me the products of our elitist school systems. I fully recognize that these attitudinally challenged individuals have always been there, even from my time, .... and likely way before, but what is of concern (a concern that is reflected in these posts and public comments elsewhere) is that these numbers appear increasing.

Unfortunately the good tend to get dragged into the mud by the black sheep. So it is a concern for the community(for the fraternity as well).... how do we rectify the situation? How do we collectively as a profession work towards bringing a greater sense of professionalism and ethics into what we do?

It is easy for me to blame the system... but at some point time time we need to do something.