Ethics and professionalism for interns

 It is the time of the year when a new bunch of medical students graduate into internship. I was given the task of talking to this group about ethics and professionalism. It was a post lunch session and my session followed a very important and serious session by a senior faculty on medical documentation, writing case sheets, lab requests etc. I started my session with a 10 min break, as the previous session had spilled over into mine and the ending note of the previous session was rather grim. I prepared lecture notes that I wanted to cover. But the session was grossly compromised in time and so I could not cover much of what I wanted to say. Therefore, I am writing what I originally intended to tell the students. 

 

Ethics and professionalism have become part of the routine medical curriculum now as part of AETCOM module. One fundamental question that can arise in the mind of a young intern entering the medical profession is “why should I be ethical?” It is an important question. What does being ethical get us? With the recent news of a young intern being brutally stabbed to death by a prisoner whom she was giving care to, this question looms large in the mind of every intern. Does being ethical protect me from such violence? Does being ethical make me more popular among patients? Does being ethical translate into more successful practice? Does being ethical help me earn more? Does being ethical help be obtain more skills? Why should I be ethical? I can see a young medical student asking all these questions. I do not know the exact answer to this question. Being ethical can directly or indirectly bring about all these things. It can also bring about none of these things. The only justification for being ethical is that, it is the only way to be. Being ethical is of inherent value. An intern must be ethical because that is the only way to be. An intern should not be taught to practice ethics as a means towards some other end. The discussion started like this, and I could see some of them have a glaze in their eyes. The typical glaze that we get when confronted by something we don’t understand clearly. 

 

The first ethical dictum that is often taught in medical ethics courses is “first do no harm”. There is a logic behind why this is kept first. One of the reasons is because the medical career puts the doctor in a position of power that could potentially cause harm to a person. This can be by virtue of giving a wrong drug or performing the wrong procedure on a person. Therefore, ‘do no harm’ is kept as the first dictum. The other important reason is that it is the easiest of the four ethical principles that we will discuss today. I will explain why ‘do not harm’ is the easiest. First let us understand what ‘harm’ is. Harm refers to causing damage to the body, bodily function, mind, emotions or social relationships of a person. Therefore, the intern must carry out their job in a manner that does not cause harm to any of these aspects of a patient. Harm to the body or bodily function can happen due to lack of knowledge about a condition or a disease, missing an important clinical finding, ignoring a key complaint or dismissing it as trivial, neglecting to do something, or giving the wrong medicine or doing the wrong procedure. Iatrogenic harm or harm due to interventions done by doctors, is one of the commonest causes of morbidity and mortality in the hospital settings. This can get worse, when the person doing the harm is inexperienced and uncertain. This is why it is a norm that the intern must always provide treatments and prescriptions under supervision. However, this is not the only harm that can be caused to the patient. There may be psychological, emotional, social or financial harms as well. For example, a patient from out of station may have been discharged. The intern may be tasked with writing the discharge summary and send them home. The patient’s last bus to home town may be at 5 PM. The over-worked, hungry and irritable intern may just plan to leave for lunch at 4 PM and the patient may come and insist that they must get their discharge immediately or they will miss the bus. Such situations will be extremely demanding to the intern, as well as to the patient. It is tricky to handle such situations. Harm could be caused if the intern ignores the request and heads out to lunch. Such a harm is a social harm. It is relatively easier to avoid doing harm, because if we avoid taking extreme steps, often we avoid harms. Some tips for interns to ensure that they avoid harms are:

1.     Always maintain a to-do list, either on the phone application or in a small scrap notebook and keep striking off the jobs completed. Make sure you always hand over the things that are incomplete to the intern taking over the next shift from you. If there is nobody taking over from you, ensure that the tasks are completed. 

2.     When in doubt, always ask. There is no ‘good’ or ‘bad’ question. There is no ‘important’ or ‘silly’ question. Anything you do not know, or are not confident of, is important and you must ask a senior. Even if it means the senior gets irritated with you, always ask. 

3.     It is better to default than to fake a finding. An intern I know was too busy in the casualty one evening, that she faked a blood pressure recording (noted it as normal) in a young woman who was admitted with seizures. It was later discovered that she had eclampsia, which could have been suspected if her BP had been properly recorded and found to be high. 

 

The second ethical principle is ‘do good’. Doing good can be extremely challenging. Compared to doing good, avoiding harm is very easy. Why is doing good challenging during internship. In a typical resource constrained, understaffed, crowded setting, quality of services often takes a beating. In such a setting, doing good is extremely challenging. For example, a patient may be admitted in the orthopaedics ward for hip replacement surgery for an inter-trochanteric fracture. The hip prosthesis may have to be bought from a local dealer and the price negotiations might be ongoing. The bureaucratic processes for getting the prosthesis may be cumbersome that the surgery may be inordinately delayed. But there is very little that can be done to speed up the bureaucratic processes. Doing good would mean to speed things up and avoid the delay. But doing good can be very difficult. The intern may have to go out of her way to do good. Sometimes, she may have to pay out of her own pocket to get some medicines for the patient. This may not be a sustainable solution to drug stock-out problem. A tired, hungry, over-worked, sleep deprived intern may be craving for some food and rest, and at that moment, going out of the way to do good to someone may be too much to ask of the intern. Having said this, I must also add that ‘doing good’ is the only way we can get through the tedious drudgery of internship. The brilliant smile of gratitude on the face of a patient to whom we have done good, gives a high, which nothing else in this world can give us. Occasional flashes of this high, is what makes the drudgery of internship tolerable. Therefore, we need these going out of the way to do good, now and then to take us through internship. I remember a lady whom I saw recently in my clinic. She had some vague right flank pain. A random ultrasound scan of the right flank had shown mild hydro-uretro-nephrosis, meaning swelling of the urinary passage up to the kidney on the right side. This happens when there is an obstruction. Usually it is an indication that there is a stone in the urinary passage. But the scan did not detect a stone. The lady had subsequently got a CT scan of the kidney, which is better in picking up small stones that are missed by the ultrasound scan. The CT also did not identify any stones. The last doctor she had seen with these results had not explained the condition. He had planted several doubts about a ‘mysterious block’ in her right kidney. When this lady came to me, she was seriously worried and was in tears. I did a simple urine analysis and blood tests to identify the functioning of her kidneys. I found them to be normal and I reassured her that sometimes, there are some benign blocks like that by birth, a condition called pelvi-uretric junction obstruction, which do not cause any harm. This gave the lady immense relief and reassurance, that she left the clinic smiling. This simple good that we did for this lady gave such a powerful response of immense satisfaction in the lady, it was so heartwarming to see it. Rarely is ‘doing good’ so simple. The other reason for why doing good is challenging is because it is difficult to establish what is good. I recently saw a 55 year old man who is a known patient of diabetes for more than 20 years. But he was irregular on diabetes medicines. A blood test done outside showed mild kidney damage. I was trying to explain to the man that the uncontrolled diabetes had started to damage his kidney, and now he has to be more regular on medications and save the kidney function. But his daughter was angry with me and vigorously gesturing me to stop telling about the kidney damage to her father. She later told me that it was a bad idea to tell her father about the kidney damage because he has a tendency to get seriously upset about the problem and go into depression. I was trying ‘to do good’ but getting him to go on regular medications and protect the kidney. But the family of the patient considered this ‘not good’. Such instances are so common and so ‘doing good’ can be quite the challenge. 

 

The third ethical principle is the principle of respect. Respect to the patient is of utmost important. How do we show respect to a person? One way may be to address them respectfully with Mr. so and so, Mrs. so and so etc. One way would be to rise when they enter the room and show respect. In case of elderly persons, in the Indian culture respect is sometimes shown by touching the elder’s feet. But the highest form of respect that we can show our patient is giving them time. If we give them undivided attention for even 5 mintues, that is one of the greatest expressions of respect. For those 5 minutes the entire universe is frozen and there exists nobody other than the intern and her patient. Such moments are priceless and such undivided attention that we give to the patient is the greatest form of respect. The strange thing is, many times our patients may not understand the value of the time that we are giving them. The people to whom we give time, may never understand the power of the time that we give them. They may never appreciate that it is the greatest form of respect. But still we give them time, and through time, our respect, because that is what we do. That is our righteousness. Respecting patients’ choices, respecting their privacy, respecting their confidentiality, respecting their right to decide their treatment and refuse treatment are all other forms of respecting the personhood and agency of a patient. 

 

The last ethical principle that we will discuss today is that of justice and fairness. One of the greatest manifestations of justice and fairness in medical practice is avoiding discrimination and establishing equity. While an intern may not always be able to right all the injustice in the hospital that they encounter, being sensitive to them and constantly being aware of them is the first step to becoming a fair and just clinician. Many patients spontaneously remove their footwear outside the clinic before entering it. I have noticed that some clinics have the notice “remove footwear before entering” written in bold letters. While patients are asked to remove their footwear, doctors enter with their shoes on. If the reason to ask patients to remove footwear outside the clinic is to prevent contamination and infections, the same should apply to the footwear of doctors also. The only possible reason for the differential treatment is to establish a power differential between the doctor and the patient. Interns must keep their eyes open for such injustices around them, and where possible question them. Being fair and just can lead to lot of conflicts, internal and inter-personal. But it is a difficult but important work ethics that the intern must try and practice. 

 

In summary, ethics and professionalism are inherent and integral to the practice of medicine. It all boils down to doing no harm, trying to do good as much as possible, respecting individuals and being fair. Though I had prepared these lecture notes ahead of time, I could not tell all this in the class. I will share this write up with the new interns, just in case any of them wants to read and maybe try to practice some of these. 

- Vijay Gopichandran