Muhammad Hanif Malik  ( Department of Dermatology, Sheikh Zayed Medical College, Rahim Yar Khan, Pakistan. )
Usman Mahboob  ( Medical Education, Institute of Health Professions Education and Research, Khyber Medical University, Peshawar, Pakistan )

Objective: To explore the perceptions of doctors holding dual jobs regarding professionalism in public and private healthcare sectors.

Methods: The qualitative phenomenological study was conducted from January to June 2016 in a tertiary care teaching hospital affiliated with Sheikh Zayed Medical College, Rahim Yar Khan, Pakistan, and comprised 10 doctors holding dual jobs. Data was collected through video-recorded interviews which were transcribed verbatim and analysed for themes using interpretative phenomenological analysis.

Results: There were 10 doctors in the study. Monetary benefit was the main motive behind holding dual jobs. Contented and internally motivated practitioners with faith in Almighty and a sense of accountability before Him were likely to behave much more professionally, and a virtue-based medical education could play a vital role in this regard.

Conclusion: Overall lack of faith and internal motivation has shifted the focus of sustenance to material resources.

Keywords: Doctor, Professionalism, Altruism, Public and private sectors, Dual job, Medical education. (JPMA 71: 691; 2021)

DOI: https://doi.org/10.47391/JPMA.715

 

Introduction

 

Professionalism is derived from the verb 'to profess', which also means 'to promise'. The promise suggested by 'to profess' is both public and collective in nature. In healthcare context, this is clearly declared in the Hippocratic Oath to the entire mankind that interests of the patients will remain foremost; the doctors shall maintain their trustworthiness through any stresses and crises; and shall not be led astray by any temptations or fear. In return, the patients will trust the doctors, including those they have never met before.¹

Human beings happen to be the finest creatures on the face of earth: …"We create man in the finest state".² Respectability conferred upon doctors lays in the public's trust upon the commitment of the former to keep interests of the latter foremost and ahead of their own. Based on this trust, patients give honest and exhaustive medical history followed by their bodies to be examined and probed in privacy as without the information thus gained, the practitioners will not be able to complete their tasks. In reciprocation of this trust, doctors give top priority to the care of sick humans. Gradual intrusion of commercialism in healthcare has generally transformed this traditional doctor-patient relationship of care and trust to that of cost and benefit.³

We are living in a world where human inter-relationships are business arrangements and healthcare professionals are not independently wealthy. Someone must pay their rent and keep the wheels rolling, but healthcare profession can never be viewed primarily as a business.⁴ The professionals are surely not required to ignore financial considerations, but they are expected to subordinate such considerations to the higher values of their responsibilities towards patients and public interests. Recent gradual intrusion of commercialism into the realm of medicine is causing breach of trust and the public is losing faith in doctors.⁵ Unfortunately, healthcare practitioners and students are equally immersed in an ocean where every aspect of human life is viewed from marketplace perspective. Hence, it is generally perceived by the public that doctors with dual jobs appear more altruistic in their private practice than in a public setup.⁶

Any resuscitative measures in this regards are likely to fail unless an insight into the perceptions of the practitioners themselves is gained. Results of a critical review of literature upon the practice of dual jobs, its problems and resuscitative suggestions of the practitioners concerned about practices of professionalism in the two sectors revealed a clear paucity of analytical qualitative studies.⁷ The current study was planned to explore the perceptions of doctors holding dual jobs regarding professionalism in public and private healthcare sectors.

 

Subjects and Methods

 

The qualitative phenomenological study⁸ was conducted from January to June 2016 in a tertiary care teaching hospital affiliated with the Sheikh Zayed Medical College (SZMC), Rahim Yar Khan, Pakistan. After obtaining approval from the institutional ethics review board, the sample was raised using purposive sampling technique from among doctors of specialist and general cadre from SZMC working in both public and private sectors as their only source of income. Those working in either sector alone and having any source of income other than providing healthcare were excluded.

Data was collected through semi-structured in-depth interviews on an open-ended questionnaire. Interviews were video-recorded and completed flexibly using prompts and probes to fully explore the participant's viewpoint. All potential identifiers of the participants were anonymised. The interviews were transcribed verbatim and the transcripts were checked for accuracy. Data was analysed using interpretative phenomenological analysis (IPA)⁹ and the themes that reflected the participant's views were identified. One of the transcripts was coded independently and discussed with colleagues having experience in qualitative research. This triangulation process was used as a validation strategy.

 

Results

 

Of the 16 doctors approached, 10(62.5%) consented to participate. The responses led to 7 categories and 3 main themes (Table).

All the participants had a clear understanding of what is professionalism in healthcare and 9(90%) agreed that it is progressively deteriorating. The participants pointed out that attitude of doctors reflects attitude of society in general. Most of them identified monetary gains and enhancing the income as the most important motive behind dual jobs and all agreed to the public perception that doctors holding dual jobs behave better in their private practice. However, they also pointed out important administrative issues in addition to financial reasons behind such a differential behaviour. All agreed that contented and internally motivated practitioners with faith in Almighty and sense of accountability before Him on the Day of Judgment will be more virtuous. Medical education through role modelling was considered very important in this regard by all. Most of the participants agreed that a sense of self-accountability based on a strong faith remains the primary driving force for an altruistic attitude, and the regulatory authorities have only a secondary though important role in this regard.

 

Discussion

 

As a part of the phenomenological analysis,⁹ it was hypothesised before the study that difference in the attitude of the dual job holding practitioners in the two sectors was attributable only to cash reward in the form of monetary benefits in the private setup.

During the study, however, it was realised that administrative, organisational and training issues were also important and that there was an under-the-surface connection between the two. Sense of accountability brings positive changes in attitude. Hence, a firm faith in Almighty's fool-proof system of documenting one's deeds and sense of accountability before Him will surely make a person virtuous with the required mindset. Continuing education in its prophetic sense charged with inculcating faith, contentment, internal motivation with a general sense of selflessness and respect for humanity coupled with a robust training and assessment programme not just to confer certificates/degrees, but to promote professionalism is all that is required to bring a lifelong change in one's attitude.

Dual job, instead of being cursed and banned, should be explored as having the potential to solve the attitude problems through self-regulation.⁷

The findings suggested that the public is rightly concerned about the deteriorating moral values and social norms, particularly among healthcare professionals. The main reason behind this is a universal progressive intrusion of commercialism in the field of medicine. Several qualitative studies and reviews^10,11 from different parts of the world have reported similar concerns. Although healthcare professionals are not independently wealthy, making healthcare profession a business¹² contradicts the very oath that doctors take at graduation. Unfortunately, this contradiction is a bitter reality now and the pharmaceutical industry has played a catalytic role in this regard.¹³

Some of the study participants pointed out that professionals of a society reflect society itself in all respects, and doctors are no exception to it. Therefore, it is important to change the mindset and attitude of the entire society before any positive change can be anticipated. Core expectation of professionalism is a virtuous attribute of subordinating self-interest to the interest of the others. Inculcating this is not an easy business and requires a lot of effort; the least of which is overcoming the human nature itself.¹⁴

Strengthening the innate self-serving barriers further is the environment in which doctors operate, like privacy of the examining room, the authority gap between a doctor and a patient along with numerous financially seductive opportunities available to them. These factors increase the need for self-vigilance and conscientious self-discipline. This is impossible unless it is firmly grounded in one's mind and heart that even if nobody is watching, 'Someone' is watching and I am accountable to 'Him' for all my doings of which a precise record is being maintained throughout my life.¹⁵ This message has been conveyed to the entire mankind from time to time through the Messengers of Almighty ever since the creation of Adam —  the very first human being on the face of earth. The final version of this message revealed upon His last and the final Prophet, Muhammad (Peace be upon Him) is addressed and accessible to all mankind as a guide giving clear messages and distinguishing between right and wrong.¹⁶

All the study participants were of opinion that unless the entire mankind follows the heavenly guidance revealed upon the prophets of the Almighty, no individual or collective issue can be resolved. One of them quoted studies with similar results from the West. If certain facts from the divine guidance^17-22 common to all religions regarding mechanism of sustenance, its equitable, balanced and final distribution by the Almighty, altruism and steadfastness are conceptualised and firmly grounded in the minds and hearts, it will be easier for both the teachers to be the role models and the students to learn to grow into the kind of persons who will not only engage in hard work to become good professionals, but will do it willingly and cheerfully.

It is a global fact that augmenting the income is the main reason for adopting dual job^7,11 and this in turn gives rise to overt conflicts of interest resulting in unpleasant attitude of the doctors in public setup. Dual practice, however, is a complex issue and more than just a means of generating extra income. Therefore, it requires to be viewed broadly from various angles, such as public-sector resources, pay for its employees and regulatory capacity of the government. A multi-centre study⁷ explored it as a solution to the deteriorating professionalism rather than a reason for it. Of particular interest in this context is professional self-regulation wherein accreditation and certification is linked to an individual's reputation as a doctor in the public sector, which in turn influences his or her income-generating capacity in the private setup.

The fact that role model educationists can play their role to change commercialism to virtuous professionalism in medicine was pointed out by almost all the participants. Students must be made to realise that 'professionalism' is not like a laundry checklist of what to do and what to avoid, and cannot be learned and assessed as such. Medical studies^12,23 propose certain key precepts in this regard and suggests that professionalism is a subset of healthcare ethics and application of virtues to the healthcare profession. A virtue transcends behaviours and this approach to ethics focuses on what sort of person or a moral character one is becoming instead of acts themselves, the circumstances, or the consequences they produce. This key precept is more important for faculty and those involved in assessment and accreditation, but students also need to realise it if they are to understand the complex relationship between professionalism and commonly employed lists of professional behaviours. A professional curriculum based on foregoing precepts will be more effective in preventing certain misunderstandings that hamper the effectiveness of teaching and assessing professionalism. A study²⁴ analysed these and proposed that it would be better to have a professionalism curriculum that addresses both observable behaviours and deeper attitudes, and the required integration among these concepts is aptly found in virtue. Medical educationists are to do more than just 'teach to the test' of expected behaviours, and promote the cultivation of virtue as a lifelong quest in the face of numerous challenges.

Some participants in the current study believed that 'energy shall go wasted if the doctors and regulatory bodies have similar mindset and monetary objectives', while others gave some weight to regulatory bodies in this regard. Studies²⁵ from low and middle income countries (LMICs) similarly concluded that a weak regulatory framework often leads to problems coming up elsewhere in the system.

Although IPA⁹ primarily aims at developing an understanding of the participants' perspective of a particular phenomenon, it acknowledges impact of researchers' experiences and beliefs upon interpretations throughout research process. The authors of the current study believe on the basis of some understanding of the Almighty's divine system of prophets and guidance for human beings, that professionalism is a part of the bigger circle of humanism. Hence, the analysis is likely to have been influenced by the Holy teachings as well as history of prophets and their nations. It is possible that the results might have been analysed differently under alternative theoretical influences.

Generalisability of the results is likely to be more valid with multi-centre studies by different researchers with different beliefs and a comparison among.

 

Conclusion

 

Lack of planned efforts for internal motivation has shifted the focus of faith from the Real Sustainer to material resources and this has caused gradual intrusion of commercialism into the realm of medicine. This situation can only be reversed through revival of efforts for strengthening faith in Almighty, contentment and sense of accountability before Him. Medical education in its prophetic sense and the role model educationists can play a key role in this regard. Any future research in this area should include dual practitioners for feedback. In addition, a mass effort to improve the moral values of the entire society and further evidence-based deeper enquiry in this regard by multiple researchers at multiple centres should continue.

 

Disclaimer: The text is part of a qualitative research done as a component of MHPE programme.

Conflict of Interest: None.

Source of Funding: None.

 

References

 

1.      Pellegrino ED. Toward a reconstruction of medical morality: The primacy of the act of profession and the fact of illness. J Med Philos. 1979; 4:32-56.

2.      Qur’an 95:4. Oxford, New York: World's Classics edition, 2004.

3.      Benatar SR. Global Disparities in Health and Human Rights: A Critical Commentary. Am J Public Health.1998; 88:295-300.

4.      Cohen JJ. Viewpoint: Linking professionalism to humanism: why it matters. Acad Med. 2007; 82:1029-32.

5.      William MS. Medicine under threat: professionalism and professional identity. CMAJ. 2000; 162:673-5.

6.      Gadit AAM. Corruption in medical practice: How far have we goneu J Pak Med Assoc. 2011; 61:93-4.

7.      Jan S, Bian Y, Jumpa M, Meng Q, Nyazema N, Prakongsai P, et al. Dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution? Bull World Health Organ. 83:771-6.

8.      Fraenkel JR, Wallen NE, Hyun HH. How to design and evaluate research in education. Newyork: McGraw-Hill, 2012.

9.      Smith JA, Flowers P, Larkin M. Interpretative Phenomenological Analysis. Theory, Method and Research. London: Sage Publications, 2009.

10.    Debas HT. Surgery: A noble profession in a changing world. Ann Surg 2002; 236:263–9.

11.    Donohoe MM. Luxury Primary Care, Academic Medical Centers, and the Erosion of Science and Professional Ethics. J Gen Intern Med 2004; 19:90-4.

12.    David HB. Professionalism: a framework to guide medical Education. Med Educ. 2014; 48:980-7.

13.    MA. Drug Companies and Doctors: A story of corruption Source: New York Review of Books [Online] [Cited 2010 July 9]. Available from: URL: http://wwwbiopsychiatrycom//drugcompanies-d.

14.    Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry.  JAMA. 2003; 290:252-5.

15.    Qur’an 18:49. Oxford, New York: World's Classics edition, 2004.

16.    Qur’an 2:185. Oxford, New York: World's Classics edition, 2004.

17.    Qur’an 6:11. Oxford, New York: World's Classics edition, 2004.

18.    Qur’an 51:22-3. Oxford, New York: World's Classics edition, 2004.

19.    Qur’an 43:32. Oxford, New York: World's Classics edition, 2004.

20.    Qur’an 42:27. Oxford, New York: World's Classics, 2004.

21.    Qur’an 2:155-157. Oxford, New York: World's Classics, 2004.

22.    Qur’an 59:9. Oxford, New York: World's Classics, 2004.

23.    Lee WT, Schulz K, Witsell D, Esclamado R. Channelling Aristotle: Virtue based professionalism training during residency. Med Educ. 2012; 46:1129-30.

24.    Cohen JJ. Professionalism in Medical Education, An American Perspective: From Evidence To Accountability. Med Educ. 2006; 40:607-17.

25.    Berman P, Cuizon D. Multiple public-private jobholding of health care providers in developing countries. An exploration of theory and evidence. London: Department for International Development, Health Systems Resource Centre, 2004.