Muhammad Hanif Shiwani  ( Barnsley General Hospital, University of Sheffield, Yorkshire S752EP, )
Amin A Gadit  ( Memorial University of Newfoundland, St. John’s, NL, Canada. )

A doctor's primary duty is to provide a safe medical practice and make sure all patients receive safe care. If health care professionals suspect that their patients are at risk, it is their professional duty to blow out the whistle. It sounds simple but how many people can blow a whistle.
To ensure the good clinical care and good medical practice, the General Medical Council of UK describes "If you have good reason to think that patient safety is or may be seriously compromised by inadequate premises, equipment, or other resources, policies or systems, you should put the matter right if that is possible. In all other cases you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them."¹
The use of public office for private gain is defined as corruption in the international literature.² In our country, unsafe medical practice, unethical behaviour and corruption is at such a high level and widely spread that blowing a whistle to alarm the authority would be simply inaudible. Even in an environment of good medical practice like in the West, whistle blowing can be heard but very often at the disadvantage of the whistleblower.³
Whistle blowing is not only at an individual level, but it could be against a corporation. Health care fraud is very well known and not a secret in the country. False claims and reporting, patients to pay illegal fees, absence of workers on duty, refusing to see patients in government hospitals and referring them to private clinics, overuse of diagnostics, over-prescription, and violation of ethical guidelines in clinical practice are well established practices considered to be a conventional norm. According to a survey 95% of the population perceives that the health sector is corrupt in Pakistan.⁴
The fear of been victimized, loosing the job and career, is the main concern very often trainee doctors keep quiet and do not raise their voice against their seniors. Whistle blowers therefore, have been told to keep quiet otherwise their career would suffer.⁵ People in general do not want to cause problems for colleagues and damage working relationship. After all, it is a matter of their survival. They do not want to be the subject of retaliatory complaints.⁶ Hence the issue of a colleague's performance and fitness to practice remains silent and concerns of patient's safety remain unheard of.
Whistleblowers frequently face reprisal, sometimes at the hands of the organization or group which they have accused, sometimes from related organizations, and occasionally under law. The message from many who have worked with doctors who have blown their cover and any whistle and then lost their jobs and careers in the NHS is: "Don't do it"-at least alone.⁷ Potential would be whistle blowers who wish to raise their concern, while minimizing any risk to their selves and maximizing the opportunity for any wrongdoing to be addressed should seek advice from professional bodies.⁸
The masses in general and health care professionals in particular wish to see their patient being treated as safely as possible. If they observe a wrongdoing what shall they do? The immediate spark is to inform the concerned authority. However, which authority is the next question. PMDC has got authority to cancel a doctor's license to practice. In our country there are millions of "quacks", the non-qualified health care providers, the technicians, paramedics and female health care workers, practicing medicine and perhaps do not even come under the jurisdiction of PMDC. PMDC can cancel the registration of a doctor, reported and found to be performing unsafe and un-ethical practice. PMDC has its own limitations with turbulent power policies within its structure. The role of Pakistan Medical Association (PMA) can be pivotal being the representative body for doctors. Any individual can approach PMA while keeping his identity protected and lodge the complaint. It is then up to the PMA to exercise its power in curbing this problem effectively. It does not appear to be that efficient keeping in view its inherent or acquired limitations. The concept of a Medical Ombudsman is fascinating and promising.⁹
Reporting to media is an alternative in the current era of freedom of journalism in the country. Media reaches to mishaps earlier and wakes up the legal authorities. Very often journalists blow the whistle for the general public matters. The changing nature of news media has caused more reporters to work freelance, outside of traditional news organizations. Having said this, journalists in Pakistan come under the grip of the government and meet harassment. So, who could be an effective whistleblower? There is a great need to overhaul the health care system of Pakistan with strong efforts at eliminating the corruption before we may be able to answer this question.

1.General medical practice. Raising concerns about patient safety paragraph. In Good Medical Practice. GMC 2006. (Online) Cited August 2, 2009. Available from URL: www.gmc=uk.org/guidance/good_medical_practice/good_clinical_clinical_care/raising concernrs.asp.
2.Bardhan P. Corruption and development: A review of issues. Journal of Economic Literature, 1997; 35: 1310-46.
3.Stephenson J. Whistleblowing. Career Focus; BMJ 2009; 187-8.
4.Nature and extent of corruption in the public sector. Transparency International Pakistan. (Online) Cited August 3, 2009. Available from URL: http://www.transparency.org.pk/documents/csr.pdf.
5.Manning CL. Crucial for a "world class" NHS. BMJ 2009; 338:b2514.
6.Gooderham P. Changing the face of whistleblowing. BMJ 2009; 338: b2090; 1136.
7.Wilmshurst P. Dishonesty in medical research. Medico-Legal Journal 2007; 75: 3-12.
8.(Online) Cited August 2, 2009. Available from URL: http://www.pcaw.co.uk/individuals/individuals.htm.
9.Gadit A, Mugford G. A pilot study of bullying and harassment among medical professionals in Pakistan, focusing on psychiatry: need for a medical ombudsman. J Med Ethics 2008; 34: 463-6.