Chapter 8. Doctor-doctor relationship
Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP
What you do not want done to yourself, do not do to others – Confucius
Ultimate test of relationship is to disagree but to maintain mutual respect – Alexandra Penny
Introduction
Ayurveda – ancient science of life – had laid down code of conduct for physicians, to be righteous in every action.
Aristotle – Greek philosopher – 384-322 BC advocated good conduct for physicians. American Medical Association formed a committee to formulate code of conduct for physicians in 1846. World Medical Association formed international code of conduct for physicians in 1947. In 1970, traditional medical ethics were found to be inadequate to deal with changing medical practices that led to widening scope of ethics. Besides four pillars of medical ethics – beneficence, nonmaleficence, autonomy and justice, there are many other related issues that are very much part of medical ethics and one of them relate to doctor-doctor relationship. Medical council of India in its notification has elaborated on doctor-doctor relationship.” I will treat my colleagues with all dignity and respect to maintain honor and noble traditions of medical profession”. It adds “don’t run down peers. Relation between doctors should be one of friendship and cooperation. However, physician should expose without fear or favor, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession.”
How important is doctor-doctor relationship?
While doctor-patient relationship is at the core of holistic care, doctor-doctor relationship has clear importance and indirect contribution in boosting confidence of patients and thereby helping healing process. Unfortunately, this aspect is mostly neglected. Modern medical science has advanced with leaps and bounds to an extent that no physician can claim to know to treat every patient well enough, under his her care. There is old Greek proverb “one man is no man”. Owing to increasing complexities of modern medicine and technology, interdependence of doctors is assuming more importance with need for its close collaboration. Every doctor, be it a family physician or specialist, is likely to need advice or help from one of his/her colleagues. On the other hand, a doctor is called upon to help a colleague, either suggested by a treating doctor or requested by patient or his relatives. Such a consultation is intended to do more justice to the betterment of a patient without causing confusion, even in the face of difference of opinion. It is vital that both the concerned doctors “discuss” without “argument” and convey unified action to the patient. Discussion is to find out what is right while argument is to decide who is right. Responsibility of good conduct during such a consultation rest more on senior colleague whose help is sought by primary treating doctor. In such a consultation, no insincerity, rivalry or envy should be indulged. Doctor must behave with his colleagues the way he would expect his colleagues to behave with him. Doctor should consider it a privilege to help his colleague when asked for. In this relationship, every doctor must learn to make unambiguous statements with measured words to avoid any misunderstanding or misinterpretation. At times, same message delivered in different words sounds contradictory to each other that adds to confusion in the minds of patients. Ideally, such a consultation is usually “one time” help to a primary treating doctor who thereafter continues to treat his patient in the suggested direction. Doctor who provides help to a primary treating doctor should refrain from direct contact with the patient. Such a conduct between doctors not only boosts confidence of patients but also improves image of the profession. It has a direct benefit to the society and is a win-win situation for doctors and the community.
Introspection – Quo Vadis – where are we going?
Contemporary medical ethics is the very foundation of medical practice and is inseparable from medical science and doctor’s competence. Unfortunately, art of medical practice is missing while there is scientific overreach with outsourcing common sense to modern technology that has increased cost of health care. Unfortunately, technology has de-humanised medicine. Patients consider medical profession as business and suspect every action irrespective of doctor’s intentions that has maligned image of medical profession. Medical council of India has miserably failed to maintain high ethical standards that are required to promote moral values. Indian Medical association has equally failed to control irrational methods of practice that has hurt general welfare of the community and has eroded faith in doctors. Negative professional criticism of another doctor, in the pursuit of money and prestige, damages reputation of the profession. May be an unintended (or was it intended?) casual remark such as “I wish I was called a bit early, it is already late” can spoil the situation. I know a doctor who would change the brand of a drug claiming better response as compared to a brand prescribed by primary doctor, making a patient doubt the very competence of his primary doctor. Such “one-upmanship” to take an advantage of a situation is a gross violation of code of conduct. I must admit that such an overt misconduct is rare today but one can always feel an undercurrent of occult attempts at such behavior between doctors in the present “rat race”. After all, even if you win the race, don’t forget you are a bloody rat.
Can good conduct be taught?
I understand that Medical Council of India has now included “medical ethics” in undergraduate curriculum. However, art of medical practice is not learnt in classrooms but must be witnessed at the bedside of patients through a role model teacher. It should start from teacher-student relationship during undergraduate training period. I was lucky to have had teachers with high ethical values whom we tried to emulate. Present generation of medical students need such teachers. During my tenure as a post-graduate student, an intern was posted in our unit who was in a habit of expressing his views on every patient during ward round and we all thought his undue and untimely enthusiasm had to be curbed in order not to waste time on rounds. But Dr M.M. Wagle, my chief differed and said “it is good this boy is thinking even though he does not know enough. So, give him time to understand his limitations but don’t stop him, he is after all learning”. It was a lesson on how to behave with a student. I recall first day of my joining as an honorary assistant Prof in Pediatric Department at J.J.Hospital, Mumbai. Dr Wagle greeted me and asked me to conduct ward round when he and other senior faculty member would join me on rounds. It was a lesson to respect and promote a junior colleague. Such a behaviour builds a close bond between one another. Dr Wagle addressed every human being as a gentleman, irrespective of status. It was only such role models that made it possible for us to learn art of interpersonal behaviour in medical practice. I have tried to emulate my chief as much as I could throughout last 50 years of my professional career and I hope this legacy is passed on at least to few students. What is appalling is lack of comradeship that starts right from training days. Five decades ago when I was a trainee, there was not only cordial relationship between students and resident doctors but also with faculty members who were our friends more that our teachers. Thus, we were closely knit. Over last one decade that I have experienced during my tenure as Medical Director of a teaching institution, that there is no comradeship between first, second and third-year residents as each junior addresses his one-year senior as “sir or madam”. I feel it comes in the way of building relationship and thereby affects smooth working together.
Self-regulation – need of the hour
There is no doubt about the role played by role model to promote good conduct. However, role model can’t ensure good conduct unless one is motivated enough. Ethics is internally defined based on motivation while morals are externally imposed. Motivation is a psychological driving force that reinforces an action towards desired goal. Intrinsic motivation driven by enjoyment of work – pleasure without expecting reward – must come from within that has positive impact on life. Once intrinsic motivation gets started, habit sustains it. On the other hand, extrinsic motivation is driven by reward, money, threat or punishment and it has negative impact on life. While motivation leads the way, it is attitude that decides how well you behave. It is the attitude that takes you to altitude. Do you know – when each alphabet is assigned a numerical number in sequence (1 for A, 2 for B), word “attitude” totals 100!
Testing time when faced with specific situations
Few common situations occur in medical practice that really test individual behavior pattern in doctor-doctor relationship.
1. A doctor may be called to attend a patient whose regular doctor is not available. It is important to attend to problems that demand immediate attention, avoiding discussion and offering opinion on other problems for regular doctor to handle. It automatically takes care of difference of opinion if any. Best way out is to reiterate that ideal advice comes from a regular doctor who knows the background health status of his patient. Such an explanation is reasonably acceptable.
2. Problem is tricky when senior doctor is called for second opinion that differs completely from the original. Even if senior doctor is convinced about need to change the diagnosis and/or management in favor of the patient’s wellbeing, it is imperative to defend original doctor’s opinion at the same time. It is easy to get away by making a statement “I would have done the same that your doctor did but now that it has failed, we need to change which we both doctors will discuss together and implement”. It ensures the right change without damaging primary doctor’s image and one could privately sensitise the doctor to correct his faults. This is very important as each doctor has faced similar situation, however experienced he may be and expects not to be fallen in the eyes of his patient. After all, medicine is science of uncertainty and art of probability and no doctor can claim to have made no mistakes.
3. It is not uncommon for patients to seek another doctor’s opinion by themselves, without knowledge of primary treating doctor. Many of them may hide information about what was done by previous doctor. In addition, unhappy patient elaborates on how bad the previous doctor was. We should discourage such a dialogue and surely not comment on it lest it is considered as approval of patient’s criticism about previous doctor or even an attempt to defend a professional colleague. It is best to move on with patient’s physical problems, cutting short unnecessary gossip.
4. Cross-reference relates to an opinion asked for from one specialist to the other from allied branch of medicine. It may often pose a problem. It is duty of primary treating doctor to discuss with the patient and his relatives and justify need for a cross reference. It should be clear to everyone concerned whether it is “one time” consultation or “daily” review. It is often a bone of contention when it comes to paying for it. It is much better to be transparent about it. It is ideal that in such a cross-reference consultation, both the doctors together convey unified opinion to the patient. However, if it is not possible for both the doctors to be present at the same time, primary doctor must explain the patient about joint discussion while other doctor should be very brief in talking to the patient and leave details to be discussed by primary doctor. This again would avoid any misinterpretation or misunderstanding on the part of the patient.
5. Biggest dilemma in doctor’s mind is whether to protect a colleague in spite of unethical or negligent act or to expose him. Ethically, physician is expected to expose a corrupt, unethical or negligent colleague and it is also moral, social and professional responsibility. However, it may be construed as an act of vengeance by other colleagues. There is a room for constructive criticism. Positive criticism attempts to change medical practice for the better. It is right to criticize a colleague but face-to-face and only in strict confidence. Negative criticism amounts to fault-finding that serves no purpose than to damage someone’s image. One should never malign a colleague. Honest comment offered in good faith is justified but how to do it is most important.
Few years ago, one of my child patient’s mother delivered another baby and wanted me to see her newborn at the maternity hospital to which I was not attached. I insisted that due permission should be obtained from treating obstetrician which was done. I went to see the baby by then 30 hours old. To my horror, I found imperforate anus though I was informed that baby had passed meconium. It was obvious a negligence. I had to inform parents about it and also need for urgent surgery and at the same time, I was obliged to protect the obstetrician. I was aware that rarely anal opening is seen as a dimple but there is a small membrane in the proximal part of anal canal that causes similar obstruction to passage of meconium. I explained the parents that as a pediatrician, I could diagnose such a condition but routinely it is not so easy to make out. Thus. I could save the doctor and also saved the baby. I also had to take the surgeon into confidence. I am sure my action is debatable but, in my mind, I acted right. Academic debates promote healthy criticism without naming a colleague, such as, one can present a real story of unethical act for audience reaction. It is likely the guilty colleague could be attending as well but without being recognized and in the process, he has learnt his mistake. I am sure every doctor wants to improve but without being made a villain.
Personal notes
I started private practice in the year 1969 and ten years later, Dr Khare joined me.As another decade passed, we thought of adding another colleague in our group and Dr Chokhani joined around late 80’s. By then we were three of us working as one unit, similar to unit system in teaching hospitals with three staff members. Subsequently Dr Pranjal Kale joined us and now we are four together. We share the place as well as patients though patients have a choice to select one of us as their primary pediatrician but are assured of help from others in the group whenever necessary. Interpersonal relations amongst us – all pediatricians – have been so good that only differences of opinion have been restricted to academic discussions and I give full credit to my colleagues. All of us have done reasonably well being together with many advantages of joint practice. This is just to make a point that doctors of same specialty can also work together as one unit, only with mutual trust and faith. I recall when I met one of my senior colleagues soon after I had started joint practice, he wondered whether my decision was right as I would lose patients to my partner. I realized he had not understood that we were one unit.
Take home message
Basis of good relation between doctors lies in mutual respect and understanding. There are rules of good conduct for doctors – referred as medical etiquettes but they are never taught in medical curriculum. Anyway, they can’t be taught in classroom but must be witnessed every day in live situations during training period to have a lasting effect. However, beyond an exposure to role model behavior, good conduct is self-regulated and all that one needs is motivation and attitude to follow it. Surely it brings joy and happiness in life. Of course, same is true about relationship between any two individuals that we need to learn from childhood through exposure in the family itself.