Importance of ethics in the medical profession

The full speech of Emeritus Prof. Janaka De Silva, former director of the Postgraduate Institute of Medicine (PGIM) as chief guest at the inauguration of the Annual Academic Sessions (AAS) of the Sri Lanka College of Oncologists (SLCO) on October 13 in Colombo.

Prof. De Silva was speaking on ‘Postgraduate training and the professional practice of medicine’: As I am not qualified to talk to you about oncology, I thought I will speak briefly from my experience of working at the PGIM and the Sri Lanka Medical Council (SLMC) on a few issues that concern our postgraduate training, the professionalism that society expects from specialists and the challenges we face in fulfilling them.

Our postgraduate training system is one of the finest in the region and our post-MD trainees also have the privilege of being trained overseas. Several of our qualifications are recognized overseas, and some, like the MD Surgery have been granted equivalence by Colleges in the United Kingdom. There can little doubt that those who undergo this type of training have the necessary knowledge and skills to practice as specialists.

But, in addition to being knowledgeable and skilled, fitness to practise is also determined by professional conduct – maintaining a high standard of professional and moral ethics and being aware of and respecting the rights of patients. And although genuine efforts are being made in our training programmes, it is here that I feel there is room for improvement.

Doctors are expected to make the care of their patients their first concern. They should be competent in all aspects of their patient care related responsibilities and keep their professional knowledge and skills up-to-date. They should recognize and work within the limits of their competence and refer where it is considered necessary, prescribe drugs or treatments based on the best available evidence, be satisfied that consent is obtained before carrying out any examination, investigation, or treatment, and communicate effectively with patients and those who take care of them.

Doctors should not express personal beliefs (including religious beliefs) to patients in ways that exploit their vulnerability or cause them distress, and should maintain patient confidentiality at all times, especially when communicating publicly, be open and honest with patients if and when mistakes occur, and be honest about their experience and qualifications.

They should also be honest and trustworthy when completing or signing documents, when giving evidence to courts and in financial and commercial dealings. Doctors should also be fully aware of the rights of the patients they treat. Patients’ rights include the right to informed consent which refers to their agreeing to undergo treatments or procedures only after receiving accurate information wherever possible. This should include the names of healthcare providers and their qualifications and the estimated costs of investigations, procedures and treatments.

I am sorry if that felt like I was lecturing you, because what I have said is hardly new and should be common practice. But we all know that this is not the case. We have only to listen to the news, read the newspapers or log onto social media to hear ever increasing incidents of patients subjected to unnecessary investigations and procedures, given irrational prescriptions, issued false medical certificates and being charged unconscionable fees.

As our country becomes more developed, admittedly rather slowly, the medical profession has a duty to ensure that the health benefits of this gradual affluence reaches all communities in all parts of Sri Lanka. There can be little argument about that. But for this to happen, we need more specialist doctors, so that specialist medical services can be expanded to cover the more remote areas of our country. And, as we progress, we must also strive to improve, not only the coverage, but also the quality of care given to our patients. At present we are struggling with both, mainly because of the current brain drain and, paradoxically, protectionism within the profession.

Almost all of us specialists here have had the benefit of free education at some time or another – at school, at university or when we went overseas for our postgraduate training. It was certainly the case for me. It is something extraordinary for a lower middle income country to provide. So, we owe Sri Lanka and her people a debt of gratitude. Giving something back to the system that nurtured us are duties that are noble and proper.

I therefore, feel sad when I read the news of some specialist doctors cold-heartedly and without notice abandoning their posts and patients, and leaving the country, and worse, doing so secretively to avoid paying their service bonds and other dues. This is disgraceful and brings our whole profession into disrepute. The shame, however, is not only theirs, but should be shared equally by the affluent countries that poach them from this not-too-well-off country.

But, our system is also at fault. While our regulator, the SLMC is currently well into the process of drafting a new Medical Act to address some of the issues I mentioned earlier, our system also needs to fulfil a social obligation – that is to provide career opportunities for the nearly 2,000-odd doctors graduating from local and foreign medical schools joining our workforce each year – may I remind you at this point that we now have 12 state medical schools. If we fail, the lack of opportunities will continue to result in our brightest young doctors leaving the country.

There are several ways that we may be able to deal with this issue: one is to develop more specialties, once adequate numbers of generalists have been trained. Another is to increase the number of mid-level qualifications like Postgraduate Diplomas and Masters Degrees; doctors with middle-level qualifications can play a very important role in our health service, provided their services are utilized optimally.

To achieve these, the medical profession needs to overcome its protectionist ideology that sadly pervades even our professional colleges. In fact, when I was Director of the PGIM, I found that some colleges were actually the biggest obstacle to developing sub-specialties and awarding mid-level qualifications and the reasons given by them were not even remotely academic. It is in matters such as this that the support of professional bodies is needed. I thought I will speak freely about these inconvenient and uncomfortable truths, firstly, because I have been waiting a very long time to do it, and secondly, because I do so at the induction of a man, who is an oncologist of the highest integrity, who, as a professional, is a role model. I am proud to have made a small and very early contribution to his professional career.