03 - 3. Social role of doctors

3. Social role of doctors

© SPMM Course 3. Social role of doctors General Medical Council (UK) and other professional organisations have expounded the concept of multitude roles expected from a doctor. The RCPsych has adapted this to suit the psychiatric practice.

The Consensus Statement on the Role of the Doctor (from medschools.ac.uk) highlights the social role of the doctor:  To support patients in understanding their condition and what they might expect, including in those circumstances when patients present with symptoms that could have several causes  To identify and advise on appropriate treatment options or preventive measures  To explain and discuss the risks, benefits and uncertainties of various tests and treatments and where possible support patients to make decisions about their own care. •Accessing, interpreting and assimilating new knowledge critically Doctors as scientists Doctors as scientists •Listening and communicating appropriately, the ability to work as part of a team, non-judgmental behaviour, compassion and integrity Doctors as health professionals Doctors as health professionals •Making day-to-day clinical decisions based on medical knowledge to assess the impact, risk and likely outcome of decisions; apply skills in the development of policy, strategy, service design, and clinical processes. Doctors as leaders Doctors as leaders •Acting as critical decision makers with responsibility for allocation of significant health resources; influence to advocate for increased resources to improve health outcomes for their patients and populations Doctors as health advocates Doctors as health advocates •Accepting duty to contribute to the education of other professionals and patients in addition to carrying a responsibility for continued personal education. Doctors as teachers Doctors as teachers •Sharing a responsibility to positively influence the culture and the environment in which they work Doctors as health sector representatives Doctors as health sector representatives

© SPMM Course  All doctors have a role in the maintenance and promotion of population health, through evidence-based practice.  The doctor must appreciate the needs of the patient in the context of the wider health needs of the population. For all doctors, the patient must come first but they will achieve this in different ways and in different settings. The social role of a psychiatrist includes being an appropriate role model providing effective support and guidance for those seeking treatment for psychiatric disorders and various societal dilemmas related to them. Some leaders extend this role as being a public figure in one’s community whose opinions are valued by laymen as well as other professionals and to serve as an ambassador for the profession by educating the public via various media outlets to erase misperceptions about mental illness or psychiatry (Henry Nasrallah in The model psychiatrist: 7 domains of excellence, 2011). Professionalism: There has been a great deal of interest in defining and adopting the concept of professionalism in psychiatry. American Board of Internal Medicine Foundation sets out three core principles specific to medical professionalism that is widely adopted by doctors in the US, the EU and the UK. The 3 principles are the primacy of patient welfare (based on dedication and altruism), patient autonomy and social justice. These principles are further set out in the 10 commitments recommended for developments to promote professionalism in medical practice (from Bhugra & Gupta, 2010): 1. Professional competence 2. Honesty with patients 3. Patient confidentiality 4. Maintaining appropriate relations with patients 5. Improving quality of care 6. Improving access to care 7. Just distribution of finite resources 8. Scientific knowledge 9. Maintaining trust by managing conflicts of interest 10. Professional responsibilities (including maximising patient care, self-regulation, remediation, disciplining) Health advocacy is the process of supporting and empowering patients and carers to express their opinions, ideas and concerns and enabling them to access appropriate information and services and promote their rights. Dual loyalty: World Medical Association’s Medical Ethics Manual highlights this issue when discussing professionalism. “When physicians have responsibilities and are accountable both to their patients and to a third party, and when these responsibilities and accountabilities are

© SPMM Course incompatible, they find themselves in a situation of ‘dual loyalty’. Third parties that demand physician loyalty include governments, employers (e.g., hospitals and managed healthcare organizations), insurers, military officials, police, prison officials and family members. Although the WMA International Code of Medical Ethics states “A physician shall owe his/her patients complete loyalty,” it is generally accepted that physicians may in exceptional situations have to place the interests of others above those of the patient. The ethical challenge is to decide when and how to protect the patient in the face of pressures from third parties.” One such situation pertains to the issue of resource allocation. Resource allocation: In most countries governments decide the overall healthcare budget; institutions and local bodies decide the allocation to each service provided locally; doctors and healthcare professionals decide on the tests to be ordered, services to be offered and treatments to be provided. From the overall allocated budgets, the distribution of around 80% of healthcare expenditures is controlled by end-providers. Where resources are limited, all patients are entitled to a fair selection procedure for that resource. WMA recommends that this choice must be based on medical criteria and made without discrimination. In practice, physicians balance the principles of compassion and justice and are called to employ several approaches for resource allocation depending on where and when the need arises. LIBERTARIAN Resources distributed according to market principles (patient is a consumer; if he/thy have the willingness to pay, the resources will be made available to them). UTILITARIAN Resources distributed according to the principle of maximum benefit for all. EGALITARIAN Resources distributed according to the need (estimated by the provider). RESTORATIVE Resources should be distributed with a positive discrimination towards the disadvantaged (e.g. poor gets priority over the rich who can pay for private care).

WMA notes “physicians have been gradually moving away from the traditional individualism of medical ethics, which would favour the libertarian approach, towards a more social conception of their role”.