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ORIGINAL ARTICLE
J Edu Health Promot 2020,  9:131

Exploring medical teachers' and interns' experiences regarding professional ethics


1 Department of Midwifery, School of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran
2 Medical Education Development Center, Qom University of Medical Sciences, Qom, Iran

Date of Submission04-Dec-2019
Date of Acceptance30-Dec-2019
Date of Web Publication28-May-2020

Correspondence Address:
Dr. Zahra Alipour
Eastern Alley No. 2, Moallem Boulevard, Postal Code - 3715835155, Qom
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jehp.jehp_706_19

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  Abstract 

CONTEXT: Medical ethics is a practical subject as well as a branch of ethical philosophy and an integral part of the proper practice in medicine. However, the ethics changes in places and over time and is variable. Furthermore, many issues that have occurred as a result of advances in technology add to the complexity of the ethical issues. Therefore, the objective of this research was to explore medical teachers' and interns' experiences regarding professional ethics.
METHODS: This study was a qualitative content analysis conducted on 10 professionals and 10 interns of the surgery and internal departments of medical and educational centers in Qom University of Medical Sciences to discover their experiences of the medical professional ethics. The sampling method was purposive, and data were collected through semi-structured interviews. Data analysis was performed using a qualitative content analysis method with a conventional approach.
RESULTS: Three main categories were obtained from the data analysis, including adherence to professional values, organizational conditions, and individual characteristics.
CONCLUSIONS: Adherence to professional values, paying attention to individual characteristics, and organizational conditions are among the factors affecting the promotion of medical professional ethics; therefore, it seems that appropriate interventions on these important components can help promote the professional ethics training in the clinical practice.

Keywords: Interns, medical professional ethics, medicine, promotion


How to cite this article:
Khalajinia Z, Alipour Z, Safaeipour R. Exploring medical teachers' and interns' experiences regarding professional ethics. J Edu Health Promot 2020;9:131

How to cite this URL:
Khalajinia Z, Alipour Z, Safaeipour R. Exploring medical teachers' and interns' experiences regarding professional ethics. J Edu Health Promot [serial online] 2020 [cited 2020 Jul 16];9:131. Available from: http://www.jehp.net/text.asp?2020/9/1/131/285171




  Introduction Top


Professional ethics is one of the new branches of ethics [1] and includes the principles, functions, and standards of individual and organizational behavior expected of the individuals in diverse careers [2],[3] which tries to respond to the ethical issues in different professions.[1] Ethics is also an integral part of the proper function and a fundamental branch of medicine,[4] which refers to the duties of physicians and hospitals toward the patient alongside other health professionals in the health domain.[5] In other words, medical ethics is a practical subject as well as a branch of the ethical philosophy, and an integral part of the proper practice in medicine.[4] However, ethics varies in places and over time and undergoes changes.[6] Furthermore, many issues that occurred due to advances in technology add to the complexity of ethical issues. Apparently, each of the new topics in medical ethics is alone capable of challenging the traditional medical education system in general, and other medical science professions in particular.[7] In fact, fixed ethics cannot be used at all times. What was considered good ethics 100 years ago may not be good nowadays.[5] These ethical challenges can be well found in the medical ethics curricula and the importance of paying attention to ethical competencies and ethical decision-making skills in different contexts can be felt more and more in the curriculum.[8] In their research, Lehmann et al. concluded that medical ethics curricula often fail to address the needs of employed physicians and students. Furthermore, they stated that the presence of some instructors may inhibit the students' ethical growth. Therefore, they decided to rethink medical ethics education.[9] On the other hand, the medical ethics curriculum should shape students' ethical knowledge, attitude, and skills based on the worldview and the philosophical and value principles of each society. Due to the complexity and the speed of changes in human societies, institutions in every society, including the academic system, need to interact with these changes and developments dynamically and continuously. However, these interactions must be based on the beliefs, cultural, and value foundations of each society.

Therefore, studying and understanding the attitudes of medical professors and interns is one of the factors affecting the promotion of valuable professional ethics principles, which will help to provide better services and train more ethical people. Despite that, studies in the field of medical ethics are limited and the subject has received less attention from the researchers despite its importance in the clinical practice. Therefore, it is necessary to examine the experience of promoting the medical ethics and professional behavior of medical professors and interns from different perspectives. Given that qualitative research can provide a deeper and more comprehensive understanding of a concept; thus, this study was conducted qualitatively to evaluate the professional ethics among the interns.


  Methods Top


The present qualitative study was conducted with the approval of the Ethics Committee of Qom University of Medical Sciences No: IR. MUQ. REC.1396.103.

Recruitment

Purposive and convenience sampling method was done among the professors and interns of the internal ward of medical and educational centers of Qom-Iran from August 2017 to April 2018 with the maximum variation in terms of age, gender, academic rank, and work experience. Eligible people for the research were those who met the criteria and qualifications (at least 5 years of the clinical teaching and having specialized qualifications and the interns who were spending 6 last months of the internship period) and were able to provide rich and complete information to the researcher. Before each interview, the researcher explained the study objectives to the participants, and through agreement and obtaining their consent, determined the time and place for the first meeting. The sampling was continued until data saturation and the nonformation of a new code.

Data collection

The data were collected through semi-structured face-to-face interviews with open-ended questions, voice recording, observation, and recording of notes in the field. Furthermore, all their rights regarding leaving the study were explained based on their willingness without giving any reason. The duration of each interview was 40–90 min. The interview started with this general question: How do you describe the adherence to professional ethics in service delivery? Moreover, it was continued with this question: Describe the factors contributing to the promotion of medical ethics at bedside? Asking open-questions would allow the participant to remember more details.[10]

Data analysis

In this qualitative study, the experiences of 10 professors (professionals) and 10 interns in the internal ward and surgery department of medical and educational centers in Qom University of Medical Sciences were analyzed using the qualitative content analysis with a conventional approach. The transcripts of the interviews were analyzed using the Graneheim and Lundman implementation method so that the text of each interview was read several times by the researcher and the research team to gain a full understanding of the whole interview.[11] The whole interview and the observations obtained from the experiences of the professors and interns were considered as the unit of the analysis. The semantic unit was identified, which included words, sentences, and paragraphs that were related to each other semantically or in terms of the content. These units came together by considering their concept. The meaning (semantic) units were then summarized and labeled with codes. The diverse codes obtained from the professors' and interns' experiences were compared in terms of differences and similarities and categorized and subcategorized. The categories created were reviewed and discussed by two researchers. Finally, by comparing the categories with each other and a careful reflection on the meaning, the embedded content in the data or themes were obtained. At the time of data analysis, we tried to avoid any assumption and the categories were allowed to appear from data.[12] To increase the validity and reliability of the research, the interview texts and extracted codes were reviewed by two members of the research team to assure the accuracy of codes, naming the categories, similarities, and differences.[11] During the data analysis, the researchers interacted with the participants and a summary of the researchers' interpretation of the findings was provided to the participants to confirm or refine the results. It also attempted to increase the validity of the research by selecting participants with the highest diversity and doing the data collection process up to the saturation level in all the themes. To increase the reliability of the research, the resulting codes and categories were provided to the experts who did not participate in the extraction of the results, which were verified.


  Results Top


The participants of the study included 10 professors aged 35–57 years and 10 interns aged 24–27 years. The demographic characteristics of the participants are presented in [Table 1] and [Table 2].
Table 1: The individual characteristics of the subjects in the study (the professionals)

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Table 2: The individual characteristics of the subjects in the study (the interns)

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Data analysis from 20 interviews resulted in the emergence of 425 primary inferential codes and three main categories, 10 subcategories, and 23 sub-subcategories. The codes were reviewed and summarized several times and classified based on the proportion and similarity. The results of data analysis can be presented in three main categories, including adherence to professional values, organizational conditions, and individual characteristics. These main categories included several subcategories, each addressing a particular aspect of the factors affecting the promotion of medical ethics [Table 3]. The findings of the study in the form of the above-extracted categories were accompanied by an excerpt from transcripts of the interviews and narratives.
Table 3: Explored main categories, subcategories and sub-subcategories from the data analysis

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Adherence to professional values

The participants identified the adherence to professional values as an important factor in the promotion of the professional ethics; they considered factors such as the respect for patient's rights, the physician's relationship with the patient and colleagues, and professional accountability as affecting factors in the formation of professional interns.

The respect for the patient's rights

One of the subcategories in explaining the experience of the promotion of professional ethics is the respect for the patient's rights. That sub-subcategories of the commitment to the patient's privacy and confidentiality, commitment to justice and non-discrimination, the patient's right to make the decision and choose were emphasized by the participants more than others, which we will discuss them in detail.

Commitment to the patient's privacy and confidentiality

Some participants emphasized that in the promotion of medical ethics, commitment to patient's privacy and confidentiality should be considered a priority. In fact, commitment to the patient's privacy in the therapeutic environments is closely related to normative values and keeping a patient's secrets is always a right for the patient and a duty for the physician. One of the professors described his/her experiences in this regard as follows:

”In the medical principles, we have books and references based on medical ethics, the main focus of which is the observation of privacy and confidentiality. Whatever field you visit the patient, commitment to the patient's privacy and confidentiality should be considered the main priority.” (Professor #5).

In addition, one intern in the field of patient's privacy stated:

”The commitment to the patient's privacy is one of the most important ethical duties in the medical field, and no one should have access to the patient's information” (intern #3).

Commitment to the principle of justice and nondiscrimination

Another aspect of a patient's rights is to consider justice and nondiscrimination for him/her. The participants believed that some of the discriminatory behaviors with the patients are opposite to the promotion of professional ethics. One of the professors with 7 years of teaching experience mentioned:

”Some physicians reserve the isolated rooms for their relatives and friends, and even an isolated emergency that is very sensitive is like this” (Professor #1).

The results indicate that physicians must treat patients with justice and respect, and they considered this behavior as one of the factors that promote the ethics of the medical profession. In this regard, one of the interns stated that:

”The treatment of patients should be done regardless of gender, nationality, and appearance characteristics of the individuals; in fact, the physician should treat all patients respectfully and equally, and there should be no difference in his/her behavior. It was observed that some physicians have discriminating behavior with the patients of other nationalities, which is not acceptable at all” (intern #6).

The patient's right to choose and make decision

The participants pointed out to the patient's right to choose and get information about the choice of treatment and culture-building in this regard in their interviews; the results suggest that the physicians and interns are poorly trained in this area. In this regard, one of the professors stated:

”We operate according to the protocols given to us from other countries and we have to tell the patient about his/her disease, diagnosis, and treatment. And we should allow the patient to choose his/her treatment method” (professor #3).

Another professor stated the lack of culture-making on providing information to the patient:

”In the medical centers, the culture-making has not been done neither for the patients nor for the physicians. We do not tell the patient about complications, we do not talk to the patient at all, and we do not let the patient have choice and awareness” (professional #4).

The physician's relationship with the patient and the colleagues

One of the subcategories in explaining the experience of promoting professional ethics is the physician's relationship with the patient and the colleagues. Warm and intimate relationships, listening to the patient, giving clear explanations to the patient, and appropriate interpersonal communication were among the points mentioned by the participants.

A professor stated his/her experience about the interaction between the physician and the patient as follows:

”The relationship with the patient should be as warm and friendly as possible and the visit should begin with a greeting. We should clearly explain all the measures taken and understand the patient's stress and listen to the patient's questions well and respond to his questions” (Professor #1).

Furthermore, the experiences of the participants indicate that the physician should speak clearly with the patient in a good interaction. In this regard, one of the professors with 6 years of experience stated:

”The first argument is about serving the patient, and the other is the treatment of a physician with a patient. The physician should speak well and explain clearly.” (professor #5).

In this regard, one intern also pointed out that:

”The patient's expectation of the physician is to talk to his physician and tell his/her problem; the patient wants to be heard more. This must be done by spending time and with patience for the patient” (intern #6).

Professional accountability

One of the subcategories in explaining the experience of the promotion of professional ethics is professional accountability. Its sub-subcategories included error acceptance and its reporting and accountability. The results suggest that the accountability and accepting the responsibility of the physicians for their performance and monitoring of the physicians' performance are important factors in the promotion of medical ethics.

A professor with 5 years of experience suggested that monitoring the performance of the physicians is a viable solution to their accountability and stated:

”The proper strategy for the physician to be accountable is that there should be a council that monitors the professional ethics among the physicians, such as those in the medical and forensic process” (professor #3).

Interns also emphasized the physicians' responsibility for choosing treatment procedures, and one of those stated:

”Accepting responsibility is one of the important duties of the physicians that can be more important than any matter in the treatment process. In fact, the patient as a human being should not be left alone and the best service should be provided to him/her” (intern #7).

Mistake acceptance

This sub-subcategory illustrates the weakness and inflexibility of physicians in facing their professional errors, and it is shown that one of the factors that promote the professional ethics of physicians is error acceptance and compensation.

One of the professors with 5 years of experience in teaching stated:

”Some physicians not only lack the spirit of teamwork but also are inflexible to their mistakes that can make their advice inaccurate. Also, physicians need to be more honest, i.e., if a physician makes a mistake, he or she must accept it to correct that mistake in the group” (professor #3).

One of the professors with 6 years of experience stated:

”Professional ethics is very important among physicians. After all, all physicians may make mistakes and no one is free from error; but it is important that they will accept their mistake and try to compensate it” (professor #5).

Organizational conditions

This theme represents the problems found in the environment in which physicians work and the results show the effect of weakness of the organization on the physicians' interaction with the patients and the colleagues. The participants' experiences highlight the challenges in the teamwork, the reward and punishment system, and the high workload of the physicians. We will elaborate on them in detail.

Teamwork

Another important issue in the medical field is the need for teamwork. Emergencies and their consequences are among the most important and threatening challenges in the hospitals and the workplace of physicians and nurses. The presence of the work and teamwork interactions and emergency management are very effective in improving the performance of the treatment team and lead the team to have correct and rapid action in emergencies.

Regarding teamwork, one of the professors with 5 years of experience stated:

”In the physician-physician relationships, the physicians need to work in a team and manage the patients in a group and simultaneously. Teamwork means that all physicians are present at the patient's bedside, share their views and implement the final opinion” (professor #3).

The results indicated that the interaction between the physician and the nurse, and in other words, the teamwork, is very weak. One professor with 6 years of teaching experience stated:

”The physician's relationships with nurses are also problematic and none of them have professional behavior, and so, a dysfunctional system is created. For example, the nurse displaces the patient in some wards that the relationship between the doctor and the nurse is low and sometimes unprofessional” (professor #7).

Reward and punishment system

One of the subcategories in explaining the experience of the promotion of professional ethics is the “reward and punishment system.” The reward system is the hospitals' investment tool to improve service quality. There are laws in place, but they are not implemented properly due to a lack of supervision system.

One of the professors with 7 years of teaching experience in the field believed:

”We generally set excellent rules in every area, but we are always weak in enforcing them. Now, the proper solution is to have a council that supervises the physicians in terms of professional ethics… and rewards the physicians who treat the patients with ethical principles, and therefore, the motive of individuals increases in this case” (professor #1).

Workload

In fact, another challenge for the physicians is workload, which included sub-sub categories such as excessive working pressure, the large numbers of patients and wards, lack of time, job stress, and the financial problems in the public hospitals. Excessive workload causes fatigue and neglect of the physician toward the patients.

In this regard, one of the professionals (professors) with 5 years of teaching experience stated:

”Due to lack of time, too many patients, overwork for the physician, difficulty as well as stress on the job, the physician becomes tired, which reduces his attention to the patient, which is indeed wrong” (professor #4).

Other challenges for the physicians were the lack of time, job stress, and financial problems in the public hospitals that cause physicians to be tired and negligent in treating the patients.

In this regard, one of the interns believed:

”When the number of patients that a physician needs to visit is high, his workload will increase and he will not be able to spend enough time for the patients” (intern #3).

In this regard, another intern stated:

”Due to the financial problems that exist in the public hospitals and the amount of work and pressure put on physicians, it should be expected that what the physician does is more than that he/she can handle. Some policies should also be put in place to solve the financial problems” (intern #10).

The individual characteristics

One of the major categories identified in this study was “individual characteristics,” which included subcategories of kindness, compassion, integrity, and trustworthiness. This category showed that personality traits play a role in the development of professional ethics and the way of interaction with the patients. Individual characteristics are the source of ethics and features of the individuals. The beliefs also orient the behavior of the people. These factors strongly affect how the treatment staff treats the patients and are the basis for the physicians' behavior with patients and their clients.

Kindness and compassion (sympathy)

The participants in their experiences of kindness toward the patients referred to sympathy with patients, kindness of the physician, showing affection to the patient by talking and greeting and helping the patients without feeling any detraction. To provide compassionate care, the treatment staff must place themselves in the patient's position and look at the situation from the perspective of the patient. This will make a real understanding of the patient, and ultimately, the physician will take measures to reduce the patient's concerns.

One professor with 17 years of teaching experience stated:

”When we treat a hospitalized patient with kindness and amiability, they will be more cooperative with the treatment team and the patient will recover faster” (professor #2).

In this regard, one of the professors with 6 years of teaching experience stated:

”Compassionate care means to put ourselves in place of the patient and feel that we are sick. We should look at the problem from the patient's point of view, pay attention to the patient's conditions, his/her body and soul, which are in trouble, and help them through compassionate care and resolve their pain and problems (professor #6).”

Trustworthiness and integrity

From the participants' perspective, the factors showing integrity included avoiding unnecessary treatment processes and visits, having honesty at work, requesting the essential diagnostic tests and procedures, and training the patient in this regard.

One of the professors with 7 years of teaching experience referred to:

”One of the most important behaviors of a physician is to treat the patient with honesty in his/her work. That is to say, for example, if he/she cannot diagnose and treat the disease, he/she will refer the patient to another doctor. Some other unprofessional behaviors that some physicians do involve performing a number of unnecessary medical processes and visits” (professor #1).

In this regard, another professor said:

”The patient should not be unnecessarily hospitalized, and the physician should explain all actions, tests, and diagnostic and therapeutic procedures to the patient consciously and as needed. We should use the treatment process that the patient can afford” (professor # 7).

One of the professors with 6 years of teaching experience stated:

”The patient's trust in physician makes him/her trust in the diagnosis and the treatment method, for example, listening well to the patient and explaining to him/her can lead to gain trust, which is very important” (professor #7).

Furthermore, the results of the participants' experiences show that the patient's distrust of the physician due to the lack of sufficient explanation by the physician and replacing the physician due to not trusting him/her puts the patient at risks.

In this regard, one of the interns stated:

”Parents whose child has had septic arthritis and needed emergency surgery did not gave their consent and said you are an intern and we would not allow you to do the operation. The risk of such a mistrust is that the kid's joint may stop functioning and fail to work forever” (intern #3).


  Discussion Top


Based on the experiences of the participants in the present study, the factors affecting the promotion of the professional ethics include three main categories: adherence to the professional values category, including the respect for the patient's rights, the physician relationship with the patient and colleagues, and the professional accountability; organizational conditions category, including the workload, teamwork, and the reward and punishment system; and individual characteristics category, including the kindness, compassion, and trustworthiness, which will be discussed in the following.

In the present study, one of the main categories was adherence to the professional values, which included respect for the patient's rights, which itself included subcategories such as commitment to privacy and confidentiality, the lack of discrimination, and giving the patient the right to choose.

In the area of commitment to privacy and confidentiality, Mahdavinejad also points out that some cases of the patient's rights relate to aspects of confidentiality and respect.[13] The Medical Ethics Charter within the country (Iran) has repeatedly emphasized the patient rights, including the commitment to privacy and confidentiality, which illustrates the importance of paying attention to the patient's rights in our society [14] and it has been emphasized that the patient's privacy and respect for patient privacy are issues that the physicians should consider and attempt to observe them.[15] Observing these rights and respecting the patients are the standards of professionalism.[6],[16]

Another subcategory is the physician's relationship with the patient and the colleagues, which actually refers to interactions between the physician and the patient. Documents from other studies also show that communication with the patients as well as the colleagues is one of the essential principles of care [6],[17],[18] and establishing a good relationship between the physician and the patient will also have positive therapeutic outcomes.[19]

Another subcategory of this study is “accountability” in explaining the professional ethics. The results show that accountability is one of the most important issues in any health-care system and is an issue that is very important for health policy-makers and managers.[20] As a result, accountability is among the criteria of professionalism,[6],[16] which is consistent with the results of our research.

The findings of the present study showed that another major category suggested by the interns and the professionals was the “organizational conditions.” The organizational conditions include the three sub-categories of the “teamwork,” the “reward and punishment system” and the “workload.”

In the present study, the results showed that one of the effective factors in explaining professional ethics is the “reward and punishment system.” The findings also show that the reward and punishment system is seen as encouragement for the people who adhere to the ethical principles and the professional function, and encourages others to pursue the professionalism.[18]

In the present study, another subcategory was the workload that actually highlighted the work challenges of the physicians and expressed the difficulty of their work. Evidence also shows that the excessive workload and inadequate facilities reduce the quality of healthcare that is inconsistent with the laws and ethics. The lack of human resources can also cause more errors for the physicians and the nurses in all areas, including ethical sensitivity.[21] Thus, the high workload will lead to inadequate service delivery, and it is one of the factors affecting professionalism,[18] which is consistent with the findings of our study.

Another major category identified in this study was “individual characteristics” and included the subcategories of the “kindness,” “compassion,” “integrity,” and “trustworthiness.” Existing documentation also suggests that the personality, family education, and personal disposition, and the way physicians interact with patients, are effective in emerging ethical behaviors and this relation should accompany the kindness of the physicians.[22] Characteristics such as integrity and rectitude, skillful communication, and respectful and nonjudgmental behaviors are the most important factors affecting professional ethics.[6]

Evidence also shows that the compassion and caring are mixed, and the compassionate care is one of the key factors in providing high-quality nursing care [23] and the affection and compassion are the most important factors affecting the professional ethics.[6]

Another subcategory of this study that was instrumental in the promotion of professional ethics was trustworthiness and integrity. The results of the studies also show that an important part of the professional ethics is manifested in paying attention to the human values and the principles of correct behavior and declaring all matters relating to the patients and being honest in their expression.[24] Mahajan also argues that trustworthiness and integrity is one of the most important factors affecting professional ethics.[6]


  Conclusions Top


The acquisition of professional ethics is facilitated by professional values, organizational conditions, and individual characteristics factors. These factors could lead to the legitimate norms and standards governing the professional behavior of the physicians in their relationships with patients. Furthermore, commitment to patient's rights, physician communication with the patient and colleague and accountability, workload, teamwork and reward and punishment system, kindness, trustworthy, and honesty could lead to observing the professional ethics in clinical practice. The comparison of the above findings with those of other studies suggests that the factors mentioned in this study are very important and reflective and should be taken seriously to promote medical ethics in Iran.

Acknowledgment

The authors would like to appreciate all specialists and interns participating in this study; conducting the study was not possible without their cooperation. In addition, we would like to thank the Deputy of Research, Qom University of Medical Sciences for financial support.

Financial support and sponsorship

This study was supported financially by Qom University of Medical Sciences, Qom, Iran.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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