Better people make better doctors • LITFL • SMILE2

The expectations modern society places on doctors are explored in the ‘good samaritan’ case of Dekker vs Medical Board of WA, where a doctor was called to account for ‘improper conduct in a professional respect’ when she didn’t stop to lend urgent medical assistance at a motor vehicle accident. This post examines how today’s doctors are judged with respect to ‘professionalism’ and how those notions have changed over time. It is then proposed that with the ever-changing landscape of technology, accessible information, medical practice, and increasing patient autonomy, professionalism needs to be driven first and foremost by high personal standards.

In April 2002, a consultant radiologist, Dr Leila Dekker, was involved in a ‘near-miss’ motor vehicle accident in Roebourne, Western Australia ¹. The motor vehicle that she was driving narrowly avoided being struck at an intersection by another motor vehicle. The second vehicle subsequently ran off the road and rolled into a ditch. Dr Dekker heard the crash and admitted that she thought the injuries sustained by the occupants of that car would likely have been serious. However, she was “petrified” from the near-miss and decided not to attend the scene to see if she could render medical assistance. Instead, she drove a short distance to the nearby police station to alert them that there had been an accident. At the time of the incident it was dark and she didn’t have a torch, mobile phone nor medical equipment on hand.

In 2013, a tribunal found her guilty of ‘improper conduct in a professional respect’ for failing to stop and provide medical assistance at the scene ¹. However, a 2014 Court of Appeal set aside that decision and determined that there was no specific duty for a doctor to render assistance (i) when a motor vehicle accident had occurred in their vicinity, (ii) when they were aware a person involved in the accident may have suffered an injury, nor (iii) when they were physically able to assist ².

Given the conflicting rulings in the case, the guidelines and standards for doctor’s professional conduct should be considered.

At the very beginning of one’s medical career, medical graduands around the world will swear the Hippocratic Oath; the 2500 year old medical text declaring to uphold the ethical standards of the medical profession. Although parts of the ancient oath are far less applicable in 2016, it’s underlying values of ‘helping the sick according to my ability and judgement, but never with a view to injury and wrong-doing ³‘ still hold true. In 1964, the oath underwent a ‘modern’ revision ⁴, which is what has often been recited at graduation ceremonies since. It could be argued that 52 years since the revision, the current version is no longer ‘modern’ either. After all, if the advances in medical practice since the mid-1960’s are anything to go by, when physicians were first being introduced to CPR training, the ethics and standards of medicine have almost undoubtedly evolved too. However, one line in particular from the current interpretation pays homage to the professional nature of the doctor and the higher standards to which they are held – “I will remember that I remain a member of society, with special obligations to all my fellow human beings.. ^4“. Therefore, what are these ‘special obligations’ and should Dekker have been compelled to oblige them?

Under common law in Australia, there are no special obligations or legal duties for anybody, doctor or otherwise, to rescue another person whom they have no prior relationship with ⁵. Furthermore, Australian doctors are regulated by the Health Practitioner Regulation National Law (WA) Act 2010 (WA), where there is no specific reference in their definitions of ‘unprofessional conduct’ or ‘professional misconduct’ to failing to render professional assistance to a person in need of urgent medical attention ⁵. However, the Medical Board of Australia’s code of conduct states that “treating patients in emergencies requires doctors to consider a range of issues, in addition to the patient’s best care. Good medical practice involves offering assistance in an emergency that takes account of your own safety, your skills, the availability of other options and the impact on any other patients under your care; and continuing to provide that assistance until your services are no longer required ⁶”.

Applying the Medical Board’s code of conduct to the case of Dekker, one must consider in particular her own safety, skills, and the availability of other options. With respect to her safety, she reported she was “in a state of shock” following the near-miss, it was dark, and in a remote area of rural Australia. However, she was accompanied in the vehicle by her male neighbour and the tribunal noted there was no reason she couldn’t have used her vehicle’s lights to illuminate the scene. With respect to her skills, one must consider how effective a radiologist with no first aid equipment would have been at a roadside trauma. Would her training and skills still have been useful to provide basic support, or at least assess the severity of the scene? Finally, the availability of other options is an important point to consider. It was not noted whether Roebourne had it’s own ambulance service at that time, but the local police station was within a few minutes drive, where they were likely to have had medical equipment and the ability to notify other advanced medical personnel.

The reader can determine their own viewpoint on the matter, but personal discussions of the case with medical and non-medical parties have elicited polarised responses. With such a lack of agreement surrounding the professional expectations of the doctor, both at the tribunal and in informal discussions, it made the writer consider just what was the position of today’s doctor in society and what does society expect of the doctor in return?

Long gone is the golden age of medicine, some half century ago, when the paternalistic doctor was a pillar of society, held in the highest esteem ⁷. Doctors are undoubtedly still highly trusted and valued members of society, but since those heady days, the doctor’s status has been tempered due to a number of factors. Armed with the internet and freely accessible medical information (of both high and poor quality), patients are more informed, expect more autonomy with their care and are less likely to defer to doctors when compared to times gone by ⁸. On the flip side of the same coin, since doctors also have easier access to evidence-based medical information, they’re more likely to admit, or at least hopefully recognise, the gaps in their medical knowledge. The flawed myth of the ‘all-knowing’ doctor has been largely dispelled. Simultaneously though, patients’ expectations of medicine and medical practitioners have increased alongside significant advances in medical technologies and capabilities ⁸. Doctors need to relinquish more autonomy, while providing greater results. In this scenario, patients want their cake and to eat it too and unfortunately for today’s doctor, they’re the cake.

Compounding the decline in society’s perception of doctors could simply be the phenomenon of ‘regression towards the mean’. However, when we see in the media doctors being charged with deplorable crimes (“Perth child psychiatrist faces fresh child pornography charge – July 2016 ⁹”) and celebrity doctors spruiking unscientific medical advice (“Dr. Oz Grilled In Congress, Admits Weight Loss Products He Touts Don’t Pass ‘Scientific Muster – June 2014 ¹⁰”), it is little wonder the public’s perception of the medical profession has diminished. Does this happen due to doctors not knowing what professional standards society expects of them? That’s debatable. Even though there are explicit codes of conduct as detailed above, they could never anticipate every scenario or situation a doctor finds themselves in, particularly in such a dynamic medical landscape. When there is uncertainty and stress, individuals default to their own personal standards. Professionalism is no different and addressing personal standards of professionalism is where the writer believes responsibility ultimately lies.

Having a strong internal moral compass, whether you’re a doctor or not, is fundamental to navigating complex issues, like in the case of Dekker. Knowing firmly what one believes in and what to ‘fight for’, will hold an individual in good stead when difficult decisions arise. As has been explored, the status of the medical profession is changing, and what better way to counterbalance, or anchor that change than with high personal standards.

As the writer often finds, the best examples are found in sport – the greatest microcosm of life. A rugby team, the New Zealand All Blacks, addresses the issue of high personal standards elegantly through their team culture of “better people make better All Blacks ^11“. Their belief is that individual character and personal leadership produces a better quality of rugby player. Unsurprisingly, the All Blacks have their own very high standards with which the group must live up to, but when it is distilled down, the responsibility is ultimately placed upon the individual. Their moral fibre is considered at least as valuable as their technical or physical abilities. There should be no difference in medicine, we too should nurture and develop high personal standards and believe that better people make better doctors.