An article on medical professionalism was published in the Annals of Internal Medicine in February 2002 outlining a charter, and the fifth-year medical students of the Medical School of the University of Pretoria were asked to comment on the charter.  The question was asked whether the principles and responsibilities as set out in the charter could also be applied to the South African context.  
The responses of the students could be divided into three groups with overlapping themes: 15,64% of the students felt that the charter was not at all applicable to our country because of its diverse cultures and languages and the variety of social classes and religions; 24,02% of the students felt that the charter was a universally acceptable document; and 60,34% of the students felt that, to a great extent, the charter was the ideal and the goal to strive for, although they only accepted some of the principles and responsibilities while having serious doubts and criticism of others.
In conclusion, the majority of the medical students felt that the charter was noteworthy and commendable in principle, but not totally applicable in our country with its unique problems and challenges.  Our challenge is to take what resources we have and use it to the benefit of all.
Keywords: Medical Professionalism, Patient welfare, Autonomy, Social justice, Continued medical education, Confidentiality and privacy, Financial considerations, Rights of doctors, Cultural differences, Government support
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Van Rooyen, M

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Original ResearchSA Fam Pract 2004;46(1)28IntroductionIn February 2002, the Annals ofInternal Medicine published an ar-ticle on medical professionalism inthe new millennium, outlining a char-ter.  The charter is the principleproduct of the Medical Profession-alism Project of the ABIM Founda-tion, the ACP-ASIM Foundation andthe European Federation of InternalMedicine. This project is a responseto a call for a renewed sense ofprofessionalism globally.  The com-mitment to patient welfare and socialjustice are the focus points of thisset of principles to which all medicalprofessionals can and should as-pire.   The charter begins with abrief introduction and rationale, fol-lowed by a statement of the threefundamental principles of medicalprofessionalism:• The principle of the primacy ofthe patient• The principle of patient autonomy• The principle of social justiceThis is followed by the heart ofthe charter, which is a set ofcommitments:• Commitment to professionalcompetence• Commitment to honesty withpatients• Commitment to patient confiden-tiality• Commitment to maintain appro-priate relations with patients• Commitment to improving qualityof careVan Rooyen, M, MBChB (UP) MMed (Fam Med)Senior Lecturer, Department of Family MedicineUniversity of Pretoria, H W Snyman North 8-21P O Box 667, Pretoria, 0001Tel: 082 785 4500 / 012 354 2144 / 012 318 6779Fax: 012 354 1317, E-mail: mvrooyen@med.up.ac.zaKeywords: Medical Professionalism, Patient welfare, Autonomy, Social justice,Continued medical education, Confidentiality and privacy, Financial considerations,Rights of doctors, Cultural differences, Government supportABSTRACTAn article on medical professionalism was published in the Annals of Internal Medicine in February 2002 outlininga charter, and the fifth-year medical students of the Medical School of the University of Pretoria were asked tocomment on the charter.  The question was asked whether the principles and responsibilities as set out in thecharter could also be applied to the South African context.The responses of the students could be divided into three groups with overlapping themes: 15,64% of the studentsfelt that the charter was not at all applicable to our country because of its diverse cultures and languages and thevariety of social classes and religions; 24,02% of the students felt that the charter was a universally acceptabledocument; and 60,34% of the students felt that, to a great extent, the charter was the ideal and the goal to strivefor, although they only accepted some of the principles and responsibilities while having serious doubts and criticismof others.In conclusion, the majority of the medical students felt that the charter was noteworthy and commendable inprinciple, but not totally applicable in our country with its unique problems and challenges.  Our challenge is totake what resources we have and use it to the benefit of all. (SA Fam Pract 2004;46(1): 28-31)The views of MedicalStudents on professionalismin South Africa• Commitment to improving accessto care• Commitment to a just distributionof finite resources• Commitment to scientific knowl-edge• Commitment to maintaining trustby managing conflicts of interest• Commitment to professional re-sponsibilitiesThe introduction of the charter con-tains the fol lowing premise:“Changes in the health care deliverysystems in countries throughout theindustrialized world threaten the val-ues of professionalism”.  The editorasked the question whether this doc-ument represents the traditions ofmedicine in cultures other than thosein the West, where the authors of thechar ter  pract ice medic ine.All of the fifth-year undergraduatestudents of the medical school ofthe University of Pretoria doing theirFamily Medicine block were askedto read and comment on the editor’squestion as one of their assignments. The students, individually or in pairs,had to discuss the charter and itsvalidity in our setting – a country withmany different cultures and languag-es and a variety of social classesand religions – in a written report asa letter to the editor.  There were 197responses.The responses of the studentswere analysed by the author.  Theresponses in the written reportscould be divided into three catego-ries, namely those who fully en-dorsed the charter, those whothought the charter to be idealisticand not applicable to our settingand, finally, those who agreed withsome of the charter’s principles, butdid not see it to be totally applicableto our society.  The themes that oc-curred most often were groupedtogether and  then written up.The responses could be dividedinto three main groups with overlap-ping themes.- 15,64% of the students felt thatthe charter was not at allapplicable to our country:“… these documents tend to beacademic, with little practical val-ue, utopian moral values thatcould only be attained in an ideal,sophisticated society, which Idoubt exists, and certainly not inSouth Africa with all its socioeco-nomic and political problems.”“…it does however fail to repre-sent the tradition of medicine inother less industrialized countries. The reason for this is the lack ofconsideration for the political andfinancial status of many countriesespecially in Africa.”- 24,02% of the students felt thatthe charter was a universally ap-plicable document:  “There is nodoubt that a charter addressingthe important issues of profession-alism is topical, and applicable toany medial setting.  The chartergives the students an opportunityto measure themselves and also tocompare the doctor they would liketo become with the doctors currentlyresponsible for their training.” “Ifirmly believe that just because weare a 3rd world country, doesn’tmean we must deliver 3rd worldtreatment.  Poor health care is notthe birthright of those born in poorcountries.”- 60,34% of the students felt thatthe charter was to a great extentthe ideal and accepted some ofthe principles and responsibili-ties, while having serious doubtsabout and criticism of the others.“The needs and rights of the pa-tient are increasingly beingbrought to the forefront of medicalpractice.  The physician is in theunenviable position of having tobalance professionalism andmoral obligation with the needfor self-fulfilment and personalsuccess.”The influence of South Africanrealities on the charter – pos-itives and negatives1.  The principle of the primacy ofpatient welfare“This principle is based on a ded-ication to serving the interest ofthe patient.  Altruism contributesto the trust that is central to thephysician-patient relationship.Market forces, societal pressures,and administrative exigenciesmust not compromise thisprinciple.”1The principle was universally ac-cepted as the foundation of everystudent or doctor’s behaviouralpatterns and thought processesabout professionalism.“Serving the interest of the patientshould always be the drivingforce for any physician.”“It has a strong moral and ethicalbasis, which has one commondenominator: beneficence of thepatient.”“Primacy of patient welfare isgood, it is what medicine is allabout: improving sick people’squality of life.”2. The principle of autonomy“Physicians must have respectfor patient autonomy.  Physiciansmust be honest with their patientsand empower them to make in-formed decisions about theirtreatment.  Patients’ decisionsabout their care must be para-mount, as long as those deci-sions are in keeping with ethicalpractices and do not lead to de-mands for inappropriate care.”1Overall, the students acceptedthis principle as the ideal andbeneficial to both the doctor andthe patient:“Even though it initially felt strangegiving the patient so much sayin his/her treatment, the realisa-tion of shared responsibility wasa relief.”Original ResearchSA Fam Pract 2004;46(1) 29However, almost all of the stu-dents had serious doubts aboutthe implementation.  The reasonsfor this are:  the language prob-lem (11 official languages in ourcountry), many illiterate patients,too many doctors looking afterone patient in an academic set-ting, and too many patients forone doctor in the public sectorclinic setting, with limited timefor each consultation. “Try ob-taining informed consent in theSouth African context, explaininga disease that affects for in-stance the lungs, to a personwho does not have the educationto appreciate the function of theorgan, the implications of thedisease process and the waysto prevent it from occurring inthe first place. That is, if commu-nication can be done through alanguage medium familiar toboth doctor and patient.”3. The principle of social justice“The medical profession mustpromote justice in the health caresystem, including the fair distri-bution of health care resources. Physicians should work activelyto eliminate discrimination inhealth care, whether based onrace, religion, or any other socialcategory.”1Again, this principle was accept-ed as representing an ideal situ-ation, “although there is only alimited supply of resources, Ithink that effectiveness and notcost of treatment should be thedriving force behind the man-agement of patients”“…but not at all feasible/ appli-cable to our country with a publicsector with limited resources,funded by an unsympatheticgovernment, serving the largerpart of the community and a pri-vate sector where medical fundsmake the ultimate decisions fordoctors.  In a system with limitedresources, those who can paythe most will get the most, andthere is very little the physicianscan do about it,”“Public health care systems areinvariably inferior to the privatesector, primarily due to the lackof funds.  For the physician tosingle-handedly eliminate barri-ers to access, based on educa-tion, laws, finances, geographyand social discrimination, is dif-ficult if not impossible.”4. Continued medical education“Physicians must be committedto lifelong learning and be re-sponsible for maintaining themedical knowledge and clinicaland team skills necessary for theprovision of quality care.”1“In an ever changing environ-ment, with new standards beingset everyday, with evidence-based medicine, and also fiercecompetition, it will always staythe responsibility of the caregiv-er/health care professional toempower and equip himself togive the best possible care.”“In South Africa the Governmentimplemented the CPD pointssystem where every doctorshould acquire 50 points everyyear for continued medicaleducation.”5. Confidentiality and privacy“Earning the trust and confi-dence of patients requires thatappropriate confidentiality safe-guards be applied to disclosureof patient information.  Physi-cians recognize, however, thattheir commitment to patient con-fidentiality must occasionallyyield to overriding considerationsin the public interest.”1“Commitment to confidentialityis commendable up to a certainpoint where patient confidential-ity must yield to overriding con-siderations of the public interest. In my opinion the AIDS epidemicin South Africa falls in that cate-gory.  How can confidentialityoverride all when the patient hasa wife, children and sexual part-ners that are placed at risk?”“This is but one of the hugeethical dilemmas doctors arefacing.  Respect for the privacyand confidentiality of patients islacking in academic settingswhere patients are used aspracticing models and dis-cussed on ward rounds as if theyweren’t there.”This responsibility is thus alsoseen as something to strive to,but not at all 100% applicablein our setting. Some of the stu-dents felt differently: “to be hon-est with your client is a universal-ly acceptable principle not onlyapplicable to doctors.  With cer-tain exceptions confidentiality isthe moral and legally correctthing to do”.6. Financial considerations fordoctorsThe question often raised waswhether the charter allowed thephysician to make a decent, well-earned living, because the bal-ance between professionalismand economic prosperity is in-creasingly being tested.“We are not a bunch of loseraltruists living and striving forequity and devoting our time topublic health advocacy whilehoping that all our financial con-cerns will have reduced them-selves by the time we get home.”“The reality is that in a hostileenvironment the doctor had tobecome a businessman, fightingfor survival.”There were also those who feltdifferently:  “Although it might beseen as financial suicide, forinstance to see patients for long-er consultations at the samerates or ask lower rates for publicOriginal ResearchSA Fam Pract 2004;46(1)30sector patients, these are thetimes that the doctor’s knowledgeis tested and sharpened and thatmeans job sat is fact ion” .7. Rights of doctors“How far should this idea be car-ried out?  To the point where oneendangers one’s own life inputting the patient’s demandsahead of one’s own desire forsafety?”“Doctors in the public sector forinstance face many difficulties,working very long hours with lim-ited resources, sometimes with-out basic materials such asgloves, and then for minimal wag-es.”“People tend to see the physicianas a perfect programmed ma-chine, incapable of getting tiredor making mistakes and not al-lowed to have a family life ofhis/her own.”8. Cultural differencesDifferent cultures view profession-alism differently, according totheir “tribal” set of rules andstandards.  In our country, wehave the phenomenon of tradi-tional healers who often use lessthan scientific methods for treat-ing patients.  The rules of auton-omy and patient primacy are alsoapplied differently by them.9. Government supportThe overall feeling of solitude dueto a lack of government supportsurfaced very strongly in the re-plies.“The doctor cannot uphold thequality of care all by himself whilethe other members of the medi-cal team and the governmentdon’t co-operate.  The circum-stances in a country where poli-ticians spend a lot of money onchanging the names of cities andbuying jets for themselves ratherthan addressing the criticalhealth issues like supplying anti-retroviral drugs to HIV (+) preg-nant woman and rape victims,make it very difficult if not impos-sible for any physician to upholdthe principles and responsibilitiesof the charter.”We can conclude by saying that themajority of students felt that, in prin-ciple, the charter is noteworthy andcommendable, but not totally appli-cable to our country with its uniquecircumstances and problems, asdiscussed above.   We thereforesuggest that the members of theABIM foundation, the ACP-ASIMFoundation and the European Fed-eration of Internal Medicine acknowl-edge the difficult circumstances doc-tors and healthcare workers face inother parts of the world and takethese into consideration when draw-ing up a charter.   However, the prin-ciples and commitments of the char-ter are the ideal, the utopian worldthat we all have to strive for, difficul-ties or not.  Our challenge is to takewhat we have, use it to the advan-tage of everybody, and build a betterfuture for those who fol low.AcknowledgementsProf. Julia Blitz is thanked for helpingto compile this document. See CPD Questionnaire, Page 47References1. The ABIM Foundation, ACP-ASIMFoundation, and EuropeanFederation of Internal Medicine.Medical Professionalism in theNew Millennium: A PhysiciansC h a r t e r.  A n n  I n t  M e d2002;136:243-6.Original ResearchSA Fam Pract 2004;46(1) 31

The views of medical students on professionalism in South Africa

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The views of medical students on professionalism in South Africa

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