A letter to AHPRA
10 MINUTE READ
The request by AHPRA mid-2018 to comment on its intended changes to the medical code of conduct sparked a widespread flurry of debate, letters and petitions via email and social media. Many of these conversations involved participation by CMDFA members. Here are some of them.
We thank you for this opportunity to contribute to the public consultation on the draft revised code of conduct, Good medical practice: A code of conduct for doctors in Australia.
We congratulate you on the many improvements noted in the new draft. We are particularly grateful for clearer guidance on safety in the workplace related to violations of discrimination, bullying and sexual harassment. We also appreciate the efforts to increase consistency with the codes of conducts for nurses and midwives.
We would like to highlight a few areas that provide opportunities to strengthen items and address omissions.
In section 3, ‘Providing good care’, we note the use of the phrase “good patient care” and in section 4, ‘Working with patients’ we note the use of the phrase “good doctor-patient partnership”. In both these sections there is no explicit reference to “person-centred care” nor “holistic healthcare” but these concepts are clearly implicit in each of the listed items in these sections. We note the statement “Good medical practice is patient-centred” in section 2.1, but this appears to be the only explicit use of this phrase. “Person-centred care’ and ‘holistic healthcare’ are powerful concepts underpinning good patient care and the good doctor-patient partnership.1 They provide valuable frameworks to understanding the health needs of individual Australians and Australian communities. We suggest they should be made more explicit in sections 3 and 4 as well.
For instance, item 3.1.1 currently states:
3.1.1 Assessing the patient, taking into account the history, the patient’s views, and an appropriate physical examination. The history includes relevant psychological, social and cultural aspects.
We suggest strengthening this item by phrasing it as:
3.1.1 Holistically assessing the patient, taking into account the history, the patient’s views, and an appropriate physical examination. The history includes relevant psychological, social, cultural and spiritual aspects.
Further, item 4.2, ‘Doctor-patient partnership’ currently opens with:
A good doctor–patient partnership requires high standards of professional conduct.
We suggest strengthening this opening by phrasing it as:
A good doctor–patient partnership requires high standards of professional conduct and person- (or patient-) centred care.
In addition, item 4.3, ‘Effective communication’, currently states:
4.3.8 Taking all practical steps to ensure that arrangements are made to meet patients’ specific language, cultural and communication needs, and being aware of how these needs affect patients’ understanding.
We suggest strengthening this item by phrasing it as:
4.3.8 Taking all practical steps to ensure that arrangements are made to provide holistic care that meets patients’ specific language, cultural and communication needs, and being aware of how these needs affect patients’ understanding.
Holistic health care and person-centred care acknowledge that spiritual belief is a key determinant of health.1,2,3,4,5 Although the World Health Organisation (WHO) are yet to amend their 1946 definition of health that endorses the three dimensions of “physical, mental and social well-being” 6, there have been many calls for ‘spiritual well-being’ to also be officially recognised as a legitimate “4th dimension” in the definition of health.7,8,9
In the draft revised code of conduct, there is no explicit reference to this spiritual dimension of a person’s health. Whilst it may be implicit in references to “cultural” and “social” aspects, we recommend that it be made explicit as well. Our colleagues in the General Medical Council (GMC) of the United Kingdom (UK) have done so in their ethical guidance for doctors.10 Our suggestion to re-phrase item 3.1.1. above reflects this.
We recommend that taking a spiritual history must be conducted with permission, sensitivity and respect and we endorse and appreciate that the items in section 4.2 and 4.3 already address this.
We also endorse and appreciate the several explicit notations to “cultural” aspects to healthcare, even though it is not currently explicit in the WHO definition of health.
Finally, we note with concern the absence of a reference to individual “conscience” in the revised code of conduct. As our colleagues in the GMC note, medical practice according to conscience is important.10
In section 2 on ‘Professionalism’, item 2.1 ‘Professional values and qualities of doctors’ currently opens with:
While individual doctors have their own personal beliefs and values, there are certain professional values that underpin good medical practice.
This subsection goes on to cogently and appropriately emphasise the duty of doctors to maintain patient and community trust.
We suggest strengthening this subsection by including a paragraph regarding the doctor’s right to practice according to their conscience. We recommend similar phrasing to that provided by the GMC for UK doctors:10
The right of a doctor to practice according to their conscience is valued by the profession. You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients. This means you must not refuse to treat a particular patient or group of patients because of your personal beliefs or views about them. Also, you must not refuse to treat the health consequences of lifestyle choices to which you object because of your beliefs.
We thank you for your sincere consideration of our suggestions and recommendations for improvements to the revised code of conduct. Once again, we commend the work that you are doing on this important task. Please do not hesitate to contact us should you require any further information or clarification.
Dr Michael Burke,
MBBS, BSc, MA, MPH&TM, MSc (Clin Epi), PhD, DCH DRANZCOF, FRACGP, FACTM, FAICD General Practitioner, Blacktown, Western Sydney Conjoint Associate Professor, University of Western Sydney.
Dr Sneha Kirubakaran
BComp, BAppSc (Hons), BMBS, Grad Dip Clinical Education, FRACGP General Practitioner (Adelaide), Lecturer & PhD student (Flinders University).
Georgie Hoddle (RN)
Clinical Nurse Educator, Vice-President Nurses Christian Fellowship Australia
On behalf of the Saline Australia Network
1. Australian College of Nursing. (2014). Person-centred care: Position statement.
2. Haynes, A., Hilbers, J., Kivikko, J., & Ratnavyuha. (2007). Spirituality and religion in health care practice: A person-centred resource for staff at the Prince of Wales Hospital. SESIAHS, Sydney.
3. D’Souza, R. (2007). The importance of spirituality in medicine and its application to clinical practice. Medical Journal of Australia, 186(10), S57-S59.
4. Koenig, H. (2007). Religion, spirituality and medicine in Australia: Research and clinical practice. Medical Journal of Australia, 186(10), S45-S50.
5. Hassad, C. (2009). The role of spirituality in medicine. Australian Family Physician, 37(11), 955-957.
6. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
7. Chirico, F. (2016). Spiritual well-being in the 21st century: It’s time to review the current WHO’s health definition? Journal of Health and Social Sciences, 1(1), 11-16.
8. Dhar, N., Chaturvedi, S. K., Nandan, D. (2013). Spiritual health, the fourth dimension: A public health perspective. WHO South East Asia Journal of Public Health, 2(1), 3-5.
9. Larson, J. S. (1996). The World Health Organization’s definition of health: Social versus spiritual health. Social Indicators Research, 38(2), 181-192.
10. General Medical Council (UK). (2013). Personal beliefs and medical practice. Sourced from https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice on September 10th 2018.