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March 2018, Volume 68, Issue 3

Editorial

Professional courtesy: End of an era in Pakistan?

Syed Muhammad Mubeen  ( Hamdard University )
Masood Ali Shaikh  ( Independent Consultant, Karachi. )

Professional courtesy is usually defined as providing either free or discounted services to fellow physicians and their families. It has roots going back to the Hippocratic Oath written in the late fifth century BC.1,2 When it comes to dealing with fellow physicians, this oath has two provisions about money.2 Firstly, physicians were obligated to teach medicine to the sons of their teachers "without fee", and secondly not to infringe on the territory of fellow physicians i.e. "I will not use the knife, not even on sufferers from stone, but will withdraw in favour of such men who are engaged in the work". Since the time of Hippocrates, professional courtesy standards for practicing physicians have been improvised, codified, and even adopted by medical associations. In 1803, Thomas Percival, under the title of \\\'Medical Ethics\\\', published "Code of Institutes and Precepts — Adapted to the Professional Conduct of Physicians and Surgeons"1,3 that approved of, and required the practice of professional courtesy. Further influenced by Percival\\\'s code, the American Medical Association in its very first code of ethics published in 1847, deemed professional courtesy as an ethical obligation for its members.1,4 In 1948, the World Medical Association adopted a physician\\\'s oath called the \\\'Declaration of Geneva\\\'; with the declaration reading "My colleagues will be my brothers"! This statement — reflecting the sexist language of the times — was subsequently revised to read as "My colleagues will be my sisters and brothers".5
As early as 1993, a nationally representative survey of physicians in the United States reported that 96% extended professional courtesy to other physicians and their family members by either altogether waiving or reducing their fee.1 Against this backdrop of professional courtesy values and ethos going back to antiquity;
voices of dissent began to appear more vociferously in the last decade of twentieth century. In an accompanying editorial to 1993 article, professional courtesy was painted as an unjustifiable attempt on the part of physicians to insulate themselves from rising healthcare costs.6 Increasingly, the ethics, legality, and fading of professional courtesy was questioned and lamented in the United States.7-9 For the past several years now, offering professional courtesy is deemed illegal in the United States.10
In Pakistan, most people visit private healthcare providers when they get sick or injured.11 Although no nationally representative studies have been done in Pakistan, but when we physicians get sick; most of us prefer to go to private clinics of physicians, rather than going to the public hospitals to seek healthcare. Increasingly, over the course of the past decade — based on our own experiences and in sharing and discussing of these experiences with our physician colleagues across the country — a new trend appears to have congealed in the country. Professional courtesy, once commonplace and deemed almost scared among physicians, is now only being offered by literally a dying and die hard breed of old school physicians; who take pride in extending this courtesy to their fellow physicians. Newly minted consultant physicians in Pakistan i.e. those who have earned their postgraduate qualifications in the past five to ten years, seem to consider the professional courtesy practice anachronistic and even archaic. They expect their regular consultation fee to be paid in full, when treating fellow physicians. This sometimes results in awkward and/or unpleasant situation for both patient physician and treating physician, when they have divergent expectations concerning professional courtesy.
How prevalent is the practice — or lack thereof — of professional courtesy, and what are its correlates? Are practitioners of any particular specialty more or less likely than others to refrain from extending professional courtesy? Are there any differences between general practitioners versus consultants? We did not come across any studies from Pakistan addressing these issues, and underline the need to study professional courtesy practices in the country.
The nexus of economics and pragmatism necessitates revisiting professional courtesy as an age-old practice in our part of the world. Although Indian Medical Council clearly specify gratuitous services to all physicians and their immediate family members.12 the Pakistan Medical and Dental Council\\\'s \\\'Code of Ethics\\\' is silent on this issue and does not even mention professional courtesy.13 The Pakistan Medical Association, and other professional medical associations need to raise the voice on professional courtesy in the country to either formally certify its death or breathe new life into it.

References

1. Levy MA, Arnold RM, Fine MJ, Kapoor WN.Professional courtesy--current practices and attitudes.N Engl J Med. 1993; 329:1627-31.
2. Hippocratic Oath. [Online] [Cited 2016 Dec 20]. Available from: URL:
https://en.wikipedia.org/wiki/Hippocratic_Oath
3. Thomas Percival. [Online] [Cited 2014 Sep 02]. Available from: URL: 
https://en.wikipedia.org/wiki/Thomas_Percival .
4. History of AMA Ethics.[Online] [Cited 2015 July 15]. Available from: URL:
http://www.ama-assn.org/ama/pub/about-ama/our-history/history-ama-ethics.page?
5. Declaration of Geneva. [Online] [Cited 2016 Sep 02]. Available from: URL: https://en.wikipedia.org/wiki/Declaration_of_Geneva.
6. Steinbrook R. Rethinking professional courtesy. N Engl J Med. 1993; 329:1652-3.
7. Miller JB. Physicians, the law and professional courtesy. Online] [Cited 2012 Mar 10]. Available from: URL:
https://physiciansnews.com/2000/11/14/physicians-the-law-and-professional-courtesy/
8. Perl AF. Is professional courtesy dying? Can Med Assoc J. 1983; 128:13-56.
9. Buncic JR. Is professional courtesy disappearing? CMAJ. 1988; 139:82-7.
10. No Good Deed Goes Unpunished for Physicians Who Extend "Professional Courtesy" or Waive Co-pays: Medicare Prohibits Waiver of Co-pays and Deductibles. [Online] [Cited 2014 Feb 08]. Available from: URL:
http://www.thehealthlawfirm.com/blog/posts/no-good-deed-goes-unpunished-for-physicians-who-extend-professional-courtesy-or-waive-co-pays-medicare-prohibits-waiver-of-co-pays-and-deductibles.html.
11. Pakistan Medical Research Council. National Health Survey of Pakistan -  ealth profile of the people of Pakistan. Pakistan Medical Research Council, Islamabad: 1998.
12. Indian Medical Council. Professional Conduct, Etiquette and Ethics Regulations. 2002, New Delhi.
13. Code of Ethics - Pakistan Medical and Dental Council. [Online] [Cited 2011 Oct 05]. Available from: URL:
http://www.pmdc.org.pk/LinkClick.aspx?fileticket=v5WmQYMvhz4%3D&tabid=292&mid=845

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: