In August 2018, Miranda Devine, a journalist, let the world know that proposed changes had been made to the Australian doctors code of good medical practice. We discovered that submissions were called for but were closing in just a few days. Changes that were being proposed intended to even more thoroughly clamp down and limit freedom the doctors have as ordinary people to express in public. Interestingly, most doctors were not aware of the proposed changes that were being made.
Here follows the letter that I wrote to them in response to their call for general comments:
Dear Medical Board,
I’m writing in response to the proposed changes to the medical code of good medical practice. I am the first person to stand up and say that we need a code of good medical practice, one that equally supports us as doctors and people as patients.
I regret to say that the current code of good medical practice does not perform such a function in its existing role, nor its revised form and in fact the revised form raises even further concerns regarding the protection of the fundamental human rights that all doctors as people ought to have honoured. It is our duty as a profession to take care of the people in the profession and people who seek the support of the profession equally so, as whilst we consider people disparate and separate then we are not supporting the health and well-being of the all, and this is patently seen in the statistics of ill health and misery that affect the medical profession. We as doctors who know about the association of cause and effect and environmental medicine scientifically know that there is no such thing as truly random. We all know there are occupational hazards related to poor working conditions which include the entire systems that people work in. Doctors, too, as people are affected by the systems they work in and their ill health reflects the poor health of the systems they are in.
The Code of Good Medical Practice reflects such a system as it is a foundation by which doctors are investigated and prosecuted.
It is unclear as to what the rules are, and doctors are expected to guess what they are. This is incredible stressful.
There are no easily spelled out ‘crimes’ but people can be brought before tribunals and sanctioned and sentenced after lengthy investigations for at times nebulous ‘crimes’.
I have particular concerns regarding the new section of ‘professionalism’ particularly where it impacts upon the right that doctors have as people to their freedom of speech.
It is a fundamental human right as stated in the Universal Declaration of Human Rights article 19 that all people have the right to freedom of speech. This does not mean the right to abuse, demean, denigrate or vilify another. This means, that all people have the right to express a truly held opinion and this is vital in discussion of things in health care.
There may be held notions that what doctors say can highly influence other people and thus their freedoms ought to be restricted. However, such notions are mistaken and misplaced and belong to a system of patriarchal medicine, a system that supposedly we are moving away from, and correctly so. If doctors were so influential with their words, all our patients would give up alcohol and smoking straight away, stop eating junk food and exercise regularly. With just one look or a few words. If doctors were so influential people would be queuing up to follow us on social media, hanging off our every word. However, as an expert rheumatologist I have under 1000 twitter followers whereas Kim Kardashian has 56.8 Million. As a doctor, no one appears to be swayed by my political opinions or my choice of fashion, whereas what Meghan Markle and Kate Middleton wear has people stampeding the shops to sell those items out immediately. In fact, I am so influential for my patients that NONE of them follow me on social media whereas I am certain many of them follow @IQUITSUGAR, and Married at First Sight and @realdonaldtrump.
It appears that people are quite capable of making up their own minds, and our own experience in the practice of medicine makes this patently clear.
Why then are there to be such stringent restrictions on the freedom of speech of doctors in violation of their own personal freedoms to express?
There may be some arguments that extend that doctors should only express opinions on health care and medicine that are ‘the generally held views’ of the profession as you have worded this section.
However, even IF such a position were able to be adequately defined and not open to gross misinterpretation of those who appear to be sitting on the tribunal of the day it is also a clear violation of the fundamental human right of freedom of speech.
Fundamental human rights are exactly that: fundamental and universal and never under any circumstance are they to be removed modified or codified simply because one has a ‘degree’. Even if it is a medical degree.
This fundamental human right is there in order to ensure that public debate can occur openly and not in restricted fashion.
Such measures as you are introducing in the section of professionalism do nothing to affirm the human rights of all doctors, treats them as less than other members of the public because ‘they are in a position of privilege’ and puts them and the future of health care at risk.
Were we to have had such stringent conditions on freedom of speech, we would not have many developments in medicine.
We would not have the diagnosis of Coeliac disease, which was discovered on observational basis during rationing in the second world war. We most certainly would not have the discovery of H Pylori as a cause of stomach ulcers which contravened the ‘generally held view’ of the profession that stomach ulcers were caused by stress. Barry Marshall was nearly drummed out of town and certainly would have had his medical licence removed were the current section of professionalism in place and we would not have the revolutionised medicine we have today.
Doctors are not there to repeat the mantras of the day. They are trained to be intelligent, to interpret, to observe and continuously learn. Doctors learn much in their clinical practices in addition to the scientific literature and need to be free to express their experiences and learnings without fear of having their medical licence removed. Even IF they are wrong, it still enables and allows free debate and discussion as to what the truth is. As we can see, people are not stupid, they are very intelligent and informed and well able to make decisions for themselves. To consider otherwise is to subscribe to the same model of patriarchal medicine that we say that we are moving away from with ‘patient centred care’. Surely the board would not wish to reflect a hypocrisy in this regard?
Key facets of professionalism are as follows:
- Live with dignity and decency
- Take care of your health and well-being
- Dress with dignity and decency, in accordance with your own style
- Do not drink alcohol or do recreational drugs
- Be healthier than your patients. Be the living example of health and health care
- Do not practice when ill
- Take care of your mental health
- Contribute to the development of the profession and health care
Health and well-being of doctors is something that is paramount and of key concern with a plethora of studies exposing how ill we are, in fact with our mental health worse than that of the general public.
How do we expect their mental health to be good if their fundamental human rights are being daily violated, in ‘the name of good’?
Human rights violations are a public health matter and such driven notions as restricting freedom of speech contribute to the ill health of the profession.
Further things that contribute to ill health of the profession are the dual standards by which doctors are held.
Patients and the ‘public’ are allowed to say whatever they like online about doctors. Even if it isn’t true. The board takes no efforts to protect doctors. However, doctors are not allowed to do anything to defend themselves and their reputation, because they are not allowed to use testimonials and anything written that is good is seen as a possible testimonial. Do you appreciate the stress that doctors are under with the standard that anyone can say whatever they like with no accountability and they can’t even get those people who know the quality of who they are and how they practice to write about them to counter the lies and the complaints?
I personally have been cyber-abused and harassed online by a woman who does not know me for the last 6 years. She has written lies about my religious beliefs, my health care practices and my practice of evidence-based medicine. There is NOTHING in the code of good medical practice that allows me to take care of myself. NOTHING that holds her accountable for her utter lies. NOTHING.
I, like many doctors, have also had fake anonymous reviews written about me online, by a person who appears to be a competitor of mine, not a patient. There is NOTHING that holds them accountable for their action, and NOTHING that I can do within the realms and remits of the code of good medical practice to undo the lies and hold that person accountable. Nothing I can do to get the truth of myself out there on so called ‘review’ sites. Even IF something is written by an actual patient, we cannot ever address things online appropriately due to ‘doctor-patient confidentiality’. I and other doctors are utterly vulnerable with the remits of the current code of good medical practice and in fact, made further vulnerable by your proposed revisions to further limit my freedom of speech as an ordinary human being and hold me potentially in contempt of the profession if I raise matters of concern regarding medicine and how the profession is regulated in the public eye. This is frankly unacceptable. Something must be done to address the inequity.
All of these factors and these situations are placing doctors at risk of abuse and its attendant consequences on a daily basis.
All of these factors are ensuring that truth about doctors cannot be told.
All of these factors are ensuring that free and open discussions that need to be had cannot be had, and this is restricting the development of medicine.
I support an excellent code of good medical practice, but a good code of good medical practice supports its doctors to develop and takes care of them as human beings. This code simply exhorts doctors to adhere to standards of perfection that simply do not exist, and contains rules that can be interpreted as desired in order to bring about a ‘prosecution’.
I would welcome the opportunity to consult with you on the development of an excellent code of good medical practice that would ensure and support the delivery of the best possible health care possible.
I would base such a code on the following:
- Live your life with integrity in all areas at all times. There is no difference between personal and professional life.
- Avoid alcohol and stimulant drugs and recreational drugs, after all our profession is about health
- Avoid pornography
- Take care of your health and well-being, seek regular support as required
- Take care of your mental health and well-being
- Relate to your patients as equals and treat yourself as such
- Keep up to date with latest developments in your profession
- Participate in public discussion about health care
- Advocate for the health and well-being of patients and members of your professional equally so
Rather than exhorting doctors to be perfect, we need to support them in their development as life is about developing, learning and growing.
The current system of punishment, and publicly so, and investigations for ‘tweets’ makes a mockery of our code of good medical practice, and this great profession. There are many things that ought to concern the medical board, such as truly negligent practice. Doctors having political and social opinions or otherwise are not one of those big matters.
I exhort the board to consider the impact of restricted freedoms on the health and well-being of doctors and how such stress comes from violation of fundamental human rights as currently proposed by the board in this current revised code of good medical practice.
Let’s have an excellent code of good medical practice, one that supports doctors to be truly free and protected by the board from abuse by others, including the board.
Dr Maxine Szramka
MBBS Hons 1 B Med Sc FRACP
Dr Maxine Szramka is a Rheumatologist in Sydney active in professional affairs, advocating for the health and well-being of the medical profession and for health care reform.