Full HTML 03 V1 I4

A study to determine the variables considered as most unethical by medical students in Goa


Pradeep SALGAONKAR, SILVEIRA Cedric Thomas*
Assistant Professor, Don Bosco College, Panaji, Goa 403001.India

Abstract

In order to find out from the medical students what they consider as most unethical and less unethical, I asked a sample of them to rank five variables in terms of most unethical to least unethical. The five variables were costly drugs, sponsorships, gifts, Government doctors doing private practice and overprescribing.  The Thurstone Case V scaling technique was used to find out which variable was most unethical and which was least unethical.

Of the five accepting gifts was considered as most unethical, because a gift can range from a simple innocent pen to an expensive car in certain cases. The second variable to be ranked as most unethical was overprescribing which is detrimental to a patient in terms of monetary cost and also in terms of adverse or side effects on account of consuming so many drugs. The Chi square technique was also used wherein the Null hypothesis stated that there was no statistical difference in considering prescribing expensive drugs as most unethical or least unethical.

Key words: Unethical, overprescribing, sponsorships, gifts, private practice.

Introduction

Medical student’s views about ethics in their practice- What Doctors consider unethical.

The Medical profession is getting to be more and more like any other business profession. This stems from the fact that medical students have to pay a lot of money as fess, especially if the college is not aided by the Government. In an attempt to recover the money spent on education, young doctors tend to indulge in malpractices which result in not practicing the ethics and values of the noble profession. Doctors indulging in unethical practices were considered taboo early. In fact a doctor was considered almost to be like a God. In many villages doctors are still revered and considered to be magicians or demi-gods. There have been instances where in a doctor has brought back a person to life, when he was almost considered to be dead.

In reality today, one finds doctors misusing their powers to a large extent. The healer of the sick is not really doing justice to his profession.  Thinking it to be interesting as to how a student of medicine looks at his /her profession in terms of ethical practices, the study was conducted.

Five general aspects were considered, namely, overprescribing, sponsorships, gifts, government doctors indulging in private practice and prescribing expensive drugs. Abortions and the like were not considered because then it dwells with a particular specialization, and does not conform to general issues.

These aspects were taken because many a time;

1) Doctors may overprescribe. It is not rare to see a doctor prescribing unnecessary drugs in order to cover up the cost of any favour that the manufacturing company may have done to the doctor. Prescriptions have been found with even 3 vitamin B complex brands, when only one would suffice. Apart from being costly to the patient, it may also be undesirable.

2) Sponsorships is also considered because many a time doctors are given sponsorships to attend conferences, along with accommodation, registration and a car to travel. These results in a doctor then feeling obliged to pay back the manufacturing company.

3) Gifts are an important aspect of many companies. They indulge in gifting doctors not only small gifts like a dinner set or clock to expensive gifts ranging from cars, Ac’s and televisions. All this costs money, and to pay back the doctor will prescribe the brand of the company who has gifted him.

4) Government doctors indulging in private practice is something which goes on unabated. Doctors are even known not to attend to a patient in an official practice only to see the patient in his private practice and extract money from him. Many doctors in government practice have even private hospitals run under the name of their relatives or friends.

5) Prescribing expensive drugs is by nature not the attitude of most doctors, but if a doctor prescribes costly drugs when cheaper brands are available then he/she is surely indulging in unethical practices. Doctors at times go by company image, and if the company has a good image then the doctor may think of prescribing brands of that company. Reputed companies usually have expensive brands.

The medical students were made to rank the following five criteria with 5 – least unethical to 1 – very unethical. Around 100 medical students were selected for the study.        

Literature Review

Wishing to learn what the medical students consider unethical the review was conducted. According to Sanjoy and Bansal(2005), medicine being a noble profession , one should not indulge in financial gains. However the above two authors  found from the medical students  that globally medical practitioners in conjunction with pharmaceutical companies are prescribing and thereby promoting unnecessary drugs just for the sake of monetary gains. This article has no statistical data to support the study.

Similarly Dana and Loewenstein ( 2003) feel that  medical students find a conflict of interest exists when gifts are accepted by doctors . According to the study conducted by Dana et al, “When physicians are remunerated for performing specific tests and procedures, they face a conflict of interest when they also recommend those same tests and procedures. When they are paid for referrals to clinical trials, physicians are in the conflicted position”(pg 252-255) Here too the data has no statistics to support the study.

Importance of the study:

The study is important because it helps us to understand what a doctors considers ethical and unethical, and no real statistically validated study is available.

Statement of the problem:

Today’s generation of doctors are indulging in various unethical practices which is a cause of concern. They are not doing service to the sick in the true sense in many cases.

Objectives

  1. To find out what a doctor considers most unethical
  2. To find out what a doctor considers least unethical.
  3. To find out if a statistical significance exists in ethics while prescribing costly drugs.

Research Design

A random, direct, structured questionnaire was utilized wherein a personal interview was conducted on 100 medical students across Goa. The research design was of an exploratory design. The students were made to rank the 5 variables from 1-5 with 1 being the most unethical and 5 being least unethical.

Research Methodology

1. The chi square hypothesis is used when the data consists of counts or frequencies with which each category of tabulation or cross tabulation occurs. The chi square hypothesis was made use of in analyzing whether with those doctors who consider overprescribing as unethical, if in those doctors the number of doctors who consider prescription of costly drugs as more unethical or less unethical were statistically different. The Null hypothesis states that no relation exists between two variables A& B. ( Of the students who say overprescribing was unethical( ie it lies in 1,2 or 3), which is 75% , the number of students  in that who consider  the prescription of costly drugs as more unethical  was nil and less unethical was 100% .

Formula:  f1    F1        (f1-F1)             (f1-F1)2/50

A

B

Where A & B are the variables, f1 is the observed frequency, F1 is the theoretical frequency, and (f1-F1)2/50 is the final result. The final result of both A and B are added together to arrive at the calculated chi sq value. If the calculated chi sq is less than the tabular chi sq at (k-1) degrees of freedom where K stands for number of variables and at 95% confidence level, then the null hypothesis is said to be true. If the tabular chi sq is 3.68, then the Null hypothesis is false and a statistical difference exists in terms of ethics while prescribing costly drugs. That is most doctors feel that prescribing costly drugs is less unethical.

2. Thurstone Case V scaling permits the construction of a unidimensional interval scale using responses from variability data collection procedures, such as paired comparisons. I this case the scale is developed from comparative judgments. The Thurstone Cae V scale was used whereby the 5 variables are compared with one another. These values are then divided by the sample size and the fractions are then read on a table. The lowest value is then added or subtracted to itself to make the lowest value zero and this value is added to the other variables. The resulting values are potted on a one dimensional scale.

Findings and Analysis:

  1. The Thurstone Case V Scaling was used to analyze the data. The comparison between the variables was first made wherein the variables A, B,C, D, and E were compared with each other. A-Costly drugs, B –Sponsorships, C- Gifts, D- Government doctors practicing and E-Overprescribing.

1 represents most unethical and 5 least unethical

Table 1: comparison between the variables 

A B C D E
A 0.5 90/100 90/100 15/100 75/100
B 10/100 0.5 90/100 25/100 70/100
C 10/100 10/100 0.5 15/100 65/100
D 85/100 75/100 85/100 0.5 70/100
E 25/100 30/100 35/100 30/100 0.5

Table 2: Converting to decimals 

A B C D E
A 0.5 0.9 0.9 0.15 0.75
B 0.1 0.5 0.9 0.25 0.7
C 0.1 0.1 0.5 0.15 0.65
D 0.85 0.75 0.85 0.5 0.7
E 0.25 0.3 0.35 0.3 0.5

Table 3: Finding the values from the Thurstone Case V scaling table 

A B C D E
A 0 1.28 1.28 -1.04 0.68
B -1.28 0 1.28 -0.67 0.53
C -1.28 -1.28 0 -1.04 0.39
D 1.04 0.65 1.04 0 0.53
E -0.68 -0.53 -0.39 -0.53 0

Table 4: Adding the values of each variable            

A B C D E
-2.2 -0.15 3.21 -3.28 2.13

Table 5: Adding the least value which is 3.28 to all the variables 

A B C D E
1.08 3.13 6.49 0 5.41

If A-costly drugs, B –sponsorships, C- Gifts, D- Govt. doctors practicing and E-Overprescribing, We get a unidimensional scale with D at the bottom followed by A, B, E and C.

2. Chi square test: 

Table 1: Chi square test

Formula f1 F1 (f1-F1) (f1-F1)2/50
A 0 50 -50 50
B 100 50 50 50
        100

Where A & B are the variables, f1 is the observed frequency, F1 is the theoretical frequency, and (f1-F1)2/50 is the final result If the calculated chi sq is less than the tabular chi sq at (k-1) degrees of freedom where K stands for number of variables and at 95% confidence level, then the null hypothesis is said to be true .

As the tabular chi sq is 3.68, and the calculated chi-square is 100, the Null hypothesis is false and a statistical difference exists in terms of ethics while prescribing costly drugs. That is most doctors feel that prescribing costly drugs is less unethical.

Conclusions 

The conclusions which can be drawn are that Government doctors doing private practice is considered the least unethical, perhaps because they feel that if a patient comes to your door you should not refuse him treatment. Prescribing costly drugs is also considered relatively unethical, especially if the drug is going to benefit the patient. Sponsorships are considered part and parcel of life and hence it is ranked third in importance.

Overprescribing is ranked second because the students feel that it is exploitation of the patient. Finally gifts are ranked 1 because the students feel that gifts could range from costing a lot of money to not so much. However a gift is a gist and can be associated with a bribe. As a result it is ranked the most unethical. A statistical difference exists in ethics while prescribing costly drugs. That is most doctors consider prescribing costly drugs as less unethical.

Limitations

  1. The study was conducted on only 100 medical students Goa
  2. Bias may have been present in answering the questions on account of not wishing to disclose information.

Suggestions:

A year later a study can once again be undertaken and the unethical factors could be checked for any change.

References

  • Dana, J., Loewenstein, G. (2003) A social science perspective on gifts to physicians from industry.JAMA,290(2), 252-255,doi: 10.1001/jama290.2.252
  • Donald cooper, Pamela S. (2006), “ Business Research Methods” , N.Delhi: Tata Mc Graw Hill,
  • Maxwell, A.E. (1961). “Analyzing Qualitative data”. New York: John Wiley & Sons, Inc
  • Mosteller ,   A test for significance for paired comparison when equal standard deviations and equal correlations are assumed. Psychometrika , 1959;16:207-08
  • Paul E Green, Donald S Tull, (1990), “ Research for Marketing Decisions”, N.Delhi: Prentice Hall Int, INC
  • RK, B., & Sanjoy,D., Unethical relationship between doctors and drugs companies. Journal of Indian Academy of Forensic Medicine, 2005;27:(1),40-42