Mind-set of Recent Medical Graduates: A Channel for Teaching Medical Ethics and Professionalism in Bangladesh

Background: The medical ethics and professionalism teaching have an influence on knowledge, attitude and skills of physicians. The scope of learning medical ethics and professionalism is limited in Curriculum for Medical Education in Bangladesh. There is an unhealthy situation in physician-patient relationship as a consequence of this limitation. Objectives: This study was aimed to assess attitude of recent medical graduates towards medical ethics and professionalism. The findings of this study might be helpful to strengthen medical ethics and professionalism in the medical education. Methods: This descriptive study was conducted on recent medical graduates of seven medical colleges under four universities in Bangladesh from January 2018 to June 2019. Data were collected using a pretested self administered semi-structured questionnaire, based on attitude measuring scale regarding medical ethics and professionalism. Results: Attitude scores of 308 recent medical graduates were in ethical conduct, autonomy, information of wrong doing during treatment, confidentiality, informed consent, sharing the condition of patient to close relatives, paternalism, treating of violent patient, abortion, euthanasia, religious beliefs influencing the choice of treatment, physician-patient relationship, informed decision making, continued medical education and role of pharmaceutical representative were assessed. The average scores were ranging from 2.1 to 4.2; with maximum clustering around score ‘3’ or “not sure”. Majority of the study population thought that the current standard of ethics practice was lower than expectation (59.1%) and should give more attention (76.6%) than the present. Furthermore, most of them (85.4%) felt a need for a separate module on medical ethics and professionalism in undergraduate medical curriculum. Conclusion: The recent medical graduates showed a positive attitude towards medical ethics and professionalism. So, a favourable environment was observed for learning medical ethics and professionalism. Thus, to strengthening of medical ethics and professionalism in medical education curricula is suggested .


Introduction
The behaviour of physicians depends on the developing attitude of future physician towards patient and medical ethics and professionalism during medical education; and their practice depends on how their mind is being set towards medical ethics and professionalism. Teaching medical ethics and professionalism enhance the competency on this topic. The recent medical graduates practiced it, if it was well-known to them. Until recently, medical ethics has not been addressed appropriately in medical education curricula in Bangladesh. 1 As a result, there are many complaints against the medical practitioners such as the practitioners do not attend their working place regularly, do not give adequate time to patients, misconduct and maltreatment. Scholars worried about malpractice, misconduct and commercialisation among medical practitioners in Bangladesh. 2 Most of Bangladeshi students (83%) did not answer the open-ended questions related to professionalism due to unawareness of the students about professionalism. To produce competent medical practitioner medical professionalism should be included in the undergraduate medical curriculum formally. 3 geo-political, religious and cultural background of a country region. 4 The first step to formulate medical ethics curriculum is to assess the existing knowledge and attitude of the medical graduates. Assessment recent medical graduates' views towards medical ethics and professionalism are important to develop necessary skills in clinical practice. This study offers some scope where efforts can be given to strengthen medical education. The proposal was submitted for ethical approval in academic council of Bangladesh University of Professionals (BUP). Permission was taken from Professor Seetharaman Hariharan for using their scale. After ethical approval, permission was taken from the Ethical Review Committee (ERC) of the selected medical colleges. Roster duty schedule was collected. The research work was explained and permission was sought from the recent medical graduates.

Results
The study included three hundred and eight recent medical graduates from seven medical colleges under four universities and 59.7% were government medical colleges. Majority of the recent medical graduates (53.2%) were male. The average age at commencement of internship of the recent medical graduates was 24.2±1.1 years. About half (51.6%) of the recent medical graduates realised the importance of ethical conduct and patient's autonomy. The medical practitioners prefer paternalistic attitude in our country. So, there was a limited scope for perceive autonomy in Bangladesh. Majority of the recent medical graduates had positive attitude regarding informing wrong doing (69.8%), confidentiality (75.0%), the need of informed consent (64.9%) and paternalism (88.6%). However, 75.3% wanted to inform patient's condition to close relatives. Majority of the recent medical graduates opined against treating violent patients (52.6%), abortion (51.9%) and physician-assisted suicide (72.7%). Islam is the major religion in Bangladesh. The religion might influence the opinion of the recent medical graduates.
The proportion of the study subjects disagreed and agreed were almost equal (41.6% and 41.2%) concerning refusal to be treated on religious grounds.
Most of the respondents thought that physicians have greater responsibility (78.9%) in physician-patient relationship, should allow adequate time (88.6%) and should engage in Continued Medical Education (74.7%).
More than one-third of the study population (43.8%) thought that the influence of pharmaceutical companies on physicians' prescription was not acceptable (figure 1). medical graduates opined that they had no interest in practice ethics and (figure 3).
The mean attitude score of different statements was ranging from 2.1 to 4.2 with maximum aggregation around '3' or "not sure" (figure 2).  The respondents did not express their attitude as confidently as expected. This might reflect lack of adequate knowledge regarding medical ethics and professionalism. More than half of the recent medical graduates (54.2%) opined that they always practiced ethics, still, more than one-third (39.6%) thought that they could not practice ethics all the time. Only, 4.9% respondents were non response and 1.3% recent

Discussions
The current study was conducted on recent medical graduates as they were freshly passed and just enter into professional life. There were three hundred and eight recent medical graduates included in this study from four universities in Bangladesh.    Majority of the recent medical graduates (75.0%, 65.0% and 75.3%) understood the importance of confidentiality, informed consent and informing close relatives about a patient's condition respectively. Patients share all information with physician and rely. This trust is keeping by maintaining the confidentiality of the information of patients. Confidentiality is important for maintaining patient's autonomy and nonmaleficent. Again, physicians need informed consent from patients. Patients do not understand the terminology and informed consent is required to make the terminology and risks clear to the patients. 7 Communication between physician and patient's relatives build the trust on physician. Patient's relatives expect that physician would explain the diagnosis and consequences. However, communication in improper way may cause depression and anxiety among the relatives and for this training on communication might be included. 8 Most of the recent medical graduates (88.6%) of the current study had a clear concept regarding paternalistic attitude concerning treating children without the consent of guardians except in emergency governed by law.
More than half of recent medical graduates of this study (52.6%) agreed, 31.8% disagreed and 15.6% were not sure regarding refuse to treat violent patients. However, physicians should realise the patient's psychology and attitude; and to be more professional whatever the behavior and attitude patients showed. 9 The de-escalation and violence prevention training should be incorporated into the curriculum. 10 More than half of the recent medical graduates (51.9% and 72.7%) opined against abortion and physician assisted suicide. This might be due to reciting the Hippocratic Oath prior to internship and the principles of medical ethics, beneficence. Religious belief may play an important role on expression against these statements. However, Crocker said about a decade ago in favour of euthanasia that it ends the patients' intractable sufferings. 11 The recent medical graduates were in a dilemma (disagreed 41.6% and agreed 41.2% with 17.4% not sure) regarding refusal of treatment on the basis of religious beliefs and values. The physician must tell to find another physician with their beliefs. 12 Most of the recent medical graduates (78.9% and 88.6%) believed that they had greater responsibility than the patients in physician-patients relationship and allow adequate time. This is a subjective relationship and built on trust. Communication may be verbal and non-verbal. Attitude of physician during communication with patient is important in establishing physician-patients relationship. About three-quarter of the recent medical graduates (74.7%) had positive attitude regarding continuing medical education, one of the principles of professionalism. About 44.0% recent medical graduates did not think that the influence of pharmaceutical companies on physicians' prescription was justified.
Mean attitude score of recent medical graduates: The average scores of maximum statements were around '3' or "not sure". So, the recent medical graduates might not express as confidently as expected.
Opinion regarding improvement: More than threequarter (76.6%) of recent medical graduates opined that teaching-learning "medical ethics and professionalism" should give more attention and 85.4% thought about a need of compulsory module on "medical ethics and professionalism" in current survey.
Most of the respondents of other studies thought that medical ethics should be taught formally (97.9%) and integrated in final year undergraduate MBBS curriculum. 12,13 The medical residents felt for more attention in curriculum and a need for a short course at the beginning of the residency training in Iran. 14 There is a limited scope for learning medical ethics and professionalism in the departments of Community Medicine and Forensic Medicine. So, 13.8% of grand total hour may be sufficient, but difficult to recapitulation for the recent medical graduates while they are entering into the professional life. 1 So, there must be a separate module on medical ethics and professionalism. Including this topic in the curriculum, especially in pre-internship training will increase the confidence of future physicians.

Conclusion
The recent medical graduates had a positive attitude towards medical ethics and professionalism. The recent medical graduates learnt medical ethics in year 3 (Phase II), so there is a chance to forget when the physicians enter into professional life after passing MBBS. So, to improve practice of medical ethics and professionalism, recapitulation of the knowledge by a short training course on "medical ethics and professionalism" in curriculum might be included. So, the knowledge, skills and practice of the physician will be boost up.