Number of Citations: 0

Submitted: 16 April 2020
Accepted: 21 July 2020
Published online: 5 January, TAPS 2021, 6(1), 119-121
https://doi.org/10.29060/TAPS.2021-6-1/PV2250

Annushkha Sharanya Sinnathamby

Department of Paediatrics, Khoo Teck Puat National University Children’s Medical Institute, National University Hospital, Singapore

I. INTRODUCTION

“To have striven, to have made the effort, to have been true to certain ideals – this alone is worth the struggle.”

William Osler

The word “values” is heard frequently in healthcare. From the moment we step into medical school, we are challenged to reflect what our intrinsic values are, or how we can “add value” to a department during the residency application.

With time, and in going through the system, our definitions of the word “values” may change. To me, values are those things which are right and wrong, and which are important in life. In other words, values include not only what is important to my profession and to being a good doctor, but also to what is important to being a good person.

The philosopher Alasdair MacIntyre argues that one should reflect on the following three questions at the heart of moral thinking (Hinchman, 1989):

• Who am I?
• Who ought I to become?
• How ought I to get there?

In the context of understanding our values in healthcare, I wondered if the above can be translated into:

• What are my values?
• Which values should we value?
• How should we value those values?

In this article, I aim to touch on some of my view on values in the healthcare system, from the perspective of a junior doctor.

II. ARE OUR VALUES MISPLACED?

How often do we really ask ourselves what is important, what is good, or what is morally correct?

I asked a few junior doctors what values they think are important to being a good doctor. For some, the first response was classical, including “perseverance”, “compassion”, and “integrity”. However, the first thought of many others was not to be a kind or compassionate doctor, but an efficient or skilful one. I quote some of them verbatim:

“If my seniors don’t have to do anything, because I’ve done it all, then I’ve done my job.”

“No matter how much we value empathy and respect… I feel this doesn’t matter unless you have the competency to treat your patients.”

These doctors are far from unkind, dishonest, or cold. In fact, I know them personally to be some of the most good-hearted residents at work. Despite this, “typical” values such as kindness or integrity are not values which they instinctively identify with.

It is important to distinguish that being a “good” doctor may have more than one definition. “Good” as an adjective can mean being skilled and competent; on the other hand, it also means being morally upright, kind, and compassionate. Of course, it should be no argument that every doctor should be all of the above. Yet, I fear that we may be so increasingly fixated on the former, that we begin to lose sight of the latter.

As a case in point, I challenged some of our contemporaries to see how strongly they held on to an arguably core value—integrity. This value is often tested in a common daily scenario for our junior doctors: bargaining for a scan from our Radiology colleagues, where questionable tactics are sometimes employed to ensure a slot.

I asked every junior doctor working in the department two simple questions:

1) If they had ever lied to get a scan

2) If they had ever augmented the truth to get a scan

I had assumed that not a single doctor would have outright lied to get a scan, but 7.1% admitted to having done so. Furthermore, 67.9% said they would augment the truth to get a scan. This implies that there is a spectrum from an exaggeration to an outright falsehood.

When asked to elaborate on the above question, many retrospectively regretted embellishing the truth. A senior medical officer described in detail his experience lying for a particular peripherally inserted central catheter as a house officer. Even after 4 years, he could cite shame at lying to a radiologist who could almost certainly see through the lie, and perhaps depriving another patient who needed the scan more of a slot.

Ultimately, I think this boils down to our personal yardstick of our own integrity, and how willing each of us is to allow ends to justify means. Though the change of phrasing in the question I asked led to a big change in statistics, this does not change the fact that for some doctors, “augmenting the truth” strays dangerously far from what the truth really is. 

Perhaps, it is then relevant to examine what would make a junior doctor re-order their priorities, and inadvertently compromise their own core values. In an increasingly busy environment, one reason we may lose sight of our core values is burnout. Studies in Singapore have described that between 55.1%-80.7% of residents reported burnout in some form, higher than their US counterparts (Lee, Loh, Sng, Tung, & Yeo, 2018; See et al., 2016). Furthermore, it was postulated that there was a negative correlation between burnout and empathy levels, and that overnight calls and low degrees of respect from colleagues were associated with increased stress levels. Burnout and emotional fatigue may cause us to erroneously weigh our values, and this could be why some junior doctors prioritise efficiency, meticulousness, or even keeping their seniors happy, to the extent of losing sight of their core values.

III. WHAT VALUES SHOULD WE VALUE?

It is no secret that a career in medicine is highly competitive. At every stage of training, medical student’s face a barrage of rigorous series of assessments that continue on into their professional careers. Therefore, it is important to examine the criteria we use to measure our doctors. Grading systems increasingly put emphasis on the softer side of medicine such as compassion and integrity, but more can be done to help our doctors value themselves and their own values more.

I recently filled up a typical grading form for my house officer. For 22 questions about his daily work, there was only one about his values and professionalism. It was a shame, as I strongly believe that an emphasis on our values should be a learning outcome, even if it is not a graded criterion. I was once taught that a patient may never remember your management, but will always remember your kindness—words that resonate with me even today.

On an institutional level, it is also important to have an emphasis on values. The institution I work in advocates the TRICEPS core values, a catchy acronym for Teamwork, Respect, Integrity, Compassion, Excellence, and Patient-Centeredness. While these values were probably established as a guideline to attract like-minded individuals to the institution, I also think these are a good set of values to emulate.

IV. HOW SHOULD WE VALUE OUR VALUES?

A system is only as great as its people. It is difficult to change a huge system, but it is easy to start the change from within ourselves, and those around us. It is also beneficial to ensure junior doctors are mindful of their values. In our daily practice, this means empowering them to self-reflect.

A simple way I do this is to ensure that after every night call, I debrief each member of my on-call team to highlight things I noticed they did well. I try not to focus solely on their medical decisions, but also the small things: staying beyond hours just to let a teenage patient with a chronic condition sleep in before blood taking, sitting with an anxious parent, or sacrificing rest time to offer moral support to a colleague doing a difficult procedure. My hope in doing this is to allow junior doctors to recognise good traits in themselves, so that they can further nurture them along their journey of medicine, and in turn inspire the people around them.

My second suggestion is for each of us to take a minute to remember what values brought us into medicine in the first place. For me, when I am at my most fatigued, feel most apathetic, or when something had gone wrong at work, I read the personal statement I wrote for my medical school application more than 10 years ago, and try to remember that inside me, my core values are still the same as the overly enthusiastic teenager who wrote them—though perhaps more mature, and hopefully slightly wiser too.

After all, it is only if we are certain of what we value, that we can inspire and encourage those around us to value their values too.

Note on Contributor

Annushkha is a Paediatrics Senior Resident. She has an interest in medical education, and is currently in the National University Health System’s Medical Education Residency Programme. She conceptualised and gathered information and drafted the initial manuscript, critically reviewed the manuscript for important intellectual content and revised the manuscript.

Acknowledgements

The author would like to thank A/Prof Marion Aw and A/Prof Quah Thuan Chong for providing her with inspiration and guidance in writing this article.

Funding

There was no funding involved in writing this article.

Declaration of Interest

The author declares no conflicts of interest, including financial, consultant and institutional relationships that might lead to bias or a conflict of interest.

References

Hinchman, L. P. (1989). Virtue or Autonomy: Alasdair MacIntyre’s Critique of Liberal Individualism. Polity, 21(4), 635-654.

Lee, P. T.,Loh, J., Sng, G., Tung, J., & Yeo, K. K. (2018). Empathy and burnout: A study on residents from a Singapore institution. Singapore Medical Journal, 59(1), 50-54.

See, K. C., Lim, T. K., Kua, E. H., Phua, J., Chua, G. S., & Ho, K. Y. (2016). Stress and burnout among physicians: Prevalence and risk factors in a Singaporean internal medicine programme. Annals, Academy of Medicine, Singapore, 45(10), 471-474.

*Annushkha Sharanya Sinnathamby
Address: 1E Kent Ridge Rd,
National University Health System,
Singapore 119228
Email: annushkha_sharanya_sinnathamby@nuhs.edu.sg