ALTRUISM & MEDICINE

Altruism and medicine

Authors: Laurence Wicks, Saqib Noor, Vaikunthan Rajaratnam
Publication date:  21 Jul 2011 BRITISH MEDICAL JOURNAL

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Laurence Wicks and colleagues conducted a snapshot survey of medical professionals’ thoughts and attitudesAltruism, the unselfish concern for the welfare of others, has been considered an inherent part of a doctor’s profession at least since the Hippocratic oath. Yet the idea of altruistic behaviour remaining at the heart of medical professionalism has often been questioned. As far back as 1895 the BMJ blamed senior doctors’ failure to properly train their apprentices on a workload with too little time for selfless acts such as teaching.[1]
More recently a BMJ article suggested that modern practice has led to a decline in altruism in medicine.[2] However, the understanding and encouragement of altruistic behaviour is vital in maintaining the public’s respect for the medical profession, and altruism is also a key dimension of a doctor’s work that helps prevent demoralisation and burnout.[2]
Since the turn of the millennium attempts have been made to redefine the core values of the medical profession. A set of characteristics or behaviours was outlined in 2000 in which altruism played a key part, with suggestions that physicians should subordinate their own interests to the interests of others.[3]
Furthermore in 2002 a group of international medical bodies drew up a charter of medical professionalism. Concerned that changes in healthcare delivery in the developed world threatened professionalism, they reinforced the centrality of altruism in the physician-patient relationship.[4] Three principles set out in the charter were the primacy of patients’ welfare, patient autonomy, and social justice. The charter describes the principle of primacy of patient welfare as “being based on a dedication to serving the interest of the patient.”
We were interested in current attitudes to altruism in medical education and clinical practice in the United Kingdom. We came to the topic with personal experience of altruistic practice in Africa and the Indian subcontinent.

Our survey

We used Google forms to design and electronically deliver a questionnaire to 254 recipients in various doctor and medical student mailing groups. These included staff members of the University Hospitals Birmingham NHS Foundation Trust, the Birmingham general practitioner training rotation, and Swansea University College of Medicine.
The questionnaire was designed to explore the perception and definition of altruism, its practice, and anticipated commitment. We also surveyed opinions on inclusion of altruism in medical school selection criteria and in curriculums.
Our response rate was 71% (180 people). Ten per cent of respondents were medical students, 29% were doctors in training, 56% were fully qualified practising clinicians, and 5% had other roles in the profession. Three quarters (79%) had a role in the education of doctors or medical students, and 74% said that they had used their medical expertise and experience in altruistic activity outside their normal working role.
Of those who reported that they had spent time participating in altruistic activity, 44% spent a total of between a day and a week in altruistic activity, 24% between a week and a month, 14% between a month and six months, and 18% more than six months.
Among those who gave time to altruistic activities, just under half of the altruistic behaviour was carried out abroad. Most participants (83%) said that they would be willing to commit a period of time each year towards organised altruistic work, with 40% willing to commit a week a year, 25% up to two weeks, 16% up to six weeks, and 6% up to six months; 19% were unable or unwilling to commit any time.
We provided several possible definitions of altruism, of which the most popular (54%) was, “To engage in any activity that will alleviate the suffering of needy patients.”
On a scale of 1 (strongly disagree) to 5 (strongly agree) to the statement “Altruism is the mark of a true professional” 89% of participants scored 3 or above, with a quarter strongly agreeing. As to whether evidence of altruism should be a mandatory selection criterion for medical school, 75% gave a score of 3 or higher. When asked whether attributes of altruism should be mandatory in the selection of doctors applying for postgraduate posts, 67% selected 3 or higher. Three quarters (78%) of participants gave a score of 3 or higher to the statement “Altruistic activities should be included in the curriculum of undergraduate and postgraduate education.”
If a major disaster occurred requiring medical support, 37% of responders said they would apply for special leave and, if leave was approved, would investigate the needs and arrange for resources before leaving their home country. A third (32%) would consider donating financially, 6% would “get the next flight out,” 14% would consider going if they knew others who were going, and 10% admitted that they “would not consider disrupting their routine.”
The survey results are encouraging—74% of respondents have been involved in some kind of altruistic behaviour outside their normal working practice, with nearly one in five respondents spending more than six months doing so. Furthermore 83% of doctors would dedicate a regular amount of time each year towards altruistic work.
It does not seem bold to suggest from these results that there is an enthusiasm and keenness among doctors to keep altruistic practice at the centre of their profession.
An exact definition of medical altruism is difficult. Most people would seem to recognise that it centres on the relief of suffering, but further defining when, where, and how doctors are or should be altruistic is not so straightforward. Also, most respondents believed that altruism is a key aspect of medical professionalism and that it should feature in the medical curriculum. How altruism can be included in education and assessment is not so obvious.

What is the future for altruism?

The benefits from the apparently selfless acts of individuals are far reaching. Doctors who act altruistically at work will find that staff members around them will also begin to behave differently, creating a positive and productive environment.[5] Furthermore, committing time to working in different countries and cultures adds to the skills that doctors can provide on return to their regular work setting.[6]
Altruistic behaviour cannot be artificially developed, but luckily it is within our nature as doctors to put the needs of others at the front of our thoughts. However, this desire to serve others must be encouraged to develop and mature as doctors progress through their career.[7] Sadly, inflexible training programmes in the UK may dampen a doctor’s enthusiasm for performing acts of good will.
Training programme syllabuses in the UK are designed to cover a wide range of competences so that, by the end of training, a doctor will have developed the skills needed in their specialty. These competences have traditionally focused on assessing the head (cognitive skills) and hand (psychomotor skills) but not the heart. If altruism is to be considered an inherent part of medical professionalism it should be assessed, with evidence required at annual appraisals of trainees and practising consultants.
In surgical training the focus of annual appraisals has led to a preoccupation with producing publications and achieving high numbers of procedures. Although these are important, they can lead to a large volume of poor quality literature, purely to boost an individual’s curriculum vitae, and to the production of trainees who are more interested in their own log book than the needs of the patient or indeed their colleagues. Could altruistic work be given due merit at annual appraisals? Although reward is not, in its very nature, sought through altruism, its recognition by training panels would show an understanding that it is an important marker that someone is developing into the kind of doctor that society needs.
The Royal College of Surgeons has recently restated its commitment to international links with the introduction of an international strategy, as outlined by John Getty, vice president of the college, in November.[8] It is encouraging that at a college level there is support for international voluntary work. Even if doctors are supported by a royal college, however, they will face many problems if they want to donate their time and expertise abroad, especially in emergencies such as natural disasters. If they can arrange the time out of their routine work they often find other problems: mobilising staff and resources once at the scene; an uncoordinated response from non-governmental organisations; and a general feeling that the developed world is ill prepared to respond in the hour of need, as was reported during the recent mass flooding in Pakistan.
How and when a doctor is or should be altruistic is likely to cause heated discussion. Judging by the feedback to our survey, however, we believe that altruism continues to be an important aspect of a doctor’s professional responsibilities and attitudes.
Although it is true that international aid work is not the only way that doctors can show their altruistic colours, there is a great need for time and medical skills all over the world. Our survey shows a willingness in the medical profession to give time each year to working abroad for altruistic reasons. Yet the current training structure and set up of hospitals in the UK mean that this eagerness cannot readily be used.
The survey results and the principles outlined in the Medical Professionalism Charter[4] have led us to these suggestions for UK medical professionals:

• As altruism is a key aspect of medical professionalism it should be included in undergraduate and postgraduate curriculums, although its teaching and assessment need further research. We propose a fixed period of mentoring with established doctors who practise altruism in the community.
• Appraisal processes should include evidence in the domain of altruism.
• A system needs to be developed to identify areas of need globally and to link these to clinical skill resources in the NHS, to optimise the use of the abundant human resources available.
• An international database of the availability of altruistic clinical skills should be established, which can be matched to a database of clinical needs in communities. This would help deliver safe and efficient medical aid as and when needed.

Competing interests: None declared.

References

1. Altruism in medicine. BMJ  1895;1:31.
2. Jones R. Declining altruism in medicine. BMJ  2002;324:624.
3. Swick H. Toward a normative definition of medical professionalism. Acad Med  2000;75:6.
4. Medical Professionalism Project. Medical professionalism in the new millennium: a physician charter. Ann Intern Med   2002;136:243-6.
5. Axelrod R, Hamilton W. The evolution of cooperation. Science  1981;211:1390-6.
6. Grudzen C, Legome E. Loss of international medical experiences: knowledge, attitudes and skills at risk. BMC Med Educ   2007;7:47.
7. Wear D, Zarconi J. Can compassion be taught? Let’s ask our students. J Gen Intern Med  2008;23:948-53.
8. Getty J. A new international focus for the RCS. Bull Ann R Coll Surg Engl  2010;92 (suppl):345.

Laurence Wicks orthopaedic medical officer  Ngwelezana Hospital, Empangeni, KwaZulu Natal, South Africa
Saqib Noor trauma and orthopaedics specialty trainee  Royal Orthopaedic Hospital, Birmingham, UK
Vaikunthan Rajaratnam consultant hand surgeon  Queen Elizabeth Hospital, Birmingham