How can physicians’ professional reputation be damaged? Patients’, nurses’ and physicians’ viewpoints

Abstract

As a rule, physicians’ reputation significantly influences public confidence in the medical profession. Unfortunately, the societal perception of physicians in contemporary Iran appears to be negatively impacted. Therefore, the present study aimed to analyze and elucidate the fundamental causes of this phenomenon.

This qualitative study employed content analysis of semi-structured interviews conducted in 2022. The study population consisted of 6 physicians, 6 nurses and 12 patients in the the affiliated hospitals in Kerman University of Medical Sciences selected through purposive sampling. Extraction of the main themes followed the Graneheim and Lundman approach, and data management was facilitated through MAXQDA 20.

The study identified five themes encapsulating the causes for damage to physicians’ reputation: physicians' relationship with patients, physicians' relationship with the community, physicians' relationship with the medical profession, challenges within medical practice, and challenges related to medical education. Within these themes, a total of 38 subthemes emerged. The primary drivers that seem to damage physicians’ reputation include: non-effective communication, negative public attitudes toward certain physicians and medical centers due to malpractice, illegitimate relationships of physicians, gaps in physicians’ skills, insufficient education, and ethical lapses.

It was concluded that several infrastructural elements negatively impact physicians' reputation. Consequently, it is recommended to monitor the professional behaviors, practices and relationships of physicians, while scrutinizing the medical education system.

Introduction

Throughout the modern history of medicine, physicians’ good reputation has held considerable importance. Individuals tend to exhibit skepticism and may choose to avoid seeking medical care from practitioners lacking a favorable reputation (1). Trust plays a crucial role in the interaction between physicians and patients, exerting a substantial influence on the processes of treatment and illness control (2). Patient satisfaction and adherence to medical recommendations tend to increase when there is a strong doctor-patient relationship (3). This connection fosters a sense of trust and commitment, ultimately contributing to the development of patient loyalty (4).

Extensive research across diverse societies has illuminated the multifaceted influences on the erosion of physicians’ reputation and the public trust. The findings indicate inadequate allocation of time to patients, insufficiently detailed explanations of medication orders, and discriminatory practices based on patients’ socioeconomic status to be pivotal elements contributing to the deterioration of the physician-patient relationship and the tarnishing of physicians' reputation (5). Kaba and Sooriakumaran suggested that doctors’ paternalistic view of their patients is a major challenge to the physician-patient relationship and can damage the reputation of physicians in a community. This view toward patients has created fundamental problems such as disregard for the patient's right to autonomy and has led to political, economic and social gaps between physicians and other members of the community (6).

The results of a study on ethical challenges in health technologies revealed that issues related to e-health ethics, such as the potential infringement upon patients' privacy or the unequal distribution of these technologies, can impact the physician-patient relationship (7). One recent study emphasized the pivotal role of trust in shaping the physician-patient relationship. Additionally, the author posited that regulatory measures and policies, notably the rising health-care costs within the private sector, could adversely impact the relationship by framing patients as "consumers" (8). A recent qualitative study investigating physicians' perspectives on medical advertising through interviews revealed that inappropriate advertising can have a substantial adverse impact on trust in physicians, resulting in enduring negative effects (9). In a study by Sun et al., physicians were queried about the factors contributing to the erosion of their professional reputation. Four key factors were identified by the physicians: “conflict transfer, cognitive bias, ineffective management, and individual deviance” (10).

The impact of a physician's reputation on public trust and satisfaction with medical recommendations and treatments is a significant concern (1, 2). However, there has been limited research on this matter in Iran. Given the potential enhancement of clinical care through knowledge production in the physician-patient relationship, it is crucial to understand this dynamic and derive strategies for improving health-care quality. Researchers posit that insights into the factors influencing physicians' professional reputation can inform effective interventions to mitigate the loss of public trust in health-care providers, particularly physicians. Thus, this study aims to investigate the underlying factors harming physicians' reputation as perceived by patients, nurses and physicians within a sample of the Iranian society.

Methods

Qualitative Approach and Research Paradigm

In this study, qualitative researchers aimed to understand the importance of individuals' lived experiences and social interactions in the context of social life. We delved into an in-depth exploration of how participants interpret their personal and social realms, including the significance assigned to specific experiences, events and conditions that might damage a physician's reputation. The interpretive phenomenology paradigm was employed in this study to uncover and elucidate participants' experiences of physician reputation damage through thematic content analysis. Content analysis is a research approach and a scientific tool whose purpose is to provide new knowledge, improve the researcher's understanding of the phenomena and identify operational strategies. Furthermore, face-to-face interviews were conducted using an interview guide to systematically collect in-depth data on relevant phenomena. This method facilitated a comprehensive exploration of concepts, issues and perspectives among various stakeholders (11).

Researcher Characteristics and Reflexivity

MM, an academic member with a PhD in Medical Ethics, served as the supervisor for this study at a neighboring institution. AA, a medical student at the time, conducted the study under MM's guidance, including performing the interviews. Methodological advice was sought from a Community Medicine professor at Kerman University of Medical University. All researchers actively contributed to each stage of the study.

Context and Sampling Strategy

The data were gathered from semi-structured interviews with 24 participants, comprising 12 patients, 6 nurses and 6 physicians. Purposive sampling, guided by predefined criteria, was employed to select participants from teaching hospitals affiliated with Kerman University of Medical Sciences in 2022. The study participants who were expected to provide crucial information on our research topic included:

• Physicians with a minimum of five years of teaching and medical experience in diverse specialties who had a positive reputation among patients, students and colleagues;

• Nurses with at least 10 years of experience and a favorable reputation among patients and colleagues, and with diverse educational backgrounds;

• Patients with an experience of at least one hospitalization and doctor's office visit, representing various social classes and holding a bachelor's degree or higher.

Ethical Issues Pertaining to Human Subjects

The selected participants were invited to a pre-interview briefing where they gave informed consent to signify their willingness to participate in recorded interviews. Participants were apprised of the confidentiality measures regarding their data and audio-recorded statements. All procedures involving the human subjects in this study were carried out in line with the ethical norms of Kerman University of Medical Sciences' institutional research committee under the ethical code IR.KMU.AH.REC.1399.163.

Data Collection Methods

The study employed a qualitative, inductive content analysis approach. A total of 36 semi-structured in-depth interviews were conducted in 2022, each lasting from 35 to 75 minutes in duration. The interviews continued until data saturation was achieved in each group of participants.

Data Collection Instruments

The interview guide comprised two sections: the first section focused on assessing participants' demographic characteristics, and the second consisted of three main questions: 1) What is your experience of physician reputation damage and the resulting public distrust? 2) What are your views on the consequences of physician reputation damage? 3) In your opinion, what practical measures should be taken to prevent the deterioration of physicians' reputation?

In a qualitative study, researchers often grapple with the challenge of responding based on their opinions, which may not lead to a comprehensive understanding. In our study, participants were invited to share their experiences in caring for patients openly and unrestrictedly, addressing their lived experiences with physician reputation damage. Then, guiding questions (Table 2) were employed to extract the necessary information during the interviews.

Table 2.

Participant characteristics

Variable	N	%
Participants	24	100
Patients	12	50.0
Physicians	6	25.0
Nurses	6	25.0
Gender
Male	16	66.6
Female	8	33.3
Age Group
20 - 35	9	37.5
36 - 50	12	50.0
> 50	3	12.5
Patients’ Education
Middle School	3	25
High School	1	8.3
Bachelor's Degree	6	50
Master’s Degree	2	16.6
Nurses’ Education
Associate Degree	1	16.6
Bachelor's Degree	1	16.6
Master’s Degree	4	66.6
Doctors’ Education
Specialty	4	66.6
Subspecialty	2	33.3

Units of Study

Table 1 illustrates the demographic characteristics of the study participants, who were divided into three groups including 12 patients, 6 nurses and 6 physicians.

Table 1.

Guiding questions for extracting the necessary information during the interviews

No.	Question
1	In your opinion, how will disclosing and addressing issues related to physicians' performance affect their professional reputation within a community?
2	Have you ever experienced a loss of trust in doctors after learning about a specific instance of poor performance on their part?
3	Do you believe that narratives regarding doctors' poor performance are authentic?
4	If the things people say about doctors' practice are accurate, do you think they have the potential to erode trust in the medical community?
5	Which factors do you believe can damage physicians' reputation in a society?
6	What measures do you think should be taken to prevent the loss of public trust in physicians?
7	To safeguard their reputation, what actions do you think doctors themselves should take?
8	To protect their reputation, what do you think doctors should refrain from doing?

Data Processing

Data analysis was done according to the steps proposed by Granhim and Lundman (12). Throughout the interviews, the researcher simultaneously recorded participants' statements and took notes. The audio file was reviewed after the interviews were completed to ensure content clarity. The interviews and observations were transcribed into written texts, and the researcher thoroughly reviewed these texts multiple times to acquire insight into and develop a profound understanding of the current situation. Data collection and analysis occurred concurrently with the interviews. The analysis involved listening to participants' statements several times to identify significant remarks and associated themes.

Data Analysis

The entire set of interviews and observations served as the unit of analysis, which comprised notes intended for coding and analysis, with words, sentences or paragraphs identified as meaningful units. Semantic units, representing collections of words and sentences connected by content, were subsequently summarized based on their respective contents and were placed next to each other.

The semantic units were assigned names upon reaching a certain level of abstraction and conceptualization through coding based on the hidden meanings within them. The codes were examined for similarities and differences, and were further grouped into more abstract classes with specific labels. Ultimately, through a comparative analysis of these classes and thorough reflection, the underlying content within the data was encapsulated and identified as the main theme.

Techniques to Enhance Trustworthiness

Data validity and reliability were assessed through self-control methods implemented by the participants and a colleague experienced in qualitative research. The participants reviewed a portion of the text containing primary codes, comparing the congruence of their extracted ideas with those identified by the researcher. Additionally, a colleague familiar with qualitative research scrutinized the data concepts and classes, evaluating the congruence of the researcher-extracted concepts. In instances of differing opinions between colleagues and researchers, a re-analysis and conceptualization of data were conducted by the researcher, and the findings were revisited with colleagues until consensus and approval were achieved (12). Finally, MAXQDA software (version 2020) was employed for organizing final themes and clusters.

Results

The data analysis identified 820 codes, categorized into five main themes: physicians' relationship with patients, physicians' relationship with the community, physicians' relationship with the medical profession, challenges within medical practice, and challenges related to medical education. These themes were further divided into 11 themes and 38 subthemes, as shown in Table 3.

Table 3.

Themes, sub-themes and participants’ statements about physician reputation damage

Main Themes	Themes	Sub-Themes	Codes	Participants’ Statements
Physicians’ Relationship with Patients	Respect	Having a condescending view of patients and clients	Tendency of physicians to consider themselves superior	Nurse 1: “Some doctors like to show off. They believe they're superior, super smart, extremely knowledgeable and have a high IQ, and they’re convinced that others don't know a thing.”
		Discriminating among patients from different social groups	Noting the appearance of patients	Patient 2: “He looked like someone who had a blue-collar job, but when he ended up in the emergency department, the medical team treated him terribly!”
		Disrespecting the patient	I know everything	Patient 11: “You know, sometimes you're having a conversation with the doctor, and all of a sudden, they're like, 'I know better than you! Who's the doctor here, me or you?’ ”
	Responsibility	Not giving enough information to the patient	Not answering the patients’ questions about their disease, prescribed drugs and possible risks	Nurse 3: “So, the doctor comes in, asks a few questions all distant-like, doesn't really hear the patient out, scribbles some prescriptions, and bolts. Then, he's like, "Hey, I've given you some meds." And the patient's like, "What in the world did you prescribe?”
		Not allocating enough time to the patient	Not seeming to notice the patient	Patient 6: “The doctor was always on the phone during our visit, and it seemed like she didn't even notice that both my mom and I were under the weather.”
Physicians’ Relationship with the Community	Public beliefs and attitudes	People’s rising awareness of the treatment system	Peoples’ information about physicians and medical treatments	Nurse 4: "Nowadays, patients are more informed about their health than ever before. They actively seek out the best doctors and gather ample information about them. Consequently, if a doctor's expertise falls short of expectations, it could severely damage their reputation."
		Public beliefs about treatment methods and procedures	Patients think about surgery as an all-in-one solution	Nurse 4: “Some patients think that all their problems would be resolved just by having a surgery.”
		Public negative attitudes toward some physicians and hospitals	People’s beliefs about medical malpractices happenning in hospitals	Patient 8: “Some people compare certain hospitals to literal butcher shops because of sketchy medical stuff that's gone down. Like, there was this one time they straight-up gave a patient the wrong medicine through injection.”
	Advertising	Online media, news or images	Impact of social networks, media, news, image releases and the policies adopted regarding these	Physician 3: “People are putting out pictures and stories about medical stuff on social media, and it's getting a ton of eyes. It's really impacting how the public perceives the medical profession.”
		Excessive and unreal advertising by some medical centers and physicians	Physician as a public figure such as a celebrity	Nurse 5: “The once revered status of physicians has undergone a shift toward being perceived as celebrities and brands. This transformation has negatively impacted the professional reputation of physicians.”
	Communication skills of physicians	Physicians’ communication problems and misbehavior	Making fun of the patients’ ailments and laughing at them	Nurse 3: “Some doctors get intimate, they hold hands and walk shoulder to shoulder. But sometimes they make fun of their patients.”
		Class differences between people and physicians	Doctors come from well-off families	Nurse 6: “People believe that doctors are born into well-off families and are not aware of the problems of poor people from lower social classes.”
Physicians’ Relationship with the Medical Profession	Professionalism	The importance of medical practice and the physician as a confidant	To trust the doctor as a confidant in examinations or other procedures	Nurse 2: "Some people feel comfortable confiding in the doctor, so they send their daughters or wives solo for check-ups in a private room."
		Doctors not committing to their profession	Physicians’ engagement in other activities and businesses	Patient 10: "People don't really trust doctors juggling two or three activities simultaneously. A dedicated doctor shouldn't be engaged in businesses such as construction."
		Conflict of interests	Financial relationships	Physician 3: "The doctor prescribes more items to boost the commission."
		The decline of professional ethics	Doctors’ abuse of their position	Nurse 4: "They [doctors] wear quite inappropriate attire." Nurse 6: "Regrettably, certain doctors are taking advantage of their positions. Their behavior is so openly unacceptable that even their colleagues recognize their lack of efficiency, yet they're solely focused on gaining maximum benefits."
		Unsuitable behavior with staff and nurses	Not respecting the nurses	Nurse 1: "See how he acts? He doesn't show any respect for the nurses. A doctor shouldn't be so full of themselves. Some doctors don't even bother saying hi back to us."
	Health system infrastructure	Income difference	Large income gap between physicians and other medical staff, and financial dealings	Physician 5: "Nowhere else in the world will you find two people working in the same field with such a massive difference in income."
		Failure to deal with a doctor who does not exhibit professional behavior	Physicians who do not uphold professional work standards often face insufficiently serious consequences	Physician 2: "There's a tendency in some individuals to generalize one doctor's misbehavior to the entire profession. If a doctor's actions are tarnishing the reputation of the medical community, it should be addressed seriously to prevent further harm." Patient 9: “One doctor made a mistake, and they didn’t put a stop to it. Another doctor picked up the same behavior.”
		The role of medical staff in damaging other physicians’ reputation	Convincing patients that a drug prescribed by another doctor is not effective	Nurse 4: “Even when you consult the most reputable and ethical doctor, they tend to, either directly or indirectly, persuade you that a medication prescribed by another doctor is ineffective or not working.”
		Physicians’ incompetence in managing organizational behavior and the monopolization of authority within the medical system	Appointing only physicians as the health minister	Nurse 5: “The health minister is consistently chosen from the ranks of physicians. While it may be unrealistic to expect a nurse to assume the role, it is worth noting that individuals with expertise such as a full professorship and a Ph.D. in anesthesiology or anatomy could serve equally well in this capacity. However, the ministerial position is consistently monopolized by physicians.”
		Inadequate infrastructure for a referral system	A referral rating system is needed	Physician 4: “Implementing an effective referral rating system would enhance efficiency. Admitting, diagnosing and treating patients could be better streamlined by a rating system that considers ethical, financial and economic factors.”
Challenges within Medical Practice	Responsibility	Visiting too many patients	Not being able to visit more patients in one day	Patient 7: “A doctor’s daily patient load typically maxes out at around 30 individuals. The limitation isn’t due to physical constraints but rather mental.”
		Excessive use of paraclinical tests and insistence on repeating them	Not accepting tests recommended by another doctor	Patient 6: “No doctor accepts the tests recommended by another doctor. You may have performed the test a day before, but the doctor does not accept it.”
		Neglecting to gather a patient’s medical history and conduct a thorough examination	Prescribing drugs or tests immediately without gathering enough data	Patient 12: “A prescription is immediately given without checking the patient’s medical history or examining his/her symptoms thoroughly.”
		Neglecting one’s responsibility toward patients	Delegating the responsibility of perfoming the surgery to resident physicians	Nurse 6: “The doctor claims to supervise the surgery, but during the procedure, he delegates the surgical responsibilities to his resident.”
	Honor and integrity	The failure to seek advice from other physicians	Insisiting that they know everything	Patient 4: “On occasion, doctors hesitate to acknowledge their uncertainty about a patient's illness and are reluctant to refer the patient to other specialists. They insist they know everything and are resistant to criticism.”
		Physicians’ insufficient knowledge and commitment	Questionable promise of a good career after finishing their studies	Physician 6: “Someone who's invested seven years in studying medicine generally anticipates a promising career after graduation and earning the esteemed title of Doctor. Passion and dedication often lead to fulfilling outcomes, and obtaining a board or fellowship degree will significantly enhance prospects. However, the current circumstances may present unique challenges.”
		Medical error Disclosure	Physicians’ malpractice and errors	Nurse 2:” Certain physicians choose not to disclose instances of their medical errors.”
Challenges Related to Medical Education	Medical education system	The inadequacy and insufficiency of medical education	Admission of too many medical students	Physician 5: “Increasing the number of admissions into medical schools might not yield positive results; in fact, it could have detrimental effects and compromise the quality of medical education..”
		Inadequate admission procedures for medical and residency programs	Cheating in entrance exams	Physician 2: “It’s perplexing to witness dishonest practices, particularly in residency exams, which seems to be beyond the ethical boundaries one would expect from a professional. It raises questions about how a doctor could resort to purchasing exam questions, betraying the trust of their colleagues in the process.”
		The absence of any criteria to identify competent physicians	There is a necessity to implement a system to filter and monitor doctors’ rankings based on their competencies.	Physician 4: “As the older generation of doctors is still in practice, figuring out who among the new generation is good and who isn’t becomes tricky. The problem is, they’ve all been educated without a system to rank them based on their skills.”
		Stresses and tensions associated with medical education	Experiencing a certain amount of worries, anxieties and stresses while studying medicine	Physician 5: “When you start medical school, you have your own thoughts and ideas, but then you end up in a totally different situation than you expected. You experience so many worries, anxieties and stresses, and you cannot move forward.”
		Unqualified professors	No monitoring system for professors’ competencies	Physician 4: “In some countries, even if you hold the title of full professor, there’s an annual monitoring requirement. In Iran there’s no such monitoring once you become a faculty member.”
		Planning for student eligibility or qualification	A gradual decline in the academic qualifications of students	Nurse 2: “Newly admitted students exhibit a lower standard compared to those enrolled in previous years. 8 or 10 years ago, interns demonstrated a level of competence comparable to attending physicians and it was like they knew exactly what to do.”
		Planning for graduating students	Graduation of unqualified students	Physician 1: “Some graduates aren’t sufficiently qualified, and this could create problems.”
	Medical ethics education	Inadequate training for practical medical ethics	Not teaching physicians how to put ethics into practice	Physicians 1 & 6: “It seems like the medical ethics course is only given two credits. Many students skip the class, and the material covered isn’t always practical. While they touch on professional ethics and behavior, the course falls short in providing practical application, unlike other subjects.”
		The lack of ethical role models in the field of medicine	The need to introduce ethical role models in educational institutions	Nurse 5: “The community fell short in effectively introducing ethical models, and now it's imperative for cultural or educational institutions to take up this mission. There might be shortcomings within the academic system that have hindered its mission.”

A. Physicians’ Relationship with Patients

Patients expect mutual respect and meticulous care from their physicians. However, it has been noted by both doctors and nurses that some physicians struggle to engage in effective communication with patients, which hinders their ability to address inquiries. Contributing factors include tension, crowded environments, fatigue, time constraints, familial issues and even substance dependency. These issues can significantly damage physicians' reputation. Furthermore, some physicians may display inappropriate behaviors, including insult and disrespect toward patients, condescension toward others, discrimination based on social class, and a lack of attentiveness. Such conduct not only tarnishes the reputation of physicians but also erodes public trust in them.

B. Physicians’ Relationship with the Community

The participants reported that social factors such as class differences, public beliefs and rumors can damage physicians' reputation. Physicians have little control over these issues, but their reputation can be directly influenced by them. At times, medical issues are disclosed on online platforms and in social media without subsequent resolution. The dissemination of such information can foster a negative public perception of certain physicians and medical facilities. Instances like misdiagnoses, treatment negligence, incorrect prescriptions, mockery of patients and communication issues can significantly harm physicians’ reputation and undermine public trust.

C. Physicians’ Relationship with the Medical Profession

Participants consistently spotlighted issues in physicians' professional ethics, ranging from moral corruption and inappropriate attire to holding a second job and illegitimate relationships. These behaviors pose a grave threat to physicians' reputation. Notably, some participants linked the lapse in professional ethics to physicians' elevated income and distinct social class, underscoring the profound impact of financial relationships and income differentials on physicians' conduct and overall performance.

Sometimes physicians exhibit unacceptable behaviors, for instance they discharge patients prematurely or employ practices solely for financial gain. The issues related to physicians' professional conduct that were highlighted by the participants in this study may be linked to broader problems in the national health system, encompassing management issues, ineffective legislation, inadequate infrastructure, an incomplete referral system and inefficiencies in medical system supervision in Iran.

D. Challenges within Medical Practice

The study findings highlight issues in physicians' practices, including insufficient knowledge and skills, overreliance on paraclinical diagnostic services, prescribing medication without reviewing patient history, neglecting advice from other physicians, managing an excessive number of patients in a day, and delegating surgeries to residents. Moreover, participants, particularly nurses, emphasized an ethical concern regarding physicians' failure to report medical errors.

E. Challenges Related to Medical Education

The findings imply that issues in medical education can adversely affect physicians' reputation due to practical challenges and unprofessional behaviors. As early as their initial admission to medical programs, students face problems such as inadequate education, absence of role models, incompetence among professors, unethical practices, limited career prospects post-graduation, and a deficiency in practical teaching of medical ethics.

Discussion

The study findings showed that physicians and nurses were inclined to pinpoint professional issues and the quality of medical education as potential threats to physicians' reputation. In contrast, patients were more prone to identifying issues related to the physician-patient relationship and physicians' practices. These results align with prior research, underscoring the disparities in the opinions of medical staff and patients regarding factors influencing physicians' reputation (13, 14).

Participants in this study emphasized the significance of morality within the medical profession, stating that physicians' conduct and relationships with patients and the community have a direct and indirect impact on their reputation. The Professional Ethics Guideline for Medical Practitioners endorsed by the Iranian Medical Council similarly underscores the importance of morality. It incorporates directives on delivering quality healthcare, refraining from actions conflicting with medical values, respecting human dignity and preventing discrimination (15). One study pinpointed 40 positive physician behaviors, which is consistent with with our findings. It emphasized crucial traits for a robust physician-patient relationship: respect, honesty and compassion. The study also highlighted the importance of physicians being knowledgeable, skilled and trustworthy. Issues like communication difficulties and disruptive behaviors, for instnace addiction, can harm physicians' reputation and diminish public trust (16, 17). In one study, researchers asserted that patients consider scientific competence, the ability to maintain positive relationships, and adherence to ethical principles as the most crucial attributes of physicians (18). Another study revealed that inadequate time allocation for patients and discrimination based on social class can significantly harm a physician's reputation (19). Both our findings and those from other studies underscore the importance of physicians recognizing the influence of their conduct on patients and upholding professional standards. Elevating patient awareness can enhance the physician-patient relationship, prevent harm to physicians' reputation and mitigate the decline in public trust. Achieving this involves delivering clear and concise information, employing plain language and promptly addressing patients' inquiries (20).

According to our findings, negative public sentiments toward certain physicians and medical centers resulting from financial associations and malpractice can be detrimental to physicians' reputation. A survey conducted online in Japan explored the trust of patients and their families following instances of incorrect diagnoses by physicians. The findings affirmed a diminished trust in the physician and emphasized the necessity for targeted interventions to restore it (21). Conversely, lack of transparency on the part of physicians regarding medical errors emerged as a significant concern highlighted by the nurses in our study. A study revealed that only about one-third of physicians reported substantial medical errors committed by their less competent colleagues to hospital authorities (22). Barriers to reporting medical errors that was identified in a study including fear of tarnishing the physician's reputation, concerns about competition from other physicians, and apprehensions concerning colleagues’ behavior (23). These findings are partly consistent with the results of the present study. Dishonesty in physicians can potentially lead to various adverse consequences for both patients and the medical community. Notably, the Professional Ethics Guideline for Medical Practitioners endorsed by the Iranian Medical Council underscores the significance of reporting medical errors and maintaining honesty with patients, as outlined in the ninth section (15).

Some physicians exhibit behaviors (such as premature discharge of patients) that may not yield financial benefits, or utilize tools and practices solely for increased income. The authors argue that the paramount duty of physicians is to provide optimal care, which requires effective relationships with others, including colleagues and industries. Physicians can earn patient trust through adept management of conflicts of interests (24). Conflict of interests may present as informal payments, a widespread practice in the Iranian health-care system, often perceived as a means to secure quality care. Such payments can foster corruption and discrimination, thereby undermining public trust in the health-care system. Researchers recommend that the Iranian government implement measures to regulate and control informal payments within the health-care system (25). Some researchers have regarded the financial relationship between physicians and pharmacists as a form of conflict of interests and emphasized that the inadequate management of this relationship could result in harm to public trust and physicians’ reputation (26). Our participants also emphasized that such relationships seriously affect physicians’ reputation. The findings indicate that, at times, physicians prioritize wealth over professional ethics. The pursuit of the financial gain sometimes leads physicians to take on secondary employment, a concern voiced by our participants, eliciting criticism for disregarding the dignity of the medical community. According to one study, the pursuit of wealth is particularly detrimental when physicians engage in illegal practices like accepting bribes. Such actions not only tarnish the image of the implicated physician, but also risk generalization of this behavior to others, thereby damaging the reputation of the entire medical profession (27).

Furthermore, caregivers of patients generalize one physician's negative behavior to the entire medical community, which will result in harm to physicians’ reputation. Public lack of awareness and seeking medical information from non-scientific or unreliable sources can also impact physicians' standing. Findings of a study showed that the unrestricted dissemination of negative public opinions on online platforms and doctor rating sites influences physicians' reputation and public trust, particularly in the United States and Canada (17).

Moreover, a recent study found that physicians who are concerned about damage to their reputation are more inclined to practice defensive medicine, thus seeking to mitigate the risk of professional stigma (10). Another study revealed that the expense associated with practicing defensive medicine is considered lower by physicians compared to the potential repercussions of losing reputation and compensating for damages resulting from medical errors (28). For this reason, physicians tend to resort to using paraclinical or diagnostic services excessively or without clear indications (29), which was also mentioned by our participants. Defensive medicine is a practice where physicians order more tests and procedures than medically necessary to safeguard themselves from legal liability. While it may enhance the thoroughness of a patient's examination, it proves to be costly and can result in treatment delays, making it challenging to deliver quality care (30). The participants in our study also stressed that employing unnecessary tests and procedures can harm physicians' reputation as patients may perceive this behavior as a conflict of interests and unprofessional conduct.

As per insights from seasoned doctors and nurses in our study, problems in physicians' education can play a role in harming their reputation. These issues span all facets of medical education, from the admission of medical students to their progression through graduation and post-graduate phases. Researchers have identified challenges in medical education, including the limited number of professors dedicated to general practitioners' education, professors prioritizing patient treatment over student instruction, and reported low motivation among both students and professors (31). Moreover, researchers have underscored the neglect of medical ethics among doctors and proposed a heightened focus on professional ethics during academic studies as a means to enhance physician reputation (32). These findings are in line with the present study results. In an optimal education system, qualified physicians are trained in a manner that the patients can trust them. One survey showed that physicians’ qualification is the most important factor for being chosen by patients (33).

The current study faced several challenges, such as participant non-cooperation during interviews, interviewees fixating on specific topics while neglecting others, and potential biases. To address these issues, researchers employed probing questions and key inquiries during interviews to redirect participants' attention toward relevant phenomena.

Conclusions

The primary drivers of physician reputation damage include non-effective communication, negative public attitudes toward certain physicians and medical centers due to malpractice, illegitimate relationships of physicians, gaps in physicians’ skills, insufficient education, and ethical lapses. The findings reveal that physicians face numerous infrastructural challenges in upholding their reputation, particularly in interactions with patients and the community, and in utilizing their knowledge. Safeguarding public trust entails prioritizing observational scientific practices, along with ethical and professional responsibilities toward patients, the community and the medical profession. To further prevent harm to doctors' reputation, establishing an ideal medical education system can alleviate existing difficulties and enhance endeavors to improve physicians' practical and ethical professional competencies.

Notes:

Citation to this article:

Abdollahi A, Mobasher M. How can physicians’ professional reputation be damaged? Patients’, nurses’ and physicians’ viewpoints. J Med Ethics Hist Med. 2024; 17: 1.

Notes:

Authors’ Contribution : Authors’ Contribution : Study concept and design was performed by Mina Mobasher. Acquisition of data, analysis, statistical analysis interpretation of data, and drafting of the manuscript were done by Mina Mobasher, and Ali Abdollahi. Study supervision was performed by Mina Mobasher.

Conflict of interest

The authors declare that they have no known conflict of interests

Funding

There was no funding resource for this study