Samorząd lekarzy w zakresie ich odpowiedzialności zawodowej: aspekty ekonomiczne, zarządcze i prawne

Introduction

Self-government of doctors is one of the oldest professional self-governments. It was established pursuant to the Act of 02.12.1921 on the System and Scope of Activity of Chambers of Physicians [1], and then the basis for its organization and functioning was the Act of 15.03.1934 on Chambers of Physicians [2]. After the war it resumed its operation for a short time until 1950, and then it was re-established in 1989 by the Act on Chambers of Physicians [3]. The currently binding law regulating the organization and tasks of the professional self-government is the Act of 02.12.2009 on Chambers of Physicians [4].
The objective of the article is to present the organization and functioning of the professional self-government of doctors in the context of their professional responsibility in the economic, managerial, and legal aspects. In connection with the objective thus formulated, the following main research problem was specified: do the organization and functioning of the doctors’ self-government contribute to making them bear professional responsibility? With reference to the main research problem, the following issues to explore have been formulated: 1. how do professional self-governments, representing people practising public trust professions, monitor whether these professions are properly practised within the boundaries of public interest and for its protection? 2. Is mandatory membership of the self-government of doctors determined by the supervision exercised by the professional self-government? 3. Do the doctors’ self-government organs perform the function and role of a codifier of already existing legal regulations at the formulation of the principles of professional ethics and deontology? 4. In which way is the supervision exercised by the professional self-government a manifestation of autonomy and submission of the activities of this corporation to state authority? 5. Is professional responsibility of doctors a consequence of supervision exercised by the self-government?
Professional responsibility of doctors refers to their duty to carry out their work in a trustworthy manner and in line with the ethical standards in medicine. Doctors have a moral and legal duty to look after patients’ wellbeing and to act in accordance with the highest standards of health care [5].
Professional self-governments, such as chambers of physicians, are usually entitled to issue medical licences, supervise doctor’s practice, conduct disciplinary proceedings, and impose sanctions in the event of a breach of professional ethics. They can also provide support, offer training courses for doctors, and promote high medical standards.
Owing to the mandatory professional responsibility of doctors, it is possible to complain about their malpractice to the professional self-government. Patients, health care staff, and community members can report violations of professional ethics or medical malpractice to relevant professional self-government organs that will conduct investigation to determine liability.
In the event a breach of professional ethics or a malpractice is found, the professional self-government can impose such sanctions as admonition, suspension from medical practice, or even revocation of a doctor’s licence.
It is crucial for professional self-governments to be independent and function well so they can provide patients with appropriate protection and maintain high standards of medical practice. Professional responsibility of doctors and self-government are the key elements of ensuring safety and quality of health care.

Economic aspects of professional responsibility of doctors in the context of professional self-government

Professional responsibility of doctors involves numerous economic aspects, both for physicians and for the health care system as a whole. Some of the key issues connected with this problem are presented below.
Firstly, insurance costs should be mentioned. Doctors are obliged to have a professional liability insurance policy that protects them in case of any medical error claims or legal actions [6]. Costs of such insurance can be high, especially for specialists in high-risk fields, such as surgery or obstetrics. The professional self-government of doctors can participate in negotiations with insurance institutions to specify the insurance conditions for practising doctors.
In Poland, liability insurance for doctors is mandatory for those practicing medical activities as individual medical practitioners. The source of this insurance requirement is Article 18 of the Act of 15 April 2011, on Medical Activity. The specific scope and conditions of the insurance are determined by the Act of 22 May 2003, on Mandatory Insurance, the Insurance Guarantee Fund, and the Polish Bureau of Motor Insurance, as well as the Minister of Finance’s Regulation of 22 December 2011, Regarding Mandatory Civil Liability Insurance for Entities Engaged in Medical Activities. Conversely, doctors who are employed under an employment contract do not need to have liability insurance. The responsibility for damages caused by them falls on the employer.
The economic aspects include also financial sanctions. If it is proven that a doctor has committed a medical error or has failed to perform his or her duties correctly, he or she may incur financial sanctions [7]. These sanctions may include fines imposed by regulatory authorities. Such expenses can have a major impact on the doctor’s finances.
Another economic aspect is an increase in health care costs. Medical errors and doctors’ failure to fulfil their duties properly may lead to prolonged treatment, medical complications, and additional costs of health care. In the case of serious medical errors, a patient may need long rehabilitation, expensive medical procedures, or repeated hospitalization, which in turn can result in an increase in general health care costs [8].
Yet another important economic aspect is a decrease in patients’ trust. A medical error can adversely affect patients’ trust in doctors and the health care system as a whole. Consequently, if patients lose their confidence in doctors, they can avoid seeking necessary health care or lean towards alternative forms of treatment, which can affect the finances of physicians and the health care system. Professional self-government can play a role in resolving disputes and conflicts between doctors and patients. It can act as a mediator or an arbitrator, helping to find a solution that would satisfy all parties concerned. Effective dispute resolution mechanisms can build trust and stability in the profession, which may also have economic consequences. The professional self-government of doctors can be involved in dealing with patients’ complaints, disputes concerning medical practice, and disciplining doctors in the event professional ethics standards are violated.
An increase in costs of training courses and standardization is another economic aspect of the discussed issue. To reduce the risk of medical errors it is necessary to upgrade doctors’ competence on a regular basis, through their participation in training courses and educational programmes [9]. This in turn generates additional costs for doctors and for the entire health care system. The professional self-government of doctors can be responsible for setting educational and training standards for physicians during specialization and further professional development. It can organize courses, conferences, and training, as well as provide financial support for doctors participating in continuing education programmes. Appropriate training courses and educational programmes for doctors should improve their clinical competence, risk management skills, communication with patients, and other key areas. Training can cover legal and ethical aspects related to the professional responsibility of doctors, as well as soft skills, because the research [10] demonstrates that a patient’s trust in a doctor is related to such factors as the doctor’s interpersonal skills, respect shown to the patient, and technical competence.
It is important for doctors to be aware of their professional responsibility and take any precautions to minimize the risk of medical errors. The systems for monitoring health care quality, training courses on patient’s safety, and proper risk management are crucial for ensuring quality medical care and curbing economic consequences connected with doctors’ professional responsibility. It follows that professional responsibility of doctors also has important managerial aspects, both for doctors themselves and for the medical institutions in which they work.
It is worth noting that the economic aspects of doctors’ professional responsibility in the context of professional self-government are complex and vary depending on the country, healthcare system, and medical specialization (Figure 1).

Managerial aspects of doctors’ professional responsibility in the context of professional self-government

The key issues related to managerial aspects of doctors’ professional responsibility include risk management. Medical institutions should have effective risk management systems which identify, evaluate, and reduce the risk of medical errors to a minimum [11]. It comprises the following: monitoring of health care quality, introduction of clinical protocols and guidelines, training courses for personnel, and a system of reporting incidents and investigation in case of adverse events.
Other managerial aspects of doctors’ professional responsibility are the policies and procedures in place. Medical institutions should create and implement relevant policies and procedures concerning health care standards, professional ethics, communication with patients, medical records, etc. This also includes policies pertaining to supervision and evaluation of doctors’ work and disciplinary measures in the event of violation of professional standards. The professional self-government of doctors can develop rules and regulations concerning standards of professional ethics, medical practice, doctors’ entitlements, etc. The managerial aspects comprise the development, updating, and enforcement of these regulations to ensure that the doctor’s profession is practised appropriately. The task of the professional self-government of doctors in accordance with art. 5 points 1 and 2 of the Act of 2.12.2009 on Medical Chambers is primarily to establish the principles of medical ethics and to ensure that they are observed, and to supervise the proper and conscientious performance of the profession of doctor. It is the professional self-government that guards the proper performance of the profession.
Another managerial aspect is the monitoring and evaluation of quality. Management of doctors’ professional responsibility requires monitoring and evaluation of quality of their work [12]. Medical institutions should inspect doctors’ performance regularly, on the basis of quality indicators, patients’ opinions [13], and other factors. This enables identification of areas that need improvement and provision of quality health care. The professional self-government of doctors can conduct actions aimed at monitoring the quality of medical services, such as audits, inspections, evaluation of compliance with regulations and standards, as well as systems of reporting medical incidents. The managerial aspects refer to the establishment of procedures for quality monitoring and remedy actions undertaken in the case of shortcomings. Another task of a professional self-government is to define standards for quality of services in a given occupation. By setting standards, guidelines, and ethical rules of conduct, the professional self-government contributes to raising the quality of services performed by doctors [14].
The managerial aspects of professional responsibility of doctors are also related to the culture of safety. It is vital for medical institutions to create a culture of safety in which doctors feel free to report errors and incidents and to participate in a quality improvement process. It is also important to promote open communication and cooperation between various members of a medical team to reduce the risk of mistakes [15]. All these tasks can be supported by professional self-governments.
Furthermore, the managerial aspects comprise the establishment of procedures for handling complaints and disputes, conducting investigations, taking decisions, and enforcing sanctions. A study [16] covering 30 countries demonstrated that the respondents from the states where health care systems are financed predominantly from public funds are more inclined to trust doctors than their counterparts from the countries with lower public funding of health care systems. It transpires that confidence in doctors is highest among people who trust their health care system financed from public funds, and lowest among people who do not trust their health care system financed from private funds. As far as the professional self-government is concerned, the level of trust in it among the Polish people is not high [17].
Effective management of professional responsibility of doctors, supported by the professional self-government of physicians, is crucial for ensuring safe and high-quality health care. The introduction of relevant policies, procedures, quality monitoring systems, and a culture of safety can help reduce the risk of medical errors and build patients’ trust in the health care system.
Nevertheless, it is worth emphasizing that the specific scope and activities of the self-government of doctors with respect to professional reliability, both in the economic and managerial dimensions, may vary depending on the country, local laws, and socioeconomic context. All these aspects are aimed both at protection of doctors’ interests and at benefiting the whole of society by maintaining a high quality of services, fair competition, and professional development (Table 1).

Professional self-government as a body supervising proper practice of a profession within the framework of public interest and for its protection

In Article 17 section 1 of the Constitution, the legislator stipulates that professional self-governments may be established by a legal act [18], for the purpose of representing people who practise public trust professions and for supervising proper practise of these professions within the framework of public interest and for its protection [19]. The ratio legis of this provision was to create professional self-governments as a decentralized component of public administration, entrusted with an auxiliary role in the exercise of authority for the fulfilment of public tasks both for members of self-governments as the so-called public law corporations, and for the benefit of all citizens, i.e. in a broadly understood public interest [20]. Furthermore, in its judgement of 23.04.2008, the Constitutional Court stated that the legislator, enabling professional self-government organs to be entrusted with certain tasks in public administration and introducing mandatory membership of a professional corporation, makes public interest a justification and an ultimate goal of assigning the said attributes to professional self-government organs [21]. What is more, in a judgement of 18.02.2004, the Constitutional Court declared that “the provision of Article 17 section 1 of the Constitution authorizes self-governments of public trust professions to supervise «the proper practise of such professions». By an explicit order of the legislator, this supervision should be exercised «within the limits of and for the purpose of protecting public interest». First of all, this phrase specifies the purpose and limits of «supervision over (...) the practice of professions». The goal is to maintain proper quality – in the substantive and legal sense – of activities constituting «the practice of professions». (...) Secondly, the phrasing of Article 17 section 1 defines the character of the «supervision» exercised. This character is determined by «public interest». The supervision should be aimed at the protection of this interest, by virtue of a constitutional regulation. Thus, the role of professional self-government with respect to «exercising supervision» is subject to constitution-oriented evaluation carried out from the perspective of public interest and directed towards its protection” [22]. Therefore, it is the duty of the professional self-government organs to exercise supervision over appropriate practice of a profession for the common good and in the public interest, which is the point of reference for which the professional self-government was established. Each professional corporation upholds the principle of compliance with professional ethics and supervises the proper discharge of duties by its members. On the other hand, members of professional self-government practising public trust professions and subject to jurisdiction of corporate courts perform their duties in line with the rules of professional ethics and binding legal regulations, otherwise they may be held accountable. It means that each professional corporation sets professional responsibility boundaries for people practising particular occupations, to promote certain standards and correct manners of conduct. Professional self-government is a type of decentralized public administration.
The independence of professional self-government consists of the exact definition of cases when the state can enter the sphere of activity of self-government, and not in its separation from the state [23]. It means that self-government is independent with respect to intra-corporation issues and public affairs delegated to self-government [24].

Mandatory membership of professional self-government of doctors as a determinant of supervision exercised by self-government

It is not possible to practise a medical profession without being a member of a professional corporation. Mandatory membership of professional self-government is determined by the supervision exercised by this entity. Although the term of supervision has not been defined by law, Article 5 of the Act on Chambers of Physicians specifies the sphere of supervision over these professions. It means that supervision refers to the self-government’s control over the correct practice of the profession from the legal, professional, and ethical perspective [25]. This thesis is confirmed in the judicial decisions of the Constitutional Court, which recognizes that “since self-government should supervise the correct practice of the profession in the public interest and for the protection of a given professional corporation and does so as if on behalf of the public authority, it cannot be accepted that some people practising a given profession are outside self-government structures and are not subject to this supervision” [26]. Therefore, this supervision is also determined by the character of medical professions practised in the public interest.
Self-government [27] is independent in the fulfilment of its tasks and is subject only to law. Hence, S. Wykrętowicz rightly claims that “the establishment of the self-government for a given profession results in the fact that this self-government is equal to other self-governments, has the right to express its opinions, and practitioners of a given occupation pursue a public trust profession. Thus, the establishment of self-government for a given profession is a distinction and recognition of a public trust profession. However, this fact has to be confirmed by the legislator in a legal act. Currently, it is not possible to practise a public trust profession without membership of a professional corporation. Membership of self-government of practitioners of a given profession is stipulated by law. Hence, membership of a relevant corporation is mandatory, and it is prohibited by law to practise the profession outside the corporation. A professional self-government is appointed for the purpose of representing practitioners of a given profession before public authorities. The establishment of professional self-governments demonstrates that the society is mature enough to trust people practising a given profession. This trust refers to the competence of people providing services in a given field. Without doubt, trust is expressed by the legal delegation of public tasks to be performed by practitioners of public trust professions, in the conviction that they are able to solve their internal problems more competently and effectively than government administration officials or common courts” [28]. The legislator, by granting the primacy of the profession of public trust to the profession of doctor, authorized the professional self-government to supervise its performance. This undoubtedly speaks for the prestige of this profession and, on the other hand, for its special status. Supervision over the practice of the medical profession exercised by the professional self-government is a guarantee of its proper performance and compliance by doctors with the principles of professional ethics and the law.

Doctors’ professional self-government organs as a codifier of legal regulations already in force at the formulation of the principles of professional ethics and deontology

As noted by M. Tabernacka, professional self-government organs [29] may have a function in the formulation of rules of professional ethics and deontology, as well as the role of a codifier of the regulations already in force [30]. This thesis was confirmed by the Constitutional Court, which, in its decision of 07.10.1992, ruled that “the entitlement for the congress of physicians to enact deontological norms, contained in the Act on Chambers of Physicians, is only a statutory confirmation of the universally recognized right of a doctors’ corporation (and also other professional corporations) to define deontological standards in accordance with the system of values upheld by these corporations. However, this entitlement is not a statutory delegation in the sense of assigning the functions of state administrative organs to the self-government of doctors. No state administration organ has been and can be authorized to define deontological standards for doctors” [31]. Thus, doctors’ self-government as a professional corporation takes an active part in the formulation of the canon of professional deontological norms. This role involves the enactment of professional ethics codes and resolutions concerning the professional responsibility of doctors. Without doubt, the participation of the professional corporation in the establishment of ethical and deontological norms has a positive impact on the formation of proper attitudes and conduct of doctors, which, as a consequence, may result in a decreased number of professional liability proceedings and thus encourage doctors to comply with the regulations related to the practice of their profession.

The exercise of supervision by the professional self-government as a manifestation of independence and submission of the activities of this corporation to state supervision

If the professional self-government had not been established, the function of supervision over the proper practice of the profession would undoubtedly have had to be performed by another public authority. This is because professional corporations always have an appropriate degree of independence of action in the performance of public tasks entrusted to them by law [32]. The performance of these tasks necessarily involves the exercise of supervision in the public interest and for the general public. Thus, the supervision of the medical profession practice by the self-government undoubtedly indicates, firstly, a certain degree of independence and, secondly, that the activities of this corporation are also subject to state supervision. It is the nature of the supervisory bond between the state administration bodies and the self-government (supervision criteria) that supports the independence of the professional self-government of physicians. On the other hand, the lack of trust in the local government results partly from the shortcomings of the legal regulation, and partly from the practice of its application. Therefore, de lege ferenda, it is necessary to postulate a change in the law in this regard and increase the awareness of doctors and the public about the validity of legal regulations regarding the functioning of the professional self-government of doctors.
In the context of the above, it should be noted that the most characteristic authoritative forms include the issuance of normative and administrative acts (administrative decisions). Based on statutory delegation, the doctors’ self-government organs formulate regulations containing legal norms addressed to the members of this professional corporation. These include, among others, normative acts containing principles of professional ethics and acts determining the internal structure, programmes of action, and budget of the doctors’ self-government. In addition, the doctors’ self-government organs undertake activities of a non-managerial nature. These mainly concern cooperation with public administration bodies, as well as with other public and non-public entities, as regards initiating and performing popularisation tasks in the health care sphere.
According to Article 5 of the Act on Chambers of Physicians, the tasks of the doctors’ self-government include, in particular: establishing the principles of medical ethics and ensuring that they are observed; exercising supervision over the proper and conscientious practice of the doctor’s profession; granting the licence to practice the profession and recognizing qualifications of doctors who are citizens of EU member states and intend to practice the profession in the Republic of Poland, and issuing the documents: “Licence to practice the profession of doctor” or “Licence to practice the profession of dentist”; granting the right to practice the profession within a specific scope of activities, time, and place of employment in a medical entity and issuing the documents: “Licence to practice the profession of doctor” or “Licence to practice the profession of dentist”; and granting a conditional right to practice the profession and issuing in this case the documents: “Licence to practice the profession of doctor” or “Licence to practice the profession of dentist”. It should be remembered that in the aforementioned Article 5, the legislator enumerates only some examples of these tasks. Undoubtedly, the independence of the professional self-government of doctors is confirmed by the establishment of the organs of a district chamber and of the Supreme Chamber. The organs of a district chamber are as follows: district congress of doctors; district medical council, district audit committee, district medical court, and district ombudsman for professional responsibility, whereas the organs of the Supreme Chamber of Physicians are the following: National Congress of Physicians, Supreme Medical Council, Supreme Audit Committee, Supreme Medical Court, and the Supreme Ombudsman for Professional Responsibility.

Professional responsibility of doctors as a consequence of the supervision exercised by the professional self-government

Members of the professional self-government of doctors can bear professional responsibility for violations of the rules of professional ethics and the regulations related to the practice of the profession. Professional responsibility proceedings consist of 4 stages [33]: verification proceedings, explanatory proceedings, proceedings before the medical court, and enforcement proceedings. The purpose of the verification proceedings is to make a preliminary examination of the circumstances necessary to determine whether there are grounds for initiating explanatory proceedings. During the verification stage, there is no expert evidence or any actions for which it would be necessary to make a report, except that the person filing the complaint can be heard as a witness. On the other hand, during the explanatory proceedings it is determined whether an act that may constitute professional misconduct has been committed, the circumstances of the case are clarified, and if any elements of professional misconduct have been found, the accused is identified, evidence is collected, secured, and, to a necessary extent, recorded for the medical court. The medical court may impose the following penalties [34]: admonition, reprimand, financial penalty [35], prohibition on exercising managerial functions in organizational health care units for 1–5 years, restriction of the scope of medical profession practice for 6 months to 2 years, suspension of the licence to practise the profession for a period between 1–5 years, and revocation of the licence to practise the profession. It should be emphasised that the financial penalty may be imposed as a sole or additional penalty and is always assigned for a social purpose related to health care, in the amount of at least one-third of the average monthly remuneration up to a maximum of 4 times thereof in the sector of enterprises without payment of rewards from profit, announced by the President of the Central Statistical Office, in force at the time when the decision of the first instance court was issued [35]. During the proceedings before the medical court, both the accused and the injured party may appoint no more than 2 defence counsels from among physicians, attorneys, or legal counsels. The parties, the Minister of Health and the President of the Supreme Medical Council, can appeal for revocation of the final judgement of the Supreme Medical Court to the Supreme Court within 2 months of the date of delivery of the judgement [36]. A revocation appeal with respect to the same accused party and the same judgement may be lodged only once by each entitled person. Such an appeal may also be lodged on the grounds that the penalty is disproportionate. It is inadmissible to grant the revocation appeal to the detriment of the accused party if it was lodged after 6 months from the date the judgement became final.
As a general rule, proceedings before the medical court are open to the public, but in some cases specified by law this public character may be excluded, for example if it could cause a breach of doctor-patient confidentiality, disturbance of public order, violation of good practices, disclosure of circumstances that, due to an important interest of the state, should be kept secret, or a breach of a vital private interest. It is worth emphasizing that the public character of a trial is guaranteed in Article 45 of the Constitution of the Republic of Poland concerning the fair and public hearing of a case without undue delay by a competent, independent, and impartial court. The public character may be excluded only for the reasons listed in Article 45 (2) of the Constitution, which include morality, state security, and public order, as well as the protection of the private life of the parties or other important private interests.
Furthermore, it should be emphasised that professional liability proceedings [37] are not instituted, or instituted proceedings are discontinued, if the following apply: the act has not been committed or there are no data sufficiently justifying that it has been committed, the act does not constitute professional misconduct or the law provides that the perpetrator does not commit professional misconduct, the accused has died, the act is no longer punishable, the proceedings on professional responsibility of nurses and midwives for the same act of the same person have been terminated by a final and binding decision, or the previously initiated proceedings are pending [38].
In conclusion, bearing the above in mind, firstly it should be stressed that, although amendments to the regulations on professional responsibility proceedings ought to be considered beneficial primarily to the injured party (patients) but also in certain aspects (e.g. possibilities of appeal) to the accused, the legal regulations, which are not always clear and transparent, still raise doubts. Therefore, it is necessary to postulate de lege ferenda improvement of the binding legal regulations, so that they are always precise and unambiguous, clear, and thus predictable. Secondly, while at the request of the doctors concerned, decisions on acquittal or discontinuance of proceedings are subject to publication in the press of the professional self-government, decisions on punishment are not subject to compulsory publication. Thirdly, the supervision of the medical profession practice by the professional self-government testifies to the self-government’s independence, but it is also a guarantee that this profession shall be practised with due diligence and in compliance with the rules of professional ethics. Fourthly, the organisation and functioning of the organs of the doctors’ professional self-government, by means of supervision and sanctions, result in professional responsibility incurred in the case professional misconduct is committed or the Code of Medical Ethics is infringed [39].

Conclusions

The present study explores the role of doctors’ self-government in upholding professional responsibility and its impact on various facets of healthcare. Established in accordance with the Chambers of Physicians Act, this self-governing body ensures that doctors adhere to professional ethics and regulations. It carries out investigations into complaints, imposes sanctions, and monitors medical practice. Moreover, it actively promotes risk management, develops policies, and fosters a culture of safety within healthcare institutions [40]. The self-government of doctors assumes a vital role in ensuring professional responsibility, monitoring medical practice, and upholding exemplary standards of healthcare. Economic and managerial factors, along with legal and ethical considerations, constitute essential elements in promoting patient safety, delivering quality healthcare, and instilling public trust in the medical profession. The economic dimension emphasizes the need for doctors to possess professional liability insurance, with the self-government advocating for favourable conditions in this regard. This article underscores the self-government’s unwavering commitment to the public interest and its integral role in decentralized public administration. In conclusion, the self-government of doctors plays a critical role in maintaining high standards of healthcare, ensuring patient safety, and fostering public trust in the medical profession.

Conflict of interest

The authors declare no conflict of interest.

References