The average age of the 88 participants was 44.1 years (CI: 42.2-46.1), the average length of time working as a physician was 19.6 years (CI: 17.6-21.5), the average time spent in daily care of patients was 6.8 hours (CI: 6.3-7.4) and that spent on medical students and residents education was 2.3 (CI: 1.8-2.7).
Among the 210 reports, five broad categories of ethical problems were identified. These ethical problems [with their frequencies, including absolute number (n), percentage (%) and 95% Confidence Interval (CI)] were related to:
a. Physician-patient relationships [n = 61 (29.0%, CI: 2.9-35.1)], which comprised difficult interactions with the patients and/or their families including issues such as:
- To ensure confidentiality, especially in adolescent care;
- To cope with difficult revelations (communication of bad news, disclosure of diagnosis, disagreement with diagnosis given by other physician);
- To cope with parents non-adherence to patients' treatment;
- To deal with difficult relationship with the patients' parents;
- To cope with unexpected reactions from family members;
- To manage parents beliefs;
- Conflicts involving the autonomy of parents and adolescents.
b. End-of-life care [n = 55 (26.2%, CI: 20.3-32.1)], which involved challenges and conflicts in terminal situations including issues such as:
- To take the decision to withdraw or whether to withhold or not advanced life support, nutritional support and resuscitation;
- To accept the decision of colleagues of admitting the patient in the Intensive Care Unit;
- To accept the decision of colleagues of prescribing futile therapies;
- To deal emotionally with the situation of patients without therapeutic perspectives;
- To diagnose brain death.
c. Health professionals conducts [n = 50 (23.8%, CI: 18.0-29.6)], which comprised disagreement with physicians or other health professionals conducts such as:
- To disagree with colleagues in the indication of procedures;
- To witness workplace inappropriate attitudes of colleagues in their relationship with patients and other colleagues;
- To disagree with inappropriate personal attitudes of physicians from other workplaces;
- To disagree with inappropriate patient relationship of physicians from other workplaces;
- To disagree with the breach of confidentiality, inappropriate use of medicines or inappropriate personal attitudes of other health professionals.
d. Socioeconomic issues and public health policy [n = 31 (14.8%, CI: 10.0-19.6)], which involved challenges concerning socioeconomic conditions and the public health care system that influence patient treatment, management and protection such as:
- To have to take decisions when the absence of inpatient beds threatens the lives of patients and surgeries are postponed;
- To cope with the social reality of patients, which imposes limits to the adequate management of care, resulting in lack of therapeutic success;
- To cope with the difficulty in referring patients to specialists;
- To cope with violence against children, including neglect;
- To experience problems in the workplace, among them, the lack of specialists, of equipments and of material;
- To cope with problems in the health care system that result in difficulties for patients to have access to more sophisticated diagnostic exams and to surgeries.
e. Pediatric Education Process [n = 13 (6.2%, CI: 2.9-9.5)], which comprised inadequate personal attitudes and interpersonal interactions in the academic environment including relationship between: student-teacher/supervisor, teacher-supervisor, teacher/supervisor-patient, student-patient, teachers-physicians of Basic Health Units such as:
- To witness an ethically reprehensible attitudes of the teachers;
- To witness medical undergraduate students disrespect for the university hierarchy;
- To experience problems such as the allowance by teacher/physician supervisor to residents to act when there is risk to the patient;
- To experience problems in the relationship professor/physician supervisor-patient, such as inadvertent exposure of patients and discussion of cases in corridors;
- To experience problems in the relationship between teachers/physician supervisors, such as public criticism and disrespect authorship in scientific publication;
- To witness problems in the personal attitudes of undergraduates and residents.
The distribution of the ethical problems reported according to the sociodemographic and occupational characteristics of the participants is presented in Table .
Distribution of the ethical problems according sociodemographic and occupational characteristics of the participants.
In Poisson regression, it was found that fewer ethical problems related to the SEPHP were reported among the participants who worked in hospitals when compared to those who worked in the Basic Health Units [PR = 0,3 (CI 95% 0,12-0,72)] (Figure ), as well as among those whose clinical practice is as pediatrician (general and subspecialties in pediatrics) [PR = 0,34 (CI 95% 0,14-0,81)] when compared to clinical practice as family physicians (Figure ). This association was maintained when medical specialties were compared: family physicians to subspecialists pediatricians and general pediatricians [PR = 0,3 (CI 95% 0,09-0,98) and PR = 0,35 (CI 95% 0,14-0,85)] (Figure ). There was no statistical significance in the prevalence ratio of ethical problems related to PPR, HPC and PEP, when comparing workplaces, medical specialties and areas of clinical practice, which shows that the frequency of reports of these categories of ethical problems was similar among the participants. The category of ethical problems related to end of life was only reported by the participants who worked in Hospitals and no statistical significance was found in the prevalence ratio of this category when comparing general pediatricians to subspecialty pediatricians.
Figure 1 Prevalence Ratio: work in hospitals compared to work in the Basic Health Units (exposure) and presence of at least one report in the category of ethical problem (outcome). Note: Two outcomes were omitted: End of Life Care (not reported by family physicians) (more ...)
Figure 2 Prevalence Ratio: clinical practice is as pediatrician compared to clinical practice as family doctor (exposure) of at least one report in the category of ethical problem (outcome). Note: Two outcomes were omitted: End of Life Care (not reported by family (more ...)
Figure 3 Prevalence Ratio: medical specialty-general pediatrician or subspecialist pediatrician compared to family doctor (exposure) and presence of at least one report in the category of ethical problem (outcome). Note: Two outcomes were omitted: End of Life (more ...)