The NMC Code of Ethics & Professional Conduct: A Practical Guide

Translating the Ethical Code into Daily Practice for a Consulting Physician

Dr Neeraj Manikath , claude.ai

Word Count: ~2000 words

ABSTRACT

The transition from the Medical Council of India (MCI) to the National Medical Commission (NMC) in 2020 brought renewed focus on medical ethics and professional conduct in India. While the ethical principles remain largely consistent, their application in contemporary practice—particularly in the digital era—presents unique challenges for consulting physicians. This review translates the NMC Code of Ethics into actionable guidance for postgraduate trainees and practicing internists, with emphasis on four critical domains: regulation of professional practice, digital-age confidentiality, pharmaceutical industry relationships, and professional misconduct. Through practical scenarios, pearls, and cautionary tales (oysters), we provide a roadmap for navigating the increasingly complex ethical landscape of modern medical practice.

Keywords: Medical ethics, NMC guidelines, professional conduct, medical confidentiality, pharmaceutical industry, professional misconduct

INTRODUCTION

The National Medical Commission Act (2019) and the subsequent Professional Conduct Regulations (2023) represent the most significant overhaul of medical ethics governance in India since the establishment of the MCI.[1] For the consulting physician, these regulations are not merely theoretical constructs but practical frameworks that govern daily interactions with patients, colleagues, and commercial entities.

Pearl #1: The NMC regulations carry legal enforceability. Violations can result in temporary suspension (months to years) or permanent erasure from the medical register, not just moral censure.

The fundamental principle underlying all NMC regulations is expressed in Section 3.1: "The prime object of the medical profession is to render service to humanity with full respect for the dignity of profession and man."[2] This review operationalizes this principle across four domains most relevant to internal medicine practice.

REGULATION OF PROFESSIONAL PRACTICE: The Rules on Running a Clinic, Affiliations, and Commissions

Clinic Establishment and Registration

Every consulting physician must register their practice with the relevant state medical council within 30 days of commencement (Regulation 5.1).[2] This seemingly administrative requirement has clinical significance—unregistered practice may void medical indemnity insurance claims.

Pearl #2: Maintain a "registration file" containing: (1) State medical council registration certificate, (2) Clinic establishment license, (3) Biomedical waste authorization, (4) Drug license if dispensing medications, (5) Professional indemnity insurance policy.

Name Board Regulations

The NMC explicitly permits only one name board at the place of practice, displaying qualifications registered with the council (Regulation 6.1).[2] Superlative descriptions ("best," "super-specialist") are prohibited.

Oyster #1: A diabetologist in Mumbai faced show-cause notice for a board reading "Award-Winning Diabetes Center" after a complaint alleged false advertising. The hearing consumed 18 months and significant legal fees before resolution.

Permitted qualifications include recognized degrees (MBBS, MD, DM), fellowships from bodies recognized by NMC, and membership in professional organizations (MRCP, FACP). However, proprietary certifications from commercial CME companies should not be displayed.

Consultation Fees and Fee Splitting

Regulation 6.4 prohibits "running an open shop" or "fee splitting in any form."[2] This becomes complex in modern practice arrangements:

Permissible arrangements:

Fixed monthly rental for clinic space (market rate, documented)
Salaried employment in corporate hospitals with fixed monthly compensation
Percentage sharing of clinic revenue when all physicians share proportional risk and investment

Prohibited arrangements:

Per-patient fee paid to referring physician (classic "commission")
Percentage kickback from diagnostic centers for referrals
"Consultation fee" paid to another physician for patient referral without actual consultation

Pearl #3: Document all financial arrangements in written contracts. The NMC presumes guilt in fee-splitting allegations unless clear documentation proves otherwise. Verbal arrangements offer no protection.

The Commission Conundrum: Diagnostics and Pharmacy

The most ethically treacherous terrain involves relationships with diagnostic laboratories and pharmacies. Regulation 7.6 explicitly states: "A physician shall not give, solicit, or receive any gift, gratuity, commission, or bonus in consideration of or return for referring, recommending, or procuring any patient."[2]

Modern interpretations:

Diagnostic Centers: Many centers offer 15-40% "discounts" to referring physicians. While framed as "professional courtesy," these function as indirect commissions. The ethical physician should:
- Refer to laboratories based on quality metrics (CAP/NABL accreditation, turnaround time, accuracy)
- Disclose any financial relationship with specific laboratories
- Never accept cash or account credits based on referral volume

Hack #1: Create a "preferred laboratory list" based on documented quality audits. Rotate among 2-3 accredited facilities. When questioned, you can demonstrate selection criteria beyond financial incentives.

In-house Pharmacies: Operating a pharmacy within clinic premises is not prohibited, but the physician must maintain complete separation. The pharmacy should be:
- Registered separately with appropriate drug license
- Managed by licensed pharmacist
- Priced at market rates without markup exploitation
- Optional for patients (written notice that prescriptions can be filled elsewhere)

Oyster #2: An internist in Delhi operated a clinic pharmacy with 300% markups on common medications. A patient complaint triggered investigation revealing the physician personally filled prescriptions. The resulting suspension lasted three years.

Multi-specialty Affiliations and Corporate Hospitals

The rise of corporate healthcare creates new ethical challenges. Physicians working as consultants in hospitals with equity relationships, revenue-sharing arrangements, or "target-based" incentives face conflicts between clinical judgment and financial pressures.

Pearl #4: Contracts with "procedure targets," "admission quotas," or "revenue-based bonuses" create documented evidence of financial conflicts. Negotiate fixed salaries with performance metrics based on patient outcomes, not volume.

The NMC permits physicians to work at multiple hospitals but prohibits "canvassing, touting, or soliciting" patients (Regulation 6.2).[2] In practice, this means:

Permissible: Informing patients of your practice locations
Prohibited: Offering financial incentives for choosing one hospital over another
Grey zone: "Steering" insured patients toward hospitals with better reimbursement

MEDICAL CONFIDENTIALITY IN THE DIGITAL AGE

The Foundational Principle

Regulation 9.1 mandates absolute confidentiality: "It shall be the obligation of a registered medical practitioner to maintain the medical records pertaining to his/her medical patients."[2] The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Amendment Regulations, 2023, extended this explicitly to digital communications.[3]

WhatsApp Groups: The Modern Minefield

The ubiquity of WhatsApp in Indian medical practice has created unprecedented confidentiality challenges. Common violations include:

Case discussions with identifiable information: Posting "47F with SLE, creat 4.2, what to do?" in consultant groups
Sharing clinical photographs: Skin lesions, ECGs, or radiology images containing patient identifiers
Voice notes discussing cases: Often recorded in clinical areas with background conversations audible

Pearl #5: The "anonymization rule": Before sharing any case, remove (1) name, (2) hospital/clinic location, (3) date of birth/exact age, (4) rare conditions that make identification possible, (5) geographical identifiers. Use "adult male" or "middle-aged female" instead of specific ages.

Hack #2: For educational case discussions, create a standardized template: "Case: [generic descriptor], Presenting complaint, relevant positives, question." Request colleagues respond in thread, not group. Delete cases after 48 hours.

Telemedicine: Regulatory Requirements

The Telemedicine Practice Guidelines (2020) established India's framework for remote consultations.[4] Key confidentiality requirements:

Platform selection: Use services compliant with Information Technology Act, 2000, with end-to-end encryption
Consent documentation: Written consent (electronic acceptable) for telemedicine consultation
Record maintenance: Telemedicine notes held to same standards as in-person documentation
Prescription requirements: Digital signature or scanned signature mandatory

Oyster #3: A physician conducting video consultations via consumer-grade video platform inadvertently had recordings stored on foreign servers. A data breach compromised 300+ patient consultations, resulting in civil litigation and NMC proceedings for inadequate data protection.

Pearl #6: Never use personal WhatsApp for formal consultations. Platforms like Practo, mfine, or institutional telemedicine services provide legally compliant infrastructure with audit trails.

Social Media: Professional Boundaries

The temptation to discuss "interesting cases" on Twitter/X, Facebook, or Instagram poses significant risks. Even thoroughly anonymized cases may violate confidentiality if:

The patient discovers the post and recognizes themselves
Unique combinations of features make identification possible
Screenshots circulate beyond intended audience

Hack #3: Apply the "newspaper test": Would you be comfortable if this post appeared in tomorrow's newspaper with your name attached? If hesitation exists, don't post.

For legitimate medical education on social media:

Obtain explicit written consent for any case discussion, even anonymized
Consider using composite cases (amalgamating features from multiple patients)
Never post from clinical areas where background elements might identify location

The Consultant's Dilemma: Hospital Email Systems

Many institutions use unencrypted email for patient information. While institutional policy may mandate this, individual physicians remain ethically responsible.

Pearl #7: When emailing patient information within hospital systems, use "secure message" functions if available. If discussing sensitive information (HIV status, psychiatric diagnosis, genetic conditions), request in-person discussion rather than digital communication.

RELATIONSHIPS WITH PHARMACEUTICAL COMPANIES

The Regulatory Framework

Regulation 6.8 addresses pharmaceutical interactions: "A registered medical practitioner shall not receive any gift, travel facility, hospitality, cash or monetary grant from any pharmaceutical or allied health care industry."[2] The 2023 amendments strengthened enforcement mechanisms.[3]

Permissible Interactions

Despite popular belief, not all pharmaceutical interactions are prohibited:

Allowed:

Attending scientific conferences with registration paid by company (if conference has genuine CME value)
Receiving modest meals (defined as <₹500/person) at scientific meetings
Accepting drug samples for clinical evaluation
Participating in legitimate clinical trials with ethics committee approval
Receiving payment for faculty positions at educational programs (if based on fair market value for expertise)

Prohibited:

Cash gifts or equivalents (gift cards, vouchers)
Expensive entertainment (tickets to IPL matches, resort weekends)
Travel unrelated to scientific meetings
Sponsorship for family members
Gifts exceeding minimal value (NMC suggests <₹1000, though not explicitly codified)

Pearl #8: The "spouse test": If you wouldn't be comfortable explaining the benefit to your patient's spouse, it's likely inappropriate. "The company paid for my conference registration to learn new treatment approaches" passes; "They sent me to Dubai with my family" does not.

Continuing Medical Education (CME) Sponsorship

The grey zone of industry-sponsored CME requires navigation:

Red flags indicating inappropriate sponsorship:

Luxurious venues disproportionate to educational content
"Educational program" that's primarily social
Faculty selected based on prescription volume, not expertise
Content consisting primarily of product promotion

Green lights suggesting legitimate education:

Accreditation by recognized medical bodies
Balanced faculty including non-prescribers (basic scientists, epidemiologists)
Disclosure of speaker relationships
Evidence-based content with literature references

Hack #4: Maintain a "CME log" documenting educational value (credits earned, topics covered, how information changed practice). This demonstrates education purpose if questioned and aids in license renewal requirements.

The Prescription Drug Dilemma

Physicians face constant pressure to prescribe specific branded medications. Ethical prescribing requires:

Evidence-based selection: Choose drugs based on efficacy, safety, and cost-effectiveness
Generic prescribing when appropriate: Indian Medical Council regulations encourage generic prescribing
Transparency about relationships: Disclose if you've received research funding or speaking fees related to prescribed medication

Pearl #9: When prescribing expensive branded medications over cheaper generics, document clinical rationale in medical record: "Patient has failed generic formulation with documented non-adherence due to side effects. Brand X chosen for improved tolerability profile."

Sample Management

Drug samples serve legitimate purposes (assessing tolerance before full prescription, providing short-term treatment for indigent patients) but can be misused. Ethical sample management:

Maintain samples in secure, organized storage
Log distribution with patient name and date
Never provide samples preferentially to insured patients while charging uninsured patients
Decline samples for drugs you wouldn't prescribe based on evidence

Oyster #4: An endocrinologist exclusively prescribed newest insulin analogs, with sample closet stocked by manufacturers. Investigation revealed undisclosed speaking fees totaling ₹18 lakhs annually from manufacturer. Although prescriptions were clinically defensible, the undisclosed relationship constituted ethical violation.

PROFESSIONAL MISCONDUCT: What It Entails

Defining Professional Misconduct

The NMC defines professional misconduct broadly (Regulation 10): "Any act of commission or omission on the part of a registered medical practitioner, contrary to such conduct as specified under various provisions of the Regulations."[2] Categories relevant to consulting physicians:

Advertising and Self-Promotion

Regulation 6.1 prohibits soliciting patients through advertisements, which includes:

Clear violations:

Newspaper/television advertisements promoting individual physician
"Health camps" primarily designed for patient recruitment
Offering consultations at reduced fees to attract volume
Testimonials or before/after photographs
Claiming superiority over colleagues

Permitted activities:

Publishing research in peer-reviewed journals
Speaking at scientific conferences
Institutional advertisements (hospital/clinic, not individual physician)
Educational content without self-promotion

The social media challenge: Personal websites and social media presence create ambiguity. Guidelines:

Educational content without promotional language is acceptable
Listing qualifications and areas of expertise is permitted
Patient testimonials and outcome claims cross into advertisement
"Book appointment" buttons acceptable if part of institutional website

Pearl #10: The "information versus advertisement" distinction: "I specialize in diabetes management" (information) versus "I provide the best diabetes care in the city" (advertisement).

Sex Determination: Zero Tolerance

The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994, makes sex determination and related activities criminal offenses.[5] For internists, this rarely arises directly but has implications:

Mandatory reporting if patients disclose sex-selective intentions
Prohibition on sharing ultrasound reports revealing fetal sex (even if performed by radiologist)
Due diligence when referring pregnant patients to diagnostic centers (ensure PCPNDT compliance)

Oyster #5: A general physician referred a pregnant patient to an ultrasound center later found conducting sex determination. Although the physician had no knowledge of the practice, his referral pattern (predominantly to this center) triggered investigation. The resulting legal entanglement lasted two years.

Issuing False Certificates

Regulation 10.1(m) prohibits issuing "any certificate, report, or other document...unless personally satisfied of its truth."[2] Common scenarios:

Sick leave certificates: The pressure to provide "courtesy" sick leave without examining patients

Ethical approach: Examine patient (even brief telemedicine evaluation) before certifying
Documentation: Note symptoms and findings justifying work absence
Refusal when appropriate: "I can't certify you're unfit for work without evaluating you"

Fitness certificates: For employment, insurance, or travel

Requires appropriate examination for purpose
Document specific assessments performed
Decline if unable to accurately assess (e.g., complex cardiac clearance without appropriate testing)

Pearl #11: Every certificate is a legal document. Use template formats that include: date of examination, specific findings, functional limitations (if any), duration of recommendation, and physician's registration number.

Sexual Misconduct and Boundary Violations

Regulation 10.1(g) addresses "infamous conduct in any professional respect."[2] Sexual misconduct constitutes the most serious violation:

Patient-physician sexual relationships are always unethical (power imbalance precludes true consent)
Chaperone requirements: female chaperone for intimate examination of female patients (mandatory)
Examination of minors: parent/guardian presence required

Modern considerations:

Inappropriate social media contact with patients
After-hours communications without clinical justification
Romantic relationship with former patients (NMC suggests minimum 2-year waiting period)

Substance Abuse and Fitness to Practice

Physicians struggling with substance abuse face ethical and legal obligations. Regulation 10.1(h) addresses "addiction to a drug or substance abuse or being under the influence of such."[2]

Self-reporting requirement: Physicians aware of their impairment should voluntarily restrict practice and seek treatment

Colleague obligation: Physicians who become aware of impaired colleagues should:

Attempt direct conversation expressing concern
If unsuccessful, report to hospital medical staff committee or state medical council
Do not compromise patient safety to protect colleague

PRACTICAL FRAMEWORKS FOR ETHICAL DECISION-MAKING

When facing ethical dilemmas, apply this systematic approach:

The Four-Box Method:[6]

Medical indications: What is the clinical situation?
Patient preferences: What does the patient want?
Quality of life: What are the prospects with/without treatment?
Contextual features: Are there external factors (legal, financial, cultural)?

Pearl #12: When an ethical dilemma arises, document your decision-making process in the medical record. "Discussed treatment options A, B, C with patient. Patient expressed preference for B despite higher cost. Confirmed understanding of alternatives. Proceeded with B." This demonstrates thoughtful, patient-centered decision-making.

The "Publicity Test": Would you be comfortable with your decision appearing in a medical journal case report with your name attached? This simple test eliminates most questionable practices.

CONCLUSION

The NMC Code of Ethics provides the framework for professional conduct, but its translation into daily practice requires constant vigilance, particularly as technology and healthcare delivery models evolve. The consulting physician must balance multiple obligations—to patients, profession, society, and commercial entities—while maintaining the integrity that defines medical practice.

Final Pearl: Ethics is not about perfection but about intention, transparency, and accountability. When errors occur—and they will—acknowledge them, learn from them, and adapt your practice accordingly. The truly unethical physician is not the one who makes mistakes but the one who rationalizes them.

The principles outlined in this review represent not merely regulatory compliance but the foundation of trust upon which the patient-physician relationship is built. As the medical landscape continues to evolve, these ethical moorings become increasingly essential.

REFERENCES

National Medical Commission Act, 2019. Ministry of Law and Justice (Legislative Department), Government of India. Available at: https://www.nmc.org.in/
Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 (as amended 2023). National Medical Commission, Government of India.
National Medical Commission. Amendment Regulations on Professional Conduct. 2023. Available at: https://www.nmc.org.in/information-desk/for-colleges/regulations/
Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. Board of Governors, Medical Council of India. March 25, 2020.
The Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994 (as amended 2003). Ministry of Health and Family Welfare, Government of India.
Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 8th ed. New York: McGraw-Hill Education; 2015.

Disclosure Statement: The author declares no conflicts of interest.