Burgeoning young medical students, clad in pristinely starched, stiff, bleached white buttocks-length coats, almost blindingly white, clean lines from having just been unpacked from the manufacture from whence they came running the length of both sleeves, not a minuscule wrinkle to be found on the heavenly uniform, with either cursive embroidery identifying them by name while subliminally marking the area where the aorta of the heart bifurcates or, if you want to save $10, in place of embroidery hangs a neat rectangular with the same formality (but nevertheless locating like a pin on a cadaver the same important split of the heart’s main vessel,) all line up next to each other, their shoulders almost touching, looking like they are about to face a firing squad, on the first day of medical school orientation.
Looking back that’s exactly what we were doing: facing a firing squad. If we had been standing individually it would have been similar to waiting for the delivery of your sentence by the jury after a lengthy trial (or so I would imagine.) “We the jury find you worthy of attending our institution for $75,000 a year to become one of us, one of the best in the world, one of the top makers and leaders of society.” But first we had to take the oath. The Hippocratic Oath that all medical students must swear by during a ridiculously formal and large ceremony before even peaking at the inside of a textbook.
The Hippocratic Oath. No one had warned me of this–not even my father. In fact, I had no idea it even existed. My first thought was: really? You’re going to make us swear by these ancient ethical set of rules? Like suddenly if one of us carried a skewed moral compass we’d freely walk off the stage, handing over our white coats to a faculty MD, and leave the auditorium in surprise and not return. OF COURSE THESE PRINCIPLES SHOULD BE ADHERED TO. What should this oath really be called? Common sense. Is it that inconspicuous to the point that any of us need to be reminded to be not just good physicians but decent human beings? I guess that was the first Code Black that I heard but disregarded in favor of the majority’s opinion.
Why are we reciting this? Because it’s always been recited. Well how would just saying these words keep any future MD from doing the opposite? Well because they have to swear by it. So what? You think one of us will be confronted with a medical ethical dilemma and we will look up this set of guidelines in our notes and know immediately what the next course of action should be? No rational thinking involved? Well it’s just medical students have always been required to recite it. OK–I mean I see what the point was but I will say right away that I came to realize over the next three years that this “oath” was too frequently ignored and adherence was only 50% at best. Guess it wasn’t common sense to some.
The Hippocratic Oath. One of the most widely known Greek medical texts. An oath taken by physicians. An oath requiring a new physician to swear, by a number of “healing gods,” to uphold specific ethical standards, historically speaking. Per Wikipedia, “The Oath is the earliest expression of medical ethics in the Western world, establishing several principles of medical ethics which remain of paramount significance today.” OK so what did we have to swear to that day?
FIRST DO NO HARM. Pretty fucking obvious. Unless one of us was an undercover assassin who had used medical school as some lengthy, and inefficiently, roundabout, means of unleashing a mass casualty event, no shit. Why would we want to do harm to our patients. Well, it turns out “harm” is subjective. Very subjective. And while I interpreted this first principle as not violating the inherent rights of a patient, I soon learned many of my classmates held various different interpretations.
So each modern medical school existent today, in the US at least, holds some variation of a Hippocratic Oath-swearing ceremony for its new students but the exact words vary from one school to another. The gist though is essentially the same.
I WANT TO BE CLEAR BEFORE I PROCEED: many, probably the majority, maybe 60% or 70%, do correctly interpret the oath and practice medicine according to its guidelines without conscious thought throughout their long-lived careers. But not all. And for sure not enough of them.
The other issue is from the viewpoint of patients, most of whom have never heard of the Oath, let alone how it guides the medical treatment they receive.
So the lines are indeed not as distinct as I initially thought. They aren’t even minutely clear. They are a haze, a blur, and entangled in a confusing web of medical bureaucracy and industry and capitalism and politics and individual thought. The oath is like factually telling a child not to touch the stove without ever explaining how a stove works or what fire is or how it burns or what a burn is or how it sears the flesh and inflicts a persistent gnawing pain or, even to the extreme, can produce something called death. Just don’t touch it ok? Ok Mom.
That’s what medical school is at it’s core: a parental governing body to teach, instruct, mentor, guide, until its students are ready and prepared and equipped to leave the nest and cope with the ups and downs of life so as to successfully deal with it and survive.
But there’s so much to learn in four short years (really two sets of distinctly different two years of absorbing then observing then trying independently.) There’s not much time to ensure everyone’s compass is pointing to True North before sending them out into the complex world of healthcare to lead and treat everyone else who never spend those years under a medical parenting unit. I guess this is how WebMD was born. A sense of distrust in the medical system and a lack of informative communication between patient and physician. Patients want that second opinion to reassure them that their provider’s moral and medical compass is indeed pointing to True North. But that’s a different subject for a different post.
Back to the drawing board: the Hippocratic Oath.
So we can’t do harm. This is also referred to frequently in medicine as “non-maleficence”—which is synonymous with the first Hippocratic vow. What else are we “supposed” to or not “supposed” to do?
As I mentioned previously, each school has its own modified version that is actually rewritten (with the original Oath as a referential backbone) by the incoming class’ students themselves. Actually, “Do No Harm” is not even found in the original oath but included as a rough translational interpretation. In its place are modernized oaths, which combine the idea of “do no harm” with vows to remember both the human beings on the other end of the stethoscope and their social, emotional, physical, and financial well-being when treating them.
The second principle is a chimera, mirrored opposite, of the first: “beneficence.” Non-maleficence balanced by beneficence—or the promise to only promote the well-being of our patients. See my original annoyance? Seems pretty fucking straightforward.
“I will remember that I do not treat a fever chart, or a cancerous growth, but a sick human being,” medical students vow at the symbolic white coat ceremonies across the country, promising to practice ethically sound medicine as they embark on the journey towards MD. Anything confusing you yet?
Well the original version of the Hippocratic Oath should. That oath has several glaring problems. For starters, it refers to looking to the Greek gods: “I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses,” the oath begins. The original oath also asks doctors never to “give a woman a pessary to procure abortion,” and to abstain from euthanasia (“I will neither give a deadly drug to anybody who asked for it”). These 2,000-year-old statements are obviously omitted in modernized versions.
A fraction of schools use an oath written by Lasagna (really.) “I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug,” Lasagna’s oath reads. Lasagna’s version further calls on doctors to admit when they don’t know the answer; prevent diseases; and to take responsibility not just for the patient’s health, but for the way an illness affects a person’s “family and economic stability.” Heavy responsibility but that’s what the heavy paycheck is for right?
Lasagna…Hippocrates. Doesn’t really matter. The oaths are inherently the same.
An article published by the US News and World Report in May of this year urges medical students to practice some version of the Oath before they even graduate; wait, so the US News and World Report, as well as all med schools, expect us to be just, kind, rational, empathetic human beings? Mind-boggling. The article goes on to remind students of 3 things:
1. Don’t be ashamed to say “I don’t know.” This is implied in all oaths. Better to ask and learn then to guess and kill right?
2. “Gladly share such knowledge as is mine with those who are to follow.” Ok doesn’t seem problematic. This statement is, in fact, extant in the original version of the Hippocratic Oath.
3. “I will remember … that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” The article states, “As a physician, you will swear to treat your patients with respect – respect for their privacy and respect for them as human beings. Your every interaction with patients, staff and colleagues requires mutual respect and consideration to create an optimal environment for health.” Further it explains, “Be more conscious of how you speak and interact with people in all walks of life. Use an on-campus job at the bookstore or dining hall as a learning lab, since people are routinely short on time and sometimes patience. Developing the ability to respond to uncivil behavior with compassionate behavior is an achievable skill that aids patient safety and quality of care.” Seems straightforward enough agreed? Well this is the principle which, I found, many medical students cannot successfully demonstrate during discussions on medical ethics or on rounds. Why? What are the issues compounding the confusion and inability on the part of these soon-to-be MDs in practicing this, in my opinion, most crucial vow of any medical oath?
In future posts I will detail some of the successes and failures of practicing these essential medical principles that I witnessed while a medical student myself. I will discuss what I think the obstacles were and how these obstacles are prevalent in various subsets of the medical field.
I INTEND NOT TO DENOUNCE MEDICAL SCHOOLS, including the one I attended. Rather I think it’s important that these deficiencies or failures on the part of too many medical students to understand THE PATIENT AS A HUMAN BEING should be discussed and addressed so the medical field can continue to improve and evolve and enroll students who have the innate ability to “tell right from wrong.” It’s not the medical school’s responsibility to correct the characters of its students. So let’s avoid further hypocrisies from occurring despite the insistence of the oath. Let’s choose students who already know how to treat people to become MDs instead of trying to continually drain the stubbornly persistent abscess present in any student’s integrity or core character. If a simple D&C won’t drain it then let’s discharge these students home with some antibiotics and wish them the best in a career other than medicine.
Pulling the Plug on American Medicine 