Sunday, July 10, 2011

The Hippocratic Oath and the White Coat Ceremony

    Has anyone ever wondered what exactly your doctor has sworn to do? Did he take the Hippocratic Oath? And if he/she did, what exactly is the Hippocratic Oath?

     Well, here are several versions ranging from the original to a much more modern one which has been changed to reflect how medicine is practiced today.
Original, translated into English:[4]
      I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods,  all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:
     To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.
     I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
     I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
     But I will preserve the purity of my life and my arts.
     I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.
     In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.
     All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.
     If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

     There are several problems with this ancient Oath. First of all, it swears by all the Greek Gods, which most of us don't believe in now. In fact since there are many religious traditions around the world even today, should it swear by a religious tradition at all? The second stanza applies to a time when medicine was learned by serving as an apprentice. Therefore the apprentice would swear great fealty to his mentor and teacher to the point of even swearing to take care of him and/or his family financially in the end. This is usually not done today. There is a statement in the Oath that is usually taken to be anti-abortion, and is now a belief not held by at least a small majority of the population. (We have a law that allows abortion.) The statement about entering a home with purity and against sexual contact with patients, as well as the second to last stanza regarding confidentiality is still applicable today. The final stanza is usually regarded as a little too vengeance oriented. That is if you don't abide by this oath and if you do a bad job, the doctor swears that he/she will have bad outcomes in all of the rest of their life. This is a little too reward and punishment oriented for many people today.

     Here is a more modern oath which takes some of these ideas into consideration:

A widely used modern version of the traditional oath was penned in 1964 by Dr. Louis Lasagna, former Principal of the Sackler School of Graduate Biomedical Sciences and Academic Dean of the School of Medicine at Tufts University.

     I swear to fulfill, to the best of my ability and judgment, this covenant:

     I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

     I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

     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.

     I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

     I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

     I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

     I will prevent disease whenever I can, for prevention is preferable to cure.
     I  will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
     If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

     Some medical schools use the Oath of Maimonides, a Jewish scholar, as their Oath at graduation. It appears below:
     "The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
     May I never see in the patient anything but a fellow creature in pain.
     Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.
     Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."

     Others use the Oath of Physicians as outlined below:
From Wikipedia, the free encyclopedia: The Physician's Oath was codified in the Declaration of Geneva (1948) by the World Medical Association. It was adopted by the General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968.

     I solemnly pledge myself to consecrate my life to the service of humanity;
     I will give to my teachers the respect and gratitude which is their due;
     I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;
     I will maintain by all the means in my power, the honour and the noble traditions of the medical profession; my colleagues will be my brothers;
     I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
     I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
     I make these promises solemnly, freely and upon my honour.

     So your physician may have sworn to any of the above, or to any of several others written by individual medical schools, or by graduating student classes. Or they may not have sworn to any Oath at all. I did not! We didn't have any ceremony to take this oath. I graduated from UW Medical School in 1970. At that time, graduation took place with all the undergraduates and all the graduate students in Camp Randall Stadium. There were different times assigned by the graduating school, and for the different post graduate schools. We were called across the stage just like law students and all the graduate students. The only difference was that we were to invite some doctor (MD or PhD) who was supposed to be our mentor to escort us across the stage. (Could have been a respected teacher or mentor or a member of our family if they were a doctor.) But there was no general administration of any oath as part of this ceremony.

     Some years later, when my son graduated from Medical School at UW, the medical graduates participated in another ceremony that preceded the general graduation. This ceremony was only for the MDs, attended by friends and family, and faculty. This ceremony is called the hooding ceremony. Some of you may or you may not know that in the United States of America academic regalia has a hood that is worn over the graduation robes. Each hood has characteristic colors for the degree and for the school which grants the degree. You can therefore recognize where a person graduated from, what degree they have and in what field by their hood. The hood’s length signifies the degree level -- 4 foot long for a doctorate degree; with the institution's colors in the lining and a velvet trim in a color that represents the field of study (Link:  standardized color that signifies the scholar’s field, green for medicine). Many schools include the administrations of the Hippocratic Oath or its replacement at the hooding ceremony.

The 4 foot hood with black and red lining of UW and the green border for Medicine.

     I of course had the same hood that I wore to graduate from Medical School, but we had no hooding ceremony. But there is one other time that I remember wearing that hood just like it was yesterday. That event is pictured below. It is the day my son graduated from UW Medical School and I escorted him across the podium to receive his degree. I had told him early in his medical school days that he better not think of asking anyone else to escort him; I don't care how close he was to other teachers during his medical school days. He said, "Mom, you don't have to tell me this. I know it." That was the proudest day of my life. My oldest son following in my footsteps. Of course, my youngest son also graduated from college and with a Masters and there was great pride there. He followed in his father's footsteps, becoming an engineer. I think it is the greatest statement of respect for your parent to follow the same occupation or profession as mom or dad.
Proud Mom and her graduating son
     Now, most medical students take the Hippocratic Oath or its equivalent which has sometimes been written by their own mentors at their medical school, while participating in the White Coat Ceremony. This is a "robing" or "cloaking" ceremony that usually precedes the beginning of clinical work when there will be patient contact, after the basic medical sciences have been mastered. The origin of this ceremony is  quite recent. In 1989 at the University of Chicago, it was noted that medical students were coming to their first class in interviewing patients in which they would have face to face contact with these patients wearing shorts and baseball caps. It was decided that year to try using a "white coat ceremony" to transition these students into clinical care, to demonstrate to them and the observers that they had a professionalism to uphold and to impress upon them how they appeared to their patients. This idea was kicked around for a few years and then in 1993 at Columbia University the first full fledged White Coat Ceremony was held, in which family and friends were invited. The class took the Hippocratic Oath (or another oath) together and they received their White Coat. It was impressed upon them that from that point on they would always need to "look the part" of doctor whenever they were likely to see patients. Originally medical students didn't start seeing patients until their clinical years of medical school, i.e. junior year. But these clinical contacts were gradually moved backwards to the sophomore year and then even in the freshman year as an emphasis on starting interviewing instructions and face to face patient contact occurred early in medical school. That emphasis of course has many good aspects but it also has some controversial aspects for the White Coat Ceremony. In many medical schools, the White Coat Ceremony is now done in the first days of medical school. This necessitates that the medical school class takes an oath that they have not read before, that they have not contemplated, that promises things that they don't even understand at that point in their education. These oaths would have much more meaning to someone who has actually participated as a team member in the care of at least a few patients providing ethical experience that would clarify some of  the things to which the student is swearing.

      I don't know what the answer is. I didn't have a White Coat Ceremony nor a Hooding Ceremony and yet I think I practiced medicine with the ethical tenets strong in my mind. It seems a little extreme to institute a whole new procedure just because some students wore shorts and baseball caps to their patient interviews. Faculty should have prepared these students beforehand and told them about the requirements in dress. I will never forget a Professor of Medicine that I had at UW. Dr. Middleton had a black derby hat that he carried to all the medical lectures. If someone nodded off, which medical students so deprived of sleep often did, they had the ignominious reception of that derby hat flung across the lecture room like a frisbee, striking their nodding head. I was once on Dr. Middleton's teaching rounds. We were standing in the hallway discussing the next patient we would be seeing on rounds. Dr. Middleton looked us over. One student had his hands in his pockets. Unprofessional! Dr. Middleton chastised him. Another was leaning against the wall. Dr. Middleton's words straightened him up. He told me that it looked like I had slept wrong on my hair. Another male student had a yellow short sleeved shirt under his white coat. Dr. Middleton told him he looked like a bartender; he'd better invest in some white shirts. We didn't need a White Coat Ceremony. We had Dr. Middleton.

     I am retired now, and I have found the following oath for Retired Physicians. I like this one: it applies to me in that I am trying to use my medical knowledge and even more my life experience to write this blog and to give public talks about various topics to groups that want to listen. Here is that Oath for Retired Physicians. I never took the Hippocratic Oath officially, so I tell you here that I have taken this one.

Recognizing that a life well lived is a debt well paid, there is yet a time for direct accounting. On my inner sense of rightness, expressed as a sacred honor, I retire from active medical practice, solemnly pledging my continuing strength of mind, body, and resources toward repaying real and current debts accrued in the course of a full and rewarding physician's life
To my family, I owe years of time they granted with forbearance and understanding while sustaining me in patience and affection despite my absences in mind and body
•To my teachers, I acknowledge an obligation of knowledge and skill that calls for return, however modest, through continuing teaching and reflection. Their wisdom in showing me how the art and science of medicine are never connected by “either or” but always by “both and” is treasure beyond recompense
•To my community, for directly and indirectly providing for my medical education, I owe considerable sums only partially repaid through charity services to the poor and duty to the nation in time of war and peace. Greater than money has been society's gift of personal respect bestowed on me and my profession with generous allowance for more than life's necessities
•To organized medicine, I am indebted for warm welcome in foreign lands, unexpected honors, and the opportunity to share in making a difference, measured in diminished human suffering
•To patients, I owe countless debts for transgressions of time, ignorance, and inadvertent arrogance. But most important, the balance is wanting in matching patients' abiding trust in sharing their pain, suffering, and their very lives, to the secrets of their hearts
•With keen awareness that remaining life is short and time is precious, as mind and body permit, I dedicate myself to a sustained sense of humanity expressed through the spirit of medicine. Though I can never repay my accumulated debt, I am proud to be known by it.


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