Monday, 01 July 2019 14:20

Medical oaths and self-care

The majority of medical graduates swear some kind of oath, usually at graduation. The traditional Hippocratic Oath is used by a diminishing number, with a version of this, the Geneva Declaration and other prayers forming more popular commitments by new doctors and nurses.

Hippocrates is widely considered to be the Father of Medicine. He founded the Hippocratic School of Medicine in ancient Greece, and oversaw the intellectualisation of healing and medicine being established as a profession.

Declarations, rather than oaths, are now more popular amongst graduates, given their nature as a commitment to an ideal of an intention to help those who are in our care, rather than swearing an allegiance to an introverted club.

Critics of oath taking site self-importance and paternalism as undesirable consequences of the process.

I consider the process of making a declaration of my resolve to behave with integrity guided by my core values, and those of my profession, is an important anchor point in the dynamic and complex environment I work in as a medical doctor.

There are many excellent examples of such declarations, and I particularly like the University of Minnesota Medical School pledge, quoted below:

“With gratitude for the privilege of becoming a physician, I pledge this oath to myself, my patients, my colleagues, and my community:

I pledge to care for my patients with all that I have to offer, knowing that when I take care of myself, I have the most to give. I will use my knowledge and compassion to empower patients to be champions of their health and well-being. I will care for patients with cultural competency and respect. Recognizing the power and responsibility of being a physician, I will meet vulnerability with humility. I pledge to see the person behind the disease. 

I pledge to exemplify the integrity and the virtues that sustain the practice of medicine. I aspire to excellence while being mindful of my limitations and open to the voices of others. I will nourish my practice with a commitment to lifelong learning. I pledge to honor the passions and obligations that define me as a person, both in medicine and life. 

I pledge to learn diligently from my patients, colleagues, and communities, to advance the art and science of healing. I will strive for excellence through innovation in evidence-based medicine, respecting its utility and acknowledging its limitations. I pledge to bridge scientific advancement and social equity. I will challenge the barriers that keep my patients from care, and I will raise my voice to call out injustice and celebrate progress.

With this oath, I pledge to honor the traditions of those who came before me, and the hopes of those I serve. May I long experience joy in the healing of those who seek my help.”

The aspects I appreciate in this pledge include:

  • Its overarching value of humility, which reduces the risk of self-important paternalism.
  • Its patient-centric message, which, again, underlines the importance of humility.
  • A theme of compassion and high emotional quotient in interactions with those in our care.
  • An appreciation of the balancing of art and science in the practice of medicine, with a high value placed on evidence and research.
  • Its value of justice, which highlights the role medicine has in our wider communities.
  • The language of ‘nourish’, ‘passion”, ‘excellence’, and ‘joy’, which speak to the goal of flourishing in our role as medical healers.
  • An acknowledgement of the meta-narrative of medicine, with respect of what has gone before, as well as the environment we work in now.

Our New Zealand colleague, Dr Sam Hazledine, from Queenstown, lit up the international media in 2017 by leading the unanimous adoption of an amendment to the Declaration of Geneva (a modern version of the Hippocratic Oath). This came as a result of concern for increasing burn-out and stress in the medical profession.

Dr Hazledine commented that ‘Doctors haven’t been taking care of their own health because we’ve been operating under the paradigm that we should sacrifice ourselves to look after our patients’.

The amendment reads:

‘I will attend to my own health, well-being, and abilities in order to provide care of the highest standard’.


 

Medical doctors are particularly vulnerable to poor self-care. The reasons for this are many and varied, including work stress, relative isolation, patient demands, lack of professional support, and poor insight.

Yesterday I met with one of my colleagues, an excellent doctor, who is successfully navigating a stormy sea of poorly managed workplace stress, concerns regarding clinical practice, and patient complaints.

A Royal New Zealand College of General Practitioners survey in 2016 identified 22% of doctors reporting burn-out. Australian figures report the medical profession suffering the highest levels of psychological distress and suicide rates of all professions and across the general population. Professor Karen Domino of the University of Washington School of Medicine reports half of all US physicians across 30 specialties complain of burn-out and 60% are considering leaving the profession because of it. Recent research by the American Academy of Orthopedic Surgeons reported 87% of doctors being stressed, and over half would, in hindsight, not choose to become a doctor.

Figures from New Zealand report 11% of complaints to the Medical Council relate to substance abuse by doctors, and recently, over a three year period, 43 cases requiring disciplinary action were reported. Of course, highly functioning doctors are very unlikely to reveal or report their substance abuse issues, and so the reality of this poor self-care is much greater than anyone knows. Australian NZ Doctors in Recovery is an organisation run by doctors to provide a safe place to report and resolve such substance abuse issues.

This makes pretty grim reading for a profession dedicated to healing.

My colleague is successfully navigating his clinical practice issues due to the support and nurturing environment offered by his work-mates, who identified concerns, raised them appropriately, and provided appropriate solutions. More importantly, he, to his credit, had enough insight and motivation to acknowledge and engage with the remedial process. This has resulted in impressive development of his clinical practice and relationships with both patients and staff.

The amendment by Dr Hazledine is one I both fully endorse and feel does not go far enough. Doctors, by virtue of their standards of being driven and committed to high performance, are often not particularly good at being self-aware. Placing the responsibility of ‘my own health, well-being and abilities’ at the feet of this, perhaps already over-extended clinician, risks further unreasonable demand, sense of failure or inadequacy, and thus more entrenched patterns of poor self-care.

Rather, I would suggest that self-care should not be separated from community-care. Very few of us work in total isolation, but many of us, who are surrounded by a team of capable people, tend to work behind closed doors or with minimal social connection. I think we, as social animals who work in health care, have an obligation to care for each other and contribute to the self-care of those around us. Of course, there is no formula for this; each person and each group needs to figure what this looks like for their own situation.

Image result for professional mentoring

One particular concern is how few of my fellow doctors participate in any form of professional supervision and mentoring. Many professions, who engage in highly emotionally demanding work, such as teachers, counsellors, psychologists, and pastors, are required by their professional bodies to engage in this process. Doctors are not. Sure, we are encouraged as part of our professional development to participate in peer group activities, but there is no formal component recognising the mental and emotional demands of the role, and the toll that can take. Again, it is left to the individual doctor to self-care.

Professor Domino states that the medical environment and workplace in which doctors find themselves stressed needs to be changed, rather than exclusively focusing on the individual’s need to self-manage. Dr Hazledine has established an organisation called MedWorld, with aims to research doctors’ stress, advocate for well-being, develop systems to help doctors thrive, and to celebrate doctors.

I encourage us all to make good use of the opportunities we have in our networks and build better systems of self and community care.

Last modified on Saturday, 08 August 2020 21:21

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