Convocation and Hippocrates.

University of Arkansas for Medical Sciences
College of Medicine
Honors Convocation, Class of 2009

Administration of the Oath of Hippocrates

I do solemnly swear by all those things I hold most sacred that I will lead my life and practice this art in uprightness an honor;

That I will be loyal to the practice of medicine and just and generous to its members;

That into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power, holding myself far aloof from wrong, from corruption, from the tempting of others to vice;

That I will exercise my art solely for the betterment and cure of my patients and will give no drug, perform no operation, for a criminal purpose even if solicited, far less suggest it;

That whatsoever I shall see or hear of the lives of men and women which is not fitting to be spoken, I will keep inviolably secret.

If I be true to this oath, may a full life and good repute be ever my fortune; with the respect of all good persons, in all times. But should I trespass and violate this oath, may the reverse be my lot!

Quite a difference from the original translation, as published in the National Library of Medicine:

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract:

To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.

I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.

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.

In purity and according to divine law will I carry out my life and my art.

I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.

Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.

Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.

So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.

My long-time followers may recall that I commented on the Hippocratic Oath in my second post, after I posted my Medical Student Oath. At that time, I mentioned that primum no nocere was not a part of the Hippocratic Oath. (See a 1595 copy with the Greek and Latin translation here.) However, the original oath does translate, "I will do no harm or injustice to [my patients]." Notice that this phrase is not in the modern version of the Hippocratic Oath that I was asked to take. Nor does it include an obligation to teach medicine to those who desire to learn it without a fee, or a promise to stay away from surgery, or a pledge against performing abortions, or an oath of not engaging in romantic relations with any of my patients or their family members. It is interesting to note the wording that the medical schools choose to adopt to keep with the tradition of a "physician's oath".

The American Medical Association does not endorse any form of the Hippocratic Oath, though it has its own Code of Medical Ethics. Many "modern" versions of the Hippocratic Oath exist, but it appears that medical schools can pick and choose a version as they see fit. According to one study, in 1993, 98% of schools stated some form of the oath, but in 1928, only 26% included this component. According to a summary of the research in an article in JAMA, while all of the oaths pledged commitment to their patients, only 43% of the 1993 versions vowed for physicians to be accountable for their actions, 14% prohibited euthanasia, 11% invoked a deity, 8% prohibited abortion, and only a shocking 3% prohibited sexual contact with their patients.

In the times of Hippocrates, a verbal oath was a sacred affair; it was more than a promise, it was the fiber upon which society was maintained. But in this day and age in the United States, a vague oath to society is more like a promise -- well-intended, but not shocking if it is broken. We are not required to sign a contractual oath as a requirement for our medical licensure; as long as we do not break the law, we are within our rights to adopt -- or to not adopt -- any code of ethics that we see fit. If someone managed to get into medical school who is unethical, yet they are able to complete the schoolwork -- well, it's too late at that point. If the Boston University medical student had not been arrested for his probable secret life as the "Craigslist Killer", then he would still be standing by his colleagues as a rising third-year medical student. As a former member of the Honors Council during half of my graduate education, I can attest that the ethical board designed for student accountability is laughable.

What does this say about the role of physicians and their requirements and educational process? When did obscure medical factoids become more important than the respect, professionalism and art of medicine? Did it begin with the Flexner report, which standardized medical education across the nation? Is it a reflection of contemporary society, that information becomes more valuable than human relations? Is it the training process, or is it the people that undergo the training? Numerous articles have been written documenting the loss of empathy through the medical education process. Perhaps it is time to reevaluate our priorites in medical education. Perhaps it is time to reinstate accountability as a priority in our contemporary society.

I feel like I am leaving medical school more jaded than I entered. I know more than I ever would have imagined, and less than I feel I should. For those of us without immediate family members in the field, we jumped into each step of our medical education without the guidance we expected. We were told we needed to learn it all, and we were told we were failures when we faltered. We were told to take nine-hour exams we were expected to prepare for on our own in our "free time", we were told to apply for residencies and interviews without guidance, and we were expected to fly around the country for interviews out of our loan checks. Yet, our knowledge of professionalism -- we were to learn by example. We never saw a copy of our version of the Hippocratic Oath until our convocation ceremony, where we were supposed to recite it.

Medical education has become fundamentally flawed. Standardization is necessary, as is the training program of 150-170 students per class -- the need for physicians is ever growing, and supply is not meeting demand. But we have lost something in the standardization and the tightly scheduled requirements -- we have lost the values that once defined our profession. And though Hippocrates' Oath is outdated, it represented inherent values and qualities of the profession. This is what our current system is lacking -- love of our patients and the art of medicine, over the love of our selves and our selfish desires and limitations.

But yay woot -- I've graduated!

Dead Man Walking.

Justin has requested my commentary on the following topic:

If a zombie was brought to my hospital with wounds that would result in the zombie's death without my treatment, would I be obligated to treat him?

I have given this topic a bit of thought. I suppose the first question is your definition of a zombie. Is a zombie a human? Would his treatment (or lack thereof) be better suited for a veterinarian, as he is no longer a human being, but a creature that follows animalistic urges?

But I will submit that the appropriate medical professional would be a physician. His prior status was as a human being, and if "zombism" is assumed to be the result of a transmittable disease in the form of a mass plague, then he would be best treated by a medical doctor. Furthermore, zombies do not exist in the natural order of the animal kingdom, either...so a veterinarian would not be suited to their care, either.

Physicians treat patients in order to ease suffering and/or to continue life. A zombie is a corpse that has been reanimated, and thus is not alive, per se. In addition, because a zombie is a corpse with no forms of communication, personality rationality, or emotion (an entity without a "soul", if you will), then it cannot suffer. Thus, the treatment of a zombie would not ease suffering, nor would it continue life -- though potentially, it could continue reanimation.

This then raises the following question -- what is the ultimate goal of medical care? Is it to continue existence, or is it to ease suffering? The American healthcare system tends to reflect the former view, though the small subset of palliative care physicians follow the latter care model. In other countries' models of care, this question of obligation of care would likely not even be discussed. Zombies are evil, and they lack that spark of humanity that some classify as a soul, and therefore it is a disgrace to the individual that used to reside in that body to allow the zombie to continue to walk among humans.

But do we have the right to define "evil"? And if zombism is the result of a plague, doesn't it follow that the new life created through corpse reanimation is indeed part of the "natural order"? Since physicians are charged to not make paternalistic decisions with regards to the lives and autonomy of our patients, are we therefore ethically obligated to treat? As we are not reanimated corpses, do we truly have the right to suggest that their existence is flawed and unappreciated by the being whose existence we would be allowing to end?

I guess a physician wouldn't know how they would act unless they were in the situation.

But anyway, I have now officially graduated. I am now, finally, a doctor. But I will wait and discuss this in another post.

Banana Pancakes.

To keep to my Jack Johnson theme -- it just continues to be applicable!

As of yesterday, I am twenty-six years old. I believe it was Garth Brooks who sang, "I'm much too young to feel this damn old." There are days when I am frustrated by the details of living I don't know, and there are others when I feel like I know too much for my own good. The night before last, I was at an Ingram Hill concert. Women older than me were partying it up in their cute attire and their flat-ironed hair. I was surreptitiously glancing at my watch at ten-thirty and hiding my yawns -- and Ingram Hill didn't even make it on stage until eleven. Now don't get me wrong -- I very much enjoyed Ingram Hill, Sterling Y, and especially The Red Suite (they were cute). But 10:30 -- unless I'm on call, that's my bedtime! Especially on a weeknight! (At least Lizzie agreed, lol.)

As you guys probably know by now, I matched into a combined double board program in Psychiatry and Child & Adolescent Psychiatry at the University of Massachusetts in Worcester, MA. I'm looking forward to the program, but the process of moving is rather intimidating. I spent the day reading horror stories about the moving process, and I'm now a nervous wreck. We're going to Worcester on Tuesday to attempt to find a place to live. I'm seriously considering selling my Saturn. I've been completing paperwork, trying on white coats, and picking out rotations for next year. My benefits paperwork is available, and I need to start working on it. I need to decide how to handle my Stafford loans in the next couple of weeks, and I need to decide what kind of relocation loan I will need to take. It's a rather stressful process -- once again, I am gambling that I will like a career and a training program, but this time, it is on the other side of the country. Wish me luck!

A wonderful thing happened on Wednesday: it was my last medical school lecture EVER. (It was titled "Not Another Damn Medical School Lecture.") It was actually a somber talk on the perspective of a resident who became a patient in the worst possible way -- as a newly diagnosed AML patient with a poor prognosis. You get a bit of reality when you remember what it is to be the person on the other side of the stethoscope. And, oddly enough, it made me miss hem/onc. It was my road not taken.

I really liked the passage of my birthday card:

Wishing you
everything beautiful in life --
time for the dreams
you hold closest to your heart,
quiet moments to enjoy,
and most of all,
the contentment that comes
from knowing you're loved.

Beautiful, eh?

I'm procrastinating, so I need to get back to preparing for the arrival of my dear friends from Fayetteville. Hope everyone is having a wonderful day-after-my-birthday. *grins*


P.S. With regards to the applicability of the title -- Justin made me banana pancakes for my birthday. He was a great birthday promoter! He knows how much I love birthdays, and he does his best to make them special. I'm very lucky to have him. ^.^

I've been sitting, waiting, wishing...

Kudos to those individuals who know the music artist to which this title references.

As most of you have already figured out, I have submitted a rank list. And in fact, I will find out where I have matched on Match Day, which is exactly one week from today. Forgive me for not posting my rank list online -- if you would like to know, please feel free to call me, where I could explain ad nauseum the reasons I made the decision I made, and, also, my regrets.

The last few weeks have inched by. The minutes have been creeping ever since the rank list was submitted. And in this time of waiting, I have thought of how my life would have been so different, depending on my specialty.

The life of a surgeon, while tempting, was ultimately not the life I would choose for myself. It is a powerful feeling, knowing that you cut people open and (hopefully) fix them. I am sure a time will come in medicine where the concept of the types of surgeries we do today will sound barbaric, but nonetheless, it is an intoxicating feeling to be a surgeon. I could have done it, and I would have been good at it. But I would be afraid that I would have become impatient, perhaps even callous, with the stereotypical annoyance at other specialties. I want to spend time with my patients. And, as my time on neurosurgery is reminding me, surgery is not that specialty. (With the possible exception of ENT. *winks*)

The life of a pediatric hematologist/oncologist, on the other hand, is quite the opposite. They devote themselves to their patients, almost to the extreme. It is the field that most drew me, outside of child psych. I wanted to be that person. I wanted to be the doctor that patients and their families trusted to help them, and I wanted to grieve with them when I couldn't. But many hematologists and oncologists exist in this world. The child psychiatrists are few, and just as needed. It is not as flashy, perhaps. But I believe it will be just as rewarding.

I see myself as a family practice physician, as med/peds, as medicine or pediatrics alone. I see my life as a neurologist, and I see my life as a physiatrist (physical medicine and rehabilitation). I see my life as a geriatrician, or as a gynecologist, or as a plastic surgeon. I see myself in all of the fields of medicine, and sometimes, the lives of those not in medicine. They are all appealing, in their own ways. I remember my first day on medicine wards, the first day of my third year of medical school. I remember the sigh of relief, when I realized I could become an internist, and I would be happy. It was a huge relief, that the previous two years had not been in vain. I was so scared that I wouldn't like medicine. But I had the opposite experience in a lot of ways. I liked it all. (Well, except obstetrics.) I had more trouble deciding what I wanted to do, because I saw myself fitting into each path. And I realized that each path would change me, affect me differently. My ultimate decision came down to, what kind of person did I want to be? How did I want to be there for my patients?

There are days that I grieve for the paths I didn't take. I hope and pray that I made the right decision. But when it came right down to it...it was the only one I could have made.

Final Decisions (Again).

It amuses me that when I finally feel like I've made my decision for good, I hear one more perspective that has the ability to change my mind again.

I am no longer worried about my residency decision. I feel like both of my top programs (and in fact my entire list) will provide good training. But I do hesitate. 'Twill be a relief when I will no longer be able to modify my list.

And, let's be honest. It would be nice to live on a beach for 3-5 years. And it's still an option. *grins*

I was thinking today that the ending of BSG is paralleling my end to medical school. I started watching it during my first year -- Justin tempted me with it while I was preparing for a gross anatomy exam (which was, of course, always, during the majority of my freshman year). As characters grow and change and are lost, I am curious how my own perspectives and ideals have changed during this four year period. In some ways, I really like the person I've become. But I do miss the idealism of first season, even amongst the turmoil.

Today is Valentine's Day. Justin and I have plans that involve sushi later this evening. And, perhaps, a pan of brownies.

I'm re-watching Veronica Mars. I like to think that I could be like her, but I realize too much of my marshmallow is on the outside instead of hidden on the inside like Veronica's. She has a sass that I find appealing. A show comes on before BSG that involves vampires...we always catch the closing scene during an emo moment involving a particular vampire and a blond girl always standing at the doorway of an apartment (last night involved a moment where the Love Interest and the Brooding Vampire (BV) were caressing both sides of a wooden door, unable to reach out and touch one another while the BV narrates the moment by saying he cannot open the door because he fears he will hurt her -- gag). All this to say, the actor who plays Logan Ecchols (Jason Dohring) is apparently a "best friend" vampire in the show. And now, I am vaguely interested in the sappy vampire show, because I like Logan in Veronica Mars. What can I say -- I have a thing for bad boys.

Suppose I have nothing of any real interest to post today. I spent a week in the state hospital with troubled adolescents. I watched a Japanese film (Ikiru) in my Medicine Through Literature class -- I highly recommend it. And I have started studying for Step 3. Same ol', same ol'.

The Last Visit.

I am sitting here in my last hotel room of interview season. It is a stressful time in some ways. But it has become significantly less stressful in others. I have to decide how I want to spend my next five years. And I have the added bonus of deciding for both myself and my significant other, who is supportive to the nth degree. It's difficult to determine what is most important: training program, quality of training, breadth, location, facilities, educational program, research opportunities.

And it is even harder to decide now. Because right now, all that I can think is, "Oh my goodness, I'm so glad it's over."

It's true. I'm going to have to rank the programs that I have visited. I'm going to have to decide if I want to be a masochist and triple board (peds/psych/child psych), or be a Yankee and double-board (combined psych/child psych), or enter a categorical psychiatry program somewhere between Honolulu and Massachusetts and go through this whole process again in three or four years.

But at least, then, it'll be out of my hands. The mystical computer system will tell me where I am going to be, and that will be that.

I'm going to submit my rank list here in a few days.

* * * * *

I was speaking with a fellow fourth year medical student about how the medical education process in many ways destroys the love of learning and the educational process. I am taking two longitudinal weekly night classes to make up for my unanticipated month of interviewing in December that have helped to remind me of the joy I used to have in the classroom setting.

"The History of American Medicine" is being taught by a history professor who is driving in from Memphis every other week for the course. She has such enthusiasm about the topic that it is hard to not love it with her. I have learned the origins of the term "mesmerized" and noted the odd anatomical drawings published by Vesalius in De Humani Corporis Fabrica.





























Yes, in the second picture, the man is holding his own skin. I tried to find the particularly disturbing image of a man holding his own intestines while smiling, but alas, I was unsuccessful.

My other new class of the semester is "Medicine through Literature". This promises to be an interesting course. It reminds me of the occasional intimate classes of undergrad, where class participation is required while we discuss how we critically analyze poetry and other such literary works. I may have gotten into a bit of a disagreement with the literature professor. But I hold by my stance that "correct" interpretations of poetry do not exist -- that it says just as much about how an individual interprets a poem as the actual poem (and author's intent) itself.

It may be a fun end to medical school.

Contemplations of an Overachiever.

I told Justin the other day that I wanted to be chief resident when I am in my last year of residency. He chuckled softly, and when I inquired, he said, "I only wonder when you will finally be able to smile and say, 'I've done enough.'"

This got me to thinking about my public service. I had nine pages of work and volunteer experience on my residency application, when most people in med school have three (so say my interviewers, anyway). And I've worked in public service work I've submitted my ERAS, just because I wanted to, knowing it wouldn't go on a resume.

Something I'm frequently asked on the interview trail: Why do I do it? It's an odd question, and I never really know how to respond. I think that as a future physician, we have the responsibility to our community. It is a blessing to have made it this far in the education process, and I feel obligated to give back to my community to make my education worthwhile.

It's a long hard road, and you change along the way. The literature shows that medical students become less idealistic and empathetic as they progress through their schooling -- my dean said the other day that it is documented that war and medical school are the two life paths that have been shown to change individuals for life. We had a lecture on stress in second year that made the same claim -- that medical students would be ideal military recruits because of their newly developed tolerance to stress, for better or for worse. Sounds rather extreme, and I don't know the measures they used to determine this. I must admit, I'd rather not know and just roll my eyes at what sounds like hyperbole.

But this does beg the question: When will I feel like I've done enough? Will I ever feel that way? I always feel like there is something more I could do, something more I could learn. And the truth is, I will never learn everything. I will never be able to participate in everything. I will never be able to help or save everyone.

There are days when I am tired. Days when I would rather not get out of bed, or simply sit on a couch all day and watch movies or TV shows. But when I give back to the community, I feel like I am accomplishing something, even with the little knowledge I have now. Perhaps I do it for selfish reasons? Because I like the way I feel. And because it needs to and should be done.

I must admit, though...I still would like to be chief resident. But we'll see.