Sworn in

Yesterday, I received my stethoscope in the mail. Today marks the two-week point since our White Coat Ceremony (shout-out to Dr. Lovering!). And this got me thinking.

One of my absolute favorite ICM sessions to date was the one a week before our ceremony, when we read through and discussed the various medical oaths that have come down through the centuries. Our profession is infused with a rich, inspiring history that brings with it the heavy weight of responsibility -- that day, we got a chance to touch on a small fraction of it.

I marked up my copies of the passages, but I just wanted to put down my thoughts on the parts that resonated the most. So, chronological order.

Hippocrates' Oath

Hippocrates, in the late 5th century B.C., set down many of the most basic tenets of medicine that we now take for granted. He swore his responsibility holding the Greek gods as witnesses. He stressed the familial/brotherhood aspect of medicine, and the importance of passing knowledge down to the next generation of disciples. His oath implied a separation between the art of medicine and the art of surgery. The oath introduced the concept of patient confidentiality. But most interestingly, in my opinion, was his very last sentence:

"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."

He didn't settle for, oh, if I do right, I'll do okay in life, but also stressed, should I do wrong, I should suffer the consequences of the violation of my responsibility. I think that idea, while not completely lost in the revisions and versions that came later, wasn't stressed quite as much as it was here, in Hippocrates' writing.

Oath of Maimonides

Maimonides, a Jewish physician and philosopher, also invoked his faith in his oath, written in the 12th century. He brought in another crucially important idea in practicing medicine: "May I never see in the patient anything but a fellow creature in pain." I can't speak from extensive personal experience, but from what I've heard and what little I have seen, this idea sometimes is forgotten in our over-eagerness to 'fix what's wrong' with our patient, and is often difficult to face. Another stigmatized idea Maimonides made mention of is admitting that yes, even doctors make mistakes. We can't afford to freeze up in face of them, but must learn, internalize, and carry forward.

Nightingale Pledge

A pledge first taken by nurses in 1893, named after Florence Nightingale, it made mention of something I don't think was quite as explicitly mentioned in any of the other oaths. Hippocrates did make mention of not administering deadly drugs to one's patients. This pledge, however, stressed neither taking nor giving any harmful drugs, acknowledging a medical practitioner's responsibility to both self and patient. It was strange to see that the pledge didn't make explicit mention of the 'art of nursing,' so to speak, the warmth that is often associated with it.

Declaration of Geneva

The Declaration of Geneva was first written and adopted by the World Medical Association in 1948. I suppose because it was an obviously international document, it more explicitly acknowledged issues of discrimination across many lines -- religion, race, nationality, political affiliation, social status, none should come between the doctor and his/her patient. This was also the second of our selection of oaths that included anti-abortion sentiments, after Hippocrates', which I suppose given the timeframes makes sense. 

Oath of Louis Lasagna

This one was by far my favorite of the oaths. Louis Lasagna put out a revision of the Hippocratic Oath in 1964, and injected a bit of quiet humor and poetry into his comprehensive breakdown. He acknowledged ongoing research in medicine and stressed avoiding the "twin traps of overtreatment and therapeutic nihilism." Lasagna wrote of the art and science of medicine, of speaking to patients regarding matters of life and death, taking care not to play God with a patient's life, remembering that you are treating a sick human being, that prevention is preferable to curing, and that we now are joining the ranks of a society that carries many an obligation. But most important, I think, is his hope to never lose the "joy of healing."

Student Oath

The student oath we read at our White Coat Ceremony was an amalgamation of many of these oaths, and incorporated almost all of the elements I most admired in the other oaths we read through. Wearing my shiny new white coat, I stood holding a sheet of paper full of words that grew heavier in the air as I breathed life into them anew, along with the rest of my class. As I reached the end of the oath, I felt the weight of those words settle from the air onto my shoulders, woven into the seams as tightly as they were into my psyche.

And it feels simultaneously humbling and thrilling.

Origins and Orientation

Until I've caught up on the first 1.5 weeks of orientation and 4.5 weeks of medical school, this will still seem too disorganized to me. Thankfully, probably no one other than me will care. So, as the saying goes: Let's take it from the top!

ORIENTATION (8/12/10 - 8/20/10)

The very first lecture I had in med school has easily been the most inspiring one so far: "What does it mean to be a physician/healer?" given by Dr. Richard Colgan. He spoke to us about the history of medicine, the art of healing, and a slew of thoughts for me to come back to for the rest of my career. It sounds cheesy and exaggerated, but it isn't at all.

We learned about many medical greats, most of whom I admit I hadn't heard of before, but I haven't been interested in history until now, so I suppose that comes as no surprise.

Hippocrates: First do no harm

Sir William Ostler: Equanimity and imperturbability

Francis Well Peabody: 'For the secret of the care of a patient is in caring for the patient'

William Carlos Williams: One of the best trainings you can have as a writer is to be a physician - people will tell you the most intimate details of their lives that they may never have told anyone else before and won't tell anyone else again

Theodore Woodward: 'Don't be a slip doctor'

Dr. Kalia (sp?): 'When you're not sure what to do, remember: focus on the patient'

Dr. Colgan: 'What does it mean to be a healer? Smart. Philosopher. Loved and hated. Case worker. Patient's advocate. Respect and disdain. Accountable. Challenged.'

I only wrote up tidbits from a handful (the ones I managed to scribble down legible quotes for), but the talk, the history, was inspiring in its entirety. The rest of the talks were well and good, but nothing quite stood out the same way, with the same relevance and gravity.

A couple of days later, we were introduced to the wonders of the MASTRI center, which is the simulation lab on the UMB campus. The traditional saying in medicine, especially regarding surgery, goes: "See one, do one, teach one." As the MASTRI tech put it, "See one, simulate many, do one, simulate some more, and then maybe you can hopefully teach one." After watching a couple of fellow classmates take a shot at simulated gall bladder removal, all I can say is, I'm definitely hoping.

Next up, medical ethics. This is an area I've always been very interested in, but my undergraduate schedule conspired against me whenever I tried to take a class in it. It focused more on breadth than depth, but even the brief overviews gave plenty of food for thought.

Four approaches:

1. Utilitarian philosophy - end justifies the means
2. "Rules" - No matter what good you might do by breaking the rules, you must always follow the rules
3. Virtue ethics - do you act virtuously?

4. Case-based decision-making - can you do each case on an individual basis?

Four principles:

1. Beneficence - doing good
   Nonmalificence - or at least, do no harm
   Should this be put above all else?

2. Autonomy - patient has a right to drive their own info, make their decisions, etc.
3. Justice/equity - should be some rough justice with how patients are treated

4. Integrity - of us individually and of the system

Of course, the complications arise in how you apply these approaches and principles. What happens if they conflict? What if you and your superiors don't see eye to eye? Or you and the family? You and the patient? Where do you draw the line at determining whether a patient is of danger to him/herself? How much responsibility can you assume in the doctor-patient relationship? There are so many more questions, but I have no basis to evaluate them on right now, so this will definitely be revisited.

Also, Dr. Mallott is a fantastic speaker. Just for kicks: "One day, my kids asked me, 'What do you do?' This is when I was in the in-patient psych ward at the hospital. 'Mostly I deprive people of their civil rights.'" -Dr. Mallott

Sometime after, we had career counseling with Dr. Martinez, another fantastic speaker, super-cool guy, and his presentation was simultaneously informative, nerve-inducing, and reassuring. Don't ask me how he pulled all of those off together, but he did. He threw a bunch of career ideas and summer opportunities at us, then promptly forbade us from thinking on it until after the first exam. Mostly, he left us with: "Learn to be comfortable with being uncomfortable." Yessir!

There were a few other highlights, too. The fashion show was entertaining, though I was heartbroken to learn I could no longer take my exams in my wallowing sweatpants. Also, tragedy of all tragedies, I don't have a sewing machine. Dr. Dolan held a talk on study tips and academic counseling with Dr. Keller, which gave us some vague ideas on how to kick our first week off right.

I think that closes out orientation week. Somewhere in the midst of all that, on the 15th, I made my first foray into having a 'thought of the day' (which I subsequently abandoned for a week). Here it is again:

 It's finally starting to hit me, the weight of responsibility that promises to grow heavier with each passing day, every ounce of knowledge. The idea is too much to wrap my head around.

It occurs to me that it might come across as defeatist, which was entirely NOT the idea behind it. In fact, that very weight and enormity is incredibly galvanizing, almost uplifting, and I hope it remains to be so.