August 16, 2024
Dear Interested Readers,
Our Professional Challenges Are Mounting
Have you read the Hippocratic Oath? At about 2500 years old, it is a bit out of date, sort of long, probably not written by Hippocrates, and refers to gods that no longer have active temples, but it is built on some enduring principles. For reference:
I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer’s oath, but to nobody else.
I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.
Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.
Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.
As quaint and out of date as the Hippocratic Oath is, it does have continuing value and is a template for the modern oaths that many medical students take as part of their graduation ceremonies. One popular version was offered by Louis Lasagna who was the Academic Dean of the Medical School of Tufts University. Another version, which I think is the one I took, the Declaration of Geneva, was developed by the World Medical Association in Geneva in 1948. It has been updated several times. The most recent update was in 2017. It reads:
AS A MEMBER OF THE MEDICAL PROFESSION:
- I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
- THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
- I WILL RESPECT the autonomy and dignity of my patient;
- I WILL MAINTAIN the utmost respect for human life;
- I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
- I WILL RESPECT the secrets that are confided in me, even after the patient has died;
- I WILL PRACTICE my profession with conscience and dignity and in accordance with good medical practice;
- I WILL FOSTER the honour and noble traditions of the medical profession;
- I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
- I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
- I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
- I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
- I MAKE THESE PROMISES solemnly, freely and upon my honour.
You might notice that the Declaration of Geneva contains many of the concepts of the Hippocratic Oath, but it does not disavow abortion. If you look back to the Hippocratic Oath, you will see that both oaths honor those who taught us. “Do no harm” is a concept that has weathered the years, as has confidentiality. Both oaths directly and indirectly focus on the primacy of the patient.
This last Friday I got an email from an old friend and a clinician for whom I have the greatest respect, Dr. Patty Gabow. Patty wrote to tell me that she was publishing an editorial in JAMA which she co-wrote with Matthew Wynia, M.D., M.P.H. of the University of Colorado School of Medicine. The editorial is entitled “Oaths, Conscience, Contracts, and Laws—The Gathering Storm Confronting Medical Professionalism.” I am not a subscriber to JAMA so I am delighted that Patty sent me a PDF of the piece. If you have access to JAMA, I hope that you will read the article. If you aren’t a JAMA subscriber I hope that what follows will be a faithful transfer of the major points that Drs. Gabow and Wynia make.
Before getting into the article, let me introduce you to Dr. Gabow and describe her remarkable accomplishments. Patty spent her medical career at Denver Health as a nephrologist, the CMO, and then as the CEO. During her years of service, she transformed Denver Health with her patient-centered dedication to professionalism, and as an early adopter of Lean as the optimal management platform for healthcare improvement. I had great respect for Patty’s work long before I met her.
We retired at about the same time and spent many productive days together as advisers to Simpler which was a leader in Lean transformation in healthcare before it was eventually absorbed into IBM Watson. In retirement, Patty has served on panels and projects within CMS and the NIH and is active on independent non-profit boards of foundations like the Robert Wood Johnson Foundation. She has recorded her experiences and advice in three books and many papers. If you aren’t familiar with Dr. Gabow’s career, it is worth your time to peruse her Wikipedia page.
The article begins with a statement about what has been true over the years. A little further along the authors will contrast what has been with what is the new reality. As you read on, you will also understand why I began this letter with a review of medical oaths. I will bold points that I want you to ponder. They write:
The bond between physicians and their patients has long been considered a unique, even sacred, relationship sealed with publicly professed oaths. Historically, an essential and ubiquitous component of physicians’ oaths and their related ethical codes is the promise to place patients’ interests above any others, including their own. This is a high bar, but it is the bar physicians swear to meet when entering the profession. For generations, many physicians have courageously met this bar, including putting their lives on the line during pandemics like COVID-19.
The problem that Gabow and Wynia want to address is the evolution of circumstances that challenge the promises made in those oaths.
Today, physicians face rising challenges in fulfilling this core professional promise not from a virus but from converging fronts: personal conscience, employment contracts, and laws. How these challenges to putting patient interests first have emerged and interrelate deserves elucidation because understanding these dynamics can help shape appropriate professional responses.
Gabow and Wynia don’t use the term moral Injury, but what they discuss reminds me of the moral injury and damage that many current practices and realities in healthcare inflict on caregivers.
The analysis that Gabow and Wynia offer begins with issues of personal conscience. They reference the First Amendment right to the free exercise of religion and the prohibition of a state religion. They point out that the formal protection of a physician’s conscience over their commitment to a patient’s interest did not occur until 1973 when “The Church Amendment” freed physicians who objected to abortions from having to perform them. The authors continue:
This prioritization of physician conscience over patient interests has since been extended by other federal laws and regulations, and many states have passed conscience laws ensuring that physicians can refuse without penalty to provide, or even refer, patients for care a physician deems against his or her conscience.
The second point, or barrier, identified by the authors to physicians making the patient’s preference their primary concern is the fact that the majority of physicians, 75%, are now employees. A doctor’s employment status may mean that she/he must perform in a way that is consistent with the interest of the employer and not with the patient’s best interest as the factor that determines how care is provided. They write:
Contractual payment issues and noncompete clauses have drawn considerable attention from physicians, but equal if not more attention should be given to provisions that limit physicians’ ability to put their patients’ interests first. These could include financial incentives to limit access to care for some patients or to overuse lucrative services for others, but more overt restrictions are often imposed in religiously affiliated health systems. In particular, Catholic health care entities require adherence to 77 Ethical and Religious Directives for Catholic Health Care Services, which explicitly prohibit a broad array of care, including referrals for certain services, and medical staff bylaws in some Catholic systems state that the ethical and religious directives supersede professional ethics.
Such contractual obligations, often presented as reflecting organization-level conscience, take precedent over both physicians’ individual conscience and their oaths, raising questions of a hierarchy of conscience rights…
The third barrier to putting the patient’s interest first comes from laws. The Dobbs decision has allowed over 20 states to write new laws or enforce old laws that preclude physicians in many states from making a woman’s reproductive health a matter of patient preference. The pressure from potential penalties has made it virtually impossible for many physicians to practice without chancing extreme penalties. They write:
Consequences for physicians accused of acting in violation of these laws may include investigations, fines, felony charges, loss of licensure, and prison time, in addition to the need for a legal defense. Some of these laws explicitly enlist members of the public as enforcers, which could invite social stigma, doxing, and even threats of extrajudicial violence. Hence, like employment contracts these laws oblige physicians to follow external mandates over their personal beliefs, professional oaths, and patient Interests, but they carry considerably higher penalties than mere loss of employment.
After defining the problem, the authors summarize the situation before offering potential solutions
These 3 trends reflect an increasingly expansive approach to conscience rights over patient interests, first of individual physicians, then organizations, and now state legislatures. But for physicians, they also represent an attack at the heart of professionalism: namely, the right of physicians to establish medical standards of care and their related obligation to put patient interests first when doing so.
They suggest:
First, physicians should recommit to their sworn oaths and codes of ethics that prioritize the patient as the center of care. Each physician must examine the difference between professional responsibilities and personal beliefs and plan for how to manage conflicts between the two.
They make the suggestion that perhaps some physicians should avoid specialties where their beliefs will prevent them from putting the patient first. That may seem drastic. There are other possibilities.
…an ethical physician will inform patients up front about limitations of the care they are willing to provide, “inform the patient about all relevant options for treatment, including options to which the physician morally objects,” and “refer a patient to another physician or institution to provide treatment the physician declines to offer.”Ensuring that physicians who exercise their personal conscience rights are honest and transparent with their patients, respect their patients’ rights to fully informed consent, and will make referrals when necessary ensures that patients can trust the medical profession to put their interests first even when their individual physician is personally unable to do so.
The issues of personal conscience may be the easiest barrier to resolve. We are in a new world of physician employment. Being careful about for whom you work is good advice that may be hard to follow. The authors advise:
As for contracts and laws, physicians should carefully examine employment contracts and, when possible, avoid employment by entities that impair their ability to fulfill their oath; but for some this will not be a feasible option. Moreover, physicians acting individually are unlikely to change contracts or laws that privilege institutional or state-level conscience rights over patient-centered care.
Another option is to try to fundamentally change the offending institutions.
Changing contracts and laws to better protect patients and the profession is best approached by organizations of professionals, acting through appropriate political, legal, and societal forums. As a profession, physicians must vigorously defend their authority to make medical decisions with their patients’ interest at heart. Where the authority to put patients first has already been lost, physicians should work with other groups, including patient advocacy groups, to help regain it.
I should add that Patty Gabow has a long history of trying to change and improve institutions. Many physicians will try to find a way to adjust to the status quo. Some of those who do try to get by by going along with things that seem too big to change will feel morally injured at some point in the future. Patty and Dr. Wynia are realists. They end the article with the statement of a harsh reality:
In the current environment, working to recenter medical care around patients’ interests can be difficult or even dangerous, but it is the only path forward if physicians hope to remain a true profession.
I think they are saying that if you have felt morally injured by policies or laws or burned out by impossible working conditions, you can shrug your shoulders and try to endure the new reality, or you can join forces with other concerned healthcare providers and plot a new path forward. I know that Patty is one individual who has tried to make a difference. She has done and continues to do what she asks others to consider.
Still Walking and Enjoying the Wild Flowers
I guess it is a sign of my geriatric status that I have become fascinated with the late summer wildflowers that I see on my walks. I no longer plot my professional path or make plans for things that might come in the future as I make my way along the hilly country roads near my home. With “Seek,” my new and free app that identifies plants, trees, birds, insects, fish, fungi, reptiles, and other offerings of nature, I am like a kid in a candy store. There is a surprise every day as new and different plants pop up for my review. I often see a new plant where the day before there was an uninterrupted sea of goldenrod or flat-top white aster, the two plants that seem to be most dominant along my byways.
Sometimes my app isn’t sure about what I have seen and attaches “maybe” or “probably in the family of…” as a qualifier of what it is seeing. The app also keeps a list of my discoveries and showers me with praise whenever I make a new discovery which appeals to my lifelong pathological quest for accomplishments and recognition. I now have thirteen different definitely identified species of local wildflowers on my list and there are others, mostly little yellow flowers, about which the app isn’t sure, that I am not counting, but I have seen. There are several different varieties of asters, and I have even learned that there is a second variety of goldenrod, the flat-topped goldenrod. The “uncertain list” contains several little white and yellow flowers which I hope to identify in time. I have also discovered that the photo app on my iPhone will also try to identify any wildflower that I photograph. Who knew?
For today’s header, I gave my son who formats my header six different choices from which to pick the picture that he thought was best. He chose the picture I had taken of White Wood Asters. I agree with his choice. I am not a good “composer” of pictures but every now and then something nice pops up. I had not noticed the pinecone and the pine straw in the picture until my son had sent the header back to me. I think the pinecone is a nice touch. We have had a bumper crop of pinecones this year. They litter many of the roads I walk along with a greater number of pine needles that are sometimes so thick that they are like a straw path along the roads.
I think global warming is the explanation for the extra pine needles. Earlier this summer I noticed that many of the giant white pines that line our roads looked “sick” and their needles had turned from deep green to a sickly yellow-green. Fortunately, the trees seem to have recovered. The dead needles now cover the sides of the road and the trees are back to their usual deep green. Who knew that there was so much to see and ponder along the country roads of New Hampshire?
We have eighty days to go till the 2024 elections. I imagine that the Democratic Convention will be a big party like the Republican Convention was back in July. The convention starts on Monday in Chicago. I am crossing my fingers and hoping that most of the action is inside the convention venue and part of a program. I am old enough to remember the disastrous 1968 Democratic Convention in Chicago with its riots in the park outside the convention venue. Those riots were a big factor in the election of Richard Nixon.
The countdown to the end of summer continues. There are only three more summer weekends left including the Labor Day weekend. Don’t waste any of these precious days. My California grandsons have been back in school for over a week. In my day, school started after Labor Day. Why was that changed? On Monday I will accompany my granddaughter and her parents as she returns to Bowdoin for her senior year. She is one of the captains of the Women’s Volleyball Team. I am rooting for them to win their conference and make it into the Divison Three NCAA tournament in November and early December. My job on Monday will be to drive her parents back to my house after she is left in Brunswick with her car.
Whatever lies ahead for you this weekend, I hope it will be great fun.
Be well,
Gene
