The Physician’s Pledge gets some bold new wording

14 Jan

by Carolyn Thomas      @HeartSisters

Fanfare, please. The World Medical Association has released a revised version of what’s known as The Physician’s Pledge (1) as outlined in the Journal of the American Medical Association (JAMA). It’s described as “the contemporary successor to the 2,500-year-old Hippocratic Oath”. And although only about 11% of medical schools still use the ancient “do no harm” Hippocratic version, oath-taking is still an important part of most med school training.(2)

But if you’re a patient instead of a physician, there are some surprises in this revised WMA document just for you.

As Berlin-based physician Dr. Ramin Walter Parsa-Parsi explained in JAMA, when doctors around the world reviewed previous professional and ethical pledge documents, one of the most important gaps identified this time was “the lack of recognition of patient autonomy”. For example:

“To address this lack of recognition – despite references to the physician’s obligation to exercise respect, beneficence, and medical confidentiality toward his or her patient(s) – World Medical Association members, ethical advisors and other experts recommended adding the following clause for the first time:

“I WILL RESPECT the autonomy and dignity of my patient.” 

This modern version of the pledge is based on the Declaration of Geneva, adopted by the World Medical Association (WMA) back in 1948. It’s not universally used – especially in North American medical schools – but this exercise created by physicians from all over the world strikes me as a unique and earnest reflection of the changes afoot in doctor-patient relationships, no matter where they are experienced.

About one-third of U.S. and Canadian medical schools use a humanistic modified version of the Hippocratic Oath created in 1964 by former Tufts University School of Medicine dean Dr. Louis Lasagna that includes, in part, wording like this:

“I will remember that I do not treat a fever chart, or a cancerous growth, but a sick human being” and “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”, and “I will not be ashamed to say ‘I don’t know’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”

But for your reading pleasure, let’s review the changes in the newest MWA Physicians Pledge as compared with the previous version. Some of the changes that are of special interest to patients include:

The words “and well-being” have now been added to: THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration. (This is an important one, and reminds physicians to consider both the physical (health) and emotional (well-being) condition of each patient).

The words “and in accordance with good medical practice” have been added to: I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice. (This change reflects the standards of ethical and professional conduct expected of physicians by their patients and their peers).

Finally, another new addition is: I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard. This is a critically important nod to the growing awareness of mental health issues and burnout rates among our physicians amid increasing workload burdens, occupational stress, and the potential adverse effects these factors can have on physicians, their health, and their ability to provide the best quality care possible. The medical profession, in fact, consistently “hovers near the top of occupations with the highest risk of death by suicide.”)

1. Parsa-Parsi, RW. “The Revised Declaration of Geneva: A Modern-Day Physician’s Pledge.”  Journal of the American Medical Association. 2017;318(20):1971–1972.
2. Foster, B. et al. “The Use of Medical Oaths in the Twenty-First Century”. The Pharos/Spring 2016

Q: What would you like to see included if YOU were rewriting the Physician’s Pledge?

 

 

8 Responses to “The Physician’s Pledge gets some bold new wording”

  1. Marjorie David January 15, 2018 at 1:57 pm #

    I applaud these changes. I continue to encounter doctors who make decisions about my medical care, done deal, without explanation, fait accompli.

    I want to be informed of treatment options (usually there are options) and be given the practitioner’s advice based on his/her experience. Then together we decide/agree on the plan, which means I understand how we arrived at this plan.

    Liked by 1 person

    • Carolyn Thomas January 15, 2018 at 3:10 pm #

      Thanks Marjorie – I wish EVERY physician would read and follow your textbook definition of shared decision-making!

      Like

  2. Meghan January 15, 2018 at 6:57 am #

    I think the term “in accordance with good medical practice” is simply way too vague and open to many interpretations and possibly situational ethics. What constitutes “good” practice?

    Maybe I’m just not understanding the term, but to me it seems like for one patient “good medical practice” may be completely different from another patient. Like, is it good medical practice to operate on this person or to do something else? Two doctors might completely disagree on that — so what constitutes the best medical practice for that patient? Or like when the term “healthy diet” became “low-sodium diet” for my husband and I realized that a “healthy” diet can mean many different things to different people.

    Also, I was shocked at the final point. I had no idea suicide rates were high among healthcare providers! I can see why the stress is so hard to bear — they are so responsible for others’ lives.

    Liked by 1 person

    • Carolyn Thomas January 15, 2018 at 3:07 pm #

      Hello Meghan and thanks for your comment here. To me, that “good medical practice” phrase is an interesting addition because – until this revision – that part of the pledge said absolutely nothing about the quality of medical care provided. Instead, that line simply said: “I will practise my profession with conscience and dignity.”

      Current treatment guidelines for physicians are based on existing science-based evidence, and are generally evaluated and updated as required. It doesn’t mean that all patients are treated exactly the same – it just means that there’s a certain best practice of care that patients should receive, no matter where they are or who they are.

      Here’s an example: a standard recommendation in every cardiovascular disease treatment guideline published worldwide is that physicians should refer heart patients with coronary artery disease to cardiac rehabilitation. This treatment guideline is based on many published studies that have found heart patients live longer and have a better quality of life if they complete cardiac rehab. Yet we know that women are far less likely to receive guideline-based treatments (including rehab referral) for coronary artery disease compared to our male counterparts, according to this 2016 report. So that’s why following guidelines for physicians created to ensure “good medical practice” is so important!

      Like

  3. Judith Larrew January 14, 2018 at 6:22 am #

    I was born with a heart defect in 1939. For some reason I survived and at age 5, the family doctor told my parents to ignore me when I complained about my chest hurting. My defect wasn’t found until I was entering nurses training at age 17.

    I’m now 78, and when Doctors don’t know what is wrong with me, I still feel they’re ignoring me. I wish Doctors would just say, we have no idea what is going on, but we’ll watch it.

    Liked by 1 person

    • Carolyn Thomas January 14, 2018 at 7:55 am #

      Hi Judith – “Ignore your five-year old child when she complains about her chest hurting”. I just cannot imagine hearing (or following!) that medical advice…

      Saying “I don’t know…” is what the Dr. Lasagna version of the modified Hippocratic Oath specifically included back in 1964: “I will not be ashamed to say ‘I don’t know’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”

      I suspect that some practicing physicians might have missed that version of the pledge…

      Like

  4. Holly Shaltz January 14, 2018 at 4:48 am #

    I’m really uncomfortable with the words “in accordance with good medical practice”.

    Doctors have a hard enough time thinking outside the box and regarding each patient as a unique person with needs that may not mesh with what they were taught in medical school. I just had a Mayo endocrinologist, who was able to think outside the box regarding my adrenal issues, tell me I was hyperthyroid based on one lab result, completely ignoring all the hypothyroid symptoms I have. Assuming that treatments must be in accordance with current dogma really stops in its tracks any hope of progress and learning from actual patients, their symptoms, and their responses to treatments, standards or non-standard.

    I’ve suffered enough from that, I really don’t want it enshrined in “The Oath”.

    Liked by 1 person

    • Carolyn Thomas January 14, 2018 at 8:10 am #

      Hi Holly and thanks for this important point. We know that many doctors are “treating to numbers” (if diagnostic tests results are A, prescribe B. Or, as in my own misdiagnosed heart attack: if diagnostic tests are “normal”, it’s definitely NOT your heart!) no matter what the textbook symptoms are clearly suggesting!

      I remember the frenzy that greeted new cardiovascular guidelines in 2013: the first to recommend that doctors should ignore high LDL cholesterol test results in favour of looking at a patient’s overall cardiovascular risk factors. It was heresy!! – especially after decades of focusing (mistakenly) only on the need to get their patients’ LDL numbers down-down-down at any cost with statins, for all patients, under all circumstances, always.

      Another way of looking at this “in accordance with good medical practice” addition is this: right now, the reality is that sometimes treatments are recommended that are NOT “in accordance with good medical practice”.

      Prescribing antibiotics for the common cold is a famous and problematic example of bad medicine. There is no scientific evidence anywhere that suggests this is good medical practice, yet it continues despite a “significant increase in adverse effects associated with antibiotic use in adults“. That’s where this new pledge to offer medicine based on “good medical practice” comes in…

      Like

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