Reflections on Hippocratic Medicine in Practice: Three Perspectives
Commissioned to Care
by Teresa Tseng, MSIII
“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being.” – Hippocratic Oath (adapted)
I vividly remember a terminal cancer patient I interviewed on my first history and physical assignment of second year. There were tumors in both his lungs and extensively throughout his colon. Even before stepping into his room, a hospital staff member warned me that this patient would unexpectedly leave his room each day to smoke cigarettes outside. When I met him, he was grumpy and in severe pain, and he let everyone know about his misery. I watched my frail patient struggle to face me from his bed, careful not to disturb his colostomy bag. At first, he did not want to answer my standard questions, but as the encounter continued, his replies grew more descriptive as he shared his rich past with me. He talked about everything from his childhood and his combat in Vietnam to his current condition and his hope for a better future with the Lord. I became genuinely interested about his personal history, and the interview slowly transformed into a pleasant conversation, culminating in the patient thanking me for my medical explanations and my patience to listen to his stories.
Sadly, my patient was all alone at the end of his life. To make things worse, his attitude and behavior were shunning even the healthcare workers. He was an outcast in a busy hospital: a malodorous, complaining, terminal patient without family or friends to care that he was dying. The patient’s demeanor combined with the pressures of the hospital environment led the staff to half-heartedly focus on patient care for this man. Even I was guilty of just wanting to finish my assignment and get home for dinner at one point early in my interview. It was actually a month later, after I had heard that this patient had passed away, when I drew the connection between this patient and an outcast to whom Jesus would minister. My experience made me brutally aware of how today’s healthcare setting makes it easy for one to lose a Christ-like approach to any patient encounter.
My encounter with this terminal cancer patient reminds me of the Hippocratic Oath (adapted): “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being.” Our patients are whole persons whom God created and loves. I look back on my patient’s experience and realize that he was treated as if he were a list of symptoms instead of a human being near the end of his life. In a busy hospital, this man’s physical health was already a hassle enough to manage in the eyes of the staff. His emotional health was all but ignored. As a compassionate student, I was able to listen to his concerns and frustrations. But as a Christian student-doctor I felt moved to inquire about the patient’s spiritual health after noticing a weathered Bible next his hospital bed. I asked him what role his religious beliefs played in how he viewed his illness. I was encouraged to hear that he was at peace with his situation because God was in control. He was not scared of dying because he knew he was redeemed through Christ’s sacrifice and would be eternally relieved of his suffering.
The encounter was a learning lesson for myself to view this patient not as a complaining outcast with a laundry list of problems, but as a suffering child of God. His body was important to the God who created him, just as were his mind, his emotions, and his eternal spirit – all a part of being a human, all a part of our responsibility as Christian doctors.
ABOUT THE AUTHOR
Teresa Tseng, MSIII, is a third year medical student at UC Davis School of Medicine and plans on pursuing a career in pediatric endocrinolgy. She is an avid sports fan and word game player. Her other hobbies include photography and playing the guitar. She tries to enjoy the journey of life, knowing she is blessed with an opportunity to pursue a career path of service.
Oaths for Liars
by Jennifer Holmes, MSIV
As medical school graduation approaches, I am of course filled with excitement. No more multiple choice tests, no more flashcards, and most of all, no more debt accumulation. But along with the relief comes a looming apprehension: real responsibility. To reinforce this sense of responsibility, most medical schools across the country administer some sort of oath in the ancient tradition of Hippocrates. Anticipating this has caused me to confront my greatest fear as a product of my generation – commitment.
The idea of commitment has taken a beating in the last few decades in both the public and private spheres. Marriages fall apart at the first crisis, church members jump ship for flashier youth groups, and companies oust long-time employees to avoid paying costly benefits. The result for people like me is a deep-seated doubt of mankind’s ability (myself included) to keep any promise, no matter how small. More and more people indefinitely postpone marriage, church membership, or having children because of this fear of failure. In short, my generation suffers from a lack of trust in other human beings. Abundant evidence exists that oath-taking does not guarantee oath-keeping or make a waverer a loyal adherent. From Luther, I learned that I can’t even want to want to keep any of my promises unless my desires are kindled and transformed by God. Why should I bind myself to an oath I know I, a sinful person, cannot keep?
My self-doubt was reinforced while I was on a rotation this past fall. Our consult team was following a complicated HIV patient who was admitted for recurrent diarrhea and profound wasting. In the midst of all the testing and therapy aimed at his main problem, I overlooked a urinary tract infection that was present on admission. On hospital day five, the patient rapidly deteriorated and died of urosepsis. Guilt flooded over me because I had missed the most important thing and had inadvertently caused harm to a patient, violating the most basic aim of medicine. The team rushed to both share and shift the blame. The upper levels were in charge, ultimately, they noted. And even if we had treated the infection earlier, the patient was so weakened by HIV that he probably would not have survived despite our best efforts. We had done everything we could. His underlying condition was irreversible. While I accepted this incident as another testament to the limitations of medicine, I also resolved to never again breeze over a urinalysis. What was this I was making, could it be a . . . commitment? It was indeed.
This case helped me understand what led ancient physicians to bind themselves before the gods. The graver the consequence of error, the stronger must be the commitment in avoiding it. It has to be the case that life’s most important events are “hedged about” with oaths. God’s covenant with Israel, the vows of marriage, and the rite of baptism are just a few that come to mind for the Christian. In all of these cases, it is the importance of the task and not the integrity of the oath-taker that prompts the oath.
As I was contemplating this idea, I heard a country song on the radio that solidified for me the rightness of making strong promises. The song is called “I’ll Try,” by Alan Jackson. Instead of swearing to the lady he loves that he will be true, he says simply, “I’ll try to love only you. I’ll try my best to be true, oh darlin,’ I’ll try.” All he is doing is being honest and acknowledging his weakness as a man. I understand the self-doubt that is forcing him to avoid the possibility of a broken promise. But on the other hand, if the man I love tried to woo me with such “I’ll try” nonsense, I would be outraged. “Come back when you get a backbone!” I’d say.
In the final analysis, medicine is a fearful and terrible task that calls for fierce and gut-wrenching commitment. So how do we, the skeptical and fashionably “broken” postmodern crowd, embark on such a task in our utter weakness? Oaths from Hippocrates onward have acknowledged some degree of human limitation with phrasing like “I will carry out, according to my ability and judgment, this oath. . . .” However, the blessings and curses at the end of the oath are still strong consequences that do not admit second chances or excuses. In a more merciful tone, the revised “Physician’s Oath” by CMDA inserts, “With the help of God, I will. . . .” This addition expresses the human need for grace in all our undertakings. The God whose grace provides me with every breath also is actively working within my resurrected soul to strengthen me in all goodness. While my own strength constantly fails, His life in me is unending provision.
God does not allow us to collapse into apathy, paralyzed by moral and intellectual failure. He calls us to have enough courage to embark on impossible journeys, like marriage or medicine, armed with all the solemnity of Hippocrates. Only through making, breaking, and renewing big promises can we make arduous progress toward true fidelity and integrity. The Oath itself forges a community of imperfect healers striving for greater perfection, not for themselves but for their patients. For example, a patient going for surgery needs to hear more than, “I’ll try not to kill you.” He deserves a promise through which the doctor risks as much of his honor on the table as the patient risks of his life and well-being. Living under oath adds urgency and weight to the familiar disciplines of confession and forgiveness. The transition from liar to oath-keeper is marked, as is the entire Christian life, by innumerable deaths and surprising resurrections.
ABOUT THE AUTHOR
Jennifer Holmes, MSIV, is a fourth year medical student at University of Texas Southwestern in Dallas, currently applying for residency in Internal Medicine. She took last year off from school to attend Augustine College in Ottawa with Dr. John Patrick, who helped broaden her perspective on medicine. The school offers a one-year classical curriculum that includes the history of ideas in the West as well as the origins of science and medicine. She enjoys discussions on medical ethics and how Christians can better integrate their faith with medical practice.
The Soul's Dark Cottage, Battr'd: A Lifetime of Hippocratic Practice
by Curtis E. Harris, MS, MD, JD, FCLM
I began practice in 1978, a time when medicine did not doubt its traditions or place in society. By 1990, the world had changed. The “Brave New World” of managed care was ushered in with a fanfare . . . as the way to improve access to care, improve fairness, remove greed, and control costs. By 2005, the experiment was over, and the failure of managed care to solve the difficulties of healthcare delivery was obvious to everyone.
I began my career dedicated to the principles of the Hippocratic tradition, watched in fascination as those principles were eroded by outside business and governmental forces, only to see them discussed seriously once again, thirty years later. In the interim, I have seen healthcare systems in every continent of the world, and from that experience have recognized a truth: the problems of caring for the ill are universal to every society, and are never solved by plans and schemes outside the privacy of the exam room or outside who we are as individuals.
I read an ancient verse by Edmund Waller (1606-1687) recently that says it well:
The seas are quiet when the winds give o’er;
So calm are we when passions are no more.
For then we know how vain it was to boast
Of fleeting things, so certain to be lost.
Clouds of affections from our younger eyes
Conceal that emptiness which age descries.
The soul’s dark cottage, batter’d and decay’d,
Lets in new light through chinks that Time has made;
Stronger by weakness, wiser, men become
As they draw near to their eternal home.
Leaving the old, both worlds at once they view
That stand upon the threshold of the new.
The history of the Hippocratic Oath and tradition is complex, and is the subject of books. Without meaning to demean scholarship, it is the biblical tradition focused in the few words of the Oath that give it modern meaning. Giving one’s self to the care of others in transparency, putting the interests of the patient in our care ahead of those of society at large, avoiding our own sinful nature, valuing each human life as made in His Image, sacred: these are biblical ideals often imputed to the Hippocratic Oath.
In these forty years, I have faced conflicts, large and small, over and again with those around me over issues of money, caring for the poor, quality of care, abortion, euthanasia, the right of conscience . . . and I have faced personal failures, those times when I have failed myself. The art of medicine is the same as the art of life: to be in the world but not of the world.
This I promise you: There is nothing you will face that someone else has not faced before, for as Solomon said, there is “nothing new under the sun.” What is new is your reaction to the moral and ethical dilemmas you encounter today. The Hippocratic Oath provides a proven focus for even more eternal values, worthy of your daily attention. You must “stand for something or you will fall for anything.”
I also promise you this: The Hippocratic tradition is not a light for the “soul’s dark cottage,” but rather the means by which we are “batter’d” to attain that light. Four decades as a physician have taught me that standing on principle will cause opposition, both outside and inside my soul. Willingly let time and circumstance cause the “chinks” that let light in, and do so without fear.
In the wilds of Africa, lions hunt and kill. One of their most effective strategies for capturing their prey is for the old, toothless males to sit at one end of a field and roar, driving the grazing animals to the far side where the young lionesses crouch for the kill. This is the basis of the African saying, “Safety is running into the roar of the lion.”
Facing the problems we have with faith in our Lord is far better than avoidance or compromise. One tool for physicians that helps focus our thinking is the Hippocratic tradition. Run into the roar of the Lion, where the safety is. And as you run, let your soul be flooded with His light.
ABOUT THE AUTHOR
Curtis E. Harris, MS, MD, JD, FCLM, is the Chief of Endocrinology for the Chickasaw Indian Nation and Director of the Chickasaw Nation Diabetes Care Center. Prior to his current position, he was in private practice as an Endocrinologist in Oklahoma City, Oklahoma for more twenty-five years, with a specialty of Diabetology. He has been President of the Oklahoma Chapter of the American Diabetes Association; and in 1998, was the first physician in Oklahoma to receive the American Diabetes Association Physician Excellence Award, with Distinction. In May 2007, he was elected to the Federation of State Medical Boards, which is the oversight organization for all of the Medical Licensure Boards in the United States and the Protectorates.