Editorial Comment: Oaths

Our medical school introduced 77 new students this week, culminating in a White Coat Ceremony.  This may not be fully familiar to readers, but it’s nothing more than a robing-ceremony.  Students are provided and cloaked with a short clinical coat, given a stethoscope and a book of Oslerian aphorisms, and congratulated on making it through the gauntlet.  All this takes place before their parents, friends, sometimes spouses or intended spouses, possibly some bank loan officers, and not uncommonly the mentors who induced them to stay the course. It concludes in the assembly reciting the Oath of Hippocrates, mindful of the fact that they are not doctors, yet; but that the tenets of the Oath still apply as students. 

The same morning, in anticipation of the ceremony, I had made a presentation that I have given in some form for over 16 years, on the meaning and value of oaths.  They are reminded that there are few professions that are sworn, that require an oath: military officers, police, firemen.  There is no oath of commitment for professors of Romance Languages, or stockbrokers. They are asked to review their objectives in becoming doctors.  We discover that how they come by these objectives is:  

• Not accidental (they didn’t awaken one day having mysteriously done well on the MCAT)
• Anticipates becoming a better person
• Entails a lot of delayed gratification
• Entails a huge amount of ambivalence:
  • I can’t be as good as everybody wants me to be
  • There isn’t enough knowledge to meet the patients’ needs
  • The patients won’t often make their needs clear (they are ambivalent)
  • I may never know the diagnosis
  • The career is a component of my life without being its entirety; how much?
  • Do I really want to be poor for the next 10+ years?

This leads to a conversation about what they have had to set aside, and will continue to abjure, in the effort to be physicians:  sleep, normal reliable social relationships, income and freedom from debt, a diet that does not involve vending machines.  They have already made a covenant with themselves, a compact that takes this or some similar form: 

1) “I will sacrifice for you (the patient)”

2) “In return, you (the patient) will only have to:

     - Tell the truth

     - Follow instructions”

…And then, on clerkship, they meet their first alcoholic patient, generally in the ER. S/He will: 1) lie; 2) disregard the instructions. 

So we needn’t be surprised at their difficulty loving our patients with addiction, a state that persists until they are able to see addiction on a par with other chronic, relapsing diseases that cause patients to behave foolishly, unwisely, even badly:  diabetes, bipolar disorder, and all long-term pain disorders.  Our obligation to advocate for their care as ill persons is enduring.

- W. Haning, MD, DFAPA, DFASAM