By Dr ALBERT LIM KOK HOOI
In being true to their Hippocractic Oath, doctors must not be afraid to acknowledge that they don’t always have all the answers.
WHEN I was an eager and wide-eyed medical student, I looked forward to taking the Hippocratic Oath at my graduation ceremony. Sadly, it was not to be. In fact, contrary to popular belief, the Hippocratic Oath is not required by most medical schools.
It would have been the height of cool to have sworn by Apollo, Ascelpius, Hygieia, and Panacea. Apollo was the Greek god of healing, truth, and prophecy. Ascelpius was the son of Apollo, and he too was in the business of healing and medicine.
Both Hygieia and Panacea were the daughters of Ascelpius, and by birthright, were goddesses. They were the first family of physicians, and it would have been fitting to have their blessings during our rite of passage.
In Greek mythology, Apollo was the god of healing, truth, and prophecy.
Historically, doctors swore to practise medicine ethically as they took the Oath. It was believed to have been written by Hippocrates, the father of Western medicine, sometime in the late 5th century BCE.
In the Oath, ethical standards of the practice of medicine were laid down. With the passing of time, certain parts of the Oath lost their relevance. “I will not give a woman a pessary to cause abortion” and “I will not cut for stone” are two examples.
But the spirit of the Oath lives on. We need to reaffirm the ethics of medical practice even more today in our crass and commercial world.
A modern version of the traditional oath was penned in 1964 by Dr Louis Lasagna, former Academic Dean of the School of Medicine at Tufts University. It exhorts us doctors to avoid the “twin traps of overtreatment and therapeutic nihilism”. We are reminded to respect the privacy of our patients. A patient is not a “case” but a human being whose illness may affect the person’s family and economic stability.
“There is art to medicine as well as science” and so we are reminded that warmth, sympathy, and understanding outweigh our surgical and medical abilities.
One part of the modern version of the Oath is new and was not found in the original Hippocratic Oath. I quote this part verbatim. “I will not be ashamed to say ‘I know not’, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”
This must have been inserted because medical knowledge has increased exponentially. More and more specialties have developed. “I know not” is not an admission of ignorance, assuming the doctor has answers to all questions. It is an acknowledgement of the limits of our knowledge. It is the wise and honest doctor who peppers his speech with “I know not”.
Sometimes, “I know not” is in the context of “I know not but I could spend this evening reading up and speaking to my colleagues about this vexatious problem of yours and get back to you”. This is so refreshing compared to a doctor who steadfastly blunders through the consultation, giving vague and uncommitted answers, all the while refusing to say “I know not”.
Three words that make him feel mortal and fallible.
“I know not” could sometimes refer to the dose, schedule, and side-effects of drugs. It would be a foolish doctor to cram 10,000 useless facts into his brain. Things that can easily be checked should be checked. Memory can fail and it is unwise to hazard facts and figures. Only the very naïve and unsophisticated patient will be taken aback if the doctor needs to check up on a drug dose or schedule.
In the context of oncology, “I know not” is often the answer to the question. “How long will I live?” “I know not” is not a satisfactory answer, but giving an answer like “six months” is neither accurate, comforting, or tactful. Tomes have been written about this. Between an evasive “I know not” and an unfeeling “six months” lies the art of speaking to patients about bad news.
Doctors strive to master this art, but none can claim total success. The most we hope for is to soften the blow.
So much knowledge has been unearthed about diseases and their treatment. No doctor, generalist or specialist, can hope to know more than a tiny fraction of all there is to know. “I know not” is most important in this context.
When a doctor is not adequately qualified, trained, or experienced in a certain field, he should ask for help from another whom he thinks can do a better job. It is not shameful. He is doing right by himself, his patients, and his colleagues. This is perhaps the most important part of the modern Hippocratic Oath.
“I know not”. It resonates well with the medical adage, “First, do no harm”.