Dec 11, 2015 - new graduates from the Medical School of the University of Malta will be .... availability of information technology, these barriers are to some ...
Graduation Ceremony 23 Friday 11 December 2015 at 1630hrs – Jesuits Church Valletta Graduation Oration Professor Yves Muscat Baron M.D. F.R.C.O.G. (Lond.), F.R.C.P. (Irel.), Ph.D. (Warwick). The Humanity of the Hippocratic Oath and our Patients It is a great privilege to be delivering this oration during the conferment of the Medical Degree to so many of our previous students. For this, I am deeply grateful to the Senate of the University of Malta and I will always cherish it as one of the highlights of my career. My oration is mainly directed towards the new graduands. In a few minutes time, you, the new graduates from the Medical School of the University of Malta will be taking the Hippocratic Oath. Only one year ago, while sitting in one of the front rows of this same church, I myself re-read the Hippocratic Oath and was pleasantly surprised how detailed and comprehensive it has become since I first took the Oath some 30 years ago. I confess I cannot remember the very first Oath I took but it was certainly shorter and less detailed. Possibly, I would like to remedy this lapse in memory, by utilizing the learning process of repetition to attempt to ingrain the basic tenets of the Hippocratic Oath in myself and you, my new colleagues. I will make use of excerpts from the current Hippocratic Oath as a framework to build my oration on. One of the very first sentences of the Hippocratic Oath gets to the heart of the matter, “Patients will be my first concern”. The word ‘patient’ is derived from the Latin verb “patiens” which means “to suffer, to endure”. The individuals we care for are vulnerable people enduring pain and suffering, resorting to us for succour. In this endeavour, we should be totally committed as declared in the Hippocratic Oath. This direction will act as our compass pointing true North, whatever assailing buffeting winds we experience throughout the journey of our professional and private lives. To reinforce you with the attributes required to stabilize your compass, most of you are currently being trained within the Foundation School Programme of Malta. Take full advantage of this structured programme. In my time our remit was primarily to service the
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Firm we were assigned to, while training and education came a distant second to the service needs. To illustrate to you the huge advantages the Foundation Programme offers, I will describe a case exemplifying the holistic educational experience this programme delivers. I have been given permission from the family to mention the case of a woman I will name as Chiara. Chiara is a 29 year old lady who at the age of 9 months, had an anaesthetic accident after being operated for an intestinal condition. The accident left the child brain-injured and moreover, three further laparotomies were required within the first year of life. A few weeks ago, (28 years later), Chiara presented with fever due to aspiration pneumonia. Despite successfully treating the pneumonia, Chiara persisted with spiking fever which, after multiple investigations and her eventual fifth laparotomy, resulted from an infected loculus in a 20 centimetre multiloculated ovarian cyst. The Foundation doctor assigned to my Firm sent me an e-portfolio ticket as a case based discussion. The following is what she described: “Cases like this one can be particularly mind boggling, even to consultants. The joint effort of the multidisciplinary team was particularly important and useful. Before a decision was taken to operate, the case was discussed at the Gynaecology Multidisciplinary Meeting and also with consultant physicians, consultant radiologists, consultant general surgeons as well as the consultant in infectious disease. Throughout the process, the relatives of the patient were constantly being updated and informed about the situation. They were involved in every step of the process and this also helped in the final decision. Decisions are not always easy, however with a systematic approach, literature reviews, and the input of different specialities, one can be directed to make the best decision whilst keeping the patient's wellbeing at the centre of care”. A prime example of a comprehensive educational experience of a doctor undergoing training at the Foundation School of Malta! Within the Foundation School Programme, not only are you assigned to a Consultant acting as your Clinical Supervisor but another mentor in the form of an Educational Supervisor is close at hand, to assist in directing you at such a critical juncture in your professional and educational career. The Hippocratic Oath refers to equity in the delivery of Healthcare. “I will take care of all patients equally, irrespective of social, racial, political or ideological differences”. Broadly, health science has divided disease as being influenced by genetics in 40% of cases, 40% impacted by environmental and behavioural variables and in only 20% can direct medical intervention help our patients. Till now, not much can be done to address genetic factors, however the future holds promise in this area. On the other hand, the medical profession can significantly affect the remaining 60%.
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Up to a few decades ago, to be a good physician, it was sufficient to have a sound knowledge base in Medicine and be able to translate this knowledge into proficient clinical practice. This is not enough nowadays. In this day and age, to attain the holy grail of effective holistic healing, one has to take into account the patient’s social status, educational level, financial position, cultural background and religious belief. All these variables can only be processed adequately through the medium of excellent communication. A good history and clinical examination are quintessential prerequisites for superlative patient care. As William Osler once said “The good physician treats the disease; the great physician treats the patient who has the disease”. The Hippocratic Oath continues “I will not put profit or advancement above my duty and service to patients. I will not provide treatments which are pointless or harmful”. Geoffrey Chaucer in his Pilgrim’s tale eloquently articulated “The Physician is skilled at finding the cause of his patients' illnesses, and once that's done, knows exactly where to send them for the cure: to his friend the apothecary, with whom he's worked out a financial deal that's made him rich. So wealthy is he that he's able to afford expensive blue and scarlet robes of taffeta and silk”. Undoubtedly, Chaucer applied a wide latitude of poetic license in his sly jab at the Physician insinuating that “gold in phisik is a cordial”. This certainly is not the case for Maltese Physicians and Pharmacists who, in their overwhelming majority, are a cordial to the compass of integrity and the delivery of excellent patient care. As regards “pointless and harmful” treatments, PRIMUM NON NOCERE will always prevail. Patient Safety should be paramount in our minds. Always allow ample time and consideration to carefully weigh in the risk/benefit assessment of any counsel, medication or any surgical procedure you advise to the patient and family. Quoting Hippocrates “Whenever a doctor cannot do good, he must be kept from doing harm”. The nature of our behaviour and relationship with patients are also conveyed in the Hippocratic Oath, “I will be honest, respectful, and compassionate towards patients. I will strive to maintain full confidentiality about my patients, bearing in mind that the relationship between doctor and patients is based on mutual trust and respect”. The doctor/patient relationship is a special one and spans a rich spectrum of rapport. Some time ago (40 years ago), I participated as an altar-boy at the local parish and remember clearly queues of people waiting to relieve themselves of their sins at the confessionary. Nowadays, confession has transplanted itself to the doctor’s office. This implies that full confidentiality is maintained at all times, reinforcing the mutual trust and respect this bond entails. Again, this necessitates ample patience to allow a full history to be delivered by the patient and/or relatives. More so, a profound level of empathy is essential to sense the patient’s innermost fears and disquietudes.
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The Hippocratic Oath refers to maintaining high standards of practice within the medical profession. “I will recognise the limits of my knowledge and seek advice from colleagues when necessary. I will do my best to keep myself and colleagues informed of new developments and ensure that poor standards or bad practices are exposed to those who can improve them”. Shared responsibility carries the hallmark of attaining clinical excellence especially in difficult cases. The case of Chiara described earlier is a leading example. Never shy away from asking advice. The application of a colleague’s advice or assistance could unravel a veiled diagnosis or improve on the treatment given to a patient. Many a time, patients’ conditions fall within the interface of specialties and the best patient outcome is only achieved with a multidisciplinary approach. Continuous medical education is mandatory. Forty years ago, the global research carried out in one year is nowadays done in one day. Research in Medicine should not be the responsibility of the few but should be within the reach of all. The exponential increase in the participation in the triennial Malta Medical School Conference is testimony to this. Actively, audit and re-audit your work practices, always aiming at attaining clinical excellence. I encourage you to undertake postgraduate studies as these will open alluring horizons throughout your career. Healthcare has taken on the form of the business model of industry to improve constantly and forever. This mindset is vital for our country, considering the limited critical mass of medical intellectuals and our natural physical isolation. Fortunately, with the effortless availability of information technology, these barriers are to some extent circumvented. Attendance at National and International Conferences and workshops also reinforce continuing professional education. Be ready to learn anytime and everywhere, from anybody young and old, medical and non-medical, your patients and their relatives, they are your best teachers. The medical profession entails a life-long multifaceted learning experience. The Hippocratic Oath also defines our relationship with other stakeholders in Healthcare. “I will show respect towards all those with whom I work and be ready to share my knowledge by teaching others what I know”. Modern Healthcare models accomplishing effective holistic patient care can only do so through efficient teamwork of all the stakeholders both in hospital and in the community. We should be at the forefront of clinical leadership with the proviso that we always maintain mutual respect towards all team-players, including the nursing, midwifery, allied healthcare professionals and all the other personnel attending to patients. Last but not least, involve the informal carers including family members and close friends. Five years ago, my whole professional and private life suddenly took on a different turn. I have permission from a close family member to describe her experience in Hospital after a fractured hip. The dynamic hip screw operation was uneventful, however the aftermath is
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too gruesome and painful to describe. Shuttling to and fro the Infectious Disease Unit and the Intensive Care Unit, the patient and her family endured a harrowing two months. Trapped in a valley of darkness and despair, a distant dim light appeared when one son decided to mobilize his fragile mother in a wheelchair despite all physical problems and religiously, on a daily basis for six weeks transported her to the Hospital Chapel. What happened next was nigh miraculous. All the complications related to an elderly, fragile patient retreated. The downward spiral transmutated into an unbelievable recovery and after a total of four months hospitalization, the patient was discharged home. The patient was my mother and I, her son. During the acute stage, the hospital team are most capable of delivering resuscitative and emergency treatment. At home, maintenance treatment is usually the remit of the patient and also of the informal carer. From my very own experience, maintenance treatment in hospital should not only be carried out by hospital personnel but the informal carers should be fully engaged in the patient’s recovery, also acting as “in-house training”. The informal carer may not only help his/her relative with mobilization and nutrition but most importantly will elevate morale. Hospitalization not only changes the physical surroundings of the patient but significantly alters the human environment. Scientific evidence has shown that liberal hospital visiting hours, even in Intensive Therapy Unit and Coronary Care Units, are associated with lower heart rates, lower blood pressure and more rapid recovery rates. In this light, I congratulate the authorities for recently increasing the hospital visiting hours from the meagre 2 ¾ hours daily to 6½, gradually emulating those of other European nations. The Hippocratic Oath widens our remit to advocate for positive Health policies in favour of our patients and the general public. “I will try to influence positively authorities whose policies harm public health and oppose policies which breach internationally accepted standards of human rights. I will strive to change laws which are contrary to patients’ interests or to my professional ethics”. My dear colleagues, this sphere of activity may appear totally foreign to what we are all about. Don’t we have enough on our proverbial plate? However, as I mentioned earlier, more than 40% of disease is impacted by environmental and behavioural factors. These factors if addressed favourably, can prevent illness or at least attenuate the burden of the disease process, alleviating much pain and suffering of our patients. Involve yourselves in Non-Governmental Organizations which seek to catalyze collective care of patients and their families. I myself have helped in founding three Non-Governmental Organizations. One in particular called SANDS Malta (Stillbirth and Neonatal Death Society) stands out as a beacon of hope to mothers and fathers who have lost babies before or shortly after birth. If the needle of our compass points towards untainted integrity, aiming firmly in the direction of unwavering patient care, you’ll be amazed what influence we have to improve the lot of our patients. Administrators and Politicians also need a compass in their
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profession, and that compass, with serene but steadfast persistence can be directed steadily towards our patients’ needs. Be it the beleaguered hospital bed-state, be it the accessibility of standard safe equipment, be it the availability of essential medicines, be it proper safe housing, clean water and safe environments as Dr John Snow (1854) campaigned for in mid-19th century London, be it efforts at circumventing huge communication barriers with our non-Maltese patients, all these are within our remit if we are to deliver effective holistic care to our patients. In an appeal to our common humanity - if we do not advocate for our patients’ needs, who will? I conclude with a modified stanza of the poem ‘Desiderata’. Enjoy the achievements of your profession. Keep interested in your career, it is a real possession in the changing fortunes of time. Exercise caution in your specialty, for the evolution of disease is full of trickery. But let this not blind you to your abilities, You were meant to be a physician. Many clinicians strive for high ideals, Be yourself. Remain humble Especially do not feign omni sapience. Neither be cynical about Healthcare, for in the face of all aridity and disenchantment, our Humanity is as perennial as the grass.
“Wherever the art of medicine is loved, there is also a love of humanity”, Hippocrates. Thank you.
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