Self-Care as an Ethical "Duty to Perform"

By Steven Reames, Ada County Medical Society
On October 14th, 2017 major revisions to The Declaration of Geneva, a modern successor to the Hippocratic Oath for physicians around the world, were approved by the World Medical Association. It is the first major change to the Declaration, now to be called a pledge, since its inception in 1948, which has become a core document of medical ethics and a modern version of the 2,500-year old Hippocratic Oath.
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It's about time!

Significantly, the oath has added is a requirement for physicians to attend to their own health, well-being and abilities in order to provide care of the highest standard. This reflects a huge sea-change to inform the responsibility physicians have to fill their own cup up before they pour their lives out in service to others.

For too long, physicians have been trained and expected to put patients' health and life above all other things. In the pledge, it still remains the physician's first consideration, but the additional self-care clause indicates that there can be others as well. It echoes something I wrote to one of our health-care leaders just yesterday: "The prevailing operational ethos of putting the Triple Aim first at all costs cannot be sustained."

The massive changes in healthcare have been so rapid, so sustained, and so intrusive to regular medical practice, that the real cost is not just in terms of actual dollars, but in physician lives as well. The incredible decrease in work satisfaction fuels the epidemic increase in work-related burnout which in turn drives earlier retirement by physicians. For those physicians who feel like they are caught in the surf with wave after wave pounding them into the sand, some refuse to stand up anymore and succumb to it altogether.

Now the real work is for institutions to stand up and say, "Yes, we support that medical ethic and this is how we're going to align ourselves with it." Consider:

• Educational institutions such as med schools and residencies which have a duty to rethink the way their instructional model creates dysfunctional work-life balance expectations that are very difficult to undo after graduation and downright harmful before. Fortunately, the new pledge also includes more equitability in the way respect flows between teacher and students: "I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due."
• Hospitals which completely flout the American with Disabilities Act in the way they approach "impairment." According to EEOC policies, employers cannot rely on speculative evidence or generalizations about these conditions when making disqualifying determinations, and common mental disorders (e.g., depressive disorders, anxiety disorders, attention-deficit/hyperactivity disorder, specific learning disorders, etc.) should almost never form the basis of such requests.[1]
• State boards of medicine, whose questions about impairment on licensing forms, either a) force honest physicians to worry about the effect of checking "yes" on the box since there's little transparency in what happens next; or b) cause really anxious physicians to hide their "stuff" and go out of town, under anonymity, paying cash to seek treatment for mental health issues.

The revised declaration may well begin a generational shift towards enhancing the well-being of medical practitioners so they can provide care with the greatest personal strength. But unless local and state institutions integrate this ethic into actual policies, procedures, and corporate habits, it is doubtful the changes will be enough to reverse the massive and rapid changes that have negatively impacted medical practice over the past decade.

The Physician’s Pledge
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL PRACTICE my profession with conscience and dignity and in accordance with good medical practice;
I WILL FOSTER the honor and noble traditions of the medical profession;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely and upon my honor.
 
 *Hat tip to Dike Drummond, TheHappyMD, for his blog post on the subject.
[1] https://www.eeoc.gov/policy/docs/psych.html