Hippocratic Oath, circa. 21st Century?

A few weeks ago I got to play violin in this place: Duke Chapel

…because the Duke School of Medicine was having their graduation, and the organizers wanted a string quartet, and I still haven’t learned the art of saying No. Playing in the Duke Chapel was a pretty wicked experience though, so I can’t complain that much.

After the speech by the chosen graduate who characterized each year of med school with a work of literature, and compared choosing specialties to selecting a mate, the newly minted doctors were asked to join the veteran doctors in attendance to recite the Hippocratic Oath. The classic text invoked the witness of the ancient deities–Apollo et. al.–that each shall keep their fealty to the practice of medicine, and to accept due punishment for failure to carry out their duties. The modern version kept mostly to the ancient version, save for editing out the gods. It was kind of moving to see all of the doctors rise to their feet, men and women alike, some who have practiced longer than most of the graduating class has been alive, before our generation of electronic medical records and instantaneous vital monitoring and surgery performed with camera attached to a tube.

And together they said, the art of medicine.

I went in for a routine check-up with my primary care provider, and had to have a prescription filled. I was told that the order has been put in, and I should go to the designated pharmacy (located in the same hospital complex of my primary care provider) to pick it up. So up I go through the intestines of this massive building, getting sort of lost twice on the way, found the pharmacy, took a seat in the waiting area, waited for a while, then decided I should walk up to the counter and get my bearings, finally got to talk to someone, who then promptly directed me to go to a waiting kiosk to take a number. Said kiosk was placed behind a door. Number taken. Cue more waiting. When I was called to be serviced, the personnel informed me that the Rx was in fact not yet in the system, and I would have to wait for it to be ordered, then filled, since the item I was prescribed was not in stock. When I asked about the estimated timeline that the item would be available, and what I can expect for a co-pay, the personnel said that since “[the pharmacy] doesn’t have it, I can’t tell you when it’s going to get here. And I can’t tell you how much it’s going to cost until it gets here.” And when I asked whether I can get the prescription at another pharmacy that might have the item on-site, I was informed that I “need to talk to [my] doctor and see what they say”.

All before 9:30am.

There’s a reason that I dread going to the doctor’s. Not so much because I disregard my health, but I want to avoid the miscommunication and confusion and gigantic inefficiencies of a healthcare system. There’s a person who is supposed to tell you what options you have for tests and treatment, another for the amount of your co-pays and out-of-pocket fees, another for your schedule (and more options!) for medication, another for what to expect for when you go home. And it seems that rarely do people actually talk to you, and even rarer to each other. Even though I have a rudimentary understanding of what questions to ask, I still run into days where no one understands who’s saying what, and my words are put up against that five-to-ten-second window where someone actually has the time to listen.

We learn in school that patient education is the most crucial, because most people don’t know what to ask.

Maybe that’s the reason we don’t see medicine as an art, because we don’t have the time for art. An art requires its pupils to stay focused, to keep learning about it and re-learning about it, and being continuously open to new ideas. We try to understand an art from as many perspectives as possible, because we want to know the totality of an art for the love of knowing, because we are curious. Nowadays medicine is a trade, a war of strategies with the end goal of wringing out the most profit. We discharge ICU patients as soon as possible short of malpractice, because ICU patients cost the hospitals the most money. We prescribe an opiate to treat pain from trauma to return to work, then pop a stimulant to counter the drowsiness brought on by the narcotic. We run people through fancy machines made of giant magnets and run blood samples through gels to see if protein markers show up and run chemicals to drown a tumor and still run into the sentence of inconclusive, so we tell the patients that it’s all in their head. Refer to psychological counseling. And even though we crank out healthcare providers faster than Pepperidge Farm pops out Goldfishes, we have somehow run into the age of providing sick-care.

I know that there’s a wealth of dedicated healthcare professionals who take to heart their art of medicine, whether or not they have MD behind their names. And in the most dismal places we hear about the work of medical professionals who tend to the needs of the needy. And among my peers who are in training to become healthcare providers, I see this drive to do better, not for the sake of renown or prestige, but because we genuinely care about what we are learning, and want to know how to apply what we care about toward those we will care for.

And there’s a looming suspicion that I can at best call inefficiency. Or perhaps, indifference towards wellbeing. We expect doctors to tell us what we want to hear, for hospitals to be hotels, and to fix our problems with a prescription. Then we fight over who’s going to pay for the sick-care, the theoretical silver bullet that should alleviate all of our medical woes, because we’ve made medicine such an expensive trade to pay for, and the common man and woman doesn’t have the means to pay for the ideal of medicine, that grossly inflated trade with the down-payments of monstrous medical tuition, unexplainable procedures, and mysterious operating costs, that has replaced art with profit.

What have we missed? And when did it start?

For an art to exist and thrive you need both the artist and an audience, and both who want to sustain what they value. And perhaps because we’ve stopped viewing ourselves, our wellbeing, our health as something to be cultivated and respected, and we’ve placed the responsibility of living healthily into the hands of others–society, institutions, government–that we’ve lost the appreciation for the art of medicine. And when something loses its internal value, the exoskeleton is scoured for profit. And with ballooning amount of regulations, standards, reviews and performance feedback, it’s hard to keep medicine from becoming a trade. A very costly one, too. A lot of people are not going to the doctor’s because they can’t afford to, and they end up having their health deteriorate even further. There are people who have no other option–save for death or chronic disability–than to see the doctor and fall in the quicksand of bankruptcy from medical bills.

Perhaps we are all to blame for the loss of the art of medicine.

We have just wrapped up finals and now into our two weeks in the clinic. I have had some really slow days, but also some amazing days where I know in my heart of hearts that this is what I am supposed to be doing. There is no shortage of stress, and I tend to fall into the mindset that school is a reward-punishment model, and the end result is the quality of my grades, with the ultimate goal being my pruning into an efficient subunit in the mammoth machinery of healthcare. I have to remind myself that I am learning all of the things for the love of learning, for the love of my art-trade-vocation, and that grades and job security should not be the only goals of my efforts, but more as the outcomes from my striving toward something more, because I want to be part of something that is more than making profits and finding loopholes and wrangling compensation out of the tangle of sick-care business.

As I stand at the conclusion of my first year of PT school I feel excited and weird and surprised: excited for the second year and even more amazing things that we will learn, weird that I still don’t really know anything, and surprised because I somehow retained the majority of my sanity. I know I will not be very excited for 10-plus hours of lecture videos when we come back from our 1-week “summer break” and faceplant into musculoskeletal and neurological patient management courses. And it will be hard to remember that I keep plodding along because I am curious to learn more about the art and science that is the human body. But I will somehow remember, and herein keep my fealty. To this I solemnly swear.