It is one of these moments you remember for the rest of your life. Standing in my brand new suit with the index and middle finger of my right hand raised, saying “so help me God’’, I completed the Hippocratic Oath, and became a doctor. I’ve forgotten the colour of my suit and the marvellous dinner afterwards, but the content of the oath frequently crosses my mind.
The Hippocratic Oath is one of the most widely known Greek medical texts. It requires a new physician to swear to uphold medical ethical standards practiced by doctors in many countries worldwide. The following sentence is the central aspect of the promise: “I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism’’.
The Hippocratic Oath is the invisible backbone of the daily activities of a doctor. The supportive friend which you can rely on when making life and death decisions. The ethics which bounds all doctors worldwide. One oath universally utilised and respected.
Almost five years after taking the Hippocratic Oath, I started working in a remote hospital in Africa. And the hard work commenced; with limited resources, few educated staff and an infinite stream of patients mostly in advanced stage of their diseases. Frustrating from time to time, but the most frustrating aspect was not the patients, but the international NGO (INGO) that deployed me. My direct supervisor and senior manager had no recent clinical experience, and therefore weren’t comfortable making medical related decisions. Protocols and guidelines were mostly written by non-medics. Decisions were made from behind laptops in air-conditioned offices miles away from the clinics. The people making these decisions conducted field trips at the beginning of their employment – with the main purpose of taking pictures to send home – but did not visit regularly.
Frequent staff meetings were prioritised over patients care, even though it could impair patient’s outcomes as patients had to wait for their medication, food and examination. Diseases with quick onset, such as acute infectious diseases (cerebral malaria in children, Ebola viral disease), acute surgical (appendicitis, bowel strangulation) and obstetric (obstructive labour, fetal distress) emergencies need urgent medical intervention – delay in medical handling does negatively affect a patient’s outcome. So delaying treatment should be seen as in conflict with the Hippocratic Oath.
Equally shocking to me was the lack of mid-term evaluation and monitoring, and the lack of interest in improving the provided health services. Monitoring focused on quantitative ‘outcomes’, such as the number of patients triaged, discharged and numbers of particular diagnoses. There were no pre- or post-admission interviews to monitor patient’s satisfaction. There was little consideration of whether patients had the right understanding of the purpose of the services, what treatment patients received, or whether diagnoses were made correctly.
In addition, there was little discussion of how to build improved national health systems. A national health worker could receive on the job training by working alongside more experienced international colleagues, but we never discussed how that might influence the national health system in the long run. The INGO focused on obeying the policies and demands of overseas donors.
We medics ask for the respect and space to use the values of the oath in our work. To have an efficient health facility in place, that enables a doctor to have sufficient time with the patient in order to answer questions and give an explanation on the proposed therapy. To have a patient-minded policy that doesn’t prioritise the costs of additional diagnostics above patients’ wellbeing. To respect the anonymity of patient’s information and outcomes, without manipulating diagnoses which might influence the value of the upcoming donor grants. We ask for medics to be fully supported by the management of the project, valuing the ethics of the medical profession in accordance with the historical oath.
Decisions should be made by staff at the field level, who understood local customs and needs. As it was, decisions were made by donors who rarely visited the field and so lacked the technical understanding that should inform the creation of regulations and policies: placing the right of the patients as the key priority.
INGOs running medical projects should hire more medical experts who have recent clinical experience and the up-to-date knowledge needed for that particular project, even if they work in managerial positions. INGOs should support them by working at the field level as much as possible, or at least undertaking regular useful field trips. An essential part of the work of medical expats should include supporting and empowering local medical staff.
With this in the back of our minds, let us set aside the top down mindset that has gradually crept in to the medical practice. Let us please reconsider the importance of the Oath of Hippocrates, and use it as the start and end point of our medical aid projects, both in the western world and in low- and middle income countries. The patients will be grateful, and so will the donors eventually.