When I first began to discuss a Hippocratic oath for administrators with my fellow EPs and friends, I was surprised by the powerful emotions it evoked. From my father, a retired orthopedist: “I say drop it right now! This idea will not put shoes on your children's feet or food in their mouths.” From several full-time EPs: “Sounds good, but don't mention that I had anything to do with it” and “I will be glad to help you, but don't mention me in any way. If you do, I will deny any involvement.”
The biggest change in medical practice that has occurred during my 25 years as a physician is the acceptance of physician employment. I was working in California in 1993, and laws prevented the corporate practice of medicine. Even then, however, physicians were actually employed, just not openly. The CEO chose a group of emergency physicians to staff the hospital's ED. The terms of the staffing contract were compared with those of other groups that competed for the contract.
Physician employment obviously is an intrinsically flawed system. It was considered absolutely unacceptable for the entire history of medical practice. My father was on the medical staff at three local hospitals. When one CEO approached him and demanded that he perform procedures under general anesthesia rather than using regional blocks, which he preferred because they were faster, safer, and far less expensive for the patient, he was able to say, “That is unacceptable. If you insist, I will perform my procedures at the other local hospitals.” The CEO rapidly dropped the issue. Were my father employed by a single hospital with his employment contract signed (or not) annually by the CEO...well, you can see the difference.
CEOs want profit, and money is a great driving force. They decide if they will choose a group with NPs and PAs or just physicians. The administration decides if the new EMR will be physician- and patient-friendly or if it will squeeze every dollar out of every patient encounter and keep all the physicians typing for hours after every shift.
We EPs have always been employed. Only in an unaffiliated, freestanding ED could we potentially be free of the business dictates of the administration. At this point, there is no hope of reversing the trend of physician employment. All we can hope to do is work to ensure that the administration shares our goals and ethos.
We physicians take an oath that ensures that our medical practice serves patients as the overriding force. Profit cannot be the goal in medical care. Our oath provides that we should have a comfortable living and prestige. Certainly, hospital administrators should also receive the fair fruit of their labor, but millions of dollars as an annual CEO bonus violates the spirit of medical care. We should extend our line of altruistic thinking and actions to the hospital administration.
This oath is intended to be a draft. I do not claim much originality; most of the concepts are borrowed from our Hippocratic Oath, ancient and modern. Collaboration and discussion between physicians and administrators will be needed to arrive at a final document. I believe that many hospital administrators will be proud to agree to and live by such an oath.
Medical Administrators' Hippocratic Oath
- I swear to fulfill, to the best of my ability and judgment, this covenant.
- I will realize that as a medical administrator, I must place people's welfare ahead of profit and prestige. If I am unable to maintain this prime directive, I will seek employment outside of the medical field.
- I will respect the hard-won knowledge and abilities of the physicians and caregivers with whom I work and who I may employ. I will assist them to provide the best care possible for those who seek our help.
- I will gladly share my administrative knowledge and wisdom with those who follow. I will share the concepts herein, and counsel my trainees to ensure they find employment that mirrors their ethos. I will assist those not suited to medical administration in their efforts to find a suitable career.
- I will work to ensure that resources are available for the benefit of the sick.
- I will aggressively support and fund the prevention of disease, utilizing those preventive measures that are proven least harmful and most effective, realizing that prevention is preferable to cure.
- I will fund and support equally those effective tests and treatments that are more and less profitable.
- I will realize that resources are not unlimited, and will strive, with the assistance of my providers, to do the most good for the most people with those resources available.
- I will be careful with incentives and awards, ensuring that the result is safe and beneficial to the people who entrust me with their health and welfare.
- I will value and support the technical excellence of my colleagues and their human graces.
- I will not reward or praise treatment or therapeutic nihilism.
- I will not be ashamed not to know medicine because it is not my realm of expertise. I will defer to my trusted physicians regarding treatment and testing decisions.
- I will respect the privacy of my patients, holding myself to the same standards in that regard to which I hold my physicians.
- I will realize that the business decisions I make have powerful and far-reaching effects on patient care, and I will bear this responsibility with great humbleness and awareness of my own frailty. Above all, I must not play at God.
- If I do not violate this oath, may I enjoy life and good health and be respected while I live and remembered with affection thereafter.
I suggest we form a group to discuss and refine this oath. A physician group that meets best practice criteria managed by an administration that agrees to such an oath would indeed be the ideal.
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Dr. Bordenis an emergency physician in Coupeville, WA. His emergency medical practice has been divided evenly between clinical professorship and private medicine. He continues to lecture to physicians on the subjects of emergency regional anesthesia and emergency pain management.