The Development of a Profession
Dr. P. Warren
Professor, Faculty of Medicine, University of Manitoba
Legislation governing medical practice is nothing new. The first example is seen in Mesopotamia. Babylon where the ruler, Hammurabi (1728-1686 BC), had a code that applied to many legal matters including land owning, divorce, boat building while a few deal with medical practice. For instance, regulations set the fees for treatment as well as the penalties for failure depending on the rank of the patient:
If a physician has performed a major operation on a lord with a bronze lancet and has saved the lord's life...he shall receive ten shekels of silver; but if he caused the death of such a notable, his hand would be chopped off. A doctor causing the death of a slave would have to replace him.
Hippocrates is best remembered for his oath although many authorities believe that it is the one that he was least likely to have written. Edelstein attributes the Oath to the Pythagorean philosophical dogma because of the attitude against suicide. The oath is both a covenant and an ethical code. Its date would be 4th century BC. Aristophanes mentioned the Oath in one of his plays 411BC. Let us look at the original - it is different in many details from the one the Dean and you shared last week but both share many principles- the oath has been modified many times over the centuries to reflect the moral climate of successive societies. Few oaths now mention a deity, most avoid the abortion issue, and many omit the prohibition of sexual contact with patients although this lapse by physicians is condemned by licensing authorities.
The Oath was translated into Latin and Arabic and later adopted by Christianity. Surprisingly the Hippocratic Oath was hardly used at medical schools until the past ten years; in 1928 less than a quarter of schools used it. There are now many versions used- some schools have allowed students to write their own. Since the Second World War the Oath has reflected the Declaration of Geneva and the Nuremburg Code 1948. The behaviour of physicians under Nazi Germany showed that the profession cannot always be trusted to place the well being of the sick ahead of self interest. More recently the pursuit of research has sometimes been put ahead of the benefit to the patient and again codes of ethics for research have been developed.
Hippocrates writings also include many comments on the profession and how physicians should practice. For instance in:
Life is short, art is long, opportunity fleeting, experiment dangerous, judgement difficult. Not only must the physician show himself prepared to do what is necessary; he must also secure the co-operation of the patient, the attendants and of external circumstances.
Regarding diseases, make a practice of two things -to help, or, at least, do no harm. The art has three factors, the disease, the patient and the doctor. The doctor is the servant of the art. The patient must co-operate the doctor in combating the disease.
Hippocrates in the books Law 2 and Physician 1 describes how the doctor must possess natural ability, be industrious and be well taught. The physician should be healthy, clean and well-dressed using suitable perfumes, keep his silence, and be grave and kind to all. His demeanour is to be thoughtful, not harsh, not forward nor excessively cheerful. After all the physician is involved in intimate matters and must exercise self-control and be mindful of the method of sitting, decorum, and speech. But Hippocrates warns that he should keep an eye on the patient's faults, "they lie about things prescribed".
Other comments worth recording include in the Precepts:
One ought not to be concerned about fixing a fee.
If an opportunity of serving a stranger in need should arise, you should especially render assistance....For where there is a love of man, there is also love of the art.
It is also not shameful when in difficulty or inexperienced to call in a second opinion.
You must shun luxurious head gear and elaborate perfumes!
The wish to give a lecture for love of a crowded audience is not a laudable desire; at least avoid citations from the poets, for laborious citations reveals a lack of ability.
One criticism of alternative medicine is that its practitioners do not follow a code of ethics and are often not regulated. Hippocrates commented on this in the Sacred Disease:
In my opinion those who first attributed a sacred character to this diseases were the sort of people we nowadays call witch-doctors, faith-healers, charlatans and quacks. These people also pretend to be very pious and to have superior knowledge. Shielding themselves by citing the divine as an excuse for their own perplexity in not knowing what beneficial treatment to apply, they hold this condition to be sacred so that their ignorance might not be manifest. By choosing suitable terms they established a mode of treatment that safeguarded their own positions.
Finally a physician must maintain and guard the art, practice it and hand it on. The honorific doctor comes from docere to teach (Latin) and that a physician has an obligation to teach is long enshrined in the profession.
Medical education began to become organized in Muslim Arabic medicine. In their society it became customary for a teacher to provide his pupils with a certificate to show that they had studied medicine. But in 931 AD in Baghdad, after the death of a patient, the Caliph introduced examinations for students. Such exams lasted until the 12th century and were found elsewhere in the Arab world.
As mentioned earlier the first formal medical school was founded at Salerno, South Italy in about 9-10th century AD. Its origins are hazy but it seems that its early teachers included Greeks, Romans, Jews and Arabs. Its teachers had great influence. [large image] Most notably women were admitted as pupils and the most famous was Trotula who became a teacher and wrote a textbook on obstetrics. The teachers were salaried. The curriculum included Anatomy with the dissection of the pig as well as practical Medicine. Teaching of Behaviour, based on the Hippocratic tradition, was included.
Promise the patient that he will get well again, but inform the friends that he is very ill; in this way if a cure is effected the fame of the doctor will be so much the greater, but if the patient dies people will say that the doctor had foreseen the fatal event.
In 1140 AD. King Roger introduced Fixed and Exclusive Examinations for Salerno and warned:
If you neglected to take the exams you will be punished with imprisonment and confiscation of goods.
In 1240 AD, Emperor Frederick II published Regulations for the school and the program consisted of :
• Pre-med 3 years of Logic
• Medicine 5 years including surgery
• Proof of study and pass examination
• One year apprenticeship before independent practice
• A fee schedule was set but graduates swore to provide free care to the poor
• The School of Salerno was closed in 1811 by Napoleon
Similar schools emerged in Europe with most being part of universities although private schools also existed. Guilds and colleges regulated their membership as to who could practice and what could be done- apothecaries, surgeons and physicians appeared as separate groups. The regulations were dominated by ruling who might do what in the practice of medicine.
Modern Code of Ethics
The modern codes of ethics emerged in the 18th century with John Gregory (1724-1773) a Scot who became Professor of Physic at Edinburgh. He would lend his students his lecture notes and one of them arranged their publication in 1770, Offices on the Duties and Offices of a Physician, and on the Method of Prosecuting Enquiries in Philosophy.
In this he advised on the moral qualities of a physician. The chief is humanity:
that sensibility of heart which makes us feel for the distresses of our fellow creatures, and which, of consequence, incites us in the most powerful manner to relieve them.
He drew attention to sympathy, gentleness of manners and compassion. He advised that the physician develop a composure and firmness of mind so as not to be enervated. This was what was to be known as Osler's Aequanimitas.
By philosophy Gregory meant the Scientific Method, Baconian, to establish truth and the scientific discipline of being open to new information. He taught that medicine must not be practised as a trade in which self-interest rules the roost, for commerce is anathema to the moral life. Gregory's teachings influenced Thomas Percival who was educated in Edinburgh and practiced in Manchester, England. He published his work, Medical Ethics in 1803. This work covers many aspects of professional life. Many of his issues are pertinent today. He described Beneficence as a genuine concern for the good of the individual. He counselled that the patient's feelings, emotions, and anxieties are addressed as much as the symptoms and signs. He forbade bedside case discussion so as to not to harm the patient by alarming them. He denounced the use of inferior drugs as an economy and discouraged quack medications but said that a physician must not desert a patient who persists in their use.
When ordinary treatment fails experimentation with new remedies is sanctioned provided the physician is guided by "sound reason and well-authenticated facts".
He wrote on the business of medicine such as the etiquette of consultations, the obligation to the poor. He considered that fees are legitimate but must be subject to "knowledge, benevolence and virtue". He stressed the importance of self-education in the maintenance of competence.
In 1847, the American Medical Association and in 1867 the Canadian Medical Association used Percival's work as the basis for their own Codes of Ethics.
CMA 1867 Code of Medical Ethics addressed three areas:
• The Duties of Physicians to their Patients and of the Obligations of Patients to their Physicians.
• The Duties of Physicians to each other, and to the Profession at large.
• The Duties of the Profession to the Public, and of the Obligations of the Public to the Profession.
Some excerpts from it include:
"A physician should not only be ready to obey the calls of the sick at all times, but his mind should be attuned to the greatness of his mission and its responsibilities."
"Every case committed to the charge of the physician should be treated with serious attention and humanity."
"Frequent visits to the sick are, in general, requisite"
"A physician should studiously avoid making gloomy prognostications because they savor of empiricism and magnify the importance of his services" "He must not abandon a patient because the case is incurable"
"The profession- on whom so many arduous duties are imposed...make many sacrifices of ease, comfort and health for the welfare of mankind"
The public was advised that its first duty was to select a medical adviser who has received a regular medical education. This was an era when virtually anyone could set up as a physician. The patient should choose a physician whose habits are regular and who is not devoted to company, pleasure, or any unsuitable pursuit.
Physicians had an obligation to uphold and advance the standing of the profession, for "there is no profession that requires the greatest purity of character and moral excellence."
One tradition of the past century was that physicians treat each other and their families for no fee. This custom has disappeared with Medicare.
In 1938, the CMA produced a new Code of Ethics and these were dedicated to DA Stewart from Manitoba who had chaired the committee. This code followed the Golden Rule: "As ye would that men would do to you, do ye even so to them".
A major fear for Stewart was the effect of advertising on the practice of medicine by such methods as communication to lay audiences in particular through the medium of radio broadcasting. By such means a doctor could build up their practice. The code was summed up thus:
It is the Art and Mission of to take all that is known in fact and science and to apply it skillfully, wisely, gratefully and beautifully to the needs of sick people and to the ways of life for men and nations.
The code finished with the Hippocratic Oath and the Prayer of Maimonides.
This brings us to what governs us in Canada and Manitoba:
1750 - First Medical Licenses in North America were granted by Intendant Bigot in Quebec.
1867 - The British North America Act. Education and Health are a Provincial Responsibility. Canadian Medical Association founded.
1871 - The Medical Board of Manitoba was legislated with the right to examine candidates to medical practice.
1877 - the College of Physicians and Surgeons of Manitoba.
1883 - Foundation of Manitoba Medical College with 13 Physicians as Faculty and the right to examine candidates delegated to it by the college.
1912 - Foundation of Medical Council of Canada. Its purpose was to provide examinations that can be used by each province for licensing purposes.
1919 - The Medical College joined the University of Manitoba as its Faculty of Medicine.
1928 - Royal College of Physicians and Surgeons of Canada founded for specialists.
1931 - Introduced examinations for specialists. FRCPC or FRCSC.
1954 - College of Family Physicians founded.
As a result in 2000 to practice Medicine in Manitoba / Canada you need:
• A degree from an accredited Medical School- in Canada and the USA accreditation is a joint affair.
• A certificate of an approved post-graduate training of at least two years.
• Completion of the parts 1 and 2 of the Medical Council of Canada Examinations.
• As a specialist, certification by the Royal College.
Of course to meet the needs of the Province there are often exceptions made e.g. ministerial waiver has often brought in South Africans.
To admit to Hospital, you need Admitting Privileges granted by the Hospital or Regional Authority.
To be paid, you need a Billing Number assigned by the Provincial Ministry of Health.
Your conduct will be judged by your peers at the College applying the guidelines of the College and the code of ethics of the CMA following the long tradition that our first duty is to serve our patients not ourselves. The public must never lose its trust that we can regulate ourselves.