Professor Graham WattMD FRCGP FFPH FRCP(Glas) FMedSci
Address for correspondence :- General Practice and Primary Care Division of Community-based Sciences, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX
Tel 0141 330 8345 Fax 0141 330 8331 E-mail Gcmw1j@clinmed.gla.ac.uk
SMJ 2006 51(1): 27-29
Summary
The
medical and dental graduation ceremony at the University of Glasgow in July 2003
marked not only the 300th anniversary of the first Glasgow medical
graduation, but also the first major revision of the graduation oath. This paper
records the process, and explains the reasons, behind the revision of the oath
and the introduction of a new graduation declaration. The new declaration
provides continuity with the past, while addressing current and future
challenges for professionalism in medicine
Key
words : graduation oaths and declarations, professionalism, values, medical
education
Introduction
The
first medical graduation at the University of Glasgow took place on 5th
October 1703 (1). Three hundred years later, by the end of 2002, a total of
33,310 doctors had graduated in medicine at the University.
The
first record of a graduation oath is in the Faculty Minutes of 8th
December 1732. It is believed that
the wording of this oath changed little during the subsequent three centuries. A
final sentence “if I keep this oath completely, let me happily enjoy both my
life and my art, but if I knowingly transgress, let all opposite things
happen” was removed in the late 18th century.
The oath remained otherwise unaltered until the substitution of an
English version to comply with the Promissory Oaths Act of 1868.
The University Calendar of 1871-72 is the first to mention this Act.
The English oath is very similar to the previous Latin version in terms
of a mid-19th century translation, with minor additions and alterations.
The version in use in 2002 had been unaltered since 1871 (Annex
A).
About
50% of UK medical schools have a graduation oath or declaration (2). Such
declarations have no legal status, but may be considered as a combined and
public commitment by the Faculty of Medicine and its most recent graduates to
professional values and to high standards of professional behaviour.
Recent
changes in undergraduate medical education
In
1996, the University of Glasgow introduced a new undergraduate medical
curriculum, in response to the recommendations of the General Medical Council on
undergraduate medical education in its report Tomorrow’s Doctors (3). The most
distinctive feature of the new course, as embodied by the architecture of the
new medical school building, is the commitment to problem-based learning in
groups as the principal method of acquiring new information. The report also
stipulated, however, that “medical students should acquire and demonstrate
attitudes necessary for the achievement of high standards of medical practice,
both in relation to the provision of care of individuals and populations and to
his or her own personal development.”
To
this end, at the outset of the new curriculum in 1996, the Faculty of Medicine
approved a statement of core values (Annex
B). No attempt is made to teach core values in the curriculum, but
opportunities are taken throughout the course to cause students and tutors to
reflect on their personal values, and those of colleagues and patients, in
particular situations.
The
first intake of students to the new course were addressed by the then President
of the General Medical Council, Sir Donald Irvine, who told them, “The
everyday behaviour of clinical teachers is the living demonstration of their
values and standards – their professionalism. What they do matters as much as
what they say. They influence everyone – for good or ill – by their own
approach to practice, individually and collectively, in their clinical teams and
teaching institutions.”
The
process begins at the beginning of the curriculum. Topics concerned with
professional values and behaviour are introduced during years 1 and 2 as part of
the Vocational Studies course, which runs in parallel with problem-based
learning. Every week, groups of eight students meet with the same clinical
tutor, who is usually a general practitioner, to cover a range of topics and
activities such as communication skills, the right thing to do (ethics and law
in medicine), working with others, understanding patients, people and
communities, evidence-based medicine and professional values and behaviour.
Experienced clinicians are adept at covering this diverse list of topics and
drawing from their everyday experience to raise issues and illustrate points.
The continuity of contact between tutors and groups provides an opportunity for
issues to be re-visited, and for the group to become confident and experienced
in discussing their personal views and values.
While
problem-based learning is a novel feature of undergraduate medical education in
Glasgow, the template for this approach had been laid down in several other
medical schools, including McMaster in Ontario, Newcastle in New South Wales and
Maastricht in the Netherlands. The Vocational Studies course, however, is a
Glasgow innovation. It is particularly pleasing that the same general approach
has been incorporated into the new, revised curriculum at McMaster University,
the transfer having been facilitated by Lisa Schwartz, formerly Senior Lecturer
in Medical Philosophy at the University of Glasgow, and now Arnold Johnson
Professor of Health Care Ethics at McMaster.
Professional
conduct
Professor
Brian Whiting, former Dean of Medicine at Glasgow, who led the changes leading
to the new undergraduate medical curriculum in 1996, not only supported the
development of the Statement of Core Values, but was also responsible for
instigating the Student Code of Professional Conduct. This code was modelled on
the GMC’s “Duties of a Doctor”, but tailored to the activities and
responsibilities of medical students (Annex
C).
Review
of the oath
In
2002, it was considered timely to review the purpose and content of the Glasgow
graduation oath. Although many medical schools no longer have a graduation oath
or declaration, the general view was that the Glasgow declaration is an
attractive and important part of the graduation ceremony.
It
was felt, however, that the oath had become outdated, indeed obscure, given its
reference to an unfamiliar piece of 19th century legislation – the
Promissory Oaths Act, whose original purpose related to officials of the British
Empire swearing allegiance to Queen Victoria. The oath was also out of step with
several aspects of the Faculty Statement of Core Values and Student Code of
Professional Conduct. At the
instigation of the then Executive Dean, Professor Michael Farthing, a new
version was produced after five rounds of iteration, variously involving senior
academic staff, medical students, Professor Robin Downie from the Department of
Moral Philosophy, Dr. Benny Sweeney, former Chair of the RCGP Ethics Committee,
Dr. Bill Mathewson of the Medical and Dental Defence Union of Scotland, and Dr.
John Gibson and colleagues at the Dental School. The penultimate version was circulated for comment throughout
the Faculty of Medicine, before final approval by the University Senate on 30th
January 2003.
At
an early stage, we looked at original and modern versions of the Hippocratic
Oath, the Declaration of Geneva and a modern language declaration, prepared and
used by medical students at Imperial College, London (4,5). We also reviewed
correspondence in the British Medical Journal and The Lancet, concerning the
nature and content of graduation oaths, not all of which was complimentary.
An
early consensus was achieved that, given its historical nature, we should retain
a significant proportion of the traditional Glasgow Oath which, without being
specific, was felt to cover concisely most of the issues included in longer
oaths and declarations. The oath focuses on professional values and behaviour
within clinical consultations, rather than some of the wider aspects of clinical
practice included in the Faculty of Medicine statement of core values.
The
style and wording of the original oath determined the appropriateness of
additional wording. The length of the possible changes and additions was also
influenced by the practical implications of several hundred graduates repeating
the text out loud at the end of the graduation ceremony. Technically, the new
form of words comprises a declaration, rather than an oath, and the text is no
longer “sworn.”
The
revised form of words continues the tradition and form of the Glasgow graduation
oath while bringing its content up to date in important respects (Annex
D). With the omission of the previous reference to the Promissory Oaths Act
of 1868 and two new sentences, the revised text is about one sentence longer
than the text of the current oath, while the word count has increased from 127
to 151.
The
changes
The
new graduation declaration is consistent with the Faculty of Medicine’s
statement of core values (Annex B).
The
first sentence has two changes. First,
“and direction” has been deleted, since this implies a rather one way
doctor-patient relationship. At the
end of the first sentence, “regardless of their individual status or
standing” is new.
The
new text keeps the second and third sentences virtually unchanged – so that
with respect to the principles of Primum Nocere and Patient Confidentiality, it
can be said that all Glasgow medical graduates have taken the same
oath/declaration at their graduation ceremony.
The
fourth and fifth sentences introduce several modern considerations, including
patient autonomy, the basis of trust and the need for continued professional
development and teaching.
Some
colleagues felt that the graduation declaration should make a specific reference
to human rights, in view of the abuse of human rights in many countries in which
medical graduates may choose to practice. Review of the United Nations
Declaration of Human Rights, however, showed that only one of the 30 Articles is
concerned with health, while most are concerned with legal rights and rights of
citizenship.
Others were uncomfortable about a possible
interpretation of “keep silence”, which might be thought to condone keeping
silent in relation to the witnessing of unprofessional behaviour by colleagues,
but the general view was that it is not possible for a declaration to cover all
possible meanings and situations without becoming impossibly long and unwieldy.
From
the consultation process, a consensus emerged that the graduation declaration
should not be considered in isolation but rather, as the end of a process
lasting throughout the undergraduate curriculum, in which professional values
are continually the subject of reflection, discussion and debate.
The graduation ceremony also marks the start of a professional career in
which all parts of the declaration will continue to be important and relevant.
For
this reason, the text of the graduation declaration is also now introduced to
students at the beginning of their course, as a talisman for their future
studies and professional development. The declaration was first used at the
medical graduation on 11th July 2003, and has been used at all
subsequent medical graduations.
Acknowledgements
The author (GCMW) was a member of the original
planning group for the 1996 curriculum (with Professor Brian Whiting, Professor
Ian Percy Robb and Mr David Lloyd), co-ordinator of the Vocational Studies
course from 1995-2003, and co-ordinator of the collaborative processes leading
to the Statement of Core Values, the Code of Student Professional Conduct and
revised Graduation Declaration.
I wish to thank Moira Rankin, Senior Archivist at the University of
Glasgow, for historical information and translation of the earliest form of the
graduation oath; Alison Spurway for providing a copy of the Promissory Oaths Act
of 1868; Professor Michael Farthing for instigating, supporting and following
through a faculty-wide review; senior academic colleagues and members of the
Faculty of Medicine (including its three constituent schools) and medical
students, who provided comments on the previous version of the oath and each
stage in the development of the new graduation declaration. Special thanks also
to Professors Jim McKillop and Jill Morrison, Head and Deputy Head of the
Medical School.
References
1.
Howie WB. Samuel Benion – Glasgow University’s first doctor of
medicine. Scottish Medical Journal 1979;24:76-79
2.
Hurwitz B Richardson R. Swearing to care : the resurgence in medical
oaths. BMJ 1997;315:1671-4
3.
General Medical Council Tomorrow’s Doctors. General Medical Council,
London. 1993
4.
Robin ED McCauley RF Cultural lag and the Hippocratic Oath. Lancet
1995;345:1422-4
5.
Sritharan K Russell G Fritz Z. Medical oaths and declarations. A
declaration marks an explicit commitment to ethical behaviour. BMJ 2001;
323:1440-1