Author Affiliations: Mayo Medical School (Mr Antiel); Program in Professionalism and Ethics (Mr Antiel and Drs Hook and Tilburt), Division of Hematology (Dr Hook), and Division of General Internal Medicine (Dr Tilburt), Mayo Clinic, Rochester, Minnesota; and Section of General Internal Medicine and the MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois (Dr Curlin).
Most US medical students participate in “white coat” ceremonies in which they recite an oath, often with reference to the Oath of Hippocrates. Reciting such oaths or endorsing shared ethical standards such as the American Medical Association (AMA) Code of Ethics can nurture professionalism by conveying a sense of gravity and belonging to something greater than oneself.1 Yet historic oaths can sound anachronistic to the modern ear, and the oaths sworn in most medical schools modify the original Hippocratic Oath by excluding significant portions and adding language deemed more fitting.2,3 Revised oaths, while more relevant to contemporary medicine, may suffer from being arbitrary and self-serving.4,5
Despite controversies over the role of oath ceremonies in US medical education, little is known about how taking a medical school oath influences physicians' professional formation and practice.
In 2009, we mailed a confidential, self-administered questionnaire to 2000 practicing US physicians, 65 years or younger, from all specialties selected randomly from the AMA Physician Masterfile described elsewhere.6 The Mayo Clinic institutional review board approved the study.
Participants indicated if their medical school conducted an oath ceremony, and, if so, whether the physician participated as well as indicating which oath was used. Then, physicians indicated how much physicians' oaths had influenced their own professional lives (a lot, somewhat, not very much, not at all) and which of several other sources of moral guidance had significantly influenced their professional practice.
Given the religious nature of historic oaths (eg, Hippocratic Oath, Prayer of Maimonides), we hypothesized that physicians' religious characteristics would be associated with their judgments about the influence of oaths and codes in practice.7 Therefore, we assessed how important religion was in their life (“the most important part of my life,” “very important in my life,” “fairly important in my life,” “not very important in my life,” or “not applicable—I have no religion”).
Of 2000 physicians, 105 could not be contacted; 1032 of 1895 eligible physicians returned completed surveys after 3 mailings (cooperation rate of 54%). Cooperation rates varied somewhat by region (Northeast, 53%; South, 52%; Midwest, 62%; and West, 52% [P = .03]) and age category (<50 years, 51%; and ≥50 years, 59% [P < .001]) but not by sex or specialty.
Most respondents reported their medical school conducting an oath ceremony (79%), with nearly all of those reporting participation in that ceremony (97%). Of those of who took an oath in medical school, most (85%) recalled using some version of the Hippocratic Oath (modified or original), though small minorities took an Osteopathic oath (6%), an Oath and/or Prayer of Maimonides (3%), or the Declaration of Geneva (2%).
One in 4 physicians (26%) indicated that physician oaths exerted “a lot” of influence on their practice. The rest indicated that oaths had influenced their practice “somewhat” (37%), “not very much” (24%), or “not at all” (13%).
When asked about other sources of moral guidance that had “significantly” influenced their professional practice, few physicians (16%) cited the AMA Code of Ethics. Many more said their “personal sense of right and wrong” (92%), great moral teachers (35%), and specific traditions (28%) influenced their practice (Table).
After controlling for age, sex, race, region, and specialty, physicians who reported their religion being “the most important” or “a very important” part of their life were more likely than physicians who “have no religion” to report that physician oaths had influenced their professional life “a lot” (odds ratio, 1.8; 95% confidence interval, 1.4-2.5; P < .001). Similarly, compared with those who “have no religion,” physicians who reported their religion as “the most important part of their life” were more likely to report that the AMA Code of Ethics influenced their professional practice “significantly” (odds ratio, 2.2; 95% confidence interval, 1.0-4.7; P < .05).
These data indicate that most practicing US physicians took some physician oath in medical school. However, only 1 in 4 practicing US physicians acknowledged a strong influence of oaths on their practice. Other professional codes, such as the AMA Code of Ethics, seem to play a smaller role in medical practice. For moral guidance in their professional practice, physicians appear to rely most on their own personal sense of right and wrong, with some awareness of the influence of great moral teachers and specific traditions.
In light of these data, the binding moral identity that oaths and codes are/were intended to inspire seems no longer to serve that function for most US physicians. Our data suggest that if oaths and codes are to play an important role in medical education in the future, leaders in professionalism may need to draw connections between standards of professionalism and the personal, philosophical, and theological traditions from which physicians actually draw their moral guidance.8
Correspondence: Mr Antiel, Program in Professionalism and Ethics, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Antiel.firstname.lastname@example.org).
Author Contributions: Mr Antiel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Antiel, Hook, and Tilburt. Acquisition of data: Antiel and Tilburt. Analysis and interpretation of data: Antiel, Curlin, Hook, and Tilburt. Drafting of the manuscript: Antiel. Critical revision of the manuscript for important intellectual content: Antiel, Curlin, Hook, and Tilburt. Statistical analysis: Antiel. Obtained funding: Antiel and Tilburt. Administrative, technical, and material support: Hook. Study supervision: Tilburt. Survey development: Curlin.
Financial Disclosure: None reported.
Funding/Support: This publication was made possible by the Mayo Clinic Department of Medicine funding to Dr Tilburt and from grant number 1 KL2 RR024151 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. Mr Antiel was supported by predoctoral fellowship support from the Mayo Clinic Program in Professionalism and Ethics. The investigators received valuable support in the design and implementation of the study from the Mayo Clinic Survey Research Center as well as the University of Chicago Survey Lab.
Disclaimer: The contents of this research letter are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR or NIH.
Additional Information: Information on the NCRR is available at http://www.ncrr.nih.gov/. Information on the Reengineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov.
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