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Join us as we delve into the world of medical traditions and their impact on patient care. Our guest is Brian Elliott, an internal medicine chief resident. From the white coat tradition to the multiple Hippocratic oaths and physical exams, we’ll discuss the origins and importance of these practices in modern medicine.
Have you ever stopped to think about why doctors wear white coats or why they take an oath? Brian will challenge us to evaluate these traditions and understand their impact on patient perceptions, trust, and professionalism. He’ll also raise important questions about the accuracy and efficacy of these practices and how they can affect patient outcomes.
Don’t miss this thought-provoking episode as we delve into the science behind medical traditions and why it’s time to ask why. Join us as we strive to make healthcare better for everyone.
Brian Elliott is an internal medicine chief resident and author of White Coat Ways: A History of Medical Traditions and Their Battle With Progress.
He shares his story and discusses his KevinMD article, “Questioning medical traditions for the sake of patient care.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Brian Elliott. He is an internal medicine chief resident. His KevinMD article is titled “Questioning medical traditions for the sake of patient care.” Brian, welcome to the show.
Brian Elliott: Thanks for having me. I’m excited to be here.
Kevin Pho: We’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.
Brian Elliott: Yeah, so I grew up just outside Philadelphia. I went to medical school there at Jefferson University, so I’m heartbroken that the Eagles just lost the Super Bowl, but moving on. I came out here to Ohio for internal medicine residency. I’m doing my chief year before pulmonary critical care fellowship next year. And then above that, I’m really passionate about medical history. I’m a medical history writer and excited to talk about it today.
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Kevin Pho: All right, fantastic. So what got you interested in medical history?
Brian Elliott: Well, a lot of it was just looking at contemporary issues, things that we do today, and saying, why? Where do these things come from? To really contextualize what’s going on today, you have to look back. Otherwise, a lot of these things don’t make sense.
Kevin Pho: All right, so we’re going to talk about part of medical history, specifically medical traditions. You wrote about that in your KevinMD article, “Questioning medical traditions for the sake of patient care.” Now, how did this article come together?
Brian Elliott: This has really been a long journey for me. It started way back in 2018, really, when I was a medical student and, like I said, really looking around and being like, why? Where do these things come from? And I’ve spent about five years now researching medical traditions, things like white coats, Hippocratic oaths, the MD degree itself, things like that, and really getting down to the nitty-gritty and contemporary issues. It culminated in a book, and this article is a little bit of a taste of that, a little taste of some of the things that I found.
Kevin Pho: All right, so talk about some of the specific medical traditions that you’re talking about.
Brian Elliott: Yeah, so the favorite one, the one that I really like to talk about, is actually the Hippocratic Oath, because I think the Hippocratic Oath is something that is so widely misconceived, and there are so many errors in how we interpret it today. I mean, even calling it the Hippocratic Oath is actually a misnomer, because even the original Hippocratic Oath probably wasn’t written by Hippocrates, and we don’t even say that oath anymore, at least in most medical schools. The vast majority say other oaths, and in fact a lot of separate oaths.
Kevin Pho: Yeah, so specifically, what’s misinterpreted about the Hippocratic Oath?
Brian Elliott: Yeah, so authorship is a big one. The second big part is what’s in it. So the Hippocratic Oath dates back about 2,500 years, about 400 to 500 BCE, and we attribute it to Hippocrates. But when we look at what was written in it, it doesn’t exactly line up with the values that we get from the other parts of the Hippocratic Corpus, the body of works that were written by Hippocratic physicians. So when some scholars look back and ask who these values really line up with, they found that what could be described as a religious cult is more aligned with the values in the Hippocratic Oath, specifically the Pythagorean religious base.
While that’s described as kind of like a scholarly hot take, it’s definitely contentious whether or not Hippocrates wrote it himself, and that’s one of the biggest misconceptions. But beyond that, we don’t really say that one anymore. What we say today are some others that came about throughout the 20th century, things like the Declaration of Geneva, which was born out of World War II, the Lasagna Oath, which was written by Dr. Lasagna in the 1960s, or some oaths crafted by medical schools themselves. So the tradition itself is really a bunch of different oaths, which I think is another misconception.
Kevin Pho: All right, so how does that affect contemporary physicians today, the fact that the Hippocratic Oath may be a misnomer and maybe even misinterpreted? Like, how does that affect physicians today? Why is that important to us?
Brian Elliott: Yeah, that’s a great question, because a lot of people will say, “Who cares? We say it one time, and then we move on with our lives.” But when we ask physicians, about 90 percent of them say that they draw their ethical beliefs from the Hippocratic Oath. A lot of them say, “I derive it from this ‘do no harm’ concept,” which is fair, you know, and that speaks to beneficence and non-maleficence, but that phrase actually doesn’t even come from the Hippocratic Oath. It was nowhere in the original Hippocratic Oath, and we kind of misattributed it.
So with physicians relying so heavily on this oath for their ethical beliefs, we should probably figure out what it is. We should probably know what it contains, and we should disseminate a uniform set of beliefs that all physicians should ascribe to, rather than a multitude of different sets of beliefs.
Kevin Pho: Now tell us, how does the Hippocratic Oath contrast with some of the more contemporary oaths that we have to abide by?
Brian Elliott: Yeah, so the original one contained a lot of things that couldn’t and definitely shouldn’t be followed to the letter today, one of which is not to do lithotomy surgery, which, you know, is not going to fly in today’s society. The more modern ones vary a little bit. So the Declaration of Geneva was born out of World War II because of the atrocities that some of the physicians in Germany performed during that time, and that really speaks to a set of beliefs where the World Medical Association said, “Nobody should do this ever again. These are things that we should not be a part of.” So they created a bunch of secular beliefs and then codified them into the Declaration of Geneva.
Whereas the Lasagna Oath came out of a New York Times article that Dr. Lasagna wrote, and he looked back at the Hippocratic Oath and said, “You know, a lot’s changed in 2,500 years. I think our ethical beliefs should change as well,” which makes a lot of sense. So his is a little bit more free-form. The Declaration of Geneva is a little bit more specific and committee-based, rather than the Lasagna Oath, which is his interpretation of the oath.
Kevin Pho: Despite these misconceptions and the historical contexts that you just articulated, why do these misperceptions about the Hippocratic Oath persist today?
Brian Elliott: Yeah, I would like to say that ubiquity invites complacency. So when we talk about something all the time, and we say that it comes from Hippocrates, or, you know, white coats, we just wear them all the time, we start to take them for granted. We start to forget to question them and why they’re really there in the first place, and we’re somewhat blindsided to the things right in front of us.
Kevin Pho: So what other medical traditions should we question?
Brian Elliott: So in the book that I recently wrote, I specifically addressed the concept of medicine as a calling, the physical exam, or at least the routine physical exam, the white coat, the Hippocratic Oath, hospitals as nonprofit organizations, the history of the MD degree and DO degree and their distinction, and cadaver lab as well. Those are the seven that I go through.
And I’m not saying that we should get rid of all these traditions. What I’m saying is we do them so frequently, and they’re so ingrained in our society, and our medical profession anchors itself on empirical evidence, so we should look to empirical and historical evidence for these traditions as well.
Kevin Pho: Now, of those traditions, of the seven that you just mentioned, let’s talk about one of those in depth. Which one of those do you think impacts patient care the most today?
Brian Elliott: I think hospitals really is one of the big ones. Hospitals, where they come from and what they’ve turned into, really impact patients every day.
Kevin Pho: All right, let’s go more into that. So tell us, what are some of the detriments, given the historical context? Like, how have hospitals turned into something that perhaps negatively impacts patients today?
Brian Elliott: Yeah, so hospitals have really done a complete 180 in how they’re built and what they represent. So in pre-18th-century medicine, hospitals were really a place of religious basis. They were funded by churches, or they were churches themselves, and they brought in destitute patients, patients that couldn’t bring physicians or caregivers into the home and pay for that. So the impoverished would seek out these places just to get food, water, and care when they were sick and couldn’t take care of themselves.
As the 18th and 19th centuries came about, hospitals became more secular. They became organizations funded by either the government or organizations to still provide the same purpose, to care for the impoverished and the destitute, but without the religious basis.
And then recently, in the last two centuries, we’ve done a complete 180, in that hospitals, in a way, have created the impoverished. Medical bills are really one of the leading causes of bankruptcy in the United States today. What’s left over from that historical origin, and why that’s important, is that we still view them and still treat them as nonprofit organizations dedicated to a fundamental purpose, to help people who really need it. And I’m not saying that we shouldn’t attribute that to them, but I’m saying that we should hold them accountable for that claim, that they are providing a service and that they are giving rather than taking.
Kevin Pho: And how can we do that? How can we hold hospitals accountable?
Brian Elliott: Well, a lot of it is legislation, policymaking, and the benefits that they really gather from nonprofit status. This claim that they are providing more service rather than taking is built into tax benefits and rules as such. And the New York Times actually did a recent, I guess you could call it an exposé, on some of the issues that have come about from that. And I think it’s really holding them accountable, to say, “If you’re going to get these tax exemptions, if you’re going to be treated like a nonprofit organization, you have to really walk the walk and take care of patients who need it.”
Kevin Pho: Now, when you question medical tradition, by definition, you’re questioning the status quo, right? Now, when you bring up some of these historical contexts of medical traditions, have you received any pushback? What are some of the responses that you receive from your colleagues?
Brian Elliott: Yeah, I receive it all the time, and definitely in discussions on Twitter too. There was just a big discussion about the physical exam, and people really hold on to the physical exam. And again, I’m not saying we should get rid of these things, but we need to do them because of rationality and not ritual. We need to make sure that we’re doing exams because we’re doing meaningful diagnostic testing and not because we just examine patients every day for the sake of examining them. It’s not about getting rid of them. It’s about pursuing rationality, and just because these traditions are the status quo doesn’t mean that they should continue to be.
Kevin Pho: Is there a balance between rationality and a lot of the symbolic things that physicians do? Because I think there are a lot of things that patients expect sometimes in the exam room that may strengthen the doctor-patient relationship but may not have a lot of evidence backing that up. So is there any role for ritual in the exam room?
Brian Elliott: Yeah, and I think the white coat is really a great discussion of that, because patients perceive the white coat very positively. They perceive it as more professional. When they see pictures of physicians in white coats, they’re more likely to trust those physicians. But it’s also debatable, because the current evidence isn’t a slam dunk that if you have an encounter with a patient, they’re going to perceive you as more professional whether you’re wearing a white coat. They’ve found mixed results, because a lot of it is really how you take care of the patient and how you interact with the patient that builds that trust and professionalism.
And I don’t come out completely against the white coat. I think some of it makes sense. I think there are certainly some issues with cleanliness and antisepsis, and if you look at the history of that, I think it’s a little bit of a walking oxymoron, because it was founded on the concept of antisepsis, but now we know it carries a bunch of pathogens on it. But there’s also that value of professionalism and building a rapport with patients, like you said, that the public also perceives it as something beneficial.
I think there is a balance, and I don’t think there is a right or wrong answer, but I think understanding the why is really the important part, and making sure you’re doing it out of reason and not just doing it because you wear a white coat.
Kevin Pho: Now, you have a long-standing interest in medical history. Now, what about those physicians who may be listening to you, and they’re beginning to question some of the things that they’ve always done, and they want to maybe ask the question why and perhaps delve into history? What kind of advice do you have for them if they want to perhaps question some of the medical traditions they’re doing?
Brian Elliott: Do it, definitely. I would say dive in, because once you start diving in, you realize there’s a lot more to it than you initially thought, and it will change your perspective, and I think that’s a fantastic thing.
Kevin Pho: Do you find that there are a lot of obstacles when it comes to, I wouldn’t say removing, but even changing or impacting long-standing medical traditions?
Brian Elliott: Oh, yeah. Change is hard, and like you spoke to, the status quo is a difficult thing to change. People hold on to it. I would say even, especially, people who like history have historical sentimentalism. We like these things because they’re nice, you know? We like Christmas trees, we like Thanksgiving turkey, we like things that provide comfort.
But those barriers are worth overcoming, because unlike Thanksgiving turkey or Christmas trees, the traditions in medicine impact patients. And as a profession that’s founded on evidence and rationality, we have a duty to not just do the medical side right but do this social interaction side right as well.
Kevin Pho: Now, you’re an internal medicine chief resident, and you also have the benefit of a lot of research when it comes to medical history. Now, if you were in charge and you wanted to abolish, with a stroke of a pen, one or two medical traditions because they negatively impact patients, what would those medical traditions be, and why?
Brian Elliott: That’s a good question. I think one of the big ones would be, I would lay down the hammer with the nonprofit status for both hospitals and insurance companies. I think that one is something that we see day in and day out. Patients want to leave the hospital because they’re worried about bills that they have to pay, or they go home and they have mountains of medical debt that they need to recoup. And I think, with seeing certain companies benefit substantially and have revenues in the millions and billions despite being nonprofit, I think that’s the big one.
Kevin Pho: We’re talking to Brian Elliott. He’s an internal medicine chief resident. His KevinMD article is titled “Questioning medical traditions for the sake of patient care.” Brian, tell us some of your take-home messages that you want to leave with the KevinMD audience.
Brian Elliott: Yeah, I would say the big thing is, when you look around and you see all these things that we’re doing with our patients, ask why. Ask where this comes from, and am I doing it because it’s a ritual for me, or am I doing it because it’s the best thing for the patient in front of me?
Kevin Pho: Brian, thank you so much for sharing your time and insight, and thanks again for being on the show.
Brian Elliott: Thanks for having me.
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