Abstract

The taking of oaths by medical students at graduation or other times during training have become common practice globally, particularly in the last century. While some use the modern versions of the Hippocratic Oath, other colleges encourage students to frame their own. Inspired by the Oath of Initiation of Caraka, a student oath at the start of medical education, when idealism is high, can be formative as it introduces the values of the profession. The proposed student pledge could find a place in the foundation course and white coat ceremony of the new MBBS curriculum.

Keywords: Student’s pledge, initiation ceremony, orientation, medical curriculum, fraternity.

Introduction

At the start of undergraduate medical training, it is not unusual for colleges to introduce students to this new phase through an extended orientation programme, designed to introduce all dimensions of campus and academic life. In the new MBBS curriculum implemented in August 2019, this has taken the form of a structured “Foundation Course”. Sometimes, this includes a session at which the students as a group formally read aloud the Hippocratic Oath, its modern versions, the World Medical Association’s Declaration of Geneva, 1948, or the Physician’s Pledge, 2017, or other student pledges, in the presence of their peers, faculty and parents (1,2). This form of activity is designed to sensitise them to new responsibilities as they enter medical training; a welcome into a wider fraternity and a rite of passage. Towards the end of the foundation course a white coat ceremony may be organised, when white coats are symbolically handed over to the new students. The student pledge could be taken at this time as part of this ceremony.

There are several forms that a medical student pledge can take at the time of initiation into medical studies. One form is a version of the Hippocratic Oath. This early in student formation, however, it is uncertain if the significance of each weighty sentence of this time-honoured oath really sinks in to make an impression. For this reason, the oath is usually administered at the end of medical training on Graduation Day, before the student transitions into professional life. Proponents of use of the Hippocratic Oath as the initiating student pledge argue that the use of the oath is not premature since students pledge to be honorable as medical students rather than physicians, and that the oath at this stage is really a statement of intent (3). Others suggest that the students cannot know or understand at this stage what they are pledging to, and this then becomes “ritualistic recitation.” (4) Another issue with the Hippocratic Oath is that it does not specifically address the ethical issues of medical studentship. The Oath of Initiation by Caraka (5) was taken by his students before a sacred fire, once they were chosen to begin their medical training. It conveyed commitment to the chosen profession, honourable conduct, dedication to their practice, adherence to a meaningful student-teacher relationship and supplementary study. (6, 7)

Following this tradition, with the intent to form values and character, student pledges can serve an important purpose at the start of college years, when candidates are idealistic and filled with positive resolve. A pledge is a solemn oath or undertaking. (8) It can sensitise students to the profession, and the values and attributes associated with it. It could contain the mission of the college, as the student joins an enculturated fraternity of faculty and students. It can be adapted to inure students to the rigours and expectations of medical training within the higher calling of the medical profession. A common pledge serves to bring all students on the same footing; irrespective of their diverse cultural backgrounds and social standing. It binds as it builds, a community with a common goal and united vision.

A suggested template for a pledge for medical college entrants is presented here:

Student’s Pledge

Grateful for the privilege of having been accepted into the medical profession, I acknowledge my parents and those who have nurtured me to this point, and solemnly pledge before my teachers and peers –

to uphold the traditions and highest ideals of the profession, and conduct myself in a manner worthy of its heritage of service to society

to diligently acquire the knowledge and skills associated with the art and science of medicine recognizing that a commitment to the practice of medicine is a commitment to lifelong learning

to respect my teachers, and all those involved in my medical training and formation

to abide by the rules and policies of the college and live up to its mission and vision.

to act with honesty and integrity during training and examinations; owning up to mistakes and shortcomings with humility

to work alongside my peers in a culture of mutual support, sharing, and advancement recognizing that great advances in healthcare can only be achieved by collaboration

to respect the dignity of the human body and every patient through whom I develop and improve my medical skills

to accept the plurality and diversity I may encounter during my training, and express compassion and empathy towards all, especially the vulnerable and marginalised.

to develop qualities of leadership, take responsibility for my actions and be open to guidance from my mentors and colleagues

To participate as best I can in sports, arts, and student activities designed for all round development and maturity

to commit myself in service to my community and society, responsive to the health needs and priorities of my country

to use my skills and knowledge for good, contributing to and living up to the ethical standards of the profession

With this pledge, I humbly accept the privileges and responsibilities of the study of medicine.

A pledge can be an intrinsic part of orientation as it uses the moment to imprint on the mind of the student, a virtuous image of the ideal. It is a ritual that offers a promising vision of aspiration, and a new path in life. It unveils the existence of traditions and ideals in medical life and training, with its ultimate goal of service to society. The teacher is revered as a mentor and guide in a student’s quest for knowledge and skills. The reputation of the college cannot be sacrificed in the pursuit of personal goals. Emphasis is placed on bonding with peers in a spirit of mutual support and trust, a socialising that can evolve into professional respect in clinical practice. It sensitises students to moral choices they will face during training and the need for professional humility. Particular emphasis is placed on respect for the human body and human dignity, as dissection and human experiments in first year anatomy and physiology can be emotionally traumatic. In later years, this respect will extend to patients, in caring for whom they will develop newly acquired skills.

As most students in India enter medical college at the age of 18, they are at different levels of emotional maturity and can benefit from healthy peer group interactions, as well as participation in campus activities and sports that develop creative talent, leadership qualities and an understanding of work-life balance. Acceptance of plurality and diversity are important attributes of a doctor that can be developed during student life, when they encounter peers and faculty from different cultures, regions and religions. Encounters with patients can generate empathy and compassion, and, prepare students for their professional work in a plural society.

The mention of service and needs of the country informs the student of his broader purpose beyond personal success, hinting at a wider sphere of influence, a broader context of medical practice and the social burden of receiving medical training to fill a social need. This is in line with the goal of the MBBS training programme to create the “Indian Medical Graduate (IMG) possessing requisite knowledge, skills, attitudes, values and responsiveness, so that she or he may function appropriately and effectively as a physician of first contact of the community while being globally relevant”. (9)

The etymology of the word “professional” is derived from Latin ‘professus’ which means ‘to take an oath’. It refers to the custom in Graeco-Roman schools for newly qualified doctors to promise publicly at the start of their careers to behave in a manner that is morally upright and accept the responsibilities associated with medical practice. A student oath or pledge at the commencement of training can develop a sense of professionalism right from the start, preparing the student for life ahead.

In its Vision document of the Medical Council of India, the role of the Indian Medical Graduate is described as that of a “Professional, who is committed to excellence, is ethical, responsive and accountable to patients, community, and profession”. (10) Student orientation into medical college life is a great opportunity to place in young minds, a vision of purpose and calling, through a student pledge, leading to the formation of the doctor for our times; ethical, compassionate and responsive to societal health needs. An important issue is the timing of the student pledge. If it is taken on the day the students join, the advantage is that parents may be present and the pledge assumes the nature of a shared partnership between the student, parent and medical college. The disadvantage is that the novelty of getting into medical college might eclipse the more sombre and meaningful nature of the pledge. The end of the Foundation Course, when students have met each other and received a broad understanding of the course they have embarked on, might be a better time; particularly if coupled with another event ie the white coat ceremony as has been done in some medical schools abroad (11).

The initial student pledge could be already formulated – a template of which we have provided – or could be developed over the course of the foundation course using a deliberative process (12). The foundation course has now been mandated by the Medical Council of India as a dedicated one-month programme for medical students immediately after they join the medical course. In some institutions medical students take a pledge later in the medical course (when they transition into clinical training) and students at this stage might be better able to formulate their own pledge (13) and take it in the presence of their clinical faculty. The introduction of Early Clinical Exposure where medical students undergo hospital experiences in the very first year of the course, notwithstanding, the shift from being a pre-clinical student to a clinical student with daily postings in the hospital is another significant rite of passage in the life of a medical student and this could be an occasion for a pledge which incorporates all the nuances of the clinical encounter.

One of us (MV), undertook the process of developing a de-novo Oath for students of the KEVAT Patient-Navigator Course at the Tata Memorial Centre in Mumbai. The Patient-Navigator diploma course trains graduates to be the interface between physicians and patients in a cancer healthcare setting. The exercise of formulating the oath involved several steps in which the following issues were addressed:

1) Who are you? What is your role? What in clear terms are the practical things that you need to do as part of your work?

2) Who do you serve? What are their special needs?

3) What values would you like to embody during your work which sets the standards for your work?

4) What are the threats to your work which could undermine these high standards – What do you not want to be?

It is clear that such a process, facilitated by faculty, allows for a greater reflection and ownership of a pledge that could possibly have a more sustained impact. This, in our view, is ideal.

Conflict of Interest – Nil
Other submissions of similar work – Nil