It's not in our oath, but it's essential to becoming a good doctor.
Medical schools across the country have just graduated thousands of students, promoting them to full-fledged doctors with degrees, and they are now ready to start many more years of training for their chosen specialties.
A storied tradition at graduations is “taking the oath.” Hallowed among doctors and taken very seriously, the Hippocratic Oath recognizes that our profession comes from ancient traditions and bears a code of ethics. Yet while humility and a duty to care are centrally important in the practice of medicine, the daily experiences of a physician in the 21st century require an expanded ethical foundation — which the oath only begins to address. Notably absent in both the oaths of Hippocrates and Maimonides is the mention of a much need virtue in today’s doctors: courage.
Stories of courage in the history of medicine abound. Working under various conditions, doctors have fought to care for their patients since the beginning of time. In the 19th century, Dr. Ignaz Semmelweis was pilloried for recommending to his colleagues that they should sterilize their hands before delivering babies. In the mid 20th-century, Dr. Virginia Apgar became the first woman professor at Columbia, created the Apgar score, and performed life-saving research in pediatrics. Dr. Neil Flynn started the UC Davis HIV Clinic in 1983 and fought the disease’s stigma, and later founded the CARES Clinic for HIV and addictions. In 2020, Dr. Li Wenliang died in Wuhan, China trying to tell the world about COVID-19 despite the government's efforts to suppress him.
Writers have been debating what constitutes courage for thousands of years. In the Laches, Socrates tried to define courage in ancient Greece as transcending the battlefield and an endurance of the soul in everyday life. Courage is one of the four ancient virtues, the others being wisdom, justice, and temperance, but has been said to be the most important because without courage, one cannot have the others.
Today, courage is usually defined as doing the right thing despite risk, uncertainty, or fear. It’s grace under pressure. It can also appear in different forms as physicians, new and old, face the challenges of the job.
Physical courage can mean fighting to stay up overnight in the hospital or what it took see patients and risk the unknown during the pandemic. Doctors are the only professionals I know who willingly join a profession in which national mandated limits on work hours are set at no more than 80 hours per week — double a normal work week for most Americans — and a brutal 30 hours on a single shift.
It takes moral courage to stand up for justice, such as countering systemic biases in care. Many inequities still exist among various communities of color or rural settings, and physicians often make sacrifices or face challenges from health systems in their fight for fairness.
Intellectual courage is raising your hand and asking questions when things don’t make sense or are not in the best interest of the patient. Dogmas can persist in any profession, including health care, but that doesn’t necessarily make them right. It also takes intellectual courage to bring ideas forward and pursue scientific discoveries that could take a decade to become a lifesaving treatment or fail in patient trials.
For many of us, especially those of us in psychiatry, emotional courage is one of the hardest forms of courage to muster. Discussing traumatic or violent events with victims can be heartbreaking. It also takes a tremendous amount of emotional courage to enter a specialty in which you know you will have difficult conversations with patients who face life-threatening, or even terminal, illnesses.
Why do we need courage? Because it is essential when we confront ethical dilemmas, especially with regard to boundaries, limits, and duties. It’s needed to treat patients whose circumstances are emotionally overwhelming and to ask the tough questions when answers need to be challenged. A physician who lacks courage will more readily accept the status quo and may be less vigilant in the care of their patient. Often, courage requires saying “no” rather than giving in to a patient’s or colleague’s request.
While there should be a foundational level of integrity when one starts medical training, evidence suggests that courage can enhanced through training and experience. Patients are often our best teachers; they put their lives in our care and this sacred trust should steel our hearts to do what is best for them when confronting obstacles in the health care system. For example, mental illness includes some of the most challenging ailments that one can go through. Overcoming severe addictions, depression, or anxiety requires an incredible level of determination from patients, and as we help them through the process their courage can inspire us to more aggressively confront our own challenges.
We can also learn from role models and mentors who embody courage. Watch for courageous acts from family or friends and learn from them. In medical school and residency, professors who are willing to serve as mentors can also help ingrain the need to do the right thing in ways that will carry throughout your career.
You can actually practice confronting fears in the same way you might practice surgical techniques. Throughout residency at UC Davis, we were videotaped to the point that it became second nature. “Practice codes” and interviewing or examining patients in front of professors and cameras were very common. The supportive and helpful feedback we were provided helped us improve and build more confidence and courage as we progressed in our training.
Courage is a virtue, but only if practiced within your own core values and beliefs. There is a big difference between courage to fight for what’s right and the recklessness of simply breaking rules because you don’t like them. There is a simple test: Are you fighting for a principle because it’s what is best for your patients or what’s best for you?
Dr. Faith Fitzgerald’s well-documented commencement address 10 years ago at UC Davis reminded that medicine is the greatest of humanities, and while external forces, such as technology or insurance companies, continue to dictate how doctors should practice, we in the medical profession should persist in connecting with our patients, knowing them, and being human.
In other words, it takes courage to be a doctor.
Email David Hsu, MD
