In July, I celebrated my 25th year of being ‘on service,’ that is, supervising residents and interns on the inpatient Internal Medicine Service. July is a time of transition; new interns begin their first clinical rotations as MDs, with new responsibility and accountability, and new residents transition to roles of supervision of interns and students. Each day comes with new learning for someone on the team – from finding the bathroom to navigating clinical reasoning, to understanding the unique life circumstances and values of a patient and their family. While always true, this year I felt unusual immense gratitude for the team – the trainees, consulting services, nurses, therapists, and pharmacist I had the honor of working with – and especially, the patients who I had the privilege to care for. It made me wonder why we refer to this time as being ‘on service’ and the relevance of this term today.
I still remember several of the patients I cared for on the wards of San Francisco General Hospital in my early months of residency. I vividly remember a young woman admitted with seizures, fevers, and confusion. Her kidneys were failing, her white blood cells were low, and she had anemia. She had young children at home and a supportive family who were scared that they were going to lose her. Ultimately, we diagnosed her with lupus, and she recovered slowly. She became my primary care patient, and I had the privilege to care for her for many years, during good times and bad, disease and health. Like others who have shaped me as a physician, I met her ‘on service,’ and she changed me forever.
Our technology is better now. Our systems are different – some better, some not. But this experience of being shaped by the work of patient care continues, and it forms the basis of our professional identity as physicians and healthcare providers.
I asked ChatGPT to tell me the origins of the term ‘on service.’ It suggested:
“The origins of the term ‘on service’ are rooted in the organizational structure of medical training and hospital operations. Historically, medical education and training programs have been organized into various rotations and assignments to ensure comprehensive exposure to different aspects of patient care.”
I poked a bit further, not quite happy with this response, although it is clearly accurate. It highlighted meaningful concepts – patient care, responsibility, accountability, teamwork, teaching, and learning. Close, but not quite there, I thought. So, I did a quick literature search which brought me to the professionalism and ethics literature and referred me back to the Hippocratic Oath, both old (the oldest expression of medical ethics in the western world and in many ways outdated now), newer versions, and those written by our own students in the Gateway Curriculum – an oath based on these historical oaths but relevant to their time, experiences, and exposures. Here is where I found the answer that had most meaning to me: to be ‘on service’ is to be of service.
For those of us who have not said an oath in a while, I thought it might be valuable to share the Modern Hippocratic Oath written by Louis Lasagna in 1964, which still feels quite relevant today to the core elements of the profession that have stood the test of time:
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.
Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
This last part especially struck me – as a reminder of the gift of service granted to us by our patients and society:
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
So, why am I particularly grateful for this time of being ‘on service’ and hopefully of service? I am grateful because I saw this covenant role modeled every day by the residents I worked with (I didn’t have a student this time, but I witnessed it on other teams), the team members we collaborated with, and the consult services who supported us. Most of all, I experienced it reflected back by the patients who let us into their lives to participate in the ‘life and art’ of medicine.
With gratitude for this gift of 25 years of being ‘on service’ in July,
Eva