When Hippocrates and Sun Simiao met in Taiwan in a highly efficient health care system
Article first published online: 11 DEC 2013
© 2013 John Wiley & Sons Ltd
Volume 48, Issue 1, pages 14–16, January 2014
How to Cite
Tsai, T.-C. (2014), When Hippocrates and Sun Simiao met in Taiwan in a highly efficient health care system. Medical Education, 48: 14–16. doi: 10.1111/medu.12388
- Issue published online: 11 DEC 2013
- Article first published online: 11 DEC 2013
The cross-cultural views of medical professionalism have been rapidly gaining attention in education circles due to the migration of patients, diseases, trainees and medical staff around the world. As a result, it is widely believed that the Chinese people generally exhibit different values and beliefs from those of Western descent. They tend to place greater emphasis on intrapersonal and interpersonal relationships as the path towards ‘true success’ for an individual while maintaining a holistic approach (including ‘Qi’, ‘blood’, food and environment) towards health.[1, 2] The Chinese pursue a state of internal peace, being proactive rather than reactive, and taking a middle stand in daily decisions and behaviours. True success in one's life is considered to be based on a stepwise progression starting from the individual (the foundation), then family, community, country and finally the world (the last destination). The Chinese are expected to show filial obedience to their parents, who decide on most of the important decisions for their children. As a result, doctors in this cultural setting are then expected to involve the patients’ families when attempting to solve medical problems. In traditional Chinese medicine, doctors developed a systematic approach and a set of philosophies to provide health care, which also differs greatly from those typical of Western medicine. Despite the many differences between the Chinese and Western cultures, however, doctors’ views from either culture are similar in the extent to which both point towards the importance of a ‘doctor's virtue and medical professionalism’.
Despite the differences between the Chinese and Western cultures, the views on a ‘doctor's virtue and medical professionalism’ are similar
This can be proven when we compare famous historical philosophers and doctors from the two cultures who never had any means to converse, considering how they were separated by both space and time. The Hippocratic Oath, which serves as the basis for this special issue of Medical Education, highlights core themes, including: honour your teachers, treat the sick to the best of your ability, preserve the patient's privacy and teach medicine to the next generation. Sun Simiao, who lived about a 1000 years after Hippocrates in the Chinese Tang Dynasty, similarly believed that for a doctor to be great, one must possess not only excellence in medical knowledge and skills, but also high standards of virtue. He believed that doctors should pursue what is in the patient's best interest at the cost of one's own self-interest, offering services to the deprived masses with empathy for nothing in return. The intention of gaining wealth or social standing from patient care was not acceptable. Hippocrates’ belief that one should pay much respect to teachers, as if they were our own parents, was similarly a core value in Confucianism, even though it was not mentioned by Sun. Furthermore, Sun highlighted the importance of the internal harmony of a doctor and their manners in daily medical practice.
In this way, swearing the Hippocratic Oath during the transition into the medical profession combines the themes of professionalism and humanism that have been widely used around the world in one form or another. Of course that is not to say that the ideals are constant, as rapid globalisation and advances in medical technology, as well as constantly changing political landscapes, create many challenges for the traditional literal statements of ‘Hippocratic Oath’. For example, the contextual features of ‘the knife, the stone, and the abortion’ in Hippocrates’ original statement may appear irrelevant or at least outdated nowadays. In order to fulfil the values of different cultures in different times and to preserve the medical profession's virtue and principles of conduct, efforts at renewing the ‘doctor's oath’ have been ongoing.
Swearing the Hippocratic Oath during the transition into the medical profession has been widely used around the world
Even as we now talk more about ‘doctor competencies’ and ‘learning objectives’, the core themes of Hippocrates and Sun Simiao's principles have generally come to be integrated into any framework of professional practice[8-10] and are incorporated into the medical curriculum accordingly. In fact, in this new era, the competencies relevant to communication and interpersonal relationships in addition to ‘self-improvement’ are stressed more than ever. Furthermore, doctors are expected to extend their abilities to collaborate from an intraprofessional to an interprofessional level. Interestingly, as the profession's ethic evolves, granting honour to medical teachers has declined in focus. That phenomenon might be explained by advances in technology and medical informatics, changing learners’ style of learning and interpersonal relationship as well as changing the teachers’ roles by reducing emphasis on apprenticeship models. The pros and cons of these changes deserve further investigation and lead one to wonder what other changes in the medical professions core values can be expected.
The core themes of Hippocrates and Sun Simiao's thoughts have been translated into the framework of medical curriculum
Upon entering the 20th century, a shortage of doctors emerged and the work environment saw an increase in the number of medical lawsuits in many developed countries (e.g. Taiwan, Japan and the USA), as well as a decline in doctor satisfaction and commitment.[11, 12] Taiwan has a highly efficient health care system, spending only 6.55% of the gross domestic product in 2011 on health care while providing nationwide coverage. These various conditions have led to increases in doctors’ workloads and work hours, resulting in fatigue and burnout. In fact, a number of doctors recently died unexpectedly from overwork, adding fuel to the fire when such news appeared in the media and leading to the loss of a significant proportion of young doctors from patient care. In other words, in addition to the known consequences derived from doctors’ overwork (i.e. the hazard to patient safety, poor clinical performance, burnout and poor quality of life), a diminished passion for the medical career experienced by Taiwanese doctors may become the most major consequence with respect to maintaining the profession's ideals. The situation may continue to raise conflict between the interests of doctors and their patients and may, finally, diminish appreciation of the professional virtue of altruism that Hippocrates expressed. To successfully cultivate doctors with professionalism and humanism, it will be important to use these historical and cross-cultural principles in renewed efforts to emphasise the avoidance of obstacles that are placing the system in tension in the modern age.
To cultivate doctors with professionalism, it is important to put renewed efforts to avoid unwanted tension in system
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- 6Medical Ethics in Imperial China, A Study in Historical Anthropology. Berkeley, CA: University of California Press 1979..
- 7The World Medical Association “WMA Declaration of Geneva”. http://www.wma.net/en/30publications/10policies/g1/. [Accessed 18 August 2013.]
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- 13Department of Health 2011. National health expenditure table. Department of Health. http://www.doh.gov.tw/EN2006/DM/DM2.aspx?now_fod_list_no=12752&class_no=390&level_no=2. [Accessed 20 August 2013.]
- 14Taiwan: ‘National Health Insurance’ System in Crisis. http://globalvoicesonline.org/2012/08/28/taiwan-national-health-insurance-system-in-crisis/. [Accessed 25 August 2013.].