Since the inception of the American College of Surgeons (ACS) in 1913, initiates become Fellows of the College at the Convocation ceremony during the annual Clinical Congress. During the ceremony, new Fellows stand and recite the Fellowship Pledge, committing themselves to the ethical and professional standards of the College. It is an exciting moment that formalizes the acceptance of a surgeon into the ACS.
From the very first Convocation ceremony, the pledge has been a commitment to honesty, respect, and honor in the profession. One key aspect of the pledge that has continually evolved throughout the history of the College is the commitment of the Fellow to not take part in any arrangements or dealings that do not support the welfare of the patient. This principle was particularly important to Franklin H. Martin, MD, FACS, and the other founders of the ACS, who were keen to create an organization that promoted high-quality and ethical practices. The unethical practice of fee-splitting, in which the medical specialist split the health care fee with the physician who made the original referral, was a primary concern of the founders. Fee splitting rewarded surgeons and physicians based on who they knew, rather than the most appropriate doctor for the patient.1
The original 1913 pledge did not mention the term “fee splitting” specifically, but addressed the issue in great detail:
I pledge myself, so far as I am able, to avoid the sins of selfishness; to shun unwarranted publicity, dishonest money seeking and commercialism as disgraceful to our profession; to refuse utterly all secret money trades with consultants and practitioners; to teach the patient his financial duty to the physician and urge the practitioner to obtain his reward from the patient openly; to make my fees commensurate with the service rendered and with the patient’s rights; and to avoid discrediting my associates by taking unwarranted compensation.
Over the years, the original pledge was revised, with several changes to how the issue of fee splitting was addressed. The changes have been in the way of modernization and exactitude of language to better reflect the profession in the modern era. The first revision of the pledge in 1916 addressed fee splitting much more concisely than the original pledge:
Upon my honor I hereby declare that I will not practice the division of fees, either directly or indirectly. I further promise to make my fees commensurate with the services rendered and with the patient’s rights.3
Revisions were brought up again in the 1950s, and as the Bulletin of the American College of Surgeons put it in the 1956 Sept-Oct edition, “During recent years there has been considerable expression of dissatisfaction with the pledge. This was not on the basis of the principles it enunciates but rather that the wording was complicated, cumbersome and anachronistic.”
Upon my honor I hereby declare that I will not practice fee splitting. I further promise to make my fees commensurate with the services rendered and with the patient’s rights.The pledge remained this way until 1986 when, interestingly, the term was changed back to “division of fees.”
As a reflection of current medical practice and terminology, the pledge was evaluated and revised again in 2004, eliminating any term related to “fee splitting” or “division of fees.” In the revised pledge, which is still in use today, this issue is now addressed as follows:
I will take no part in any arrangement or improper financial dealings that induce referral, treatment, or withholding of treatment for reasons other than the patient’s welfare.6
With so much advancement in the health care profession as well as in modern society, the Fellowship Pledge has been updated multiple times to reflect current terminology and to ensure that the surgeons of today are upholding the values of Fellowship in present terms. In doing so, the College has ensured that the commitment a Fellow makes not only remains consistent with the original founding values of the ACS, but also reflects the evolution of surgical practice over the past century, and keeps the patient at the center of the profession.
ACS Archives Highlights is a series showcasing the vibrant history of the American College of Surgeons, its members, and the history of surgery. For further information on our featured highlights, search the Archives Catalog or contact the ACS Archivist.