Do no harm - it's not as easy as it looks

This week was filled with sleepless nights, tossing and turning, the hamster wheel in my head whirling wondering what I could have possibly missed. One of my seemingly well patients came in asking for a routine treatment. I asked all the right questions, did the appropriate vital signs, and a complete physical exam. The treatment that I provided was reasonable, evidence-based and guideline-supported. And yet, I got a message the next morning that my patient deteriorated overnight and died suddenly the next day. I spoke to a family member asking what had happened and the death seemed unrelated to the care I provided. I poured over their chart reviewing past and current notes, bloodwork, imaging. Nothing. Nothing that I missed, nothing that could have clearly precipitated her death. I had caused no harm, it was simply her time to go.

We are indoctrinated from early on in our training to "do no harm" when caring for patients. However, as I progress through my career the definition of harm has changed. There are clear forms of harm like prescribing a medication that someone is allergic to. And then there are grey zones of harm that are much more challenging to navigate. Chemotherapy is an example that comes to mind. It's one of the mainstays of cancer treatment aimed at targeting rapidly dividing cancer cells to save a person's life. However, chemotherapy comes with many side effects to varying degrees that can deeply affect a person's physical and psychological wellbeing. We accept this harm to prevent a greater harm - death. 

While originally this concept of "do no harm" was developed for direct patient care, I'd like to argue that it can be applied to our healthcare system at large. Lack of access to primary and preventative care means more ER visits and longer patient wait times. Delays in colonoscopies and other investigative tools means progression of disease burden. Significant delays in access to specialists means more visits to the primary care providers, leaving less time to see other patients for minor emergencies and preventative care, which can in turn lead to more ER visits. Redistributing the responsibility of patient care increases the risk of healthcare provider burnout and further fueling this vicious cycle.

In my everyday patient interactions "do no harm" is always on my mind but not in the ways one might expect. Do no harm to the person in front of me. Do no harm by putting in safety nets for patients to prevent unnecessary ER visits. Do no harm by putting the time and detail into my consults to make sure that they are prioritized appropriately by patient needs. Do no harm by delegating tasks to colleagues (while simultaneously not overburdening them), and setting boundaries with myself to prevent burnout. Do no harm -it's not as easy as it looks.

Family Physicians: The Safety Net of our Healthcare System

"I'll take my chances at home; I'm not going back there. Last time when I had a stroke, they sent me home without catching it, and when I had a blood clot in my leg, I waited seventeen hours before being seen. I understand the risks, but I just don't feel safe going back there," she said solemnly. Her face was pale but her expression decisive. I looked down at the typed note in front of me - my clinical assessment strongly suggested a heart attack in progress, but I couldn't be certain without an electrocardiogram (ECG) and blood work. Instead of sending her to the emergency room (ER) as I felt to be medically necessary, I respected her wishes and via shared decision making devised a plan together to manage the situation as an outpatient. This mostly involved me arranging follow up with the pharmacist, urgent blood work, serial ECGs, an urgent cardiology consult, and frequent phone calls with the patient.

 

I never expected the Hippocratic oath I took all those years ago stating, "do no harm" to become "mitigate the harm done by our healthcare system". From the staggering wait times to medical errors/negligence, patients have become increasingly reticent to go to the ER. There was always some hesitancy, but it has only escalated since COVID. The fear of wait times, past negative experiences, and mistrust are all reasons patients have cited when I have advised them to seek emergency care.

 

In medicine we learned about something called "the Swiss cheese model". This model represents the various safety nets put in place to prevent adverse events from happening to patients. Like lining up slices of Swiss cheese, the ideal scenario involves the holes being staggered so that while an individual may pass through one or two holes, they will eventually be caught by another layer. Redundancy in a system is critical for safety. However, if the holes line up perfectly, a person may pass through all of them without being caught and something bad may happen. For example, imagine a medication error where a doctor prescribes an antibiotic that a patient is allergic to. Ideally this should be caught by the doctor re-reading their prescription. Yet if it is missed, the other barriers in place include the pharmacist reviewing the prescription, and the nurse cross-checking the medication before administration. On a more systemic level, slices would include accessible primary care/walk-in clinics, abundance of commonly used medications, and timely access to hospital care. Every time we cut corners, another hole is added to that slice of cheese. Forced overtime for nursing staff means more burnout and a higher number of patients assigned to one nurse. Insufficient PREMs (permits doctors need to practice in a given region in Quebec) in an area with high rates of doctors retiring means decreased access to primary care. Inadequate ward staffing means less beds open and longer wait times in the ER.

 

Not enough recognition is given to the critical role family medicine doctors and other frontline workers play in filling the holes of our Swiss cheese model. From catching a cancer on a scan that was missed while a patient was in hospital to frequent follows ups with the suicidal teen waiting to be seen in psychiatry despite repeated visits to the ER, sometimes we are the only slice preventing an adverse event - an overwhelming burden adding to the many reasons why primary care physicians are leaving the field altogether. 

 

The above scenarios do not reflect negligence or incompetence on the part of any individual, but simply exemplify the outcomes when healthcare professionals are overburdened and forced to care for more patients than they can reasonably handle. Instead of forcing primary care physicians to take on more patients or other band-aid solutions that look good on paper, we need our government to work with us at all levels of the healthcare system. Else the holes in our Swiss cheese will only continue to grow until there is nothing left.