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.
