A "First, do no harm" campaign to change culture in medical school

                                                                                                                                                                                                                   Aaron Stupple 5/2/12

Introduction:                                                                                                                         

First, do no harm has a curious place in medicine and culture. On the one hand, it is widely recognized, and sometimes celebrated as “the cardinal ethical principle sacred to medicine.”¹ Simultaneously, it is often rejected by bioethicists as “inadequate”, “confounding”, and serviceable only by “inert nostrums.”^2,3,4 Clearly, the phrase’s utility depends on its interpretation.⁵ 

Do no harm can be interpreted in a way that is especially valuable to the Avoiding Avoidable Care movement. This document introduces five points of supportive interpretation, and then offers a proposal to use do no harm to influence medical school culture.

1- It is a moral injunction to listen. Primum is alternately translated as “first” and “above all else.” Notions of primacy have been interpreted as invoking medicine as a “moral enterprise”. ⁵ Since the basic morality of medicine is to serve patient interests above those of the doctor, a moral physician cannot serve, and therefore may harm, a patient’s interests if he or she does not actively determine what those interests are. Rather than actively sought, these interests are often simply assumed at best, and dismissed, even compromised, at worst. Quite simply, if a physician does not know their patient’s interests, First, do no harm invokes an image of an unhurried physician who begins with the patient’s interests well before embarking down the road of testing, diagnosis, and treatment. Such a physician recognizes the temptation for even simple tests to turn into painful and expensive treatments that the patient never had, or even wanted investigated. Such a physician thereby adheres to the principles, if not the techniques, of shared decision-making and its concomitant reductions in overtreatment.⁶ In addition, as explicated by Bernard Lown,⁷ listening clarifies the motives behind this service of patient interest, thereby engendering trust. Essential to the enterprise of medicine, trusting patients are more likely to adhere to their medications, return for follow-up, persevere with physical therapy, pass up alternative healers, and prefer the advice of their doctor over the speculation of Google, all consistent with reducing overtreatment. Further, patient trust is essential for doctors to successfully resist the common perceptions that drive treatment: doing is better than not doing, knowledge is power, certainty is strength, and errors of commission are preferred to errors of omission.

2- It emphasizes avoiding harm. Abjuring carelessness and malice, or the principle of non-maleficence, is so obvious that saying so is not saying much at all. However, there are several subtle implications of the specific need to avoid harm that are specifically related to overtreatment and that may be lost if not they are not stated. Drivers include physicians’ lack of evidence about which treatments and devices are truly effective, as well as a common inability to appraise existing evidence. Another is the fear of medical malpractice suits that spurs defensive medicine. According to Shannon Brownlee, the most powerful cause of overtreatment is that doctors are paid according to the amount of care they provide.⁸ Crucially, this last point illustrates the value of harm avoidance language rather than care promotion. On a simple reading, “providing care” can readily be used to rationalize overtreatment, and its attendant revenue. Pharmaceutical and device companies routinely disguise their profit motives behind a veneer of care, but rarely invoke an avoidance of harm in any way similar to Bernard Lown’s dictum: “Foremost, we did as much for the patient, and as little to the patient as possible.”

3- It addresses the culture. Conveniently, do no harm is a cultural fixture that can be used to address another cultural fixture, namely, the belief among well-meaning physicians that more care is better care. According to Steven Smith, such beliefs are so pervasive, so deeply embedded within our ethic of caring and duty to patients that they become “the air we breathe,” and paradoxically easy to miss. Do no harm, unlike duty to treat or even serve the interests of my patients, includes a specific reminder that almost all care has risks. The phrase may be uniquely suited to identifying such a fundamental assumption. As well-meaning doctors begin to root out this subtle cause of overtreatment, then more overt profit-driven causes will become all the more evident.

4- It unifies the profession. Do no harm is notable for its widespread recognition among physicians. Regardless of its origin and interpretation, Primum non nocere is to medicine what Semper fidelis is to the marines and Be prepared is to the Boy Scouts. Accordingly, the phrase has value to the extent that it strengthens the unity of a profession widely perceived to be under siege. At a time when cynicism among the ranks is growing, when forces of government and corporations are encroaching on physician autonomy, and when public trust is waning, physicians are abandoning professional societies like the American Medical Association just when they most need to organize and collaborate.⁹ Do no harm can become a rallying cry, attracting both physicians in training and established doctors who pursued medicine from a moral calling, but may have since lost faith. By offering a core value, one that harkens back to the roots of medicine, as a remedy for today’s dire health care situation may re-engage members with the profession’s mission.

5- It renews public trust. Since do no harm is so widely recognized by the public, using it to brand the avoidable care movement may be an effective strategy to counter the vast marketing machine of pharmaceutical companies, hospitals, and other health care corporations as they triumphantly tout the latest and greatest treatments. The phrase’s humble tone rebrands the mindful physician who listens and restrains inappropriate treatment as a paragon of trustworthiness, all the while carrying an attendant rejection of trust that is based on action. Finally, since very few market mechanisms are incentivized to promote the mission of avoiding avoidable care, co-opting the most famous line in medicine is an effective way to get the word out.

Proposal: Avoiding Avoidable Care, as a movement, co-opts First, do no harm and outlines an interpretation of the phrase’s meaning specific to the aims of the movement, a condensed version of the above. It then approaches the Arthur P. Gold Foundation, sponsor of the Gold Humanism Society and the White Coat Ceremony, in which almost every medical student participates at the start of medical school. The movement requests the inclusion of a First, do no harm campaign within the Gold Humanism Society’s White Coat Ceremony. Since oath taking is a requirement of this ceremony, including do no harm is consistent. The movement could also create a pin, similar in fashion to the Gold Foundation pin that is distributed at the White Coat Ceremony. Students would affix this do no harm pin to their lapels, as a sign of their mindfulness of overtreatment. Central to this campaign would be an emphasis on listening. Specifically, students would be encouraged to query patients about their interests and goals as something akin to the fifth vital sign, whereby it is sought from every encounter. By affixing a moral spotlight on listening, students would be charged to advocate and innovate methods to increase the length and effectiveness of patient encounters. Thereby, as the Movement develops guidelines and best practices for avoiding avoidable care, this charge can become a hook with which to publicize these developments to students themselves, thereby obviating the need to negotiate with the medical schools to incorporate this material into curricula.

Conclusion: Do no harm does not specifically speak to all aspects of Avoiding Avoidable Care. Specifically, interpreting it to comment on the need in some cases to perform care that is being neglected is tenuous. However, the phrases near universal recognition, moral invocation, negative language, and humbling spirit outshine its liabilities in interpretation and comprehensiveness. Admittedly, co-opting the phrase is more about leveraging its spirit than in creating the ideal slogan or tag line. However, an essential role of any movement is to capture the hearts and minds of participants. Do no harm is already in their minds, and by showcasing it at formative periods in physician training, it can capture their hearts. Since much has been made of the limitations and failures of medical training to address overtreatment, do no harm offers an easy way to redress the dwindling patient focus in medical schools and residencies.

References:
1- McGarrv L, Chodoff P. The ethics of involuntary hospitalization. In: Bloch S, Chodoff P, eds.
Psychiatric Ethics. Oxford: Oxford University Press, 1981:217.
2- Smith C. Origin and Uses of Primum Non Nocere−−Above All, Do No Harm! Journal if Clinical Pharmacology. 2005 45: 371
3- Caelleigh AS. Cover note: medicines and poisons. Academic Medicine. 1998;73:842.
4- Lasagna L. The Therapist and the Researcher. Science. 1967;158:246-247
5- Jonsen A. Do No Harm. Annals of Internal Medicine. 88:827-832. 1978.
6- Joosten E, DeFuentes-Merillas L, et al. Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status. Psychotherapy Psychosomatics 2008;77:219–226
7. Lown, B. Social Responsibility of Physicians. Address presented at Avoiding Avoidable Care Conference, Cambridge, MA. April 26, 2012.
8. Brownlee, S. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. Bloomsbury USA.
9. Wynia M. The Short History and Tenuous Future of Medical Professionalism: The Erosion of Medicine’s Social Contract. Perspectives in Biology and Medicine. Volume 51, Number 4, 2008

A Case for Medical Diversity

Diversity trumps ability.

As described by Scott Page in his compelling book The Difference, the thinking is rather straightforward. Good problem solvers in a field are similar, so a collection of them rarely outperforms any one of them by themselves. However, a diverse group of intelligent people is far more effective, so long as they bring difference perspectives and different methods to bear on the problem.

I considered it a powerful argument for doctors to explore social media: to harness diversity. Specifically, it's an argument for physicians as managers of diverse patient care teams, including nurses, dietitians, and social workers, as well as the patient's family, friends, and other patients like them.

Page outlines four conditions necessary for diversity to trump ability. For each of these, I consider how they relate to healthcare.

The problem must be difficult. Good health is famously difficult, and you need only look at the Dartmouth Atlas to see how they vary.

Individuals must know about the problem. There are a great many people, not just doctors, who know a whole lot about not just the health issue in question (the disease and treatment), but also the patient's habits and values

Incremental improvements must be suggestible by the group. Much of health, particularly for chronic conditions like diabetes and heart disease, are about continual optimizations that could be gathered by diverse suggestions.

The group must be large and genuinely diverse. Many patients, particularly those with chronic conditions, interact with a growing number of healthcare providers.

Reasons for Optimism About Tech in Medicine

The DIKW Hierarchy

In David Weinberger's fascinating Too Big to Know, he taught me about the Data, Information, Knowledge, Wisdom hierarchy, which apparently is so commonly referred to that it is better known by it's acronym, DIKW. It's one of those ideas whose power derives from its staggering simplicity. Stated briefly (or, if you prefer, extensively on wikipedia), the idea is that information is more valuable, and more scarce, than raw data, and the same goes for knowledge and wisdom.


The hierarchy says a lot about the perfectly valid concern that the influx of modern technology in medicine is ultimately dehumanizing.


As someone who has could be accused as proselytizing med tech, the hierarchy gave me pause at first. Our fancy gadgets stand to create a data deluge that leaves little room for knowledge and wisdom, which are the stock and trade of medicine. A wealth of information certainly is no substitute for knowing what to do with the information, when, and to what purpose. Those who wonder if more technology is really the answer for medicine must not be casually dismissed as narrow-minded Luddites.


But there is a less obvious application of technology, and this is nicely illustrated with the DIKW hierarchy. Some of our new tools not only collect and dispense more data and information, but transform these into knowledge, any maybe one day, wisdom.


An example is IBM's Jeopardy master computer, Watson, currently being engineered to assist physicians. This tool is interesting because it turns information into knowledge. Far from overwhelming doctors with information, and even farther from attempting to replace doctors, Watson aims to help doctors by reducing the information they're faced with by converting it to knowledge. Ideally, a doctor working with Watson can spend more time turning knowledge into wisdom, and spend less time calculating information from data, or synthesizing knowledge from information.


My guess is that patients would prefer to have their doctor impart wisdom rather than manage data. To the extent that our tools promote this end, we should be optimistic about the future of tech in medicine.


Disclaimer: I receive no compensation from promoting books on this site or anywhere else.

Doctor Digitus: Recipe to Retake a Profession

Published in 1982, relevant in 2012.

In The Social Transformation of American Medicine, Pulitzer Prize winner Paul Starr outlines a medical history wherein doctors were exemplars of professional sovereignty: authoritative, powerful, "unambiguously important to their clients," nourishing their "thirst for reassurance."

Mastery of their profession was easy when doctors' heads were the sole repository of medical information, when medical error rates were not measured or published, and when a doctor's reputation was respected a priori, rather than questioned a Google. Patients had to come to them, in person. With no conceivable alternative, they had to bestow upon them their trust.

Unfortunately, that trust has eroded. Is there a way for physicians to retake their profession?

Simply put, professional mastery tracks with information mastery. In the 1980's, the two cohered: a doctor could master books and journals in a way patients couldn't dream, and control of the profession was unquestioned. Today, the digital explosion has left doctors playing catch-up, with patients arriving at the office with their own list of Web-derived diagnoses.

To retake the profession is to regain information mastery, which is to attain digital dominance: Doctor digitus.


In The Creative Destruction of Medicine, Eric Topol writes about Homo digitus, where the bright future of healthcare is a convergence of patients' digital and bodily selves. For Topol and others, the future of health is digital. Digital digital digital.*


What can Doctor digitorus do?

1- Outperform Google by giving patients the background information on their diagnosis, treatment, and prognosis from good, clear sources created by doctors and/or vetted by doctors.

2- Outperform alternative medicine by connecting with, communicating with, and supporting patients' need to feel empowered and in control of their health future.

3- Outperform scorecard medicine in magazines and online, where reputations hang on the caprices of frustration and marketing, by establishing a robust online presence that drowns out healthgrades.com.

4- Outperform distractions by creating engaging apps and other tools that encourage patients to maintain healthy behavior patterns, from diet and exercise to adhering to treatment regimens.

5- Outperform voter apathy and discontent by using modern media to promote the mission of medicine.

6- Outperform the past with quality improvement tools that measure and highlight avenues to decrease medical errors and avoid avoidable care.

7- Outperform the pace of knowledge-creation with tools that curate valid medical breakthroughs that matter clinically.

8- Outperform traditional medical education by teaching with digital tools.


Every one of these steps involves mastery of digital tools. Which have I left out?



*Don't take it from me, check out some of my favorites

Daniel Kraft

Kent Bottles

Jay Parkinson

Bryan Vartabedian