Friday, 28 October 2011

First – Do No Harm

The aphorism has been directed at generations of doctors and medical students. It may be hackneyed, but it has never lost its relevance. For the potential for doctors actually to harm rather than heal their patients is always there and always will be. Harm may come about as a consequence of omission (negligence or inadequate skills and knowledge) or over-enthusiastic, if well intended, intervention.

I often told my patients who were eager that “something must be done” that, while I acknowledged the discomfort or pain that their predicament was causing them, my first priority had to be that of their safety. Powerful medicine may have powerful – indeed sometimes lethal – side effects. Particularly so if the patient is very young or very old.

Not long ago a gentleman in his 80s came to see me. I was working as a locum – “helping out” on a one off basis at a surgery where one of the doctors had been taken ill. I invited him to tell me why it was he had come to see me. He did so at some length. He has seen both regular doctors in the practice and had been referred to hospital where he had had tests including scans to determine the cause of his abdominal bloating. He was on several medications including a pretty fierce laxative. My own view was that therein lay his problem. I noted that he emphasised that he had been told that there was “nothing wrong” with him but that he was unable to accept that to be the case. My own assessment was that his symptoms related to chronic constipation and were very probably compounded by the medications he was taking, and, of course, his age. But he expressed the view that no doctors had been of any help to him at all.

I expressed my concern and sympathy and assured him that I never tell a patient that there is “nothing wrong with you” (not least because there has to be something wrong with all of us, imperfection being the nature of the human organism). I then tried, tactfully and at length, to put across the ill-advisedness of what we, in the profession, call “doctor hopping”. This has the potential to be the most dangerous thing a frustrated patient can do. Some hold on to a common misconception that a “new” doctor can through a new light on to their symptoms. Sadly, this is rarely the case.

I went through his records and assured him that the opinions and investigations he had been given did not demonstrate the likelihood of any serious illness. I then went on to attempt to put across the fact that my first concern was that of “doing no harm”, something that might very well be the result were I to “try another treatment” or referring him for yet more tests.

I must have got it wrong. For he misconstrued my honest and genuine concern as dismissiveness and lack of interest. He threw the classical barb at me “so you’re not going to help me, doctor?” He then went on to make a personal comment about me that was actually quite rude. No matter. 40 years in the job mean that I am little hurt by these things.

It may be that I will be slandered in the pub or post office queue. I will take that in good heart as there is nothing I can do about it. But you may be very sure that I wrote a detailed and accurate account of the consultation and what I said to him in his records. For I have no doubt that when he returns to see his “regular” GP he will have things to say about the useless doctor they’d employed in his absence. And I am less tolerant of slander delivered about me to medical colleagues.


  1. I know of an elderly and experienced doctor who is currently charging (private) patients for treatments which are known to be useless. These treatments are expensive, and many of the patients are self-funded. My source (and I have to be very careful here) has done all he can to stop this, and feels frustrated, angry and helpless that he has been unable to bring about any change. Patients have a touching degree of trust in medics of all kinds, and deserve the total honesty that you show your patients.

  2. The topic of charlatans - medically qualified or not - is one that deserves a blog of its own. I will apply my mind to that!

    Yes - trust can be misplaced. And there are bad apples in every profession and occupation. Who would ever have thought that a doctor would be capable of callously murdering his patients in their own homes? Yet that is what Harold Shipman did. His patients trusted him and often held him in high regard.

    The sick and suffering offer a hugh source of financial gain for the unscrupulous, in their desparation for relief or a cure. My views on this are actually quite polarised: look at the full shelves in the pharmacists' bursting with 'remedies' that make carefully worded assertions, never guarantees but which have never been proven to work in any properly conducted clinical trial.

    Homoeopathy has become pretty well elevated to the realms of respectability now. But it is entirely hypothesis based. Whatever you might be told, no decent clinical trial has shown a single one of such remedies to be any more use than a placebo.

    As I say - more of this in a future blog. Keep watching this space!

  3. For sure there are always people who want attention. But what of people who truly need a cure but are harmed? Having had two friends seriously damaged by difficult operations, I feel that it would be best if patients were actively directed towards hospitals specialising in their type of problem, if possible. Neither of my friends were advised to even consider other hospitals.

    Not to criticise the doctors who treated my friends, as I am certain they did their best.

  4. You've raised a very good point, Jenny, but it's quite different to (though just as important) as the topic I raised originally. And thanks - I will put my mind to it and give my thoughts in another blog. Again - watch this space!

    So - you refer to "people who truly need a cure but are harmed". The harming bit is real enough and happens much too often, most often, as I said, because of the desire for treatment and the desire of doctors to appear to be doing a good job.

    But how often is a "cure" a realistic outcome? Another aphorism springs to mind: "To cure occasionally, to relieve often, to comfort always". This was a directive given to aspiring physicians I think by a Dr Trudeau who ran a TB sanatorium in the 19th century. For the truth is that the true "cure" at the hands of a doctor or surgeon is a rarity. No cure yet for rheumatoid or osteoarthritis. No cure for the common cold. What modern medical science is undoubtedly good at is disease modification. It is the natural healing propensity of the body that does the rest.

    I can't disagree with your point about patients being actively directed to hospitals specialising in their type of problem. Best to be in the hands of a specialist who is doing a particular procedure every day.

    But cure - as I said - is too often an unrealistic expectation. And so much harm can result from trying to achieve it against all odds.

    But thanks very much for reading my blog and commenting on it.