First, Do No Harm

The Latin “Primum non nocere”, which translates to “first, do no harm”, has been a guiding principle for physicians since the beginning of time. It means that whatever the intervention or procedure, the patient’s well-being is the primary consideration. Although this phase is not implicit in the Hippocratic Oath, which nearly 100% of physicians recite on graduation from medical school, its intent is clearly a focus of this important graduation ritual. With this said, how could it be possible that, based on a recent study by Dr. Makary at Johns Hopkins University, medical errors are now the third leading cause of death in America, behind heart disease and cancer?

Surely, there could be numerous explanations for this extremely shocking statistic in the country which spends the greatest amount of money for healthcare. These possibilities are:

• Many doctors see the oath taking as little more than a tradition of the past, holding little value in the healthcare delivery process today. Because some of the tenets in the oath are controversial today, such as not participating in abortions and not assisting in euthanasia, the commitment to “doing no harm” somehow gets lost.
• The education process for physicians has changed over the last decade, eliminating the required year of general internship, and a decreased emphasis on physical diagnosis using inspection, auscultation, percussion, and palpation.
• An arrogance that is tolerated in the profession which precludes the practitioner from admitting what he or she “does not know” and seeking more experienced assistance.
• Hiding a clinical mistake has become more commonplace. In a December 1. 2016 Medscape Medical News article by Robert Lowes, the author indicated “more physicians are willing to hide mistakes”. He reported survey results which indicated that 7% of physicians say it is acceptable to hide a clinical mistake that harms patients while another 14% leave the door open, saying it depends on the circumstances.
• Use of technologies that seeming “have the answers”, thus allowing physicians to not do a final review of the data applying their experience, knowledge, and, above all, “common sense”.
• An excessive workload for some practitioners, driven by revenue production, which prohibits accurate diagnosis and treatments, particularly for the young and less experienced physicians.
• Practicing health care in silos, with little coordination between primary care and specialists, acute care, and post-acute care, and between physicians, nurses, and other support personnel. It has been a long known fact that poor care results from a poor and uncoordinated hand-off of the patient from one level of care to the next. This includes no commitment to doing any follow-up on the patient to assure that the discharge instructions were fully implemented.
• Physicians not supporting best practices and evidenced-based medical protocols.
• Physicians listening to guidance from pharmaceutical and medical devices sales persons as to how to best treat their patients and, subsequently, using medical devices and medications which all have known toxic side effects.

If indeed, any or all of these reasons are contributing to medical errors being the third leading cause of death for Americans, then by knowing them, action plans to correct them can be identified and implemented into the physician practices. As in all challenges, one solution will not fit all. But it is clear that the competencies for practicing physicians overall must be elevated. The knowledge, skills, abilities, attitudes, and behaviors of doctors must be enhanced and the tolerance of mediocrity must not stand in the way of reaching excellence. At a minimum, physicians must commit to not only the mandate in the Hippocratic Oath to never intentionally do harm, but also commit to always doing what they believe is beneficial. Practitioners must never ever consider the possibility of amending or ignoring their moral compass.

More specifically, physicians should consider embracing the following and incorporate these actions plans into their practices:

• Be totally transparent in reviewing their medical outcomes, focusing on those resulting in mortalities and morbidities. These cases should be reviewed, at a minimum, by the physician himself or herself, but ideally by a group of peers who can offer constructive feedback for improvement
• Utilize, as much as possible, evidenced-based medical protocols which will support and drive the Value Equation into their treatment plans

Value = [ Clinical Quality and Safety + Service Quality ] divided by Cost

• Recognizing what “they may not know” and seek help and advice from peers and superiors when facing new complex cases, Physicians should be comfortable in seeking second opinions, and encourage patients to do so
• Only use new technologies after being adequately trained and comfortable with their level of proficiency
• Be comfortable with the interdisciplinary approach to integrated health care, working as a team member with nursing, pharmacists, and other ancillary providers, together creating the best possible results
• Supporting case management for their acute patients, care management for their chronically ill, and care coordination for their well populations, minimizing the need for hospitalization and unnecessary services, thereby also reducing the cost of care
• Staying current on the toxic side effects of new drugs being introduced into the market, their significant negative interactions with other drugs, and their contraindications
• Support a medication reconciliation program so that patients, particularly the elderly, are taking the least number and least toxic medications possible
• Attend continuing medical education programs to maintain and update their competencies as new medical approaches evolve

Being a physician is an honor and an awesome responsibility. People trust physicians enough to turn their most precious procession over to them – their life. This trust cannot be weakened by a physician and other health care providers who knowingly are providing less than the highest quality of medical care, and who are willing to hide their mistakes.