62. Primum Non Nocere (First, Do No Harm)
In this episode we hear from eight leading physician educators about the core principle of patient care: primum non nocere. We learn that limiting harm can translate into doing what’s medically right, putting the patient’s welfare first, judicious use of IV fluids, reducing opioid prescribing, making a habit of pausing when depleted, acknowledging the end of life, and allowing a natural death.
Guests: Cam Berg MD, Neda Frayha MD, Scott Weingart MD, Josh Russell MD, Haney Mallemat MD, Alan Sielaff MD, Vicky Vella MD, and Mike Weinstock MD
The importance of figuring out the core principles that drive your medical decision-making [1:30];
Is it: Don’t get sued? Get a good patient satisfaction score? Rule out the life threat? Have good metrics at the group meeting? Have compassion? Be masterful?
In each of us, there’s the balance of all of these things. But what is the core principle?
Primum non nocere, and how it is good for patients and good for us [02:40];
Hippocrates wrote: “Practice two things in your dealings with disease. Either help or do not harm the patient.” In the 17th century this was shortened to the phrase we know today -- “primum non nocere”, which means, “first, do no harm”.
Primum non nocere has become the central ethic of medical practice. But how does one introduce both the philosophy and the actions of ‘do no harm’?
Cameron Berg is concerned about the harm caused by excessive prescription of opiates in the ED [05:10];
In 2016, the CDC and MMWR “demonstrated fairly compellingly that even a 2 or 3 day prescription of oral opiates confers very real downstream harm. Approximately 5-10% of those patients will be dependent on daily opiates one year later. That’s a number needed to harm ranging from 10 to 20. When I think about my own practice, it’s hard to think of too many other things that are that dangerous.”
Dr. Berg changed the way he manages pain. “Now, 100% of the time, when I’m sending a patient home with an oral opiate, I have a conversation about the risks and benefits of that intervention.”
He’s found that many patients want alternatives to opiates, as they are not willing to accept the known risks associated with them. He has decreased the number of opiate prescriptions dispensed by more than 50% in the last year. When he does give prescriptions, they are for smaller quantities. Patients seem to be more satisfied.
Neda Frayha learned that ordering more tests on patients can cause more harm than good [07:25];.
Neda had been in the mindset of working up every patient complaint. She equated ordering tests and informing patients of the normal results with good care. Now she has learned that the tests themselves can cause harm.
“As I’ve gained more experience, I have embraced the idea of doing no harm by doing less. I realize that most of my patients will get better on their own. The human body has an incredible capacity to heal.” When she explains this to patients, “a lot of times, that’s enough and the patient can leave feeling like they’ve been listened to and heard and cared for.”
She appreciates that tests can be difficult for patients. Lab sticks can hurt, MRIs can cause anxiety, and appointments with consultants can be difficult if you don’t have transportation or time off from work.
Neda tries to do less harm by thinking about what the patient is going through when she subjects them to different tests. And only order tests if they’re completely necessary.
Scott Weingart applies the “do no harm” principle to the use of IV fluids when resuscitating patients in septic shock [09:20];
He looks back with dread on the days when we used to flood septic patients with fluid. We now know the benefit of early vasopressors and the detriment of excess fluids. “It just makes no sense to me at all to give large volume fluid resuscitation to septic patients, unless their septic state is actually one of fluid loss outside the body.”
“I’ll give most patients 20-30 ml/kg, but if based on my clinical and ultrasound exam I don’t think they’re going to benefit from it, I won’t even give them that. As soon as I hit 30 ml/kg, if they’re not in a situation of losing fluid out of their body, I just put them on a vasopressor.”
Josh Russell tries to limit harm by thinking about what he’d want to have done, if he were in his patient’s shoes [11:00];
“It’s important to be honest with ourselves that the potential for harm exists with every procedure we do, with every test we order.” Instead of “do no harm”, he suggests that we “strive to behave in such a way that the likelihood of causing harm is as low as reasonably achievable.”
We can reduce the likelihood of our not prioritizing a patient's interests above our own by predicting when this is most likely to happen. We are at risk for behaving this way when our willpower is depleted. “When our willpower is spent, such as at the end of a shift, we favor doing the easy thing more than doing the right thing.”
“What I find to be helpful is making a true habit of pausing at any moment when I notice that my willpower is not what I’d like it to be. I take a full 15 seconds to reflect on what I would want done for me if I were in the same situation as the patient.”
Limiting harm is a natural consequence of us putting our patient’s interests first.
Haney Mallemat has come to learn that many patients are predestined for bad outcomes, and the provision of maximal therapy is actually harmful [13:40];
Haney finished critical care fellowship with the philosophy that he must aggressively resuscitate all critically ill patients so he could look the family in the eye and tell them that he did everything possible for their loved one. But then he learned that maximal therapy is not always the best therapy.
“We’re harming them in the sense that we’re not giving them the dignity to die of the natural causes that they present with. We’re not giving them the dignity to die a painless death. We’re not giving their family the dignity of spending quality time with that person. Instead, we're there doing procedures, taking time away from the loved ones and the patient.”
“I try to highlight the fact that this person has a natural disease that is leading them to have a natural death. We have the choice to either prolong this or to ‘do no harm’ to the patient and use other resources that we have available to us to make the patient comfortable.”
Alan Sielaff uses shared decision-making to help guide him in doing no harm [15:50];
He stresses the importance of “making sure that I’m doing what I think is medically appropriate, but that is also inline with the patient’s goals for their own healthcare. This has led to better interactions and minimized the amount of testing without the negative consequences of bad outcomes.”
Dr. Vicky Vella believes that “do no harm” is recognizing when a patient is near the end of their life and, as a physician, trying to act in a way that reflects that [16:20];
When elderly patients are at a point that their quality of life is very poor, “we’re not letting them die because we’re sticking needles in them, we’re starting drips on them, and we’re doing investigations when really we should be recognizing that they’re at the end of their life.”
Mike Weinstock makes an effort to treat all patients as he would treat them if they were his own family member [17:15];
When we try to satisfy patients’ expectations, we can cause harm.
Mike has learned that patients with the highest satisfaction can also have the highest early mortality risk, noting that we modify our typical best practice to do what we think the patient wants.
He tries to “make sure that the patient and their family know that I’m managing their care as I would a family member.”
Also, “I ask them for permission to practice good medicine. This is a powerful and effective technique to be able to provide the best care and avoid harm, which could come as a result of over-testing or over-managing.”
All of these things are about giving ourselves permission to practice good medicine that considers the patient's needs above all else...There is a reason that we take an oath that gives us the central ethic of medical practice: primum non nocere.
Shownotes by Melissa Orman, MD
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