‘Realism does not say how things are but only that there is a way that they are.’1
First Do No Harm is a series of articles with internet footnotes about general practice focusing on ways in which we can replace iatrogenesis, making people ill, with salutogenesis, making them well.
The emphasis is not on unequivocal errors like absent-mindedly prescribing penicillin to an allergic patient but on the insidious harm resulting from well-intentioned and apparently good acts. Examples may be relieving distress with diazepam, reassuring the patient that they don't have cancer when the thought had never crossed their mind, investigating the worried well, telling the patient that some other professional should not have given this treatment last time or should do that procedure next time, doing a test the result of which we're unable to interpret, screening without evidence of likely benefit, and encouraging rest for back pain.
We don't intend to do harm, so how does it come about?
We can think about it in terms of attitude, knowledge, and skills. Our attitude is sometimes one of fear: that if we fail to take action we'll get a complaint or a lawyer's letter. Our knowledge is limited by our narrow perspective: we see only a small part of the picture and can be ignorant of the harm that we're doing. And sometimes we simply lack the skills to deal with difficult situations more effectively.
In these articles an alternative is proposed: an attitude of compassionate and measured confidence; knowledge of science; and skills that enable us to help patients both by means of our relationship with them and by using appropriate technology. If the patient is to perceive our compassion as caring, not patronising, and our confidence in science as reassuring rather than heartless, compromise is required. Without compromise, we'll be out of step with the patient and with society. The judgement as to the best compromise in any particular situation is necessarily provisional.
Some things we do are better than others and we manage to do these better things only some of the time. Ignorance of the right things to do and failure to do them on some occasions shouldn't lead us to abandon the effort.
The aim of the series is not prescription but description. Each article is based on one of the 12 RCGP competency domains and uses the following structure: introduction, how to harm, how to heal, attitude, knowledge, and skills. In some cases the notion of healing and harming applies not just to the patient but also to colleagues, students, and ourselves.
Supplementary information
The internet footnotes accompanying this article can be found at: http://www.darmipc.net/first-do-no-harm-footnotes.html
- © British Journal of General Practice 2012