‘First Do No Harm’ is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each article is based on one of the 12 RCGP competency domains, this month’s being:
‘It is far better to predict without certainty, then never to have predicted at all.’2
It’s as important to recognise variants of normal as it is to identify pathology. For variants of normal, treatment causes harm without benefit. Even where pathology is present, for many medical interventions harm precedes benefit, and for some interventions, total harm exceeds total benefit.3,4 A good consultation, without investigations or drugs, is potentially all good, a form of treatment called ‘doctor’5 which is better than an inappropriate prescription.6
HARMING
Responding to problems by routinely suggesting intervention1,7 just to make sure.8 Attributing outcomes to past and therefore unalterable events — ‘you/they shouldn’t have done that’.9 Raising expectations that can’t be met. Making the patient worried and insecure4 — hopeless (that problems are insoluble) and helpless (that things are outside their control).10
HEALING
Working within the bounds of the possible,7 being ‘there’ for the patient (if not physically, then figuratively), bolstering the patient’s self-confidence and security,4 fostering a ‘sense of coherence’ (that things will work out reasonably okay).10 Agreeing the management plan with the patient, exploring the patient’s understanding of what’s happening, providing explanations that are relevant and understandable to the patient, using appropriate language. Identifying the urgency and gravity of the situation and responding appropriately.1 While using knowledge of natural history of disease, monitoring progress to check for deviation from the expected path.1
ATTITUDE
Being comfortable with two roles: as bio-mechanic using technology and as humanist using ourselves in a relationship with the patient.5
KNOWLEDGE
When the odds of cancer are 1:19, the odds are 19:1 that the patient doesn’t have cancer and may therefore be harmed by a referral and by failure to address their true problem.4 The 10% of patients with the highest predicted risks calculated by validated computerised algorithms include 61–77% of all lung,11 gastro-oesophageal,12 pancreatic,13 colo-rectal,14 and ovarian15 cancers diagnosed over the subsequent 2 years. So cancer diagnosis (and exclusion) will require serial consultations in these patients at high risk; and 23–39% of cancers will be found among patients at low risk. Furthermore, symptoms may point to cancer in general but not one cancer in particular: loss of appetite and loss of weight are common to all five cancers. Tests are often instigated by doctors rather than by patients.16 Whatever the situation, a positive approach by doctor and patient4 is beneficial.
SKILLS
Using the patient’s own words and checking the patient’s understanding1 repeatedly with open questions.4 Offering choice judiciously17 — for instance, over formulation of paracetamol. Averting conflict by means of a checklist of options: agree, disagree, counsel, or refer. Finding out what the patient is expecting and addressing unmet wishes. Talking reassuringly.4
- © British Journal of General Practice 2012
