‘First Do No Harm’ is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each instalment is based on one of the 12 RCGP competency domains, this month’s being:
12. Fitness to practise: the doctor’s awareness of when his/her own performance, conduct, or health, or that of others, may put patients at risk and the action taken to protect patients.1
‘ ... one of my most important tasks is to protect my patients from undue medical interference and its ensuing inherent dangers.’2
INTRODUCTION
Doctors are constrained by societal expectations,3 contractual obligations,4,5 the GMC code of conduct,6 the needs and wishes of patients,4,5 responsibility for the public good,4 and concern for the wellbeing of colleagues.1 The emotivist patient and the utilitarian bureaucratic healthcare system cast the doctor as mediator in the consultation and as the accused in the subsequent enquiry; and the legal spotlight reveals for scrutiny not the truth, but its shadow.7 Patients assume us to be medically competent and judge us primarily upon personal, rather than medical, grounds:8 their estimate, for instance, of the degree to which decision making is shared is based not on our skill in shared decision making but on our generic interpersonal skills9 — and often, therefore, on our personality. It can be hard to please the punter. Consulting is demanding work and to avoid burnout it’s sometimes a professional veneer that protects and preserves our humanity.10
HARMING
Letting down colleagues, being late, over-indulging, overlooking these failings in others. Letting down family, working late, under-indulging, encouraging these faults in others. Exhibiting without moderation any of the big five personality traits: Openness, Conscientiousness, Extroversion, Agreeableness, Neuroticism. Dehumanising and being dehumanised, patients becoming sub-humans, and doctors automata.11
HEALING
Balancing personal needs and professional duties in ourselves and others.1 Being clear about roles and responsibilities. Reconciling evidence, policy, and practice.12 Basing feedback not on subjective interpretation but on objective description of specific behaviour.
ATTITUDE
Regarding professionalism not as a state of perfection but as a continuing process of renewal requiring us to recognise and rectify lapses and to forgive and accept forgiveness.
KNOWLEDGE
Variety, continuity of care, and work–leisure balance are the reasons most commonly cited by general practice specialist trainee applicants for interest in general practice.13 Cognitive function is enhanced less by cognitive training and more by physical exercise combining movement, thought, and pleasure.14,15 Happiness is enhanced by a sense of meaning, hope, and purpose and, most of all, by good personal relationships.
SKILLS
Preparing for failure by practising failing safely.16 After adverse events, creating emotional distance and seeking explanations. Developing insight and self-acceptance (rather than self-esteem).17 Digging not a lonely pit of shame but a communal well of shared learning from experience.18 Finding and fostering something good in everyone. Keeping in touch with our personal feelings whatever our professional veneer.19 Making time for family and friends. Looking after not only patients but also ourselves. Registering with a GP. Sleeping well.20
Notes
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 2013