Docs: How often do you think "First do no harm?"

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nisiprius
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Docs: How often do you think "First do no harm?"

Post by nisiprius » Sun May 23, 2010 9:36 am

[Added: what I really wanted to know is how practicing doctors relate to any ceremonial oath of ethics they might have taken. I used "first, do no harm" as an example, in the mistaken belief that these words were a literal part of these ceremonial codes!]

A question for the MDs. In regard to the discussion of the MBA oath, how many times a year do you ever consciously think "First, do no harm?"

Did your medical school have an occasion at which students were expected to formally subscribe to a code of ethics, informally known as a "Hippocratic oath" or "modern Hippocratic oath?"

Example: Duke University Medical School - 2010 Hippocratic Oath Good grief, I was just about to watch that thing but it's an hour and a half long. Ah, here it is, 35 minutes in. Whoa! "Will any in the audience who are physicians and wish to re-take the oath please stand." They don't actually swear "by Apollo," no surprise there. No explicit "first, do no harm." They will exercise their art "solely for the cure of my patients and the prevention of disease. And, yep, "I will give no drugs and perform no operation for criminal purpose and far less suggest such a thing."

UCLA. The oath is at 1:29, and, interestingly, is taken just after he declares them to have "all the rights and privileges thereof. Doctors, please be seated." So I guess a new-minted doctor could away with sitting out the oath as apparently they have already graduated! They explicitly promise "never to inflict harm, injustice or suffering." No mention of "criminal" procedures. A multilingual postlude.

Albany medical college. This one includes a statement about not considering patients' "religion, nationality, race, party, politics, sexual orientation, or social standing." "I shall not use my medical knowledge contrary to the laws of humanity."

Watching these YouTube videos is actually pretty interesting. Based on a sample size of three, I get the impression that every school must compose its own oath. "First, do no harm" is not in any of them.

Do students ever refuse to take the oath and, if so, what happens to them?

If you took the oath, what would you say your attitude was? Say, on a scale of 1 to 10 where 1 represents cynical pro forma conformance and 10 represents completely sincere commitment?

Were you given an opportunity to review the oath before taking it, or did they just hit you with it, cold, the day of the ceremony?

[Added: And this is my real question]: As a practicing doctor in the real world, do you feel that you have a responsibility to "the medical profession" that is distinct from your responsibilities to your employer, your family, yourself, and that "responsibility to the profession" does carry some weight in the balance of your decision-making?
Last edited by nisiprius on Sun May 23, 2010 10:44 am, edited 10 times in total.
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Post by Call_Me_Op » Sun May 23, 2010 9:43 am

I would think it is difficult to truly uphold this oath if you are prescribing medications you do not understand - which is almost universally the case.
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Post by sschullo » Sun May 23, 2010 9:46 am

Was at my nieces' MD graduation from UW at Madison and they took this oath: http://www.cirp.org/library/ethics/geneva/.
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Post by mhalley » Sun May 23, 2010 9:50 am

I don't think I ever consiously think "first do no harm". It is more like a global gestalt, thinking of all the different things that could go wrong when treating a patient. There is always the possiblity that the test or treatment you prescribe MAY do harm, and you think about the risk and reward profile. Say someone comes in with abdominal pain and I need to rule out appendicitis. The test of choice for this is a CT scan with IV contrast. A certain number of people can have an allergic reactioin to the dye and it could kill them. So I have to consider, what is more likely to kill or harm the patient, missing a case of appendicitis or the remote chance of an allergic reaction to the dye?
As far as the oaths go, I believe they are not mandatory. I believe people have refused to take the oaths in the past with no consequences. I think I was pretty sincere when I took mine 20 some years ago, probably a 7 or 8. Alas, the years have beaten me down and I am now pretty cynical. 3 or 4.
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Re: Docs: How often do you think "First do no harm?&

Post by gasman » Sun May 23, 2010 10:03 am

nisiprius wrote:A question for the MDs. In regard to the discussion of the MBA oath, how many times a year do you ever consciously think "First, do no harm?"

Did your medical school have an occasion at which students were expected to formally subscribe to a code of ethics, informally known as a "Hippocratic oath" or "modern Hippocratic oath?"

Example: Duke University Medical School - 2010 Hippocratic Oath Good grief, I was just about to watch that thing but it's an hour and a half long. Ah, here it is, 35 minutes in. Whoa! "Will any in the audience who are physicians and wish to re-take the oath please stand."

Do students ever refuse to take the oath and, if so, what happens to them?

If you took the oath, what would you say your attitude was? Say, on a scale of 1 to 10 where 1 represents cynical pro forma conformance and 10 represents completely sincere commitment?

As a practicing doctor in the real world, do you feel that you have a responsibility to "the medical profession" that is distinct from your responsibilities to your employer, your family, yourself, and that "responsibility to the profession" does carry some weight in the balance of your decision-making?
-There are many versions of the hippocratic oath given at graduation. Including the original. They are nonbinding.
-At my med school graduation we were simply told to remain silent and not say parts of the oath that we individually objected to. Many did so for the part about not assisting in a pregnancy termination.
-A corollary of "first do no harm" is that errors of omission are better than errors of commission. It is fairly pervasive. IMO it is the reason why conditions with risky therapy are the most undertreated.
-As far as your 1-10 scale question, I would say that I was a 5 at graduation but there were plenty of 10s among the crowd. Today I am a 1 Still know a few 10s.
-I feel no special responsibility to the medical profession, other than I identify with doctors.
-20 years since graduation.
Last edited by gasman on Sun May 23, 2010 11:26 am, edited 1 time in total.

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Post by Phatphoeater » Sun May 23, 2010 10:07 am

i think about it with every patient encounter. in pediatrics there is a tendency to minimize interventions since managing patient discomfort is important in the plan of care.

i think most med schools have a "white coat ceremony" at the beginning where the oath is taken.

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Post by nisiprius » Sun May 23, 2010 10:12 am

sschullo wrote:Was at my nieces' MD graduation from UW at Madison and they took this oath: http://www.cirp.org/library/ethics/geneva/.
Ah. That seems to be exactly the one used by Albany Medical College in the random YouTube clip I stumbled on.

No, it isn't. They added a phrase about keeping secrets. They added "and sisters" to "my colleagues shall be my brothers." They added "sexual orientation" to the list of things that will not "intervene." They omitted the phrase "from the time of conception."
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Post by anthau » Sun May 23, 2010 10:16 am

I'm not a doctor, but I can report that one of the reasons my wife and I chose our current doctor is that it's clear he remembers it. Without going into specifics, my wife had already been treated by two practitioners, both of whom had hazarded a differential diagnosis, neither of which had panned out. Now-current doctor reasons to us, "Well, A did A, and B did B. Both seem incorrect now, though I also would have tried A & B. I'm stumped. Let's do some tests, but do nothing, and follow up in a week." It was remarkably refreshing, oddly enough.
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Re: Docs: How often do you think "First do no harm?&quo

Post by fsrph » Sun May 23, 2010 10:25 am

nisiprius wrote:A question for the MDs. In regard to the discussion of the MBA oath, how many times a year do you ever consciously think "First, do no harm?"
First, I am not a physician. But in my job as a hospital pharmacist I work primarily in the critical care units .... and work closely with pulmonologists/critical care specialists who make tough decisions on a daily basis. The idea of "do no harm" is not specific enough. I'd say more "do no intentional harm" is more realistic. I say that because in the real world many decisions physician make are based on risk/benefit to the patient ... and harm indeed can be an outcome. For example, if you are allergic to contrast dye, but the MD pre-treats with steroids, and you still have a reaction to the dye is that "doing harm"? I think not, because the greater good is diagnosing your primary problem which may need immediate attention. Hopefully (and in the vast majority of cases I believe it's true) these decisions are made with only the patients best interests in mind. I've seen these pulmonologists sit with the family for 30-60 minutes and thoroughly explain what they want to do, and only then obtain informed consent from the family to proceed.



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Re: Docs: How often do you think "First do no harm?&quo

Post by Munir » Sun May 23, 2010 12:37 pm

[quote="nisiprius[Added: And this is my real question]: As a practicing doctor in the real world, do you feel that you have a responsibility to "the medical profession" that is distinct from your responsibilities to your employer, your family, yourself, and that "responsibility to the profession" does carry some weight in the balance of your decision-making?[/quote]

When I was in practice, my responsibility was exclusively to my patients. All my expertise, knowledge, and energy were focused towards helping my patient who was right there in front of me. All the other phrases and what I would call gimmicks never entered my mind.

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Post by camden » Sun May 23, 2010 12:51 pm

I graduated in '74, just after the Rowe vs. Wade decision. My class decided to take the Oath of Maimonides instead of the traditional Hippocratic oath, as the latter has an anti-abortion pledge. There would have been no consequences, however, for anyone who merely declined to take any oath.

As to your real question, I think about the ethical responsiblity I have to the patients I encounter, and to the concept of using my best judgement to come down on the correct side of the risk-benefit ratio of what I suggest, every single day.

The chairman of the Pathology department at my med school traditionally reserved the last lecture of the sophomore year course in that subject for himself, and the last 15 minutes to his concept of what it meant to be a physician.

He told us that when we graduated, we would automatically be granted a measure of trust by the public that was given to no other profession; trust that we would keep their confidences and trust that we would do our best in our temporary custodianship of their most precious assets---the lives and health of themselves and their families. He told us that we, ourselves, had done nothing to earn that trust; it had been earned for us by the actions of generations preceding us who had demonstrated that it was warranted. Finally, he told us that it was our solemn obligation to conduct our professional lives in such a manner that the trust we inherited would be passed on to the generation to follow, undiminished.

Cynics may scoff if they wish, but I found those to be strong words. Then, and now.

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Post by bc3x » Sun May 23, 2010 12:57 pm

As noted in Wikipedia, the Hippocratic Oath has not been a part of the graduation ceremony since the 1870's. The principles expressed in the Modern Version have been taught alongside the Basic Sciences and throughout postgraduate training.

Primum nocere was understood to be the minimum in ethical behavior in the practice of medicine. Mentors stressed instead that physicians treat their patients as they would family members and if need be, better than family members. The interest of family members often becomes secondary to that of patients (missing a child's birthday or a family celebration). This tenet also means the subordination of the physician's comfort (getting up at 2 a.m. for an emergency procedure) or interest (not ordering that study just for financial reasons) to the best interests of the patient.

Physicians, like any other group of people, have strong and weak adherents; with a majority somewhere in between.
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Post by adave » Sun May 23, 2010 1:05 pm

medicine is a unique profession - extremely complex personalities abound. but, many times doing "nothing" is the best course of action, and finding a physician who understands that is key.

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Post by donocash » Sun May 23, 2010 1:09 pm

I'm a retired physician, but . . . . .

The oath taken at graduation, at least when I graduated, was a joke. It was just a formality that no one paid any attention to at all before, during, or after the ceremony. I likely forgot the oath two minutes after it was recited. I certainly can't remember any of it now.

As for "do no harm", that absolutely was the first consideration in my mind from the day I graduated until the day I retired.

I'm not exactly sure what you mean by responsibility to the "medical profession", but I can say I never gave the idea any thought.

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Post by White Coat Investor » Sun May 23, 2010 1:12 pm

I think about this multiple times a day. Every time I order a CT. Every time I do a procedure. And many times when I give a medication or order a lab or EKG.

Part of the reason I am so conscious of it is I take care of a lot of the complications of therapy by other physicians- adverse medication reactions, wound infections etc.
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Post by norookie » Sun May 23, 2010 6:46 pm

-delete--
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Post by norookie » Sun May 23, 2010 6:51 pm

I'm far from a medical dr, however they have their "practices". Trying many treatments and finding some that work for the majority of "patients' is a odds game IMO. I'm sure hospitals have records going back to the 70's or more like most credit scores. i'm sure there are a small % out to CYA and maximize income.-just a thought- One friend this winter had a flesh eating infection @ Fishermans Hosp. One Dr gave him a DX of your going to loose you leg or die. I forget the name of the infection. Not Mercer.Another said, Give me 1k cash, I'll fix you. Hes fixed for 1k,.. for a 5 suture infection he got after horrific care because of no insurance as he was a self-employed fisherman. I know this as fact from his mouth. There are always 2 sides to every story, I only heard his.
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Post by arthurdawg » Sun May 23, 2010 8:12 pm

we took the modern oath of hippocrates at graduation, it wasn't required, but i don't think anyone refused in my class. i would say the goal is always to do the best for each individual patient, but the potential for harm is there.

i treat people daily with chemotherapy which can certainly cause harm even under ideal conditions. i've had patients with potentially curable cancer die from side effects of treatment, and so has every other oncologist i've known. i don't like to lose patients in this way, but it is going to happen.
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Post by oragne lovre » Sun May 23, 2010 9:13 pm

Call_Me_Op wrote:I would think it is difficult to truly uphold this oath if you are prescribing medications you do not understand - which is almost universally the case.
I don't know if you're a medical doctor or not. If you are not, I think you are ignorant of medical profession when you conclude "almost universally the case." If you are a medical doctor, I think you're either arrogant or ignorant of medical practice.
First, I am not a physician. But in my job as a hospital pharmacist I work primarily in the critical care units .... and work closely with pulmonologists/critical care specialists who make tough decisions on a daily basis. The idea of "do no harm" is not specific enough. I'd say more "do no intentional harm" is more realistic. I say that because in the real world many decisions physician make are based on risk/benefit to the patient ... and harm indeed can be an outcome. For example, if you are allergic to contrast dye, but the MD pre-treats with steroids, and you still have a reaction to the dye is that "doing harm"? I think not, because the greater good is diagnosing your primary problem which may need immediate attention. Hopefully (and in the vast majority of cases I believe it's true) these decisions are made with only the patients best interests in mind. I've seen these pulmonologists sit with the family for 30-60 minutes and thoroughly explain what they want to do, and only then obtain informed consent from the family to proceed.
I agree with your honest observation.
Last edited by oragne lovre on Sun May 23, 2010 9:19 pm, edited 1 time in total.

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Post by madpunster » Sun May 23, 2010 9:18 pm

Do no harm is absolutely the first rule - especially in these times when clinical protocols or "doing without thinking" is the new glorified mantra. Every test has potential physical and economic consequences - ie: perforation from routine colonoscopy or uninsurability 'till 2014 (if we're lucky) due to workup and diagnosis for untreatable disease.

As for duty to the profession, the patient comes first, before their insurance, before your reimbursement, before their pharmacy benefit plan, before their work comp manager, before their boss who wants them back at work or fired, and before my own family, and before my own health. Sometimes we are the only people on earth looking out for the patient.

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Post by OnFire » Sun May 23, 2010 10:53 pm

I attended medical school, but dropped out. I'm now a licensed paramedic/firefighter in Chicago. I worked for 4 years in the worst ghettoes in Chicago. I have seen so many people die I can't even garner a guess. I am sure I have saved numerous lives. I am also sure I have killed people. It comes with the job. I try to act in the patients best interest at all times. Just today, I had a heroin overdose and if we hadn't given him the antidote he surely would have died. Last shift I spent 45 minutes with a patient who I could have just as easily put back into bed and left in five minutes. He was seriously sick, but the family had NO medical training didn't know that. He was elderly and had Alzhiemer's.)

I asked myself, what would I want done if this was MY father? That's how I try to treat all of my patients.

I believe we had to take a paramedic oath, and I'm positive I took oaths at both my paramedic swearing in, and my firefighter swearing in. I don't really ever consider those. I'm more of a fan of the Jewish carpenter, Do unto others as you would have done unto you..."

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Re: Docs: How often do you think "First do no harm?&

Post by Babakhani » Mon May 24, 2010 12:07 am

nisiprius wrote:how many times a year do you ever consciously think "First, do no harm?"
[/quote]

Every surgery that I do. It is the highest rule we surgeons have; "do no harm."
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do no harm

Post by traumamoma » Mon May 24, 2010 7:19 am

The first thing I tell a new medical student who is training with me is that patients can accept you not making them better if they are convinced you are doing your best, but they cannot accept you making them worse. In almost 30 yrs of direct patient care I have found this to be true. Best Regards, Peter

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Post by czeckers » Mon May 24, 2010 8:19 am

I think that for the new medical school graduate it is more of an abstract concept. However, once you've seen your share of complications and bad outcomes, it is a very real tangible concept that affects nearly every decision you make. Every action or even inaction has a spectrum of potential consequences, some good and some bad. Physicians constantly weigh the potential benefits of their actions with the potential to cause harm. Unfortunately it is rarely black and white, and there is rarely conclusive evidence to steer you in a specific direction. That's where the art of medicine comes in. Tailoring a diagnoistic or therapeutic plan to the needs and wants of a particular patient, in the context of their particular situation, while minimizing the risks. Alas all risks cannot be eliminated entirely.
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Post by LarryG » Mon May 24, 2010 8:44 am

As a medical student,I recall the latin inscription on the wall of the delivery room- Primum non nocere.

We didn't take any oath upon graduation.

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Post by neverknow » Mon May 24, 2010 9:16 am

..
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Doctor No...

Post by Jethro2007 » Mon May 24, 2010 10:07 am

Hey all,

No, I am not a doctor...

I am seriously concerned about the large number of Psycho-therapists( see Social Workers) that can and do recommend vast arrays of anti-depressants and other drugs vainly in search of the "silver bullet" for PTSD and depression...

This culture of "take two, they're small" or "have some meds" they will get you feel fine; Has short term benefits and long term hazards...

Nuff said...
Y'all hava Happy Memorial Day Weekend...

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