Harm Can Be Found in Many Forms While Under Doctor's Care

Sept. 10, 2008— -- Primum non nocere.

First do no harm.

This wise teaching by the ancient Greek physician Hippocrates was drilled into us during medical school. We made this implicit pact with society when we entered medical school. We took this oath at our graduation ceremony.

This lesson was brought home to me again today when I read a study in this week's Journal of the American Medical Association. In this study, Dr. Vineet M. Arora and colleagues at University of Chicago and Northwestern University surveyed incoming interns at three training sites, anonymously evaluating these young doctors' participation in, and attitudes toward, unprofessional behaviors.

These researchers found that up to 79 percent of doctors-in-training report at least one unprofessional behavior. (For example, having nonclinical, personal conversations in patient care areas; making fun of other doctors; wearing inappropriate clothing.) Worse, 17 percent of these interns reported making fun of patients when the patients were under anesthesia or not present; and those that participated in this specific behavior were the least likely to think that it was unethical.

Primum non nocere.

How should we, as doctors, parse this out?

Obviously, avoiding harm means avoiding treatments and procedures that are dangerous or unnecessary. It means practicing medicine with solid scientific evidence as your guide. It means keeping up to date with new developments in medicine, ensuring that you will practice the standard of care.

But harm to patients is not always physical. It can be emotional as well. Patients can be abused by their physicians who are cold, uncaring or cavalier. They can be abused when the physician, directly or indirectly, disparages them, making them feel embarrassed, even angry.

I know this feeling, because, even though I am a physician, I have experienced it. Years ago I had outpatient surgery requiring general anesthesia. The staff was very professional in "prepping" me for surgery, explaining the procedure, putting me at ease.

What I did not know is that they were mocking me as I was emerging from anesthesia. A friend of mine, who is an anesthesiologist and knows the operating room staff that cared for me, came up to me a week later, laughing.

"Hey, John, I heard all about your procedure. The O.R. team thought it was hilarious that you kept asking the same question over and over again as you were waking up."

He was not involved in my procedure, so obviously I had been quite the subject of mocking and ridicule in the surgical suite. In the guise of humor, my story had spread throughout the O.R. staff.

My face flushed with shame. There was an inarticulate sense of inner anger. How dare they laugh at me when I was not in control of my mental faculties? How dare they spread personal information about me to anyone, especially to my friend?

I am a family physician and a medical school professor. Believe it or not, most of us medical teachers try both to teach and to model ethical behavior. We educate students in empathy. We coach them in communication. We stand firmly against any behavior that does not put the patient first.

I am not trying to sound self-righteous. Surely there have been times when I have not attended to my patients' needs -- physical or emotional.

I am human, after all.

But I strive to instill in medical students a helpful, nonjudgmental and compassionate approach to caring for patients -- like me.

I am human after all.

Which means I have feelings. Which means sometimes I am a patient. Which means I can feel shame and anger at derogatory treatment when I am in my most vulnerable condition, literally naked before the operating room staff.

Although empathy comes more naturally to some medical students than others, students can be taught ethical behavior. They can learn compassionate communication.

I have served on my medical school's admissions committee, and virtually every applicant in some fashion states during their admission interview that "I want to help people."

And research bears out that medical students enter medical school with compassion, a desire to be supportive and to be the patient's advocate.

Sometime during the third year of medical school, however, the same research uncovers a shift in attitudes among students. Cynicism creeps in. The patient becomes de-personalized. "Dr. Spangler, we have a pneumonia in room 5 and a potential suicide in room 9 which need admission."

Not Mrs. Jones in room 5 with pneumonia. Not Cindy Johnson in room 9 with suicidal ideation. Not someone who needs admission, but a case which needs admission.

The shift sometimes is subtle, but as my own experience bears out, it can also be egregious.

"But, Dr. Spangler," some of my students and residents might say. "You're in your ivory tower of academic medicine. You're not getting slammed with six admissions each night. You have time to reflect and to teach. You're not really in the 'real' world."

Perhaps I do have that luxury that you, resident and student, do not have.

But I have an educational responsibility.

And I am also human.

And I am sometimes a patient.

I want my doctor to be compassionate and see me as an individual with feelings.

Primum non nocere.

Isn't this what all of us want?

Dr. John Spangler is director of tobacco-intervention programs and a professor of family medicine at Wake Forest University School of Medicine in North Carolina.