Below, another provocative story from Pulse–voices from the heart of medicine, an online magazine of personal experience in health care. The piece raised some questions in my mind about how we train medical students. You’ll find my comments at the end. (To join the Pulse community, and receive every issue, online, at no cost, click here.)
First, Do No Harm
By Alison Block
It's one of my earliest memories: I'm wrestling with my brother, and I'm losing, because I'm five and he's seven, and he's bigger and stronger than I am. So I bite him, hard.
Instantly I know I've crossed some sort of line, and I employ my most primitive defense mechanism, shouting out, "He bit me! Jon bit me!" I feel shame, because I am old enough to know it is wrong to hurt people–and to lie.
Some years later, I am accepted to medical school. I go to the first ceremony of my medical career–the one where I get my short white coat–and I take a modernized version of the Hippocratic Oath. I will try to do the best I can for my patients, and I will recognize the awesome responsibility that it is to care for other human beings. I notice one thing is lacking, though–the often-quoted phrase "First, do no harm." The sentiment is there, but the words are not. I don't make too much of it.
I spend two years sitting in class learning about various -ologies, and then I take an eight-hour test, the national board exam, to prove that I've learned something. I leave the classroom, and I am finally allowed to see real patients, not just the actors in the fake clinic rooms who get paid to pretend they have thyroid disease. I ask people probing, personal questions, and I listen as they talk about their devastating diseases and lives. I try not to cry, because it feels unprofessional, and nobody wants a doctor who cries.
I ask complete strangers to undress and put on flimsy paper gowns. I touch them on their bare skin and feel embarrassed when little old ladies wince and tell me my hands are cold.
I see my first emergency room patient, a well-dressed, twenty-four-year-old man with a polite smile and fearful eyes. He complains of terrible abdominal pain that started around his belly button and has progressed to his right lower quadrant. I'm excited to examine him, certain that this is my first appendicitis. I press down on his raw, inflamed intestines, and he screams in pain–pain that I caused. I feel terrible, and unsure, but I put on my best air of confidence, because nobody wants a doctor who lacks confidence.
A few weeks later, I try to look into the infected ear canal of a fussy three-year-old, sweaty and disheveled from days of fever and discomfort. The examination hurts him, and he screams and cries so hard he can't breathe. He wiggles away before I can see anything, and I stop trying because I can't bear the thought of wrestling a small child onto the exam table.
I learn how to place IVs on plastic dummies. It seems simple and basic. I decide to try it on a real person, a genteel but anxious forty-something woman about to get her gallbladder taken out. Inexpertly grasping the needle in my visibly shaking hand, I bring it close to her fragile-appearing skin, where it suddenly looks big and sharp and scary. I poke too gently and too slowly, and it hurts her that much more. I poke deeper, at too much of an angle, and a little black-and-blue bubble starts to form under the skin around the needle.
The nurse looks at me, annoyed.
"You blew the vein," she says. "You have to take out the needle and start over."
I try three times and blow three veins. Then the nurse does it herself. Quickly, easily. I feel incompetent, and I am acutely aware that nobody wants a doctor who is not competent.
I do a trauma-surgery rotation at the county hospital, where most patients are recovering from gunshots and stab wounds. My job is to carry the wound-care bag and run ahead of the team of surgeons to undress the wounds.
I enter the first patient's room and take off her bandage, revealing a bloody, pus-stained pad of gauze underneath. I start pulling out the gauze, and much more unravels than I'd have thought possible, exposing a deep, raw, fleshy hole.
The patient shrieks. "Why are you doing this to me?" she asks, sobbing.
I want to stop, but I know that I have to keep going. I tell myself that this is all part of the healing process–that I am going to be a doctor, that my job is to heal, and that nobody wants a doctor who's afraid to rip off a bandage.
In two months I will climb onto the stage in a big auditorium to receive my robe and diploma, and I will complete the transition from medical student to medical doctor. I will sit at graduation and listen to my mentors and classmates talk about the honor and privilege of being a physician. I will know that it's true, and I will be excited. But I'll also be scared. I can tell already that this doctor thing is a lot of responsibility, and I find it hard to believe that I'm good enough for the job.
Despite my fears, though, I will stand up, and I will repeat the oath. I will be grateful for an oath that doesn't make me promise to do no harm–a promise I've come to realize that I will not be able to keep. Because it turns out that healing, more often than not, is a messy, painful, complicated process. And while I may not have known it when I signed up for this job, I now understand that, as a physician, I will need to work together with my patients through the hurt and chaos of illness in the hopes of achieving the relative calm and order of wellness.
So instead of promising to do no harm, I will promise to do my best. And I will hope that the good will outweigh the harm. Because nobody wants a doctor who does more harm than good.
About the author:
Alison Block is a graduating medical student at the University of California, San Francisco. In July she will embark on a career in family medicine. "I have always enjoyed writing about my experiences, and I began exploring writing more seriously while pursuing a research project in South India. I hope to incorporate personal essay writing into my career as a physician, as a way to continue the work of healing myself and my patients."
Inevitably, doctors hurt patients. Some treatments are painful, and occasionally, every physician makes a mistake..
But while reading this story, I couldn’t help but wonder whether both this doctor-in-training and her patients might have been spared some of the pain, shame and trauma that she describes.
The conventional wisdom has it that doctors have to practice on someone. This may well mean “blowing” more than a few veins while learning how to insert an IV.
But as we put more emphasis on “patient-centered” medicine, I wonder if “watch one, do one, teach one” really makes sense. Think about it from the patient’s perspective: you’re sick, you’re about to go into surgery, you’re afraid, and, thanks to a combination of fear and medication, you may be nauseous. Suddenly, someone who clearly doesn’t know what he or she is doing is sticking needles into you. The nurse is looking annoyed; the student is panicking, you feel the anxiety wash over you and your stomach tightens.
Why, I wonder, couldn’t students learning to insert IVs practice on those actors who are paid to pretend that they are patients? Presumably, most of the actors are healthy. They’re not sick; they’re not afraid, they’re not frail. They could sign a release form. (Those who don’t like needles wouldn’t have to participate.) The actors could be told to scream out if the procedure hurts so that the student could learn to remain calm even if the patient isn’t. And I would suggest that students practice not just on one, but on a dozen, or more– however long it takes until they are are entirely comfortable with the procedure., and can do it jsut as well as a nurse.
I also think about the patient who shrieked when the gauze packing was being removed from a deep wound. It seems pretty clear that this is a situation where pain is unavoidable. But my guess (and this is only a guess) is that a seasoned trauma nurse would be able to minimize the patients’ suffering by moving quickly–or using a technique that experience has taught her. Why ask a resident on rotation to undress the wounds? Is this part of the ‘hazing” of medical education that is supposed to "toughen them up" so that they don't mind hurting patients? I would suggest assigning the task to veteran nurses and let residents watch while the nurse explains how the job is best done–not just once, but many times.
I also wonder what happened to the toddler with an ear-ache? Did anyone ever manage to look into her ear to see just how bad the infection was? Again, this seems a case where perhaps the resident should have been observing while either an ER nurse or a pediatric nurse did the examination–especially when it became apparent that the child was exhausted and terrified . Let me be clear: I don't fault the doctor telling this story. I fault the system that didn't give her the help she needed.
What I’m proposing is, first that we make better use of nurses when training medical students and residents. I realize that, today, residents do, in fact, learn a great deal from nurses. But I would like to formalize the relationships, making it clear to medical students, from the outset, that in many cases, nurses will be teaching them. (A long time ago, when virtually all doctors were men, and virtually all nurses were women,the notion of nurses training residents was unacceptable. Times have changed.)
Secondly, I’m suggesting that the traditional way of training doctors: “watch one, do one, teach one,” goes back to the bad old days of doctor-centered medicine when everything was organized around what might be most convenient for the physician or the hospital. The doctor was the subject, the patient, a body part that the physician treated.
In an earlier era, when physicians had few cures, there was more emphasis on comforting the patient–and making him as comfortable as possible. In many cases, empathy was all a doctor had to offer. But in the second half of the 20th century, as modern medicine became more sophisticated, it also became colder– sometimes as cold as the glittering new technology that took center stage. Suddenly, everything seemed “curable.” The idea that medicine also is about “comfort “and “compassion” began to drop away.
In that authoritarian world, the patient was expected to do as he or she was told, making as little fuss as possible. In a profession dominaed by men, a macho code applied,–both to the physician and to the patient. A physician didn’t wince if a patient screamed; he remained silent and impassive. (Never say you’re sorry. Someone might sue you. ) And, of course, a “good” patient didn’t shriek. She dug her nails into the palm of her hand.
But as Harvard pediatrician and CMS director Don Berwick suggests in an essay on patient-centered medicine, health care reform requires rethinking how we train medical professionals: “We will not teach future professionals emotional distancing as a strategy for personal survival,” he writes.” We will teach them instead how to stay close to emotions that can generate energy for institutional change, which might help everyone survive.” For more on his essay, scroll down to “The Heart of Patient-Centered Medicine” in this HealthBeat post.
The author of “First, Do No Harm,” is clearly sensitive to what her patients’ feel. I would add only one line to this fine story: “No one wants a doctor who never says, ‘I’m sorry, I know that hurt.’”