Where's the Harm?

Today's post is somewhat a follow-up to the last post on wisdom deficit. In other ways, possibly importantly, it is a reflection on my struggle with the precept of healthcare professional codes of ethics which all in some form or other preclude the practitioners from harming their patients. It's not that I struggle with the Hippocratic truth that we as caring professionals should render care and not harm first and foremost. Rather, it is my struggle with how poorly we enact and live out this professional ideal in everyday life. Harm happens in so many ways and is in fact so pervasive, that practitioners (IMHO) become desensitized to the very fact that they are breaking a key ethical tenet multiple times every day. In my experience, this is the number one factor leading to practitioner burnout. Let's explore some of those harms (and I don't have near enough blog space to list them all - you will probably come up with many more). It doesn't take long for new recruits (so to speak) to learn that they will labor in systems that have been created to wring every possible dollar out of the interactions they have in order to feed the institutions that employ them. This harms both the practitioner who is a caring individual who seeks to have caring relationships and the person in need of care. When limited to 10 minutes (at best) with each person a couple of times each year, no meaningful relationship can develop. Thus the interactions become driven by direct-to-consumer marketing and limited scientific interchange. No wonder that so many antibiotics are prescribed for viral infections and 50% of all prescriptions written are never filled - and more harm ensues! Certainly we are all aware when major harm occurs through errors of omission or comission (e.g., surgically removing the wrong limb, giving the wrong dose of chemotherapy). Organizations then put into place a huge review process called a Root Cause Analysis of a Sentinel Event and try to figure out how the event happened and how to prevent it. They don't, however, look deeper into how the whole system allows for harm to occur and the cumulative effects of that continuous harm (mostly emotional and psychic). The Institute of Medicine (IoM), the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the numerous State Boards of Professions and Health, the Institute on Healthcare Improvement (IHI), the Quality Improvement Organizations (QIO), and soon (if not found unconstitutional) the development of Accountable Care Organizations (ACO), are all focus on improving quality - and have been for the better part of three decades. Yet, harm occurs each and every day - even though quality is improving. Sarcastically I could thus state that the harm that occurs nowadays is of a much higher quality that heretofore! Seriously though, shouldn't we expect that our healthcare systems should operate like our healthcare professionals and be dedicated to "first doing no harm" in all of the myriad ways that harm presents?! Maybe it's time to broaden the discussion of improving the healthcare system through the lens of doing less harm everyday. Instead of focusing solely on the quality of episodic care, why not look at lessening the physical, emotional and psychic harm that occurs to our practitioners and their patients. Let's work to create a system that is fair and wholesome and that realizes and rewards the development of healthy and supportive relationships - which have been shown time and again to lead to improved health. Let's stop the harm and start the healing. Peace for the journey, Dan