Sunday, August 7, 2016

primum non nocere

I learned something new today. This is a good sign because some people like to joke about my incipient dementia. At least, I hope they’re joking.

I was toying with the topic for today’s post when the phrase “primum non nocere”—first do no harm—came to mind. I learned that the Hippocratic Oath is not its source. It actually comes from Hippocrates’ writings in “Epidemics”: “The physician must…do no harm.” These words are the bedrock of medical ethics and practice. Hippocrates is regarded as “the father of medicine” for good reason.

In fact, many of the traditions that influence the way we practice medicine today were passed down to us by men. Not because women were excluded from the practice of the healing arts in ancient Greece. On the contrary, women were highly respected as physicians and healers. Even Plato held them in esteem. Though they were few in number, patients sought them out. They were regarded as the “wise women” of the community. Their “soft hands” were considered to be “healing hands.”

But as the science of medicine advanced, the feminine ethic lost credibility. Its wisdom and power to heal were dishonored in favor of dispassionate technical expertise—testing, procedures, and proofs. Today speed and efficiency reign, and reimbursement issues drive the system. Over time, tradition has suffered. As a result, patient care has suffered, and even physicians have suffered.

One of the time-honored traditions that survives today expressly prohibits the physician from entering into a personal relationship of any kind with his patients. This, of course, is an impossibility. It disavows the emotional intimacy that is the inevitable fruit of shared suffering. It contradicts the compassionate physician’s experience and denies him a powerful tool.

Today, the physician is taught that it is unprofessional to share personal experience, insight, beliefs or values with the patient. This rule of non-engagement is hammered into our heads during training when we’re still easily moved to empathy, at a time when connectedness with other human beings is still something to be desired and defended.

Sadly, this means that patients may know more about their hairdresser or mechanic than they know about their doctor—the person they trust with their health and their children’s health. With their lives. Most patients know nothing about him but what they can gather from the plaques and certificates displayed on the walls in his office—what schools he attended, when he graduated, what honors he earned…which speaks to his intelligence but what about his inspiration, his motivation, and his conduct?

This can be troubling for patients. They have little choice when it comes to selecting a physician and, except for the credentials hanging in his office, they may know nothing at all about him. They worry about it, and they should. Is he competent? Is he caring? What motivated him to undertake years of grueling study and training? What sustains him? How does he manage it all?

This precedent distances us from our patients at times in their lives when what they may need from us more than anything else—more than another prescription or another test or another procedure—is our presence with them, our strength, compassion and support especially at times of serious illness and suffering. At times when fear and grief cut deep. At times when they may need to understand that nothing more can be done for them…or for someone they love—a friend, a spouse, or a child. When our patients need us the most—that is, when there is no hope for them—we are trained to turn their care over to the nurses, or the family, or their pastor.

We leave the bedside the way we approached it—as strangers, not storytellers.
“Some patients, though conscious that their condition is perilous,
recover their health simply through their contentment
with the goodness of the physician.”
~Hippocrates (460-400 BC)~

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