Blog Challenge, Reflections

First Do No Harm

Welcome of Day 24 of #30PostsHathSept. [PLEASE READ all my other challenge posts HERE.] Enjoy!


Western medicine is a problem-oriented profession. Clinicians are trained to interact with patients and families with the purpose of keeping health hazards at bay, and treating those conditions that come along. Not being normal is a disease to be stamped out and replaced with normalcy.

Whatever normalcy is.

As a pediatrician by training, I know this first hand.

In an emergency situation this mentality comes into sharp focus and is instrumental at saving lives. But in everyday situations that are a large majority of medical practice, it may potentially backfire.

We live in a society that is increasingly obsessed with fixing things – sometimes when there isn’t always anything to fix, or normalize. We buy into caffeinated products to boost energy. We rely on sleep aids to help us achieve rest. We long to extend our youthfulness via cosmetic means or hopes of the great medical cure of ageing. Some of our children are erroneously medicated for conditions they actually do not have, like ADHD, due to their behavior not meeting age expectations. We hear of a new pharmaceutical medication on our television and just know it was meant for us, based only upon a series of vague and broad physical and/or emotional symptoms. To some clinicians as well as patients, leaving a doctor’s office empty-handed without a diagnosis and a prescription seems like a wasted trip. Time better spent elsewhere.

So we await the cure for obesity, are convinced every diet is the next big thing, and jump on new untested ideas and medical treatments to somehow make our lives better through medicine.

The clinicians are meanwhile overwhelmed with responsibility and lack of time. Being able to assess un-wellness is frequently taught as the key to success. Wellness sadly comes secondary. Our conversations with patients often follow a routine along the lines of “Can you tell me the problem that brought you here today?” or “How can I help you feel better?”

I was reminded of this in an article by Sandra Smith M.D. M.P.H. entitled “What should be the core conversation between a doctor and an individual s/he sees for 15 minutes per year?” In the article, Dr. Smith references the latest National Academies Press (the publication of the National Academy of Sciences) Workshop Summary on Health Literacy: Past, Present, and Future (2015) In that summary bulletin Dr. Winston F. Wong of Kaiser Permanente writes,

“One interesting proposition is that we should start the discussion with every person we come in contact with by asking ‘what does a good day mean to you,’ because that’s really a much more important question than ‘what hurts’ or ‘have you been taking your medicine today. As a health plan, we have to start thinking about what do we do to proactively address what makes for a good day.”

This is so very important of a concept shift. An incredibly different way to look at patient care. And such a powerful one. In Eastern medicine, clinicians are rewarded when patients are well. In Western medicine, when they are ill. While Western medicine clinicians wish their patient good health as much as Eastern medicine clinicians, the approach may often comes from the opposite direction.

In the short 15 minutes we frequently are given in the fragile doctor/patient relationship, we spend an exorbitant amount of that time assessing for problems. An approach that addresses the whole person can raise the focus on health and well-being.

By asking a patient that important question of “What does a good day mean to you?”, a clinician can instill a closer and more caring bond with the patient. Such open-ended questions can be unusual in medicine, where questions are commonly posed to gain information quickly, efficiently and succinctly. For example, “What problem brings you here?” may lead to “I have headaches.” This is followed by a series of questions that help elicit a differential diagnosis, and a subsequent answer to the headache. Appointment complete, and the patient leaves with a plan for addressing the pain.

But so many other questions may be left unasked. For example, why did the patient come in that day for the headaches, and not another? What if the patient has a long history of headaches, but something else in their life changed? What if emotions and fears were the driving factor? Does addressing the fears help more than addressing the headaches?

This is only one of a myriad of situations. In pediatrics, small children ages 0-6 are assessed with what is called the Denver Developmental Screening Test (DDST) for a variety of measures including motor function, social interactions, and language development. The purpose is to discover the presence of developmental disabilities. The newer autism screening for 0-3 years of age also emphasizes the need to discover disabilities and seek treatment immediately.

What’s missing in the DDST is a better understanding of what is normal and what is pathology. In most situations in health, there is a wide range of normal, and treating everyone according to one definition does not allow the concept of the Whole Patient. In the case of a child who passes all the DDST questions to the child’s accurate age says little about what that child is capable of and whether the family may need more support and understanding because the child actually exceeds the scale by a significant degree.

In the case of the early autism screening, while commendable, the screening may both provoke fear in a parent as well as not completely and accurately predict autism in a child who perhaps has a level of developmental asynchrony. Developmental norms are averages. We see this in the varied presentations of ages of walking, speaking, reading, and so forth. We forget that while seeking pathology, we need to also seek health and exceptionality.

Even in the situation where a child has autism, empowerment of the parents can change the entire outlook of the child to a positive one. Many cancer treatments programs have likewise found that a whole person approach by addressing how a particular patient defines a good day, can also potentially increase immune response and help in recovery efforts.

These open-ended questions can give patients a sense of self-confidence, allowing them to think deeply on their life choices and achieving satisfaction. They also give more control to patients, so patients take an active role in their health, and do not simply feel the medical field is doing things to them, but rather with them.

Not all people have the same definition for a good day any more than they have the same definition of a successful life. Addressing each patient as an individual increases their sense of permission to set control over their life. Some people may not feel the need to extend their lives with a complex regimen of medications and treatments if it doesn’t improve their quality of life. Some people cannot imagine life without some of the achievable pleasures that make life worthwhile.

What the question of good day truly addresses is the concept of quality of life. Quality of life is a whole person criterion that may supersede the natural approach to medicine of wiping out disease. Patients are people, and as such, they are individuals. Individuals have the right to choose how they wish to maximize their health while also serving their quality of life criterion of a good day.

The difference may seem subtle, but in so many ways it enriches life. Like a return to the old ways of doctoring, seeking an understanding of the whole patient, and individualizing medical approaches to serve those needs is a powerful statement. As clinicians, we are given this solemn vow of Hippocrates not to vanquish illness (something that not achievable), but rather to maximize quality of life. In the pursuit of maximizing quality of life, we need to be cognizant that too much intervention can sometimes lead to harm on the patient’s part, either in health and/or quality of life.

Of course, every person – patient or clinician – needs to be cognizant of how their actions affect others. A person can go to the extreme to live a good day by doing things that are harmful to the greater population. Impinging on another’s quality of life is the antithesis of the message. There are many examples to fit this scenario.

Ultimately, the message is an important one…Clinicians can do well to always place the motto of “First do no harm” high on the list of absolute requirements for patient care.

So, take a moment and think about the question for your own selves…”What does a good day mean to you?”

[You can enjoy all the daily posts from the #30PostsHathSept bloggers HERE]