November 24, 2014
by Meredith Niess, MD, MPh
During training, medical professionals travel the path from the ideal of medicine to the reality. This path is paved with many challenging lessons, among them, our system is broken and we can’t always cure our patients. Facing these hard truths can be disheartening at the least and soul-crushing at the worst. The sense of futility and powerlessness to improve these realities often left me even more discouraged.
The Do No Harm Project provided me a lifeline of hope in this learning setting. I examined cases where clinicians with good intentions, or seemingly benign habits, had patients with less benign outcomes. This helped me recognize an unhealthy pattern of decision-making in the medical system, and better manage patient care in my own practice. The knowledge I gained empowered me to question what is the right care and how we as health care providers can help effect change needed to provide it.
We’re taught in medical school to admit our individual mistakes – a new development over the past decade. The Do No Harm Project takes that a step further by encouraging us to identify a type of mistake that clinicians often categorically overlook: too much medicine. Common are the patterns of clinical decision-making that have been standardized, though may hurt our patients. Patients and clinicians alike often subscribe to the belief that more is better – more tests, more treatment. The medical community loves data and evidence, so why aren’t we asking for the evidence supporting “more is better”?
As trainees we are encouraged to ask questions, but there is a hidden curriculum dictating what questions we are supposed to ask and of whom. “What biochemical pathway does that drug affect?” or “What on the differential have we not tested for?” are safe questions for our attendings. Rarely does one hear a trainee ask, “How could doing this stress test harm the patient?” or a nurse ask the doctor, “Do you think a three-times-a-day medication would be a burden on this patient?” Questions like these that target the “more is better” culture are often discounted as they challenge authority. However, the Do No Harm Project creates a safe place for trainees to ask the meaningful question of “why are we doing this?” and seek an answer.
Unlike the pharmacokinetics of a drug, the question of why we order tests or treatments that may not benefit our patients is not likely to be answered on rounds. We cannot memorize a change in the culture of medicine the way we can memorize drug pathways. Culture change is slow, and starts with brave people asking the questions those before weren’t routinely asking. This often comes from the newcomers in the field. It often has to. In a hierarchical system like medicine, asking the newcomers – like trainees – to be the agents of change is a tall order. We need support to do this: Mentorship. Guidance. Inspiration. With this, we will not only have the courage to ask questions that challenge the culture, but equally important, we will also have the courage NOT to do something.
The Do No Harm Project is part of a movement in medicine, and that’s exactly the movement I needed.
To learn more about the Do No Harm Project, click here.
Meredith A. Niess, MD, MPH, is a National Research Service Award primary care research fellow in the Department of General Internal Medicine at the University of Colorado. Among her research interests are healthcare policy with a focus on the access to care for underserved populations and socioeconomic determinants of health.