Do No Harm

I was assigned to care for a patient who had been newly diagnosed with cancer. A midline IV line had been inserted with plans to start chemotherapy. Unfortunately a blood clot had developed at the midline IV site (a common occurrence in patients with cancer). The midline IV line was pulled out. She needed some sort of access for chemotherapy. She had also complained of chest pain.  A CT scan, EKG and blood tests didn’t show the heart or lungs to be the source of her chest pain.

I came to the patient’s bedside to introduce myself. She smiled at me. I had barely started my introduction when her father stormed in and started shouting. (At me, in case there was any doubt.)

He had multiple complaints.

He blamed “you people” for the blood clot.

He was angry at me that the patient’s Oncologist hadn’t run to the patient’s bedside already.

He was angry that I hadn’t figured out what was causing her chest pain. I reviewed all the results with them and advised them that the pain was not cardiac or pulmonary.

He was angry that a follow-up ultrasound was not ordered to check the clot after the IV line had been pulled (this is not standard of care).

The truth is really he was a father. Angry that his daughter was diagnosed with cancer. Probably the head of his household and doing his best to try to protect her as a father would. Advocating for his child.

Me and my stethoscope and white coat stood before him. We represented disease and chemo and more tests and bad news. He unfurled his anger at me and what I represented to him for over an hour.

In an attempt to bridge our gap, I ended up ordering the ultrasound of the arm. I cautioned him that the ultrasound was not standard of care and that it would show a blood clot that we already knew she had and her treatment would remain unchanged. The ultrasound result showed exactly what I told him it would: a clot. Which triggered a second round of the same anger cascade as above, again for over an hour.

After the encounter, I learned that the father filed a complaint against me. His grievances were that I didn’t want to order the ultrasound and I didn’t know why his daughter was having chest pain.

Most physicians are perfectionists and we struggle to understand how we could have done better. Like any normal compulsive person, I have revisited the encounter in my mind and racked my memories looking for opportunities where I could have done better.

I was honest with them. I made no false promises. I admitted what I didn’t know. I checked in multiple times. I reviewed all the test results with them multiple times. I made sure any potentially life-threatening condition had been evaluated and addressed.

Ultimately I realize this father just did not like me. No matter what I said or did, I was on his wrong side. 

When we enter medical school, physicians pledge to “do no harm.” This means we don’t abandon care of a patient no matter how difficult the case or situation. Physicians continue caring for the patient and weather through the storm. 

Medicine has increasingly become a hospitality industry. Patients’ demands have also changed. Would yelling at staff for an hour be tolerated in a hotel? A restaurant? A coffee shop? Is our pledge to care for patients deserving of abuse and mistreatment? 

Many restaurants carry signs that say “We reserve the right to refuse service.” In an era of skyrocketing physician burnout and increased violence on healthcare workers, it’s time to pledge no harm to physicians. How much abuse and mistreatment of physicians and will it take before physicians start declining to provide service? 

(Views my own. Question posed as a hypothetical question only. I bring this up to highlight the challenges we face in the field.)

Comments

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  2. We recently enacted behavioral contracts in our ED when patients or their companions lash out at staff in this way. It's understandable and human to a point, after which it is simply inappropriate behavior that would not pass muster at anyone's mother's dinner table.

    There's a significant difference between do no harm and absorb harmful tirades.

    You saw this father's hurt and tried to do him a kindness - he turned it into yet another "no good deed goes unpunished" moment.

    This is why many of us are cutting back, and why the next physician his daughter sees will likely exhibit far less patience than you kindly extended him.

    When did medicine transform into an adversarial field?

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