Of all the false hopes perpetuated by doctors, “Do No Harm” is, to me, the worst of them. This ideal, that we force graduating medical students to swear by, is nearly impossible to achieve under the current state of health care. It leaves little room for the expected errors of fallible physicians and it especially doesn’t hold true for surgeons for whom harm is a risk we necessarily assume in the operating room. Ideally, we should strive to “Do Less Harm than Good” and to own up to the harm we invariably inflict.
In wrapping up my second year of residency, I’ve been thinking about some of the clear ways I’ve hurt my patients, other healthcare workers, and even myself. On the Jewish holiday of Yom Kippur, there’s a confessional prayer we sing over and over, which enumerates the various sins one might have committed the prior year. While singing, we place a closed fist over our hearts, and with the utterance of each sin, pound against our chests:
Ashamnu - we are guilty
Bagadnu - we have betrayed
Gazalnu - we have stolen
The list goes on. Nearing this holiday, I’m writing my own version of the confessions.
“This will be quick” - I lied
“I’ll swing by to talk to the family if I get a chance” - I misled
“If she’s sleeping now, I imagine her pain isn’t too bad” - I ignored
In the past two years, I’ve committed occasional sins of deceit, omission, and neglect that haunt my conscience. I’ve been more outwardly harmful too: short with nursing staff, angry with difficult patients, disrespectful to equally overworked consulting physicians as I near the end of a 28-hour shift. These are short-fuse behaviors that I deeply regret, and I symbolically beat my chest and strive to be kinder, more patient, and more empathetic in the future. But a greyer area in the sin arena is the physical harm I’ve caused.
As a surgical resident, I’ve accepted that, by approaching the pathway to healing with a scalpel and suture, I will inevitably cause pain. I’m usually upfront with my patients about it. “It’ll feel like you did 100 sit-ups and then got kicked in the ribs,” is how I describe an abdominal incision. “But we’ll give you pain medication, and it’ll get better every day,” I hedge. Pain can be ameliorated but it can’t be avoided when amputating a limb to stop the spread of life-threatening infection, when opening the abdomen to remove large tumors, or when performing chest compressions while fracturing ribs to give someone another shot at life.
People always joke about how surgeons only want to interact with sleeping patients. This couldn't be further from the truth for me, but what is true: I only want to inflict pain on sleeping patients. And sadly, that isn’t always the case.
On one chaotic weekend shift at a busy community hospital, our operating rooms were backed up. People with inflamed gallbladders and appendixes on the brink of rupture, were waiting all day and night, through sharp abdominal pains, for a slot in the OR. As new emergent cases would arise – a woman bleeding out after delivering her baby or a teenager in a grave motorcycle accident – our less-emergent patients would fall lower on the OR list. So, when two men with butt abscesses walked into the emergency room, we knew they wouldn’t make it to the OR anytime soon.
I’ll pause to share that a butt abscess, technically a perianal abscess, is no joke. It’s an infection that lives beneath the skin: in essence, a large pimple. But unlike a pimple, these infections can, at their worst, make people very sick, causing sepsis, a multiorgan state of distress. At best, they’re excruciatingly painful. The treatment is simple: obliterate the source of infection before it spreads. The process, although far from glamorous, is also simple: cut out the inflamed skin and release the pus – surgically pop the pimple.
There’s some debate among surgeons regarding when to lance an abscess at the bedside versus in the operating room. Sometimes it’s clear: if the abscess is too deep or too large, then it should be dealt with in OR, with the patient under anesthesia. Otherwise, technically, an abscess can be lanced at the bedside. But most of my colleagues and I agree: just because it can be done, doesn’t mean it should. If it were my butt on the table, I’d choose to be nicely sedated. But on a night where it was a choice between waiting over a day for space in the ORs or doing the procedures right away in the Emergency Room, the attending surgeon said, “Let’s just get this over with and get these guys home.”
The first, a man in his 50s, bit the pillow and screamed bloody murder. At one point, he flinched so badly that I poked myself hard with the knife. Although it hurt, since it didn’t break through my glove, I continued my work. “That was hell,” he said at the end, as I cleaned up my needles and knives. I had just taken a tiny shark-bite lump of skin out of his bottom with only a novacine-equivalent to minimize his pain. The second patient, a man in his 30s, sobbed. “You’re doing great,” I kept repeating, as though I was offering some award for enduring the torture.
Rattled with the guilt and discomfort of having inflicted so much pain twice over, I was already at the edge of my moral compass when my attending suggested we do a wound dressing-change at bedside that was scheduled for the OR, but certainly wouldn’t happen that evening. “Alright,” I grumbled, and reluctantly went to collect the supplies.
The man spoke only Mandarin and he had a wound on his arm the size of a baguette. We used an iPad interpreter to explain that, although we had wanted to do his dressing change in the OR, to give him sedation to ease the process, it couldn’t happen tonight and so if he was agreeable to it, we’d give him some pain medication and start the change there in the hospital room. He hadn’t eaten anything since midnight the night prior, awaiting possible sedation, and we incentivized him by telling him he could eat as soon as we were done. Starving, he agreed. Our first mistake was thinking this was okay to do at bedside and our second was hanging up on the interpreter before beginning. The man cried out as we stripped tape off his skin, and pried a wound sponge, a special type of dressing, out from his raw wound. “Stop” was the only word I recognized, and we honored his request, taking long breaks until he nodded, presumably signaling he was ready for us to continue. It took over an hour to do a dressing change that could have taken 20 minutes of OR time.
“I’m glad we got that over with,” my attending said to me as we left his room.
I’m usually hesitant to talk-back to attendings, but I was too upset this time. “I’m not,” I said. “That was really painful for him.” And for me, I wanted to add.
“Yeah, I guess it was. Next time, we could try a little Ativan too,” he said, offering an anti-anxiety medication as a future salve, a half-admission that we could have done less harm.
I write about these events by way of confession, acknowledging that we absolutely should have done better by each of those patients. But I also want to tease apart the systemic factors that force our hands to cause even more pain. The reality of the health care system, with backed-up operating rooms and insufficient staffing, is one that sometimes compels us to make compromises around patients’ pain in lieu of advancing their care in a timely fashion. But it isn’t even just that simple. How do we quantify the pain the men with perianal abscesses would have endured while waiting an additional 24 hours for their procedures and compare that to the pain I inflicted on them at the bedside? My own discomfort would have been lessened by doing the procedures in the OR, by operating on “sleeping” patients, but I do question whether theirs would have. In the case of the man needing a dressing change, I’m more confident that he would have been better off waiting. There was no rush to his procedure, other than our own desire to check off to-dos on our ever-growing list. Then again, with him in the OR under anesthesia the next day, who else would have had to wait their turn for surgery?
Identifying the harm we, as clinicians, cause can be a challenge; and much of the harm I witness or inflict exists somewhere in the grey zone between avoidable and unavoidable. On Yom Kippur we, as Jews, chant a list of possible sins. As a community, we assume one another’s faults. Although I may not have stolen in the prior year, I still stand beside others and pound on my chest as I say Gazalnu, we have stolen. I wonder if there’s an equivalent for doctors, a way to cover our bases, and to collectively acknowledge our faults. Instead of pretending like we “Do No Harm,” I’d rather we stand together and announce those possible harms, year after year, recognizing the inevitable pain that’s part of our practice. We should vow only to do better, without any false promises.
In some ways the weekly morbidity and mortality conference (known as M&M) is the surgeons’ opportunity to stand up and announce our faults. But this only covers the major bases: times that our actions lead to a patient’s declining health or death. What about the less-visible harms? The way we talked a patient into a painful bedside dressing change or the way I cut into barely numbed skin, hurting the men and risking my own safety in taking a scalpel to a moving body. What about the ways I occasionally snap at nurses or gossip with colleagues? To whom do I confess these sins? Who will share in my wrongdoing? Who will hold me accountable?
I feel oddly alone despite knowing that every one of us has done our fair share of harm.
Comments