Do No Harm

This is something I am learning as an intern, and it is a hard lesson. Do no harm. For me, this applies mostly to older patients. In my last post, I alluded to a patient who I may have harmed by being pressured by family to do something when I should have done nothing. I will be honest. Doctors make mistakes. We will make mistakes, and some mistakes matter. It is incredibly hard for non-physicians to hear - after all, we are treating mothers, fathers, spouses, grandparents, children - but believe me, it is even harder for us as doctors to bear. In a single day, I make a hundred clinical judgments and decisions. If I am 99% accurate, one will fall through as an error. This is inevitable. Every morning, when I see each of my ten patients, I am making a judgment of whether I hear crackles in their lungs, whether their rash looks worse, whether their antibiotics need to stay on or off. I write a hundred orders each day - some of little consequence (stool softeners, diet orders), but some of intense importance (discharge instructions, medications).

One patient I had at Stanford had loving family members who knew him very well. They micromanaged each little condition. They called around to multiple doctors and would meet us in rounds each day with a list of suggestions. Some were clearly inappropriate and some were clearly indicated. But much of medicine is gray, and this is the problem. The patient was mildly anemic and actively bleeding; his hemoglobin was not at a level that transfusion was clearly indicated, and it was not at a level in which transfusion was absurd. I felt that I did not want to transfuse this patient at the time. But the family requested that I do. This was not an unreasonable request and in consultation with the resident and attending, we did transfuse. It is important not to confound correlation and causation but I felt the transfusion marked the transition between him getting better and him getting worse. There are actually a lot of medical reasons why the transfusion could have harmed him (and medical reasons why the transfusion could have helped). We will not know which happened. But I have since been haunted by this incident not necessarily because I think I harmed this patient, but because I was persuaded to do something I was not inclined to do, and because it ended up correlating with a poor outcome.