First, do no harm. Primum non nocere

21 03 2009

Regular readers will know of my hesitancy in becoming significantly involved in medical management. Some of this is due, on my part, to a lack of education and understanding of the complexities of the role. Partly however this is also due to deeply held, negative views regarding the overall aims of management compared to those of a clinician. I struggle with the different mindsets required to fulfill the two roles as I find the goals are not complementary but may often be totally divergent.hippocrates2

Now, as any good Greek scholar will know, “Primum non nocere” (first do no harm) is NOT part of the Hippocratic Oath. Primarily of course, the phrase is in Latin and Hippocrates was Greek! Secondly, even rough translation of his original treatise does not reveal a section that could even be mistaken for this now clichéd phrase. There are various interesting thoughts as to the genesis of the myth but the most common is that  in Epidermics, Book 1, section XI, Hippocrates wrote,

“Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm.”

The concept is however true that a physician, by whichever oath or code they practice, regards the health and care of their patients as of paramount importance. The scope for debate within that statement is huge but in the sternest of interactions between clinicians and management the power of that phrase and its interpretation underpins the behaviour of clinicians.

The news yesterday of yet another hospital; Birmingham Children’s, being severely criticised for its lack of care for its patients leaves every clinician with a feeling of shame. No matter the management edict, the targets or the funding issues, clinicians will struggle, often against the odds, and yes, even against the management, to provide the best care they possibly can. My sadness is further increased that this is yet again happening in the face of a current Healthcare Commission Report of apparently excellent (measured) standards and the award of Foundation Trust Status for delivery of these standards.

What does all this mean? It shows the gross inaccuracy of  heuristics applied to patient care, it shows that management are repeatedly willing to sacrifice patient care on the twin pagan altars of targets and foundation status and all this depresses me. These situations are clearly a failure of management and whilst the reasons for this failure may be complex, unknown or even unknownable they are contrary to our basic premise; “first do no harm”.

Do I want to take on a management role and prevent this happening? Is it possible to prevent this in the face of management pursuing goals at such expense?




4 responses

21 03 2009

who or what exactly is or are “management”?

I blogged on a similar theme yesterday and agree on targets culture being at odds with care: however, I have yet to meet a “manager” in healthcare who was ready to sacrifice patient care in order to become a foundation trust! The reasons for the disjuncture between a genuine desire to do good and actual outcomes is really pretty complex I suspect…..

21 03 2009

i think simplifying the issue always leads to easy blame allocation.

no-one clearly would want to be see to advocate or openly sacrifice patient care for those ends but there can be no denying that it has happened.

failing to hold such care as sacrosanct and even considering it negotiable is clearly apparent in centres already found out. the problems have not arisen by chance and are not the fault of the clinicians. the “award” of foundation status along side this failure cannot be seen as co-incidental. failing to recognise the (likely) outcome of one’s actions is no excuse either.

my huge worry is that the same problem is likely to be true and as yet undisclosed in many, many other centres. a failure of management is a failure of management and when that failure leads to compromised patient care, blame is easy to allocate. this is the responsibility of management.

24 03 2009
anne marie

I haven’t read the reports but I can’t help wondering if the distinction between management and clinicians is as clear as you see it. Isn’t it the responsibility of clinicians to speak out about obvious gaps in care before the problem is detected by excess mortality? If that happened then I am not seeing it reported.

25 03 2009

1) the emergency review was requested/demanded by senior clinicians.
2) the management comprises clinicians and management.

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