Good Things…

I went to the doctors this week. Well more precisely I went to see one of the staff nurses at the doctor’s practice. I had received a letter telling me that the UK government were offering free health checks for all citizens over 45 years old. And this was my opportunity.

It was all quite straightforward – a questionnaire, blood pressure, BMI, and cholesterol. I passed. My only real issue is that I am older than I used to be and am therefore at increased risk. There doesn’t seem to be a lot I can do about that!

Whilst we were waiting for my cholesterol read to appear on the screen, I asked the nurse how much more Lipitor was being prescribed now it was off patent (and yes I had mentioned that I worked in pharmaceuticals). “None”, was the surprising answer. I had predicted that with increased competition, use would have sky-rocketed. “So why not” was my follow on question?

“Our doctors are much more cautious”, was the reply, “they always want to avoid doing any harm”. I assumed that this was reference to the Hippocratic Oath – Do No Harm – but decided two questions in the one session was my quota, so left, proudly clutching my health report.

This philosophy of ‘Do No Harm’ struck me as being quite prevalent and not just in UK medicine. Many companies introduce new strategies with an implicit, or sometimes explicit, strap line of ‘Do no Harm’. And this makes sense. Doing Harm is never a good plan. Do no Harm, then, sounds positive. In truth, though, and to be more exact – ‘Do no Harm’ does not sound bad.

And this made me think a little more. I came to the conclusion that we could define – broadly speaking – three philosophies for any action or strategy. Do Harm (negative). Do no Harm (neutral), or Do Good (positive).

To apply the ‘Do no Harm’ philosophy in any situation seems – at best – a significant handicap. The simplest way to Do No Harm is to do nothing. But to do nothing assumes that the current course of action is working well and is guaranteed to succeed. So to change strategy, or introduce new activities, we first of all need to accept that our current approach is not working, or will not succeed optimally. Change is therefore necessary.

So back to the Hippocratic Oath. A medic friend of mine explained to me over dinner later in the week that the literal translation is First, Do no Harm. This really helped me. First, Do no Harm implies to me that there should always be a Second action – Do Good. In almost any situation there has to be a viable option for a better, or more successful, approach – To do Good. For example, although its good news that my cholesterol is low, how much better would it be if my cholesterol was 10 fold lower?

In our work, I am happy that our projects or strategies start with a philosophy of ‘Doing no Harm’, but I would prefer a philosophy that we can and will do better. I don’t know anyone who sets off with the intent of ‘doing harm’. But we shouldn’t ever accept ‘Doing no Harm’ as enough. There are always ways and means to do better. It may not always be obvious and it may often be difficult but it is always possible to Do Good.

And we each and every one of us has a support role to play. Do Good requires empowerment and confidence; Do Good benefits from praise and encouragement. Blame will only ever Do Harm.

Cheers

Steve

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About Steve Street

I have worked in R&D within the Pharmaceutical industry for over 29 years. Up until April 2012 all of my career had been with one company, but that has now changed. I left that company and took up a new role on May 1, 2012 - still very much within the Pharmaceutical industry and again based in the UK. I have been blogging every week now for over 9 years but only on an external site since January 2012. Email updates of the blogs can be requested using the ‘follow’ option within Wordpress. The blogs are only ever my personal view of what I see, think and feel. I am delighted if you agree and find value; happy if you disagree with my views and overjoyed if you feel motivated to comment. Most of all I am simply grateful that you read. Cheers Steve
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10 Responses to Good Things…

  1. Briggs says:

    Nice post, Steve. It turns out the phrase “first do ho harm” is actually not part of the Hippocratic oath, although it is found in the writing of Hippocrates. Wikipedia has a nice explanation. They also explain that the phrase is generally meant that “given an existing problem, it may be better to not do something, or even to do nothing, than to risk causing more harm than good”. It is really an ancient benefit-risk statement. It is quite unfortunate for the people of the UK that the NHS has misunderstood the concept — or at least, this one nurse. If one only thinks about harm — and not the balancing benefit — one will under treat, and thereby do great harm to their population by deriving them of the benefits of modern medicine. Conversely — and this is common thinking in pharmaceutical industry employees — if one only thinks about the benefit and doesn’t consider the risk, one can also violate the premise of “primum non nocere”. It is always about benefit and risk and the overall balance of those 2 things in any given patient. Hence the keen interest across the public health community in identifying people for whom the benefit-risk is most favorable, either because their is greater benefit, lesser risk, or by avoiding medicines in people where there is greater risk.

    Cheers,

    • Steve Street says:

      Briggs

      This is a really excellent comment – many thanks. The introduction of risk-benefit analysis is a very helpful way of clarifying what’s going on here. Apologies for the miss-quote -that was me – although it looks as if my friendly medic was correct with the translation of ‘primum non nocere’.

      Cheers

      Steve

  2. John McCall says:

    The movie Avatar recently dealt with the issue of inaction. The character Grace Augustine said ” Parker. You know, I used to think it was benign neglect, but now I see that you are intentionally screwing me”.

  3. Celia says:

    Hi Steve, your point is well taken but, as a patient and consumer, I’m reassured with having pharma park in the spot for Do No Harm. It would terrify me if a drug having the bells and whistles to Do Good were put forth and subsequently turns out to have rather damaging latent effects. FDA and the body of regulatory guidance is really a basic standard for proving there is no harm or at least miminal exposure to patients. To use your drug example, the general class of atorvastatin has provided breakthrough treatment for lowering cholesterol. Taking an atorvastatin over a long term can produce degenerative side effects. @Briggs comments that doctors will consider a benefit-risk assessment in prescribing treatment. That is a commendable approach, but pharma still needs to have an ideal of zero harmful impact as a quality measure that far exceeds regulatory requirements. I think that maturing a culture that emphasizes Do No Harm will arrive at a place of Do Good with zero side effects for patient treatment.

    • Steve Street says:

      Celia

      Very many thanks – it’s great to hear from you. Your thoughts are a little more circumspect than I believe I was proposing, but I can understand your view and what you say definitely make sense. An in addition, my thoughts were as much directed at other areas of our work away from the specifics of drug profiles.

      Cheers

      Steve

  4. Steve,

    One of my hobbies is understanding how we make decisions and the science behind it is pretty fascinating.

    Wikipedia has a great list of cognitive biases that are important to think about when making a good argument or making decisions.

    http://en.wikipedia.org/wiki/List_of_cognitive_biases

    No matter how smart we are, we can’t avoid these all the time. In fact some of the smartest people I know fall prey to these things the most frequently (probably because they don’t think they’re capable of making these errors!) Scientists are no more immune to these traps than anyone else.

    I think the phenomenon you’re talking about here is the pseudocertainty effect and the phenomenon of “loss aversion.” Basically, we seem hard wired to avoid losses as opposed to acquiring gains; the negative effect of losing $1,000 is far more damaging than the benefit from finding $1,000. If given a choice, we’ll avoid the loss. In human health, of course, the outcomes of poor treatment are so dire and irreversible (i.e., patient death) that this makes a lot of sense. But it also plays to something about our decision making that seems shared by people across cultures.

    -Dave

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