First, do no harm


by Alison Block

It’s one of my earliest memories: I’m wrestling with my brother, and I’m losing, because I’m five and he’s seven, and he’s bigger and stronger than I am. So I bite him, hard.

Instantly I know I’ve crossed some sort of line, and I employ my most primitive defense mechanism, shouting out, “He bit me! Jon bit me!” I feel shame, because I am old enough to know it is wrong to hurt people — and to lie.

Some years later, I am accepted to medical school. I go to the first ceremony of my medical career–the one where I get my short white coat–and I take a modernized version of the Hippocratic Oath. I will try to do the best I can for my patients, and I will recognize the awesome responsibility that it is to care for other human beings. I notice one thing is lacking, though–the often-quoted phrase “First, do no harm.” The sentiment is there, but the words are not. I don’t make too much of it.

I spend two years sitting in class learning about various -ologies, and then I take an eight-hour test, the national board exam, to prove that I’ve learned something. I leave the classroom, and I am finally allowed to see real patients, not just the actors in the fake clinic rooms who get paid to pretend they have thyroid disease. I ask people probing, personal questions, and I listen as they talk about their devastating diseases and lives. I try not to cry, because it feels unprofessional, and nobody wants a doctor who cries.

I ask complete strangers to undress and put on flimsy paper gowns. I touch them on their bare skin and feel embarrassed when little old ladies wince and tell me my hands are cold.

I see my first emergency room patient, a well-dressed, twenty-four-year-old man with a polite smile and fearful eyes. He complains of terrible abdominal pain that started around his belly button and has progressed to his right lower quadrant. I’m excited to examine him, certain that this is my first appendicitis. I press down on his raw, inflamed intestines, and he screams in pain–pain that I caused. I feel terrible, and unsure, but I put on my best air of confidence, because nobody wants a doctor who lacks confidence.

A few weeks later, I try to look into the infected ear canal of a fussy three-year-old, sweaty and disheveled from days of fever and discomfort. The examination hurts him, and he screams and cries so hard he can’t breathe. He wiggles away before I can see anything, and I stop trying because I can’t bear the thought of wrestling a small child onto the exam table.

I learn how to place IVs on plastic dummies. It seems simple and basic. I decide to try it on a real person, a genteel but anxious forty-something woman about to get her gallbladder taken out. Inexpertly grasping the needle in my visibly shaking hand, I bring it close to her fragile-appearing skin, where it suddenly looks big and sharp and scary. I poke too gently and too slowly, and it hurts her that much more. I poke deeper, at too much of an angle, and a little black-and-blue bubble starts to form under the skin around the needle.

The nurse looks at me, annoyed.

“You blew the vein,” she says. “You have to take out the needle and start over.”

I try three times and blow three veins. Then the nurse does it herself. Quickly, easily. I feel incompetent, and I am acutely aware that nobody wants a doctor who is not competent.

I do a trauma-surgery rotation at the county hospital, where most patients are recovering from gunshots and stab wounds. My job is to carry the wound-care bag and run ahead of the team of surgeons to undress the wounds.

I enter the first patient’s room and take off her bandage, revealing a bloody, pus-stained pad of gauze underneath. I start pulling out the gauze, and much more unravels than I’d have thought possible, exposing a deep, raw, fleshy hole.

The patient shrieks. “Why are you doing this to me?” she asks, sobbing.

I want to stop, but I know that I have to keep going. I tell myself that this is all part of the healing process–that I am going to be a doctor, that my job is to heal, and that nobody wants a doctor who’s afraid to rip off a bandage.

In two months I will climb onto the stage in a big auditorium to receive my robe and diploma, and I will complete the transition from medical student to medical doctor. I will sit at graduation and listen to my mentors and classmates talk about the honor and privilege of being a physician. I will know that it’s true, and I will be excited. But I’ll also be scared. I can tell already that this doctor thing is a lot of responsibility, and I find it hard to believe that I’m good enough for the job.

Despite my fears, though, I will stand up, and I will repeat the oath. I will be grateful for an oath that doesn’t make me promise to do no harm–a promise I’ve come to realize that I will not be able to keep. Because it turns out that healing, more often than not, is a messy, painful, complicated process. And while I may not have known it when I signed up for this job, I now understand that, as a physician, I will need to work together with my patients through the hurt and chaos of illness in the hopes of achieving the relative calm and order of wellness.

So instead of promising to do no harm, I will promise to do my best. And I will hope that the good will outweigh the harm. Because nobody wants a doctor who does more harm than good.

Alison Block is a medical student. This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.

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