First do no harm: the impossible oath

Kamran Abbasi

BMJ 2019; 366
doi: https://doi.org/10.1136/bmj.l4734

Here is the beginning:

Discussions about patient safety describe healthcare as an industry. If that’s the case then what is healthcare’s business? What does it manufacture? Health and wellbeing? Possibly. But we know for certain that healthcare manufactures harm. Look at the data from our new research paper on the prevalence, severity, and nature of preventable harm (doi:10.1136/bmj.l4185). Maria Panagioti and colleagues find that the prevalence of overall harm, preventable and non-preventable, is 12% across medical care settings. Around half of this is preventable.

These data make something of a mockery of our principal professional oath to first do no harm. Working in clinical practice, we do harm that we cannot prevent or avoid, such as by appropriately prescribing a drug that causes an adverse drug reaction. As our experience, evidence, and knowledge improve, what isn’t preventable today may well be preventable in the future.

The argument, then, isn’t over whether healthcare causes harm but about the exact estimates of harm and how much of it is preventable. The answer that Panagioti and colleagues deliver from their systematic review of the available evidence is the best we have at the moment, though it isn’t perfect. The definitions of preventable harm differ. Existing studies are heterogeneous and focused more on overall rather than preventable harm. The standard method is the retrospective case record review. The need, say the authors, is for better research in all fields and more research on preventable harms in primary care, psychiatry, and developing countries, and among children and older adults.

How Evil Happens

Noga Arikha
www.aeon.co
Originally posted July 30, 2018

Here is an excerpt:

An account of the inability to feel any emotion for such perceived enemies can take us closer to understanding what it is like to have crossed the line beyond which one can maim and kill in cold blood. Observers at the International Criminal Court (ICC) at the Hague note frequently the absence of remorse displayed by perpetrators. The clinical psychologist Françoise Sironi, who assesses perpetrators for the ICC and treats them and their victims, has directly seen what Lifton called the ‘murder of the self’ at work – notably with Kang Kek Iew, the man known as ‘Duch’, who proudly created and directed the Khmer Rouge S-21 centre for torture and extermination in Cambodia. Duch was one of those who felt absolutely no remorse. His sole identity was his role, dutifully kept up for fear of losing himself and falling into impotence. He did not comprehend what Sironi meant when she asked him: ‘What happened to your conscience?’ The very question was gibberish to him.

Along with what Fried calls this ‘catastrophic’ desensitisation to emotional cues, cognitive functions remain intact – another Syndrome E symptom. A torturer knows exactly how to hurt, in full recognition of the victim’s pain. He – usually he – has the cognitive capacity, necessary but not sufficient for empathy, to understand the victim’s experience. He just does not care about the other’s pain except instrumentally. Further, he does not care that he does not care. Finally, he does not care that caring does, in fact, matter. The emotionally inflected judgment that underlies the moral sense is gone.

The information is here.

Preventing Med School Suicides

Roger Sergel
MegPage Today
Originally posted May 2, 2018

Here is an excerpt:

The medical education community needs to acknowledge the stress imposed on our medical learners as they progress from students to faculty. One of the biggest obstacles is changing the culture of medicine to not only understand the key burnout drivers and pain points but to invest resources into developing strategies which reduce stress. These strategies must include the medical learner taking ownership for the role they play in their lack of well-being. In addition, medical schools and healthcare organizations must reflect on their policies/processes which do not promote wellness. In both situations, there is pointing to the other group as the one who needs to change. Both are right.

We do need to change how we deliver a quality medical education AND we need our medical learners to reflect on their personal attitudes and openness to developing their resilience muscles to manage their stress. Equally important, we need to reduce the stigma of seeking help and break down the barriers which would allow our medical learners and physicians to seek help, when needed. We need to create support services which are convenient, accessible, and utilized.

What programs does your school have to support medical students' mental health?

The information is here.

Many Academics Are Eager to Publish in Worthless Journals

Gina Kolata
The New York Times
Originally published October 30, 2017

Here is an excerpt:

Yet “every university requires some level of publication,” said Lawrence DiPaolo, vice president of academic affairs at Neumann University in Aston, Pa.

Recently a group of researchers invented a fake academic: Anna O. Szust. The name in Polish means fraudster. Dr. Szust applied to legitimate and predatory journals asking to be an editor. She supplied a résumé in which her publications and degrees were total fabrications, as were the names of the publishers of the books she said she had contributed to.

The legitimate journals rejected her application immediately. But 48 out of 360 questionable journals made her an editor. Four made her editor in chief. One journal sent her an email saying, “It’s our pleasure to add your name as our editor in chief for the journal with no responsibilities.”

The lead author of the Dr. Szust sting operation, Katarzyna Pisanski, a psychologist at the University of Sussex in England, said the question of what motivates people to publish in such journals “is a touchy subject.”

“If you were tricked by spam email you might not want to admit it, and if you did it wittingly to increase your publication counts you might also not want to admit it,” she said in an email.

The consequences of participating can be more than just a résumé freckled with poor-quality papers and meeting abstracts.

Publications become part of the body of scientific literature.

There are indications that some academic institutions are beginning to wise up to the dangers.

Dewayne Fox, an associate professor of fisheries at Delaware State University, sits on a committee at his school that reviews job applicants. One recent applicant, he recalled, listed 50 publications in such journals and is on the editorial boards of some of them.

A few years ago, he said, no one would have noticed. But now he and others on search committees at his university have begun scrutinizing the publications closely to see if the journals are legitimate.

The article is here.