Primum non nocere Ch 1

How many doctor-writers have tackled this? No, today I am not offering new insights into the iatrogenic harms we cause with our medicines, treatments, keeping dying patients alive so they can suffer some more, steering patients this way or that. It is the evey day harm to the heart and spirit, hidden, percolating below the surface that is more challenging. It is the little hurts we cause with our attitudes, opinions, biases. We know how fragile white folks are when it comes to admitting to our own racism, how biased doctors are against people of size, lack of education, how tainted the encounter can be by awful personal hygiene, but the list turns out to be quite endless. True mindfulness, not the kind taught in a lecture, weekend conference, by a consultant at a Board retreat, but slowly developed after substantial practice, discloses that an unconditioned mind is rarely found in most bodies of everyday health care practitioners, and even those mindful enough to make the effort are "off" most of the time. We bring our conditioning with us wherever we go, whatever we say, do, we take it to bed, and we wake up with it.

The other day, fresh from retreat, I was challenged by a patient I have gotten to know a bit only in the last year or two, wearing Trump 2020 paraphernalia, and a tea shirt with convict Hilary peering out from a jail cell. I wondered why she had chosen to wear these to the office. Was she angry with me? The internal dialogue I had with myself came rather fast and furious: was I being as kind as possible, or asking the right questions? Had I unknowingly previously revealed a political bias that offended her?

When I started practice here 34 years ago, I realized quickly I was giving up opportunities to be politically active and outspoken in local town matters, since I would invariably come head-to-head with patients, probably MANY of my patients; our sacred vow is to put the care of our patients above almost all else. A patient puts her trust in me, and that includes my unspoken promise to not alienate her with political or other opinions that would make her uncomfortable the next time she sits in my exam room with all of her vulnerabilities exposed. As time has gone on, and times become more dire, and the time I have to help change things becomes shorter and more precious, I realize how much of a sacrifice I have made on behalf of patients privacy, and I also know that they don't have any inkling about my experience of that sacrifice.

This does not mean I abide racism, ill-manners, offensive hygiene, indeed part of my responsibility to my patients is to care enough to protect them from self-harm in these ways too, if possible.

Here we can learn from the Buddha who talked about right speech. A matter had to be factually accurate AND of value to make it worth discussing. But in addition the speaker had to weigh whether the factually accurate, and valued material would hurt a person's feelings. If it might, it is still appropriate to speak but the speaker needed to be mindful of the proper time and context for speaking.

More than once I have been obligated to care for an abuser, and sometimes his victim as well, sworn to secrecy by my oath by both of them. The abuser does not know I am aware of his behaviors and expects the same high quality care everyone should. More than once, I have purposely determined to tone down my usual friendly attitude and stick to the business of doctoring as a way of negotiating my own conflict. I would gladly accept a way out of an ongoing relationship with such a patient, but one never presents itself. In this case my conditioning provides a means for tempering karma in what I consider to be an appropriate way. More importantly, it reduces my internal sense of conflict and allows me to better function. And I can say, with a fair amount of confidence that I am not creating more suffering.

(Originally written, 4/29/2019, published 3/27/20, RD)

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had chosen had chosen to wear it to the office