text: Until recently, the main framework for thinking about reform has been one of shortages and disparities. That has begun to shift as patients and providers become more aware of the problem of unnecessary or avoidable care. Efforts to improve care and control costs will not be successful unless policymakers, payers, providers, and patients address the problem of avoidable care.
  Considerable uncertainty remains. How much care in the US is avoidable? Can we quantify its consequences, in terms of financial impact and harms? What factors drive overutilization and inappropriate medical services, how can we curb it, and do physicians have an ethical duty to do so?
  Primum non nocere, or First, do no harm, has a curious place in medicine and culture. On the one hand, it is widely recognized, and sometimes celebrated as “the cardinal ethical principle sacred to medicine.”1 Simultaneously, it is often rejected by bioethicists as “inadequate”2, “confounding”3, and serviceable only by “inert nostrums.”4 Clearly, the phrase’s utility depends on its interpretation.5
  Do no harm can be interpreted in a way that is especially valuable to the Avoiding Avoidable Care movement. This document introduces five points of supportive interpretation, and then offers a proposal to use do no harm to influence medical school culture.
  1- It is a moral injunction to listen. Primum is alternately translated as “first” and “above all else.” Notions of primacy have been interpreted as invoking medicine as a “moral enterprise”. 5 Since the basic morality of medicine is to serve patient interests above those of the doctor, a moral physician cannot serve, and therefore may harm, a patient’s interests if he or she does not actively determine what those interests are. Rather than actively sought, these interests are often simply assumed at best, and dismissed, even compromised, at worst. Quite simply, if a physician does not know their patient’s interests, First, do no harm invokes an image of an unhurried physician who begins with the patient’s interests well before embarking down the road of testing, diagnosis, and treatment. Such a physician recognizes the temptation for even simple tests to turn into painful and expensive treatments that the patient never had, or even wanted investigated. Such a physician thereby adheres to the principles, if not the techniques, of shared decision-making and its concomitant reductions in overtreatment.6 In addition, as explicated by Bernard Lown,7 listening clarifies the motives behind this service of patient interest, thereby engendering trust. Essential to the enterprise of medicine, trusting patients are more likely to adhere to their medications, return for follow-up, persevere with physical therapy, pass up alternative healers, and prefer the advice of their doctor over the speculation of Google, all consistent with reducing overtreatment. Further, patient trust is essential for doctors to successfully resist the common perceptions that drive treatment: doing is better than not doing, knowledge is power, certainty is strength, and errors of commission are preferred to errors of omission [Steven Smith].
  2- It emphasizes avoiding harm. Abjuring carelessness and malice, or the principle of non-maleficence, is so obvious that saying so is not saying much at all. However, there are several subtle implications of the specific need to avoid harm that are specifically related to overtreatment and that may be lost if not they are not stated. Drivers include physicians’ lack of evidence about which treatments and devices are truly effective, as well as a common inability to appraise existing evidence. Another is the fear of medical malpractice suits that spurs defensive medicine. Arguably the most powerful cause of overtreatment is that doctors are paid according to the amount of care they provide.8 Crucially, this last point illustrates the value of harm avoidance language rather than care promotion. On a simple reading, “providing care” can readily be used to rationalize overtreatment, and its attendant revenue. Pharmaceutical and device companies routinely disguise their profit motives behind a veneer of care, but rarely invoke an avoidance of harm in any way similar to Bernard Lown’s dictum: “Foremost, we did as much for the patient, and as little to the patient as possible.”
  3- It addresses the culture. Conveniently, do no harm is a cultural fixture that can be used to address another cultural fixture, namely, the belief among well-meaning physicians that more care is better care. According to Steven Smith, such beliefs are so pervasive, so deeply embedded within our ethic of caring and duty to patients that they become “the air we breathe,” and paradoxically easy to miss. Do no harm, unlike duty to treat or even serve the interests of my patients, includes a specific reminder that almost all care has risks. The phrase may be uniquely suited to identifying such a fundamental assumption. As well-meaning doctors begin to root out this subtle cause of overtreatment, then more overt profit-driven causes will become all the more evident.
  4- It unifies the profession. Do no harm is notable for its widespread recognition among physicians. Regardless of its origin and interpretation, Primum non nocere is to medicine what Semper fidelis is to the Marines and Be prepared is to the Boy Scouts. Accordingly, the phrase has value to the extent that it strengthens the unity of a profession widely perceived to be under siege. At a time when cynicism among the ranks is growing, when forces of government and corporations are encroaching on physician autonomy, and when public trust is waning, physicians are abandoning professional societies like the American Medical Association just when they most need to organize and collaborate.9 Do no harm can become a rallying cry, attracting both physicians in training and established doctors who pursued medicine from a moral calling, but may have since lost faith. By offering a core value, one that harkens back to the roots of medicine, as a remedy for today’s dire health care situation may re-engage members with the profession’s mission.
  5- It renews public trust. Since do no harm is so widely recognized by the public, using it to brand the avoidable care movement may be an effective strategy to counter the vast marketing machine of pharmaceutical companies, hospitals, and other health care corporations as they triumphantly tout the latest and greatest treatments. The phrase’s humble tone rebrands the mindful physician who listens and restrains inappropriate treatment as a paragon of trustworthiness, all the while carrying an attendant rejection of trust that is based on action. Finally, since very few market mechanisms are incentivized to promote the mission of avoiding avoidable care, co-opting the most famous line in medicine is an effective way to get the word out.
  Proposal: Avoiding Avoidable Care, as a movement, co-opts First, do no harm and outlines an interpretation of the phrase’s meaning specific to the aims of the movement, a condensed version of the above. It then approaches the Arthur P. Gold Foundation, sponsor of the Gold Humanism Society and the White Coat Ceremony, in which almost every medical student participates at the start of medical school. The movement requests the inclusion of a First, do no harm campaign within the Gold Humanism Society’s White Coat Ceremony. Since oath taking is a requirement of this ceremony, including do no harm is consistent. The movement could also create a pin, similar in fashion to the Gold Foundation pin that is distributed at the White Coat Ceremony. Students would affix this do no harm pin to their lapels, as a sign of their mindfulness of overtreatment. Central to this campaign would be an emphasis on listening. Specifically, students would be encouraged to query patients about their interests and goals as something akin to the fifth vital sign, whereby it is sought from every encounter. By affixing a moral spotlight on listening, students would be charged to advocate and innovate methods to increase the length and effectiveness of patient encounters. Thereby, as the Movement develops guidelines and best practices for avoiding avoidable care, this charge can become a hook with which to publicize these developments to students themselves, thereby obviating the need to negotiate with the medical schools to incorporate this material into curricula.
  Conclusion: Do no harm does not specifically speak to all aspects of Avoiding Avoidable Care. Specifically, interpreting it to comment on the need in some cases to perform care that is being neglected is tenuous. However, the phrases near universal recognition, moral invocation, negative language, and humbling spirit outshine its liabilities in interpretation and comprehensiveness. Admittedly, co-opting the phrase is more about leveraging its spirit than in creating the ideal slogan or tag line. However, an essential role of any movement is to capture the hearts and minds of participants. Do no harm is already in their minds, and by showcasing it at formative periods in physician training, it can capture their hearts. Since much has been made of the limitations and failures of medical training to address overtreatment, do no harm offers an easy way to redress the dwindling patient focus in medical schools and residencies.
  7. Lown, B. Social Responsibility of Physicians. Address presented at Avoiding Avoidable Care Conference, Cambridge, MA. April 26, 2012.
  I have one suggestion based on experience in British Columbia: when restrictions on coverage must be implemented, use design delays (staggered implementation.)
  Ideally these would be randomized control groups, but controlled time series designs, especially with matching, are almost as rigorous as RCTs in my experience, and institutionally they seem to be more feasible.
  I was inspired by my interview with Tom Chalmers almost 20 years ago, to advocate within the British Columbia Ministry of Health for control groups to be used when the public drug plan (‘PharmaCare’) introduced restrictions on drug coverage. I call this approach ‘designed delays’ because delays are the norm, and ‘designed’ feels like adding orderliness to the process, whereas ‘randomized’ feels like adding chaos to a program that is already complex.
  Chalmers told me he had urged the Veterans Health Administration to pair-match hospitals and randomly select one of each pair to be first with a new service while the other hospital was delayed as a control. Despite his close connections with the VHA, he thrice failed to convince the VHA to use designed delays — for Coronary Care Units, for CAT scans and for MRIs. He was very frustrated by the experience and stymied on how to routinize randomization.
  In British Columbia, we now routinely implement prescribing education initiatives with randomized delays but our success in using designed delays for changes in drug coverage has been much more limited. Our main success in using designed delays was in 1999 when we partially restricted coverage of nebulized medications. It went so smoothly that the method of designed delays was endorsed for 2 other drug restriction policies (but the restrictions were never introduced for other reasons.)
  In contrast, designed delays when ADDING coverage of a new medication seems to be much more difficult. The hope (or hype) that the new drug will yield better outcomes, makes delays unacceptable. On the other hand, SUBTRACTING a medication or service that is believed by many (but not everyone) to be of little value, is made easier by promising rigorous evaluation by use of delays controls.
  The most vehement critic and the strongest proponent of the policy AGREED that randomized delay was a good idea. They were both convinced that rigorous evaluation would prove they were right. Commitment to rigorous evaluation thus instantly refuted the criticism that the government was only interested in cost control, not patient outcomes.
  A university ethics committee had no difficulty with randomized delays of the restriction because it eventually would apply to everyone, unless the evaluation showed the restriction was harmful (in which case the drug plan director was committed to reassessing the policy.) In contrast, another ethics committee was critical of our proposal for delayed coverage of a NEW medication.
  My hypothesis is that when a health organization is forced to restrict services (e.g. the UK National Health Service must cut 20 billion pounds in the next four years), there will be many opportunities to evaluate the balance of benefits versus harms of the restrictions by using delayed controls.
  Although Tom Chalmers’s advice mostly fell on deaf ears during times of plenty, I predict his advice will become more appealing to decision makers as cost pressures increase.
  (These comments are my own opinions and observations in my academic capacity as Chair in Patient Safety at UBC. That appointment includes my continuation half-time as Co-Director of Research and Evidence Development, an advisory role in the Pharmaceutical Services Division of the BC Ministry of Health. I wish to stress that my opinions are not to be interpreted as representing the Ministry’s positions on these matters.)
  To some extent appropriate utilization can be taught to senior medical students by committed physicians who are knowledgeable about the negative consequences of not avoiding avoidable care. Included among likely instructors would be primary care physicians, internists (including medical subspecialists), pediatricians, surgeons and radiologists.
  A six week curriculum with both didactic lectures and case presentations could form the substrate for the course. But there would have to be involvement from other knowledgeable individuals in each medical school who would educate the students about the economic, sociological and public health issues intrinsic to the topic.
  Where could the time be found? The fourth year of medical school is in many ways a wasteland, (pun intended). It is in large measure a waste of time with allotments of weeks to meaningless requirements often merely to allocate treasured hours to satisfy the special desires of powerful actors who can influence curriculum assignments. It is a waste of money – both for the hours spent without a sound education focus and most specifically for the long and costly interview process incurred by students as they seek internship and residency positions.
  Why should a student travel around the country on his or her dime to interview at the home site of a prospective training site in accordance with schedules which serve the convenience of Program Directors? And these odysseys occur predominantly in December and January when travel is most difficult.
  Why not change the process? Program Directors could evaluate the applicant without a visit to the medical center. For example, law school is also a three year commitment
  (like many residencies). Site visits to them are not mandatory, let alone necessary. In truth, applicants to medical training programs for the most part are more interested in the environs of the hospital, (the neighborhood and the city) than the structural character of the hospital or its amenities. Such information can be gleaned by web site displays and other material most programs now readily provide.
  Or for small and moderate sized internships and residencies, interviews could be held at one or two locations nationally so that all applicants and interviewers come together for one week or so allowing for multiple interactions in a short time. These visits are secured by lower cost and lessened time away for both students and Program Directors than by customary visits at the behest and convenience of potential hirers. Podiatry does this now. Why can’t residency programs in medical specialties do it as well?
  The time freed up in December and January can then be made to accommodate an uninterrupted course of study at the home base. The curriculum could be focused and sustained, devoted to the important mission of educating students about the specifics of appropriate rather than excessive care which is too often a product of the sensibilities of contemporary American medical graduates.