As another graduating podiatric medical class excitedly goes out into to the “real world,” some will soon appreciate the challenge of “primum non nocere.” This is the portion of the Hippocratic Oath referring to “first, do no harm.” Modern medicine is now so complex that “doing no harm” may be more difficult to accomplish, despite the efforts of educators to try to prepare future doctors accordingly.
Recent graduating classes may adapt well to electronic medical records (EMR) and simulation labs to improve patient safety but, in the real world, physicians must understand health care policy, operations, processes, management and finance. All of this is in addition to understanding the evidence behind the medicine. Most importantly, a physician needs to metaphorically find a balanced and safe position where he or she can uphold the tenet of “do no harm” among the aforementioned elements.
In the midst of this pandemic, the stress arising from meeting these expectations becomes more and more prevalent. As the country tries to combat economic turmoil by reopening society, this forces outpatient clinics to become the “front line” to triage patients with symptoms of inflammatory responses such as fever, chills, fatigue, diarrhea and so on. Podiatric physicians have started facing more questions and challenges than ever before, even when a patient with a common foot problem knocks on the door.
Although telemedicine may now be readily available for patients, in the field of podiatric medicine and surgery, I feel telemedicine effectiveness is quite limited. It does not allow us to properly assess a chronic wound, definitively treat an ingrown toenail or help reduce a malaligned fracture. Thus, we keep the doors open to see anyone who needs immediate podiatric medical attention.
However, when a mother is concerned about her daughter’s sole symptom, a fever possibly related to an infected ingrown toenail, how can we be sure the origin of the fever is not something else, like SARS-CoV-2? In this instance, I set up a telemedicine visit to see if the toe is acutely infected, ask about other symptoms and request the parents pick up antibiotics and check the child’s temperature for the next two days before we reconvene. Her parents report no fever for two days. Accordingly, we let the patient come in to further examine the painful toe but now the child has a fever of 101.9 degrees F at check-in. Normally, I would proceed to examine the patient to be sure the ingrown nail is not acutely infected. But is it fair to wonder if I should decline to perform the examination at this time? If I have the patient come in, am I doing more harm to our staff and other immunocompromised patients who are here for wound care?
Maybe I am not seeing someone who is COVID-19 positive and is struggling to breathe on a ventilator. However, the risk and the responsibility of any health care provider are equally burdensome. Facing the mother and the child with the ingrown nail, we discussed and formulated the plan, I removed the ingrown nail and recommended follow-up with the pediatrician to see if the child needs to be tested for COVID-19.
We potentially saved the family another trip back to the clinic and the possibility of exposing the staff and other patients to the virus a second time. However, this visit only seems to come to an end when the child tests negative for SARS-CoV-2. I now sit in my office with more uncertainties. I wonder if I will spread the virus to my loved ones at home? If I schedule a testing appointment for myself, will it give me peace of mind? I wonder if one of my patients or staff becomes ill, what are the potential consequences?
A simple visit of an ingrown nail is no longer simple during this COVID-19 era. Each decision matters to not only the patient but to everyone around the patient as well. Each patient visit may tap into an uncharted territory where we have no process or protocol to govern our decisions as health care providers. Nonetheless, perhaps this is why “primum non nocere" is a simple phrase but an extremely enduring one.
Dr. Shih is an Assistant Professor at the California School of Podiatric Medicine at Samuel Merritt University and a previous fellow Lawrence B. Harkless Fellowship in Limb Preservation at the University of Southern California. He is a Diplomat of the American Board of Podiatric Medicine and an Associate of the American College of Foot and Ankle Surgeons. He is in practice in San Francisco, Calif.
The author wishes to acknowledge Corey J. Housepian, DPM, LT, MSC, USN for his assistance in reviewing this guest blog.