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The about the practice of medicine is to "First, do no harm."

The reality is that we do harm all the time, but with good reason. The rule should be more like, "Do no net harm." But even that wouldn't be enough. We should only do the minimum harm necessary to achieve a net benefit. Somehow though, that isn't quite as catchy.

The point is obvious enough. When I wield a scalpel to make an incision in an infected area of skin, I'm doing harm up front, in service of net benefit by the end.

Meanwhile, the obvious goal is to make patients as comfortable as possible before any pain occurs without misleading them. Collectively, we clinicians are terrible at this. Over the years, this has been something I've been working to improve in my own practice, and I want to tell you about some of my approaches.

The Misleading Often Comes From a Well-Intentioned Place

First, I think the reason we doctors are so bad at preparing patients for pain that we are about to cause comes from a genuine place. We feel badly about this because we are not mean people! Plus, I think there's the concern that if we scare a patient by being a little too honest about what is about to happen, we actually may make things worse. Sometimes the anticipation can amplify the suffering.

In writing this, I'm thinking that inflicting pain -- even momentarily in the service of helping a patient -- is probably the most uncomfortable routine part of my job. I know my colleagues feel the same way because I constantly hear them trying to say reassuring things to patients before a painful part of a procedure is about to occur.

The biggest "b.s." in medicine may be variants of statements like, "you may feel a poke," or "you'll feel a pinch and a burn," or "this may cause some discomfort."

I've watched a lot of these procedures and performed just as many. Sometimes the patients feel almost no pain. Other times, the pain is not too bad, just as described. Other times, the pain is far worse than one might have anticipated. I find that this often occurs in patients who have had prior traumatic experiences in hospitals. I know because I ask, so that I can validate that their concerns are reasonable and that I'm there to make it better, not worse.

A Better Way to Prepare Patients -- I Think

Instead of downplaying any pain or discomfort that a procedure is about to cause, I either give a range of possibilities, or, in some cases, err on the side of overselling things.

Here's one I used the other day when I was about to inject numbing medication into a sensitive part of a patient's body. "Okay, so this might hurt like hell for a couple of seconds. Then you'll feel a lot better. Some patients tell me it isn't that bad. Others say it hurts more. Some really hate it, and they curse at me for a few seconds. But then they say they feel great shortly after."

A lot of times, I go the other way. "Some patients tell me this hurts a bit. Others report more pain. Some have a lot of pain and I'm worried they're going to strangle me or something. If it's really bad for you, just tell me to stop and I will pause. But I'll do my best to make the pain or discomfort as mild as possible. No matter what, though, if I'm successful, once we are done, you're going to be in less pain than you are now."

You may have noticed that in both versions of the pep talk, I inserted a "goal-oriented statement." That is, I reminded the patient that at the end of this momentary misery lies an outcome that we both want: less pain. When I remind patients that I'm doing something that is going to help them feel better, they can tolerate a lot more pain for a few seconds. So, being reminded of the goal can help a lot. Look, the pain of childbirth is (I've heard) a lot worse than many other kinds of pain. But knowing that it is headed towards a long-anticipated happy outcome gets many mothers through some obviously painful moments. (That, and in many cases, a good epidural.)

Why Downplaying Feels Kind, but Is Not

In my view, patients want the truth. When they are told a pretty little lie like "this won't hurt a bit," it can actually cause a lot of emotional distress. If a patient is told something won't be too bad, and then it sucks, they might internalize or externalize the unexpected discomfort. Internalizing means blaming themselves: "I am not a strong enough person." Externalizing means blaming the provider: "They are not very good at their job." Neither outcome is good! Downplaying feels like a nice thing to do to help a patient steel some courage. But generally, it backfires.

Try Not to Make Promises You Can't Keep

Here is another catchphrase I often hear from clinicians while a patient is expressing pain during a procedure: "Almost done!" This phrase is often uttered well before the halfway point of a painful procedure. That's bad. Think of what that misrepresentation does to a patient's state of mind. It might be as bad as downplaying the pain ahead of time.

I actually have to correct trainees about this occasionally. Recently, we were doing a procedure for a patient who was having a fair amount of pain, as anticipated (and despite attempts to treat the pain ahead of time). The patient was accepting of the situation, and clearly enduring it, but let's say, holding on.

"Almost done," the student said. But we weren't almost done. So I stopped.

"Actually, we are not anywhere close to done," I said. "But you're doing very well here. Let me know if you need us to stop."

The patient had been through the procedure before and knew the deal. "Keep doing what you need to do," she said. "I know we have to get this done."

So, I try very, very hard to never say "almost done," until we actually are wrapping up. But since there are always potential reasons for a procedure to suddenly require more time than expected, I generally repress the urge to say this type of thing. (The urge is there.) Instead, I'll say exactly what I have done so far, and what I have left to do.

Things Not in the Hippocratic Oath

The phrase "First, do no harm," is not actually in the Hippocratic Oath. But the spirit of it is there. Another phrase that is not in the Oath -- and maybe should be -- is this: "Honesty is the best policy."

This post originally appeared in .

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