LAUSR

Conceptually embodied within the Hippocratic Oath, this phrase is taught to students in healthcare across the world as one of the core principles of medical ethics and clinician responsibility. In part, the phrase is meant to prepare clinicians for a career where on a daily basis, they will be forced to weigh the risks and benefits of almost everything they do for patients, whether diagnostic or therapeutic. However, like many maxims, ‘first, do no harm’ serves only as a rudimentary piece of advice.1 Receiving much less emphasis is the reality that nearly all attempts to benefit a patient involve the potential risk of harm (e.g. risk of side effects with any prescribed medication). Rather, well intentioned clinicians make decisions with the expectation that potential benefits outweigh potential harms, but there are rarely any absolute guarantees and complications inevitably occur with virtually any diagnostic test or therapy. Indeed, practicing under a literal interpretation of ‘first, do no harm’ may lead a clinician to delay indicated tests or treatments to the point of doing nothing at all.1 In the care of patients with heart failure (HF) with reduced ejection fraction (HFrEF), multiple lines of evidence suggest a strong culture of hesitancy, needlessly prolonged sequencing of beneficial therapies, and clinical inertia towards making medication changes in routine outpatient practice.2–5 Among patients eligible for therapy, longitudinal follow-up shows most outpatients have no alteration in medical therapy, and initiation and dose escalation of guideline-directed medical therapy (GDMT) remain relatively rare.3,6 As a consequence of this ‘get to the next therapy or dose titration one day in the future’ approach, many patients eligible for therapy never receive medical therapies proven to