The Decision
Section titled “The Decision”The patient had entered the hospital a week ago with a stroke caused by bleeding into the brain. The bleeding seemed to have stopped. Now he had new, troubling symptoms, and two of my medical school professors were questioning him. "Where does it hurt when you breathe?" "Does it hurt when you breathe in or when you breathe out?" "Have you noticed any irregular heartbeats?"
The questions went on and on. Next the professors began going over the man's body with a fine tooth comb. One examined the man's neck carefully, discussing the appearance of the veins as we medical students watched and listened. He looked at the neck veins while feeling the man's pulse. They examined his legs carefully, pressing on his thighs and calves and in his groin.
After an extensive exam and review of his lab work, the docs shared their thoughts with us and with the patient. Possibly his shortness of breath arose from blood clots in his lungs, a not infrequently fatal condition. However to treat his blood clots with an anticoagulant increased his risk of a repeat bleed into the head. They explained to the man that medical technology in 1967 was limited in its ability to determine the exact reason for his symptoms and that further invasive diagnostic tests entailed more risk than benefit. They would watch him carefully over the next few days and change course if necessary. At that moment, however, based on their exam and experience with similar problems, the safer course was to withhold anti-coagulation.
As it turned out, they were correct.
Of all the things I learned at Duke medical school, that type of incident remains lively in my mind. My professors made best use of that most valuable tool, the human mind. And they had the wisdom to accept that sometimes doing nothing is the best approach.
Something Is Not Always Better Than Nothing
Section titled “Something Is Not Always Better Than Nothing”From the beginning of medicine, the wisest physicians knew that sometimes the best course was to do nothing. Every treatment can cause unexpected side effects, hence the ancient Greek aphorism "primum non nocere" or "first, do no harm." They didn't say "first use this herb." Instead, first think very carefully so that whatever course you follow does not hurt the patient.
Wise physicians have followed this advice ever since. Unfortunately wisdom is not epidemic. The history of medicine is littered with treatments that were worse than the illness. One medical historian went so far as to say that it was not until the 20th century that a person could consult a physician and have at least a 50-50 chance of coming away the better for it.
Looking back over just the past century we've had entire epidemics of ineffective and harmful medical treatments. These[1] include
- radical mastectomy for breast cancer (disfiguring and unnecessary)
- diethylstilbestrol to prevent abortion (caused cancer in female children)
- oxygen for premature infants (caused blindness)
- internal mammary artery ligation for heart disease (no benefit, just harmful effects from the surgery)
- Jejunoileal bypass for obesity (caused liver disease, arthritis, malnutrition, occasional death, and was not helpful)
- chloramphenicol, an antibiotic often used for colds when I began in medicine (sometimes caused bone marrow suppression and death)
- unnecessary tonsillectomy
- lobectomy for schizophrenia
- collapsing a lung to treat tuberculosis
- removing the adrenal glands and certain parts of the sympathetic nervous system to treat high blood pressure
- removal of the thyroid to treat high blood pressure
- radiation for acne
- radiation to shrink an enlarged thymus (the thymus is normally larger in newborns)
Anything we do can cause problems. As John Hsiang, a neurosurgeon at Virginia Mason told me once, "There is no medical condition, no matter how terrible, that surgery can't make worse." The same holds true for any medication or any herb.
The Pressure to Do Something
Section titled “The Pressure to Do Something”Here's something that happens to every physician. A patient shows up with a sore throat. You quiz them about fever and other symptoms, examine them, and determine they are suffering from a viral infection of the throat. When I started out in the late 1960s, it could take a further fifteen minutes to convince that person that they did not need an antibiotic. They would tell me, "Dr. Smith always gives me penicillin when I get this and it goes away." I would explain that it would have gone away anyhow. They would reward me with a perplexed look. Here they had come to the doctor in good faith with money or an insurance card in their pocket and I had not given them the penicillin they needed.
This battle over penicillin for the sore throat from a cold is largely over now. And I must confess that my own skills have now evolved. As a result of my interest in botanical and nutritional medicine, I can tell people with a cold or sore throat about nonprescription methods that will reduce their pain, allow them to sleep or breathe, or in some other way lessen the impact of their illness.
Now the battle has shifted to MRI scans[2], back surgery, coronary bypass, and a thousand other interventions.
The Economics of Doing Nothing
Section titled “The Economics of Doing Nothing”Every medical institution knows that revenue comes only from doing something. Spending the extra time to be able to safely tell the patient that they don't need this diagnostic test or that treatment just increases cost and cuts revenue. Physician time, surgical suites, scanners, nurses – they all cost money.
Not only that, but patients expect doctors to do something and are often not happy when they don't. To revisit my experience with sore throats in the old days, a disconcerting number of those patients would phone me back a few days later to tell me they had gone on to visit Dr. Smith, that he had given them the required penicillin, and not to worry about them taking up any of my time in the future.
Just this week, a New York Times columnist noted that certain medical authorities believed that about one third of the national health bill is spent on diagnostic and treatment measures that are not necessary.[3] Two important points:
- This spending is driven, not just by the perverse incentives of our medical payment system, but by the demands of healthcare consumers.
- Once established, unnecessary procedures become habit. There are many examples of procedures shown to be harmful or useless that are still in use.
Restoring Trust
Section titled “Restoring Trust”As I've discovered over my career, this less-invasive approach takes a lot of faith from patients. If you don't trust that your provider has it right, you'll have difficulty accepting the "wait and see" option.
When Less is More
Section titled “When Less is More”A quick story: I was trained to reduce extremely high blood pressure immediately, sometimes with sodium nitroprusside,[4] an expensive and resource-intensive procedure. Some time in the 1980s a woman came into my office with a pressure of 240/140. To see if I could save her a trip to the emergency department for sodium nitroprusside, I telephoned the cardiologist with her medical history and physical findings. He told me that particular bit of medical tradecraft was changing: she'd be better off with a more gradual blood pressure reduction at home with conventional methods. It would be both safer and less expensive.
The moral of the story: Sometimes, the more you know, the less you do. And you really aren't doing nothing. You are allowing the patient's own powerful healing mechanisms to operate without interference. Many times we have no medical intervention that can improve upon that.
Just-Right Medicine
Section titled “Just-Right Medicine”So, you may feel like Goldilocks as we collect information from previous doctors, ask questions, and fuss about with physical examination, but you benefit a great deal in the long run from Just-Right Medicine--not too little, not too much.
You carry powerful restorative powers within.
Endnotes
Section titled “Endnotes”[1] Most of this list comes from Eugene Robin "Matters of Life and Death: Risks vs. Benefits of Medical Care" W H Freeman 1984
[2] In a previous newsletter, we applied the same thinking to diagnostic testing.
[3] Jane Brody "When Costly Medical Care Just Adds to the Pain" New York Times May 28, 2012
Ms Brody lists a number of tests and procedures you can safely avoid.