Primum non nocere or first do
no harm.
It is a double entendre that was derived from the collective
wisdom of Hippocrates and was frequently spoken of such by Wm. Osler, MD in his
foundation of modern medicine. It is actually meant, as I was taught,
purposefully to be ambiguous. The doctor-patient-disease relationship was
primitive before Osler. His great strive in medicine was to take his students,
not to the dissection rooms, but to their bedside. He intentionally believed
that the patient would reveal to you both his disease and his symptoms.
The modernization of medicine has brought a new and fierce
interpreter of the maxim- the malpractice lawyer. Albeit at times a necessary
evil, the art of medicine has been forever weakened by over scrupulous
interpretations of physician patient rights and decisions made in the context
of that relationship.
The true nature of medicine is based on prevention and harm
reduction tactics. Hippocrates original words would fit the Oslerian Model.
To do no harm was in my early days of practice- to evaluate
the nature of the complaint and in conjunction with the patient's presentation,
to come to a consensus on the best, not always the safest route of care. Take
chemotherapy- it may prolong life or be curative- but it causes a degree of
harm (hair loss, infection that might shorten a patient's life) but also the art
of medicine gives the suffering hope, a better lifestyle and a continued sense
of being a part of life and not on a rapid path to death.
What has perverted the patient-doctor co-decision making
process is the loss of a once understood notion that medical practice had its
risks, the patient knew these risks and that the patient accepted the healer as
a person working with all his might to decrease suffering, came from several
sources.
1. As Medicine
entered the 20th Century, so did the industrial revolution and the notion of
profit and regulation.
2. Medical judgment
become more scrutinized- not a bad thing in itself, but healing through bedside
observation and discussion of a patient's desires, changed to a test result and
medication therapies.
3.The country doctor
who made house calls and knew his patient, often from birth to late life, was
supplanted by specialists and home care or care in the doctors own hospital was
replaced by large hospitals, often with profit motives.
4. The individual
physician and his manner of care became regulated and standardized- most often
by non-medical bureaucrats, the drug became the healer and the physician the
dispenser.
5. Former patent
medicine companies became pharmaceutical companies, and officially the art of
medicine shifted from the hands on approach to the tail wags the dog antics of
the now expanding Big Pharma.
6. The barter system
of medicine with outcome and relationship more important than payment was lost
to the cost of treatment and a new breed of physician that evolved as cities
grew and people and authorities demanded perfection.
7. Big Pharma grew
and as their profits increased their influence on medical practice accelerated.
8. Medical care
became expensive. Regulations
increased. And the FDA was born.
9. Societal belief
that medicine would stop death increased physician pressures to go to any
lengths to prevent that death.
10. The atheism of
medicine arose and the notion that death and side effects was doctor based
changed the Dr. Patient relationship forever.
Malpractice suits rose as the practice of you only pay the lawyer if you
win evolves.
11. With the advent
of insurance and unregulated cost we see the onset of Big Pharma supported FDA
oversight of what they wished to have investigated became hugely profitable.
12. Medicine is no
longer physician based; it is fear and protect yourself based. Medicine is
technology based instead of patient based.
13.The notion of
errors of omission and commission blur and the average MD spends as much, if
not more of his or her time creating protective paper trails and reading lab
and scan reports.
14. Hospitals begin
to direct how care is provided, insurance companies say when where and how much
and Pharma and the FDA what can be used.
15. And as costs
rise, so does the nature of care change.
The doctor is replaced by the group, paraprofessionals and care begins
to be directed not at quality, but at quantity of life.
The ideal of at first do no harm now changes in
definition. Harm goes from do not
prolong suffering and listen to your patient's needs to Morbidity and Mortality
reports that base success and failures on statistical and cost outcomes.
The patient becomes a number in a statistical paper put out
weekly.
Oh there were those that ranted against the dehumanization
of Medicine- Kublai-Ross, the resurgence of the Family Practice movement and
evidence based medicine.
So back to Hippocrates paraphrased- physician do no harm. It
is dualistic. Do not stop a patient from using snake oil if it helps reduce
symptoms and has no evidence of increasing harm over other treatments. At times doing nothing is the best medicine, but
most of all the dualistic thoughts of Osler. The patient will tell you what he
has and needs. Listen to him, observe her and intervene if harm is evident.
This is where the ANTZ get us. A single finding that is
perhaps indicative of a problem and publish it as factual and repeated ad
nauseum... They take one vial with DEG and condemn the use of all e-cigarettes.
Yet they eat their Big Macs and double the fries.
They strut some women with a lung cancer not associated with
smoking out on stage as a victim of her parents smoke filled rooms.
Hippocrates would roll in his grave.
Why is this idea of at first do no harm an important idea-
it speaks of duality. Smoking kills, vaping is in reality an unknown- but when
one sees is that the vapor feels better. He may still say it is not fully
researched, but it is doing something. That is harm reduction.
The "at first do no harm" edict driven into the
heads of first year medical students is to say stop vaping, quit cigarettes and
I'll see you in a year. That is harm that would be making decisions counter to
the big picture. Don't smoke, quit or be gone from my practice. To those who
cannot quit- the patch, gum, vaccines, or medications (like Chantix). Most curious is Chantix a drug with a black
box warning, reminiscent of a coffin that is FDA approved despite deaths,
mental illness and at times irreversible depression and suicide. Smokers are second hand citizens who kill
babies in the womb. They have less
value. The treatment fails. Cigarettes are legal and another potential
survivor bites the dust
Osler would tell us that to know yourself is to better know
your patient. He would say that if your patient is doing better-emotionally and
physically and for fear of censorship or suit you tell them to quit vaping,
then you are not listening to the patient you are projecting bias and fear and
doing harm. At first do no harm means, do not mandate first and offer solutions
second. Do not imagine anything as fixed truth-treat each individual as a
person of needs different from any other. Do not stop the vaper from her
untested system and condemn her to return to smoking.
To give her to smoking when the art of medicine gives
alternatives that may be less harmful is harm.
And then there is nicotine, a calming drug that increases attention
span, may help in Alzheimer's disease and gives pleasure. Over 70% of schizophrenics smoke and if you
ban smoking in psychiatric wards medication use elevates as do the symptoms of
the disease. There is hope as evidence gathers to show nicotine itself is much
less dangerous than smoking. The TSNA's in
e-cigarettes are comparable to the patch.
Oh the ANTZ will tell you of the dangers of second hand smoke and third
and eventually 22nd hand smoke, so why do they detest smokeless tobacco. Let us hope, meditate, pray, or just think
loudly that an amazing Grace settles in-----and those once were blind might
see.
And to the doctor, nurse, counselor, priest, FDA, ANTZ, and
WHO: look beyond the obvious, practice Oslerian and Hippocratic dualism- Primum
non nocere- at first do no harm, at first understand, always seek healthier
methods, accept risk and reduce it, be open, accepting and fear nothing but
your inability to separate your own inbred idealizations from the truth of the
universe. Smoking kills, Chantix kills, and driving kills bot to mention that the
union of the sperm and egg that created you will eventually lead to your death.
As I said to my first interviewer when I applied to Medical
School-when asked what I thought best defined life, I responded- it is a risk
that we each manage every day of our life- but it is also a gift that we must
share with others. The ill we give hope,
the infirm of mind kindness and safety and those who have chosen paths we see
as self-destructive empathy and as we paraphrase Hippocrates- we shall do them
no harm. I would add now that we will
endeavor not to judge them, not to stigmatize them, but to try to encourage a
less harmful way even if it is not perfect.
