primum non nocere

Standard

“First do no harm.”

As of late I am starting to think this phrase is more befitting of homeopaths than doctors. After all, medically, homeopaths don’t do any harm, their ‘treatments” actually don’t do shit.

Of course, over the last year, it has been my observations most doctors don’t do shit either. As such, I think a new mindset and slogan is in order.

When this phrase was originally spoken as a value of doctors, medicine was in its infancy. Most of the disease processes and sicknesses people were afflicted with were poorly understood. Even the basic knowledge of how the human body worked when healthy was largely incomplete. Treatments, both surgical and medicinal were just as, if not more likely, to physically harm or kill you than the disease. The warning was clear, do not be quick to apply medicine to a patient, because it is likely to do more harm than good.

However, that dogma has persisted to the modern era. Medicine has changed considerably. In fact, it is barely recognizable as the same thing it was in its early days. Most medicine and surgery actually helps more than it does not. Scientific testing, retesting, and even moral and ethical issues have to be addressed before any medicine, surgery, or medical device is permitted to be used. Admittedly, there are some shortcomings of both science and how easily scientific methodology applies to medicine, but by far it is an outstanding tool. It is definitely the best tool we have.

Medicine has long been described as both a science and an art. Certainly I do not dispute that. In fact, I actually consider myself more of an artist than a scientist. That probably sounds rather strange coming from somebody who has a piece of paper demonstrating I am a scientist, but I do not have a paper attesting to my ability as an artist. I should probably explain this dichotomy.

In my younger days, I was involved with performing arts of various disciplines. In performing arts there are basically 2 types of artists; those with raw talent who do not commit to studying their art and just “perform” and those who are “trained” in their respective arts at academies. Whether it is music theory, dance techniques, drama techniques, etc., they are all based in exacting scientific and mathematic concepts. This “science” of performance is studied by the second type of artist in what is known as “classical training.” It is probably called “classical” because the types of performance, such as symphony, ballet, Shakespearean theatre, etc. are rather conservative and seemingly rigidly basic compared to more modern forms of expression. However, it is well known within the artistic circles and evident by more than a few successful and popular performers, that an artist with raw talent usually has fewer employment prospects or ability to make a living in the arts. This is mostly because while they are quite specialized in a narrow range, they lack the basic foundations to move out of that range. Some of you may be thinking right about now, that sounds an awful lot like medicine… Because it is.

Medicine is not really “an art and science”, as many would like to believe. Medicine is wholly an art. If you think about it, you can see where there may be some confusion. After all, many doctors are involved in science and constantly doing clinical studies. They like to create guidelines and justify their actions both legally and for pay using these “scientific” studies. However, despite an introduction to the scientific method, statistics, and other parts of science in professional education, they are not required to perform independent research or write and defend a dissertation as scientists are. Historically, biomedical research and medical practice were undertaken by 2 entirely different groups. Medical science was for all intents and purposes a collection of observations by clinicians. In the modern age, this “clinical science” as we call it, is scrutinized by various statistical models in order to lend credibility to it, and very deftly reclassify it (aka rename it) as something other than a collection of anecdotes.

The role of the physician or “doctor” (I am just going to stick with “doctor”, for no other reason than I like that term better) is to attempt to apply scientific knowledge in a practical way for the purpose of preventing, treating, palliating, and investigating disease. This is what is professed and taught in medical school. After medical school, during “residency training,” basic scientific knowledge is slightly expanded upon and a set of behaviors and some psychomotor skills are imparted upon residents that define them as a specialist in a given field. In my observation, it is actually a step backwards rather than forwards because in practicality, it limits responsibility and therefore knowledge rather than expanding upon it.

The very practice of residency is not historic to doctors. It is actually a practice of non-physician surgeons that was adopted by doctors in order to get surgeons to accept formal medical training in medical school. This further demonstrates the case that residency is in fact, not advanced knowledge, but specifically limited knowledge. Doctors like to defend this practice by claiming there is so much to medicine, no one doctor can be good at all of it. This I find extremely suspect since all medical school students are expected to have knowledge and skills in every major medical discipline, where post resident specialists are not.

The role of the scientist is quite different from a doctor. This is the person undertaking the role of advancing knowledge using the scientific method and mathematics. Because of the vastness of modern knowledge, scientists have to be specialized in various disciplines in order to achieve the required level of knowledge in order to discover more. There was a time and exact citations of individuals mastering all of human knowledge. It has been a few hundred years since the last of them. However, unlike doctors, scientists are not subject to much variability in their professional endeavors.

Many times I am asked by colleagues, how a person goes from being a firefighter to a paramedic to a doctor and even a scientist. I would like to think from my personal standpoint it is something like being a renaissance man. But despite both my artistic and professional accomplishments, I don’t think it is fair or accurate to say I have achieved such greatness yet. What I often say is that my role has actually never changed. I have always been the one to help people. My cloths (uniforms) change. The tools I use at a given moment change. The skills and knowledge I need to use those tools change. My experience is continuous. From the point of view of helping people, I have not changed at all; I have simply added more ways to do it to my repertoire. My pursuit of knowledge through science is in essence the classical training I have learned and use in order to best perform my art.

I am sure many doctors who have not also undergone advanced education in science would like to think they are just as capable as those who have, but I would simply compare it to my discussion of talented and narrow based performance vs. the classically trained artist above. I suspect if you ask many doctors who are also scientists, they would agree with my assessment. (I wonder if I will see as many “not me I am the exception!” comments from doctors as I get from paramedics?)

But what does any of this have to do with doing no harm?

Doctors harm people. I have observed that the hyperspecialization of medicine leads to patients seeking help from doctors who either do nothing for them and send them to another doctor, or guess at what the likely diagnosis could be and use the most minimal treatment, forcing the patient to endure extended courses of disease, loss of work and quality life, and in some areas, increased economic costs. Often far beyond what the treatment they received prevented loss of.

Given that is basically the exact same thing achieved by homeopaths, right down to demanding payment for it, I think what needs to happen is to set doctors apart from homeopaths by adopting a new philosophy.

Primum succurrere

“First hasten to help”

This sounds more like it befits a firefighter than a medical doctor. But where do people turn to when they really need medical help? The emergency department. It is open 24/7/365. No appointment necessary. No formal dress required. All comers taken. In places where point of service fees are required, emergency sends the bill after, payment upfront is not mandatory. Whether payment comes direct from a patient or a system, the doctors in the emergency department are the 1 stop shop to diagnose your problem, take care of your problem and send you on your way (Treat and street), or send you directly to the specialist that can help you. The hospital usually has everything from X-rays, to CT scans, a lab operating 24/7 to a host of specialized consultants. The emergency department answers the most pressing of all patient questions. “How bad am I now?” In today’s world, unlike in my childhood, patients probably don’t even have a regular primary care provider. They go to whichever one can get them an appointment the fastest when they are sick. Primary care as a medical specialty is obsolete. Nobody needs to make an appointment a month from now to get help for basic ailments like strep infections, yeast infections, Urinary tract infections, or even to find out “how bad they are.” Parents don’t want or have the luxury of skipping multiple days of work to find out how sick their kid is or if they can go to school or not. Parents don’t want to see their kid suffering for days, weeks, or months to get an appointment. Plus most primary care providers will either start with a pitiful underpowered treatment based on a guideline for initial presentation, at no point taking into account the time of initial presentation of the disease is different than initial presentation to the appointment, which will not help, and force prolonged sickness, more doctor visits, etc. or they will collect a middleman fee and send you on to a specialist. (This middleman fee is even worse in single-payer system countries, because it is the epitome of being paid for doing nothing, in fact practitioners should probably face criminal charges of extortion)

Many emergency providers become frustrated with the fact they are the primary care provider for most patients they see. They didn’t sign up to be in primary care. Much of their specialization revolves around cases that are a minority of what they do see. What is more, even when they want to help, they do not always have the organizational support or resources to help even when those resources are simply on the other side of a door in their building. The Emergency Department is the modern version of primary care by necessity and function.

Even most specialists outside of primary care, working 9-1500 or less do not meet the needs of patients. An excellent example of specialists who recognized they are primary care providers as well are OB/Gyns. They have identified, accepted, and adopted the role of being not only the primary care provider for their female patients, but all; the point of first resort for the male partners of female patients! We all know in the modern western world, a man is motivated to go to the doctor for 2 reasons. 1. He cannot tough it out anymore and 2. Because his wife, girlfriend, mother, sister, aunt, etc. forced him to go. OB/Gyns are both personally and via their professional bodies stepping up to the challenges of the modern day. Why aren’t the others?

This applies both ways. Traditional medics (nonsurgical physicians) can expect to have to actually perform minor surgical procedures they learned in medical school. They should expect to have the basic equipment needed on hand. Doing something like prescribing an antibiotic and then referring somebody to a surgeon for wound care is completely a waste of money, everyone’s time (including the surgeons’) and doesn’t actually help the patient. In fact, as described initially here, it harms the patient in multiple ways. Surgeons should likewise need to recognize when patients under their care or consultation have minor medical problems (like skin infections, upper respiratory infections, etc.) and take care of them without referral or as I have seen, completely ignoring them.

The other day I broke character and attempted to demonstrate to some asinine anti-vaccer vaccines don’t actually harm. I shouldn’t have done it. I know you cannot convince the crazy to be sane with logical argument. I know you cannot possibly convert the beliefs of a true believer. It was a foolish waste of my time to try. But I bring it up because this psychopath did remind me of something I had not thought about in a while. He asked me what kind of doctor I am.

When I was growing up, my family doctor was Dr. Kolliker. I don’t know his first name. He liked to be called “doc.” His office was cool. In the waiting room he had a collection (that would make any museum jealous) of antique medical texts, pharmaceuticals, and medical equipment. Whatever your problem was, doc would take care of it, often preemptively for the whole family. “Here is a prescription for you, and one for the sibling you share a room with so when she starts getting symptoms in a few days, you don’t have to come back.” “By the way, here is a prescription for your acne too,” and when mom wasn’t looking a handful of condoms. (which I must admit never did me any good, but some friends had appreciated them) When we were sick in the middle of the night we didn’t go to the emergency room. Whether it was mom or dad or us kids, we called doc. At home. His patients had his number. No answering service, when the call was answered, it was doc. (in fairness sometimes you had to call a couple of times before he answered) His solution? “Meet me at my office.” (at 0 dark 30, not tomorrow, next week, next month.) Not only could he do everything, from stitches to prenatal care, you could ask him anything; about anything. Usually he knew, and if not, he simply said he didn’t. While he did refer to specialists on the rare event he felt help beyond him was needed, only one time did he send a family member to the emergency room and not until after we went to his office.

What kind of doctor was Dr. Kolliker? The doctor kind; the type who you went to when you needed help, large or small, night or day. I would say he was a great doctor. While I see my exact future role as being different than his, I think every doctor needs to be the doctor kind. Not like homeopaths, who “do no harm.” Like firemen, who “hasten to help;” Classically trained, knowledgeable, available, capable, accurate and precise, and above all dependable and decisive.

 

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