DO NO HARM

One of the most important tenets in medicine is, “Do no harm;” yet all docs realize that everything they do carries the risk of causing harm. The disconnect between the commandment, “Do no harm,” and the realization that we are always at risk of doing harm is a major cause of physicians’ daily stress and has a tremendous effect on how physicians practice medicine.

Some physicians will take a strong defensive attitude in response to their duty to do no harm.  Defending against doing harm, of being accused of harm (malpractice), often leads to a form of medical care called CYA (cover your ass) which can lead to over ordering referrals and tests, as well as under or over ordering of medications.

Others realize that there is a risk-benefit ratio for everything we do in life and become comfortable with the necessity of taking and monitoring risk while working to eradicate or alleviate suffering.  Organized medicine’s approach to solving this dilemma is to rest on the shoulders of “Informed Consent,” a document designed to spell out the risks and benefits of procedures and signed by the patient verifying that he/she has read it an understands.  Every physician eventually figures out how to live with the risk of doing harm it.

Early in my practice, I was sued by a patient I had never seen and had no relationship with.  Sounds unbelievable, doesn’t it?  That suit taught me that worrying about lawsuits and practicing CYA does no good.  I accepted the risk of practicing medicine and mitigated that risk by partnering with my patients, providing with a realistic and practical approach to caring for them.

An example will help clarify my point.  Steroids are marvelous medications effective in the treatment of many diseases.  Steroids also have the potential of causing lots of harm.  While the risk of causing diabetes is real, it is theoretical until diabetes develops and that is fairly rare.

Currently, I am on prednisone (a steroid) and I am much improved.  I probably have PMR (polymyalgia rheumatica), a disease that responds well to the long-term use of steroids.  I am so much improved that I would call my improvement miraculous.  PMR is a tough disease to diagnose but one of the diagnostic tests for PMR is to see what the effect of a low dose of prednisone is.  Again, mine is dramatic.

As I mentioned previously, the long-term risks of prednisone are many.  I’m obese, have a family history of diabetes, and at risk of developing diabetes.  Prednisone will increase that risk. I have mild hypertension.  Prednisone can adversely affect BP.  The list of risks that apply to my health is long.

Most physicians would be afraid to give me long-term prednisone for fear of causing me harm.  They shouldn’t be!  What is real is that I have Parkinson’s, chronic pain and a highly significant disability that responds well to prednisone.  What’s real is my life is much better on prednisone.

Possible side effects or harm from steroids are theoretical.  They aren’t real until they develop, and they may never develop.  As I previously stated, I partnered with my patients.  Ultimately, my patients made the decision of how much risk they were willing to accept.  Frankly, if I knew for sure that prednisone would shorten my life, I would opt to live a shorter but less painful and more mobile life.  Age has a lot to do with the decision.  At my age, I’m looking for quality, not quantity.

Too often, having heard the risks of a medicine on televised advertisements and on the internet, patients refused appropriate treatments out of fear.  They chose to live in misery now for fear of theoretical future problems.  What a pity!

Here’re a few jokes for today:

A mother complained to her consultant about her daughter’s strange eating habits.

–”All day long she lies in bed and eats yeast and car wax. What will happen to her?”

–”Eventually,” said the consultant, “she will rise and shine.”

Docs often write funny things in charts by mistake.  The following is one of my favorites: While in ER, Eva was examined, x-rated and sent home.

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