Tuesday, September 13, 2016

First Do No Harm

There was recently an article published in a leading newspaper, referring to opioids, entitled "First Do No Harm".  I have discussed is this in the past and may again in the future, however the use of this adage struck me. 

I first heard this adage way back in medical school referring to anaesthesia and the fact that anaesthesia contradicts this principle.

In fact when the urologist discovers after the patient is asleep that the patient passed the stone already or the orthopod after the patient is asleep realizes that maybe he should have examined the patient or at least looked at the X-ray  and all the patient needs is a cast, I reassure them.  "Anaesthesia is good for you", I tell them.  I hope this makes them feel better but  most surgeons have no conscience anyway.

The fact is in medicine that we are constantly exposing patients to harm in the hope that we will make them better.   We are in effect betting the ill effects of a treatment versus the likelihood of helping the patient.

The House of God had it down with rule XIII:


This of course isn't always in the patient's best interest either although is probably in their best interest more often than we think.

For example how often do you hear an doctor justify a procedure or test by saying, "I didn't no what else to do" or "Well I had to do something".  I have been guilty of this back when I was in general practice, in the pain clinic and quite often in anaesthesia when things are going south, how often do we try something random which we know probably won't work.  

Here's some questions to ask yourself.

1.  Based on your assessment is the patient going to die within the next few hours without treatment?
2.  Do you have any idea of what is going on and will either the test you order help make the diagnosis or does the procedure or treatment at least have a reasonable chance of stabilizing things.  

But speaking of aphorisms, what about the Hypocratic Oath.  A patient advocate asked me about this oath a few months ago in connection with an op-ed he was going to write.  

"First", I explained to him, "Many doctors, including me, have never taken the Hypocratic Oath."  Some schools have an elaborate oath taking ceremony.  My school didn't.  Am I a worse doctor for that?  "Secondly, " I went on, "there are multiple versions circulating including a modern version."  
"Thirdly", I pointed out, "Many of the things proscribed in the Hypocratic Oath are actually part of medicine, like cutting for stone, administering noxious substances (chemotherapy, anaesthetics) and abortion (controversial but still part of medicine). ". 

The Hypocratic Oath also has things like treating your teacher(s) for free.  We have socialized medicine in Canada and I work in a city where I didn't train, but that doesn't mean I would be interested in treating pro bono the 100 or so physicians who taught me.

About 20 years ago, I bought a handsomely bound of the "Aphorisms of Hypocrates" which now sits in my bookcase along with some of the other handsomely bound historical books from the same series.  And I read the Aphorisms.  I can tell you that if you practised in the Hypocratic fashion, it is a question of who would get you first, the licensing body or the lawyers.  I often wonder why we place such importance on the thoughts of somebody who practised over 2000 years ago.  I do like reading the history of medicine if only because seeing how wrong prominent physicians were in the past, puts into the context the modern practice of medicine. 

I think we need to spend less time worrying about doing no harm and more time stopping using outdated and irrelevant aphorisms.


Anonymous said...

At first I thought you were making a joke about the "hypocritic" oath. Then I realized you meant hippocratic. I'm slow on the uptake today.

Anonymous said...

At first I thought you were making a joke about the "hypocritic" oath. Then I realized you meant hippocratic. I'm slow on the uptake today.

Old FoolRN said...

These youngsters today certainly do not mind changing the words to important professional statements. Take the Nightengale Pledge which was actually loosely based on tenets of The Hippocratic Oath. There is a line in the pledge about a nurse being loyal to physicians that these smart alecky young nurses have updated to reflect more independent nursing practice. When I worked in the OR I was happy to do whatever I could for the surgeons because my flying hemostat ducking skills were suboptimal. If you disagree with the Hippocratic Oath feel free to update it just like the neophyte nurses did with the Nightengale pledge.

Anonymous said...

I have a question about marijuana. I'm in the US, my state legalized medical marijuana about 3 years ago and they still haven't set up any way to obtain it legally in the state. Their requirements to set up dispensaries are ridiculous compared to other states, it has taken them 3 years to finally approve 15 growers and 15 dispensaries. They just approved them last month, so I presume the dispensaries are breaking ground/signing leases right now. They also ban edibles.

Why would they ban edibles but support smoking, vaporizing, extracts, tinctures, lotions and ointments? Is there something that I'm missing about edibles? I went to Colorado, had a weed vacation and found that edibles were the best thing for my chronic pain, which I have had for 20 years. I'm disappointed that I won't have access to that form of marijuana, especially since I have asthma and the idea of inhaling stuff doesn't sit well with me.

Bleeding Heart said...

If you look down the posts, you will see some of my posts commenting on the process in Canada for Medical Marijuana. Can't really comment on the situation in your state.

Anonymous said...

It's more that I'm curious why would edibles not be allowed? In the states the laws are all over the place, but one constant is that just because they allow smoking or vaporizing, edibles are completely different. I just don't understand why and I can't really find anything regarding it. Some say that the "strengths are not allowed" but edibles are made in a variety of strengths. It's more a question about edibles than it is about laws, and I figured you'd have some experience with edibles as a doctor who prescribes marijuana.

Bleeding Heart said...

Companies in Canada are able to produce oils. A few are doing so and they seem to be very popular if somewhat expensive.