First Do No Harm

Institutional, organized American medicine has become a craven shadow of its former self. It was not long ago that the day-to-day practice of medicine reflected the science of
the day in as accurate a way as humanly possible. The practice was flawed because the understanding of fundamental biology was flawed. Still the practice and the science were tightly linked.

I must admit that the underlying science of medicine, the understanding of the biology of human health and disease, is now much greater. Brilliant gains in almost every area of biochemistry, physiology, micro-anatomy and physiology have enriched mankind’s knowledge of human biology.

Oddly, during this same time a concerted effort has been under way to limit the physician’s use and understanding of that science in one’s day-to-day practice. Doctors in training are taught the practice of medicine devoid of any analytical skills; they are taught instead how to follow simplistic decision-tree, algorithmic approaches to most disease. This is done in the guise of those very gains in fundamental knowledge; ‘we know so much now all you have to do is follow this treatment protocol.’  This line of thinking leads to a pharmacy only approach to disease.

Another aspect of the constraints placed on the practice of medicine is concerns about cost. This plays out as an effort to limit testing. The medical literature has more articles about the misuse of tests and the cost and frequency of unneeded tests than ones describing which new tests to use and in what way to advance diagnostic accuracy. But this apparent attempt at frugality in fault finding about the cost of over testing is actually another smokescreen for constraining the practice of medicine within somehow politically accepted channels of practice. For example: if you have chest pain a group of doctors can spend/charge almost any amount performing catheterizations, stint placements, prescribing very expensive medications and scheduling a veritable smorgasbord of physician, nurse practitioner and nursing related appointments and follow up tests. Almost no one will try to stop this or even limit it. However, try to spend a few hundred dollars to find such problems before they become life threatening and your doctor is vilified by insurance companies and professional associations as an enemy of the people.

Research is needed to clarify the boundaries of preventive testing but any honest review of the medical literature will turn up poorly grounded ‘statistics’ that show such testing is no better than just treating all patients by the same algorithms and pre-emptively placing them on the approved medications; whether or not they need them.

Until such time as American institutional medicine returns to its Hippocratic roots of ‘first do no harm’ which can only be accomplished with as much information and science as is available, will it be safe to just follow your doctor’s advice. Until then be your own advocate. Get as many tests as you can reasonably afford and work with a physician who respects you enough to engage your arguments, reservations and concerns.