That Latin maxim roughly translated as “above all, do no harm” is a key element of the Hippocratic Oath.
One of the foundational elements of medical ethics is non-maleficence, the notion that when treating a patient, it may be preferable to not do something, or even do nothing at all, if the intervention risks causing more harm than good.
Yet, in our modern era, with its dizzying technological innovation, ready access to a cornucopia of drugs and impatience driven by the jolts-per-minute pace of daily life, the guiding maxim has become: “Do something. Do anything.”
You see it every day in medical practice. No one wants to leave a physician’s office without a prescription or a high-tech test. Everybody wants to be screened so they can nip cancer in the bud or catch Alzheimer’s early, even when this information can do more harm than good.
The Nike “Just do it” and the consumerist philosophy that more is always better may carry the day on TV dramas such as House, but it has no place in real-life medicine. Acting swiftly and firmly may provide succour, at least temporarily, but every action has an equal and often greater reaction.
We seem – in medicine as in life – to have lost the precious ability to ponder. To wait. To utter the three magic words “I don’t know.” To wisely do nothing until we do know more, or until nature takes its course.
The result is an epidemic of overtreatment that is both financially costly and physically harmful.
The reality was exposed in a sobering book by journalist Shannon Brownlee entitled Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.
The issue has also been taken up in a couple of recent U.S. reports.
In May, the Good Stewardship Working Group – physicians who believe good care can be delivered cost-effectively – published a list of commonly used tests and treatments that are unnecessary.
Then, early this month, a group of academics costed out the savings that would come from eliminating a dozen wasteful interventions – a whopping $6.8-billion a year in the U.S.– and published their results in the Archives of Internal Medicine.
Health-care costs are not on the rise because physicians are going around doing unnecessary heart transplants. Rather, it is the routine use of banal – and generally useless – tests that is costing us all a bundle.
The researchers found, for example, that blood, urine and electrocardiogram tests are routinely ordered for patients with no related symptoms or risk factors. These are too often done merely to give a patient the sense that the doctor is “doing something.”
Among the most frequently inappropriate practiceswere those that involved children with minor ailments: Writing antibiotics prescriptions for children with sore throats who didn’t havestrep infection; recommending unnecessary cough syrup for children with upper respiratory infections, and ordering imaging tests such as CT scans for kids with minor head injuries (those that did not involve dizziness or loss of consciousness). Again, there are real negative consequences to this kind of overtreatment, including fuelling antibiotic resistance and exposing them to potentially harmful radiation.
In Canada, we like to pretend that overtreatment is a problem unique to the profit-driven U.S. system, but we have many of the same problems. They are driven by culture more than by greed.
It’s worth noting that the Good Stewardship Working Group focused strictly on the blatantly wasteful.
It deliberately avoided tackling more controversial issues such as PSA testing for prostate cancer and mass screening of young women for breast cancer. In those cases, the admonition is not for doctors to do nothing, but rather to be more targeted in their interventions. For some young women – those with several risk factors – early screening is appropriate. And for some men, the PSA test can be useful, as can surgery and/or radiation.
But watchful waiting also has its place. While that terminology is just coming into vogue, there is a more long-standing term, clinical inertia, though it seems to have more negative connotations.
For example, clinical inertia means having a patient with mildly elevated blood pressure or high cholesterol and deciding to not prescribe a drug. Instead, the doctor might encourage him to take a brisk walk each day or lose a few pounds, approaches that would be as effective as drugs and have no negative side effects.
There was a time, not so long ago, when health professionals used this approach much more commonly, rather than immediately reaching for the prescription pad or the diagnostic test. Yet, over time, physicians have been trained increasingly to become technicians, and overly dependent on technology.
Medicine is a science, but it is also an art. At its heart should be the art of listening, and the recognition that not acting is as important as acting.
In the seminal work of satire The House of God, author Samuel Shem provided a list of commandments for good medical care. The infamous 13th Law of the House of God was: “The delivery of good medical care is to do as much nothing as possible.”
Yet, since the book’s publication in 1978, overtreatment has reached such tragicomic proportions that the satire has melted away, leaving only age-old wisdom.
It’s as if we have come full circle back to Hippocrates, who said: “To do nothing is sometimes a good remedy.”