'Medical Principles: Part 3'

CAERS SUBSTACK ARTICLE #54

‘Medical Principles: Part 3’

CAERS Substack Article #54

In my last article I discussed tests. Another way of looking at tests is that some reveal structure and some reveal function. An ultrasound of your thyroid looks at its structure, whereas a blood test measures its function. Some tests manage to do both, but many do not. And sometimes a part of your body can appear to have a normal structure but function abnormally, and vice versa. Someone who suffers from ‘Irritable Bowel Syndrome’ (IBS) will have a bowel that looks normal but functions abnormally, being prone to spasms, etc. Livers can look abnormal on ultrasound with benign hemangiomas and adenomas but function perfectly normally. The structure that we see with the naked eye, referred to as macroscopic, does not always inform us completely about what is happening at a microscopic, functional level which involves a large biochemical component within each cell.

In fact, the specialities in medicine are divided into two broad categories: medical (functional) and surgical (structural). The medical disciplines, such as endocrinology and cardiology, primarily use medications that alter function; the surgical ones use physical tools like scalpels that alter structure, although again there is considerable overlap.

Whenever we contemplate any type of treatment for a patient, we consider several things. First, what are the indications for the use of this treatment? A drug that is only good for controlling an abnormal heart rhythm, for example, will not help other heart problems; it has only one indication. However, there are drugs that have many indications; they can be used for a wide variety of ailments. Next, we look for contra-indications: situations in which we should NOT use a treatment. There are absolute contra-indications when we should NEVER use the treatment (such as allergy), and relative ones (such as high blood pressure), when we might use it only in exceptional circumstances. Third, we check for warnings: settings in which we can use the drug but we have to be more careful, for example, in someone with liver or kidney disease in whom we must reduce the dose of the drug. And finally, we check for adverse effects that might influence the decision to use a therapy. A treatment that has common adverse effects of diarrhea or constipation may not be dangerous but can be very unpleasant for someone who already suffers from IBS.

Every time we use a treatment, be it a medical one or a surgical one, we must consider all four of these: indications, contra-indications, warnings and adverse effects because every treatment has all of them. No exceptions. And as I have said before, the more powerful the treatment and the more serious the condition it is trying to improve, the more risks there are in general. With greater power comes greater responsibility to use it wisely. Nuclear fuel is more dangerous than a match.

Because none of us, including doctors, has a crystal ball, and because we are not all identical, it is important that we continue to monitor someone once treatment has started and often even after it has ended. It is always gratifying to see someone improve with our treatment, but we must keep an open mind about the unfortunate reality that even highly successful treatments can produce some harm. The benefit may greatly outweigh the harm, but if we don’t look for the harm, we could easily miss it. We learn early in medical school: Never say never!

Part of this is because every treatment interacts differently with each unique person in a complex and not always predictable way. There is nothing fundamentally ‘bad’ about gluten, unless you are intolerant; the same holds true for treatments. Which means that when we encounter a patient with new symptoms, and they have recently received a new treatment for some other medical problem, we must consider the possibility that those new symptoms could relate to that treatment. No matter how safe and effective any treatment may be, we should always consider an adverse effect from it in the differential diagnosis of new symptoms.

Treatments are tricky things, so we must always maintain some caution and monitor them closely. The purpose of medical practice is to improve the quality and/or quantity of patients’ lives, but we must never forget the dictum: primum non nocere, above all do no harm. Iatrogenic disease is harm that results from our treatments (from the Greek ‘iatro’, meaning physician, and ‘genic’, meaning cause), and it is more common than we would like to admit.

Compassion urges us to help others who are in pain or who are suffering, and despite our many shortcomings as a species, humans are unsurpassed in this capacity. But we should always remember that our understanding of medical science is incomplete, we are prone to error and we cannot predict the future. For these reasons, the most important lesson I learned from studying ethics is this: good people doing what appear to be good things with good intentions can still do harm even though that is not their goal.

The same is true for every intervention used during the pandemic: they all have the potential to produce harm. The moment we forget this is the moment when it is most likely to happen. Are you aware of any harm to you or those you love from the various pandemic measures? If so, do you think it would be a good idea to reflect on what has transpired over the last three years, just in case, and correct that harm if we can?

My next article will explore ways that we can minimize doing harm, rules of thumb that come in handy when we feel under pressure to act but need to tread carefully.

J. Barry Engelhardt MD (retired) MHSc (bioethics)

CAERS Health Intake Facilitator