Are Doctors Truly Able to 'Do No Harm'?

Doctors are people too. This doesn’t get said enough. Just like everybody else they make mistakes, but despite that they spend their entire lives learning how to avoid these mistakes and being as careful and meticulous as possible. The Hippocratic Oath which all doctors take during graduation makes them vow to do no harm. It’s why doctors spend years in training that costs a lot of money. A mistake from a doctor can cost a life or a permanent disability. Even after graduating and becoming residents doctors are still supervised by attendings to make sure they don’t make any mistakes out of a lack of experience. It’s also why vital specialties such as surgery and cardiology are very difficult to get into.

When we think of mistakes made by doctors we always think of medical mistakes. You think what if he or she can’t diagnose or treat me properly. A lot of us, however; don’t consider another kind of harm that doctors can inflict upon patients mostly unintentionally. What I’m talking about here is financial harm. Perhaps you don’t really consider this if you have great insurance that covers everything so you’re not the one paying out of your own pocket. If you don’t have good insurance coverage however, then you’re probably someone who suffers from this especially considering how expensive healthcare is. The list includes unnecessary investigations, procedures, and simply doctors who aren’t really sure what they’re doing.

First let’s take a condition everyone is familiar with: ischaemic heart disease. Almost every single family has at least one person who suffers from coronary heart disease. There are a few ways someone with coronary heart disease may be exposed to financial harm. For starters if someone comes in with a suspected heart attack what investigations does a doctor order? An EKG would be very suitable as well as one or two cardiac enzymes. For instance if the patient has had the chest pain for only 3 hours which cardiac enzymes will a physician order? Certainly ordering all of them would be a huge mistake. A lot of cardiac enzymes start to rise after 6 hours so in someone who has had the condition for 3 hours they wouldn’t be elevated and ordering them would be a waste of resources. In this scenario the best choice would be myoglobin which rises after just 2 hours and is considered very sensitive meaning that if it’s negative it can rule out a myocardial infarction.

In patients with stable coronary heart disease some doctors may advise them to insert a stent. A stent is simply inserted into a coronary artery in order to keep it patent. Studies, however; have shown that inserting a stent in someone with stable coronary heart disease has no role and will not improve their chances of survival or decrease the risk of mortality. So what’s the point of the procedure? Theoretically it seems like a good idea to insert a stent but it’s important to see what studies have to say in order to prevent patients from paying unnecessary expenses.

Another example would be someone coming in complaining of chest pain, coughing up of blood, and shortness of breath. You’ve ruled out a heart problem and the primary suspect is the pulmonary system. Of course two of the most serious conditions that cause acute chest pain and shortness of breath due to a lung disease are pneumothorax and pulmonary embolism. A pneumothorax could be ruled out by an xray which is fairly cheap. What about a pulmonary embolism? The best and most specific test would be CT pulmonary angiography. CT scans aren’t cheap, so should they always be done considering they’re the most accurate? The answer is no. First of all there are a number of risk factors to be taken into consideration. Based on these a patient will either be classified as less or more likely to have a pulmonary embolism. In patients with a high risk then money is not a main concern and the best thing to do would be the CT. However, in those with a low risk then it’s better to start with a D-dimer test which is cheaper and can safely rule out a pulmonary embolism in someone who doesn’t have the risk factors that make them highly suspicious cases.

Back pain is one of the major complaints people go to doctors for. It’s hard to find someone who has never suffered from back pain at one point or another. A lot of physicians take the easy way and order MRIs for their patients. An MRI is definitely the best option and would give all the necessary information about a certain region in the back, but it’s not necessary. An MRI should only be ordered if there are neurological symptoms along with the back pain. These symptoms include numbness and tingling, weakness in the limbs, and bladder/bowel control problems. To ask so many patients for an MRI is a massive waste of resources considering most of them don’t have neurological issues and are mostly suffering from a muscle strain which is extremely easy to treat.

Another example of an erroneous use of MRIs is for the thyroid gland. If your doctor sees that you need to perform imaging on your thyroid gland in order to acquire more information the best choice would be an ultrasound. An MRI has no additional benefit to an ultrasound. It’s also bizarre to ask for an ultrasound then afterwards an MRI. At the very least only perform one of them.

These were all examples of expensive investigations but there’s expensive treatment as well. If a patient with a thyroid lump undergoes a surgery only for the surgeon to not end up removing the lump then how is that doing no harm? The surgery will cost the patient a lot of money in addition to the stress a person feels when it comes to surgery and all for nothing. The surgeon didn’t do their job by removing the lump.

Another example is a patient complaining of GI problems and having an ultrasound that revealed gall stones. So naturally the surgeon removes the stones from the gall bladder only for the symptoms to persist. In this case the gall stones were an incidental finding which means they just happened to be there but did not cause any symptoms or problems for the patient. The real culprit is a functional bowel disease such as irritable bowel syndrome which is a common condition that lots of people suffer from. So it’s important to take all things into consideration before rushing into surgery that does not help the patient, but may actually hurt them.

Medical treatment can also be too expensive for some patients. If there are different drugs to treat the same condition then it’s important for a doctor to be clever enough to choose the drug that fits the patient’s financial status but is still effective and will improve their condition. This may apply for oral anticoagulants for example which have a range of prices. The more expensive ones for instance may not be covered by a person’s insurance so it’ll be necessary to use the cheaper ones that are covered. This will also be influenced by how long the patient will take the drug because it may be okay to prescribe an expensive drug once, but it wouldn’t be wise to prescribe expensive drugs for a chronic condition.

Keeping the patient’s best financial interests in mind is not the primary goal of a doctor but it should still be a priority. You need to consider the patient’s condition and keep it in mind while creating a management plan for them. Admittedly this is not easy to do, but with the correct medical knowledge and experience on the long run it is achievable to do no harm.