Primum non nocere -First, do no harm. I remember the phrase was used in one of the first lectures I attended in medical school and it nested -sometimes uncomfortably- in my conscience as the lectures and the years progressed. It would signal me from the back seat in Pharmacology lectures and tug on my sleeve in Physiology labs when we would be asked to subject laboratory rats to unconscionable ‘experiments’ whose outcome was already known and whose purpose would have been questionable even had we been seeking a Nobel Prize rather than a passing grade.
It especially fought for my attention after I’d graduated, when my decisions would actually be accorded credence. I would be asked to see someone in pain -with endometriosis, say- who had decided she’d had enough and wanted a hysterectomy. Often she would have been aware of other options -medications or ablative surgeries- and have tried them all unsuccessfully; sometimes she might be speaking out of frustration or desperation. But in none of these situations would she have felt in control, a full and willing participant in her destiny, able to make a reasoned, or at least equitable decision for herself.
One might argue the role of the dispassionate physician here: the person who can consider the ramifications of each option, present them in a reasonable and sensitive fashion, and help the patient decide. And yet, one might also point out the possibility that the patient might be unable to make a truly informed decision for herself under duress. There’s a term used in Medical Ethics that we were also taught in medical school: non maleficence. This is a concept that suggests that it is important -no, necessary– to consider whether a particular decision might do more harm than good, no matter how well-intentioned. It is yet another version of the primum non nocere phrase that so influenced me.
If I feel the patient actually understands the ramifications of her decision, and has at least considered and then rejected other possible pathways, then I am more than willing to accede to her request and help in whatever way she feels would be in her best interest.
But I have always believed that informed, or at least insightful empowerment -if I dare use that overworked and voguish neologism- is the key to compassionate decision-making. It’s object is not so much to convince or direct, as to allow her to come to an appropriate and acceptable decision, as much as possible unencumbered by all the trappings and emotional accoutrements of pain and frustration… As I have already mentioned, the problem of counselling someone in dire straits is that her pain or anxiety, quite apart from its obvious distraction, often permeates her entire being and impedes her ability to look out for her own ultimate best interest. Sometimes, the person can hear nothing but her own suffering. Counsel has to be heard as well as given.
I’ve explored many techniques to help the person help herself: meditation, relaxing exercises, music… But apart from the latter, they do not lend themselves readily to a half-hour appointment in a busy gynaecological office. And although music is my constant companion through the day, it is often background noise, if heard at all, for the patient stressed by more immediate problems. Most are unwilling, or more likely, unable to believe that meditation or relaxing exercise, will contribute anything to the resolution of their particular issues. It is difficult for them to see through the fog of their distress, and in many circumstances they do not need to do so.
If the problem does not admit of any other solution, then action of some sort is required. If the patient has a ruptured ectopic pregnancy and shows up in the Emergency Department, the solution is obvious and immediate. If she is hemorrhaging from a miscarriage, an explanation of a reasonable approach to the problem and then a D&C is appropriate.
I am not so concerned about the conditions that do not beg for a decision, or ones that cannot be resolved in any other way -conditions for which choice is mandated by necessity. But for those afflictions for which options are available and for which none are paramount, there should be other constraints to the decisions made. These are questions of ethics again: autonomy -the patient has a right (and indeed a duty) to decide for herself, and beneficence –the doctor should act in the best interests of the patient. And sometimes this requires techniques to enable the patient to exercise this right, and the doctor to feel he is in fact acting in her best interests.
Hypnosis is one approach to this that lends itself to an office setting. It is not for everybody, nor is it necessarily attainable in each and every patient, however willing. But I feel that in my office at least, it should be a non-directional tool if it is used at all -one that seeks not to influence or counsel, but merely to engender some symptomatic relief. It is an easily teachable skill, and because the relaxation is so readily apparent to her once she has encountered it, probably an effective one that she may well decide to try again. And with some goal-direction.
I am reminded, however, of the time when I initially began to use the technique. I seemed to attract rather unfortunate referrals then. At first the referrals were for innocent things: stress relief, panic attacks… even smoking. I had to quickly disavow myself of these consultations: although gynaecology entails a lot of psychology, I don’t see myself as the answer to panic attacks.
Then, undiscouraged, they began to send me more difficult problems: warts (yes there exists a body of literature of immune enhancement to engender a bodily response to the viral scourge of warts, et alia), endometriosis, PMS… anything for which the family doctor felt she was losing the confidence of her patient.
I have always felt more comfortable dealing with topics for which I am nominally trained, so I attacked the gynaecological issues with contemporary skill and knowledge. Only on the third or fourth visit and when all else seemed to have failed would I delve into the alternative toolbox in desperation. Sometimes it worked; often it helped. Visualization was especially popular I remember. Endometriosis? Right: visualize a field of flowers and with each breath in, you pick some, and with every breath out, you throw them away. Yes, the flowers are endometriosis implants.
When planetary eco-consciousness took hold, I had to modify the picture, however and switched it to picking up litter on the street then depositing it in a suitable refuse container… Anyway, same idea, same results if they remained enthusiastic adherents. Placebo? I don’t know, but even placebo works for a while, doesn’t it?
The problems worsened from the die-hard family doctors, however. Elated by the success of diverting their problems to me I began to get referrals that really made no sense. One that stands out particularly colourfully in my mind was the woman who was sent to me because she was anxious.
At first I assumed there was a gynaecological reason for the visit, but she quickly informed me that she was actually healthy: normal non-painful periods, no mood swings, no pelvic pain… Her pap smears were even normal and up to date, and she’d just had a mammogram.
I was beginning to despair of helping her when she admitted the reason for her visit: she was running for public office in the Philippines and was anxious about getting up in front of a crowd and speaking. She’d heard about hypnosis and wanted to try it. Although a little out of my line of work, I thought maybe I’d try a little standard hypnosis to alleviate her anxiety since she was in the office anyway.
She looked relieved and smiled at me. “Thank you doctor,” she said relaxing in her chair. “I’ve tried everything I could think of -even tranquilizers- but I’m still terrified each time I get up there to speak.”
Although I sometimes try to explore the reasons under hypnosis and help the patient to recognize what might reasonably be expected to work for them, I decided to ask her beforehand if there was anything in particular that worried her about speaking in front of an audience.
She didn’t give it a moment’s thought. “Oh yes, doctor. It’s in the Philippines, you know…”
I nodded pleasantly, and assumed perhaps the venue, or maybe heckling from the crowd was her concern.
“And there’s a lot of opposition to my stance on Birth Control, you know.”
I assured her we run into the same thing on occasion even here. “Sometimes it’s hard taking a stand on something isn’t it? You can never please everybody, can you?” It was so banal a comment I immediately regretted saying it, but she seemed to take some solace from my words.
“No you can’t please everybody, it’s true. And I’m glad you understand; that’s exactly where my problem lies. It’s why I want you to teach me hypnosis.”
I smiled the doctor smile, satisfied, benevolent, convinced that I was perceptive and could recognize her difficulty despite our difference in cultures and gender. I could help.
“Yes,” she continued, ” Every time I get up to speak in front of a new crowd in a strange village I’m afraid I’m going to get shot.”
I believe in counselling and I try to take the time to listen for what they sometimes cannot verbalize. I like to believe I can make a difference, but I don’t think I really helped her, you know… Maybe I should have referred her to someone else, but she left the office happy. Beneficence sometimes trumps non-maleficence, I guess -even if it’s only in the beholder’s eyes.