The Uber-obvious in Medicine


I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! http://www.cbc.ca/news/canada/montreal/quebec-doctors-can-now-prescribe-exercise-1.3215821 And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”

 

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