Wednesday, February 18, 2015

The Nutrition Debate #289: Physician: “First, do no harm” (Primum, non nocere)

This aphorism, commonly and apparently erroneously considered to be a part of the Hippocratic Oath, is nevertheless attributed to Hippocrates (Epidemics, Bk. 1 Sect XI, according to PiedType). And “While there is currently no legal obligation for medical students to swear an oath upon graduating, 98% of American medical students swear some form of oath,” Wikipedia says, and a modified Hippocratic Oath was the most common, according to a 1998 survey of Medical Schools.
“Physician, first do no harm,” is nevertheless, “One of the fundamental principles of medicine according to which the physician should not cause harm to the patient” (Mosby's Medical Dictionary). Regardless of the oath taken (or not taken), it is the moral obligation of the physician to do “the right thing” by his or her patient. Who could disagree with that?
It is therefore all the more interesting that in the original oath (as translated in the Wiki citation above), Hippocrates pledges, “With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.” And it was, after all, Hippocrates, the father of Western medicine, who said, “Let food be thy medicine and medicine be thy food.” I first cited this in “The Nutrition Debate #173.”
In #173 I compared what were then two translations in the Wikipedia entry for the Hippocratic Oath. The first had the sentence, “I will apply dietetic measures for the benefit of the sick according to my ability and judgment.” The current translation in the earlier Wiki revised it to, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” Notice the difference? “Apply dietetic measures” was replaced by “prescribe.”
I understand, of course, that pharmacotherapy did not exist in ancient Greece, although herbal medicines, salves, etc. have existed since the beginning of time. But so has the enduring and timeless truth: “Let food be thy medicine and medicine be thy food.” And can any doctor not acknowledge that the best medicine for treating type 2 diabetes is “the best diet?” Then, assuming that every doctor would agree with this prescription, the question arises, why would any doctor not prescribe for every patient a diet much lower in carbs than the 60% carbs that is the USDA’s Nutrition Facts Panel standard? (See #288).
If the physician is truly and sincerely acting in the beneficent spirit of the Hippocratic Oath, why would he or she not literally “…apply dietetic measures for the benefit of the sick according to my ability and judgment?”  The answer to this question is, of course, complicated: There’s the question of 1) laziness, 2) a lack of time, 3) patient “non-compliance,” 4) a dietary plan (restricted calorie, “balanced,” low-fat) that is doomed to fail, 5) guidelines that a doctor must comply with to be paid for services paid for by 3rd party payers (government agencies like HHS/Medicare and Medicaid and private insurance that must conform with government guidelines and 6) low reimbursement rates by those 3rd party payers for patient services.
As a consequence, writing a script and updating the patient’s electronic medical record are all that most physicians have time to do. Medicine as practiced today in many large offices is at best just a business; at worst, it’s a sham. I’m lucky. I have a caring physician (I hope he reads this) who is glad to see me and give me the time I need. Now if I can just get nurse to treat me the same way. She has been with him so long that to her I am just another product on the office assembly line. Remember Lucille & Ethel wrapping chocolates on a factory conveyor belt? It was one of the funniest pieces they ever did.
You may have noticed that I failed to mention one more possibility for why a physician would not regard a low-carb diet as the “best medicine” for virtually everyone, but especially for people with Metabolic Syndrome, borderline lipids, chronic systemic inflammation, or who are overweight, obese, pre-diabetic or diagnosed with type 2 diabetes. I didn’t include the possibility that the physician may actually believe that a restricted calorie, balanced, low-fat diet is the best way to lose weight and keep it off and see improvement in all these conditions, plus hypertension (high blood pressure) and reduced risk of coronary heart disease, cardiovascular disease, several types of cancer and even Alzheimer’s disease.

The reason I didn’t mention it is that I can’t believe that there are any doctors left who still believe that. The evidence has been piling up from so many sources, and is now aggregated in huge meta analyses - they cannot not have seen it. Just in case, though, this very comprehensive 12-points-of-evidence elucidation in the January 2015 issue of Nutrition, by Richard Feinman et al., covers just about all the bases. So this can’t be the reason anymore. There must be more to it. Could it be that it’s very hard to switch horses in mid-stream (mid-career)? Will we have to wait until the current generation of doctors all die? Will that be too late for you? The doctor who started me on low-carb (Atkins Induction) was semi-retired. Maybe he figured he had not much to lose. He took a chance and put his patient’s health first. Maybe you, the patient, should too.


  1. It is interesting that you bring up the Hippocratic Oath and the creed "do no harm." It is only in the last century that the medical ethics have changed to recognize that the knowledge and expertize of doctors is really limited and can be terribly faulty and harmful. A study in 2000 found that doctors were actually the third leading cause of death in the US. While the current AMA ethics recognize the rights of the patient we still must battle the thousand year old patronizing attitudes of many healthcare professionals. Even though they think they have knowledge and expertise it is at times horribly flawed and as patients we have a right to protect ourselves from being harmed, not just by doctors but by the entire profession.

    ps. You might find Eric Topol's book "The Patient Will See You Now" very interesting.

    1. Topol's the MD who created Medscape, right? Definitely going to get that book. Thanks for the lead.

      My doctor, whose office is on my email list for the blog, generated a message, a day after I posted this one (#289) that they no longer, for privacy reasons, can respond to emails addressed to them. I wonder -- was this a coincidence of timing, or his sense of humor, or did I tick him or his nurse off. I wonder...

  2. Many (not all) people who adopt a "calorie restricted, balanced, low fat diet" DO lose weight, initially. But the chances of someone strictly maintaining such a diet in the long term and remaining successful on it with all of the metabolic insults that it causes are very low. Meanwhile there are a percentage of "naturally thin" people who think that their so-called "good" diets are responsible for their staying slim, instead of recognizing their good metabolisms which really maintain their slim figures despite their dietary choices.

    But because of that initial (but short-lived) weight loss and health improvement success for those many and because some people manage to stay slim because they are naturally slim in the first place thanks to good metabolisms, many doctors think that the patients who don't succeed in the long term are therefore non-compliant, lazy, stupid, and liars. They absolutely believe the conventional advice will work, "if only" their patients will bother to really follow it. They mistrust patients who say they ARE following the conventional advice to the letter when they are not successful at losing weight and gaining health.

    So yes, despite the evidence-based studies and what they see right before their very own eyes, they continue to believe their own bad advice.

  3. Well, said, Jan. It's convenient for "them," and frustrating for "us." It's another reason that we need to take charge of our own "healthy eating pattern," to use the current vernacular. After all, when it comes down to it, it really doesn't matter what THEY believe.