Tuesday, December 3, 2019

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


This aphorism, considered to be part of the Hippocratic Oath, is attributed to Hippocrates. Wikipedia say, “While there is no legal obligation for medical students to swear an oath upon graduating, 98% of American medical students swear some form of oath,” and a modified Hippocratic Oath was 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, 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,” as I cited in “Retrospective #173.”
In #173 I compared two translations in Wikipedia for the Hippocratic Oath. The first was, “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 with “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 every doctor would agree with that, why would any doctor not prescribe for every type 2 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 sincerely acting in the 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 complicated: There’s are 1) guidelines that a doctor must comply with to be paid for services by 3rd party payers and 2) low reimbursement rates by 3rd party payers for patient services, 3) lack of time with the patient, 4) patient’s “non-compliance” with a restricted calorie, “balanced,” low-fat diet that the clinician believes is a “healthy diet” and that is doomed to fail, and 5) probably most significant of all, education, pressure and monetary incentives from Big Pharma.
As a consequence, writing a script and updating the patient’s electronic medical record are all that most physicians have time to do. As practiced today in many large offices, medicine is at best just a business; at worst, it’s a sham. I’m lucky. I have a caring sole practitioner who is glad to see me and gives me the time to answer all the questions I have.
But if you are overweight, obese, pre-diabetic or diagnosed with type 2 diabetes, and your physician is one who actually believes that a restricted calorie, balanced, low-fat diet is the best way to lose weight and keep it off and see improvement in these conditions, plus hypertension (high blood pressure) and reduced risk of coronary heart disease, cardiovascular (CVD) disease, several types of cancer and even Alzheimer’s disease (AD), but you’re not sure, read on.
The evidence in support of another, much healthier Way of Eating has been piling up from so many sources, and is now aggregated in huge meta analyses – a very comprehensive 12-points-of-evidence elucidation by Richard Feinman, el al. in the January 2015 issue of Nutrition. Google this scientific review, and give your doctor a copy. If this doesn’t work, it can’t be the why your doctor doesn’t prescribe these “dietetic measures” for you, instead of a cocktail of pills.
Could it be that it’s very hard to switch horses in 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 Very Low Carb was also a sole practitioner and semi-retired. Maybe he figured he didn’t have much to lose. He took a chance and put his patient’s health first. But, YOU, not your doctor, DO have a lot to lose. Maybe you, the patient, should take a chance, before it’s too late.

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