When To Intervene: A Fundamental Dilemma in Medicine
In observing trends among my patient encounters there appears to me to exist a distinct difference in clinical encounters between more "holistically-minded" patients and more "traditionally-minded" patients, for lack of better terms. One is not necessarily better than the other. There are definite benefits and risks associated with either group. Whereas the "holistically-minded" tend to see western medicine with some degree of skepticism, the "traditionally-minded" tend to be comfortable with most interventions offered and tend to trust their physicians' perspectives and recommendations without much question or reservation. On one side, certain "holistically-minded" patients might only present to the doctor's office when they feel the icy grip of the reaper closing in but only after they have completely exhausted the witch hazel and echinacea in their cupboard. On the other side, certain "traditionally-minded" patients might come in to get their monthly Z-Pak every time the weather changes because they are convinced that a mortal illness is lurking in the shadows ready to spring on them.
Of course, I have represented the extremes on either side of these 2 groups and realize that most people fall in a broad spectrum between the ends. Nevertheless, most people have an inclination between the two dispositions and this influences the direction of the clinical encounter and how we as practitioners perform our duties. All of us have felt the temptation to settle for a plan of care we weren’t really comfortable with in order to appease the dispositions of our patients.
Among the decisions we must make on a daily basis in the clinic, one of the most fundamental but often overlooked is this: "must I do anything for this?" We can be torn over this question because there is certainly some intervention we can provide for almost every complaint that comes through the door, but that does not mean that we should. One not need look farther than drug resistant infections and the opioid epidemic to see the import of this question. As a result, a cursory glance at treatment guidelines will reveal a significant shift toward conservative approaches for many common clinical conditions with the underlying suggestion that many of these will improve or resolve spontaneously. Of course, there are exceptions and part of our job is to know when those exceptions present and what to do about them.
One of the tenets of Osteopathic Medicine is that the body possesses self-regulating mechanisms that are self- healing in nature. This is a fundamental truth that must be understood and trusted by clinicians in order to appreciate our proper role in health and disease. Is our role to really heal disease or is it to facilitate the natural healing process inherent in all living things? A.T. Still, the founder of osteopathy said: "An osteopath is taught that nature is to be trusted to the end." Whenever I see patients in clinic, I try to remember this quote and to realize that during times of illness, within each of us, there is present a very complex healing mechanism already at work attempting to fix the problem and to restore health.
So rather than seeing ourselves as the dragon-slaying knights of medicine, perhaps we should see ourselves as humble servants of an ancient wisdom and whose primary task is that of support. We imminently trust this wisdom and are often more inclined to step back and let it work than to quickly join the battle with our mighty weapons of war. We look for signs that the battle is not going in the right direction and if we do decide that it is time to intervene, it should be to accomplish 2 objectives:
1) to support and optimize the healing process already in place.
2) to inflict just enough damage to the disease-causing process so as to tip the scale of the battle to the favor of the healing forces.
This is not some new-age idea. Hippocrates is quoted as saying: "natural forces within us are the true healers of disease." He also stated: "To do nothing is sometimes a good remedy." Voltaire stated: "The art of medicine consists in amusing the patient while nature cures the disease." The complicating factor for us today is that we have some sense of business acumen and self-preservation at play. How many of us have seen that look of disdain when we informed our patient that their symptoms were not warranting of the pill or shot they knew they needed? I remember one patient angrily stating that she had wasted her money all for nothing when I would not prescribe an antibiotic for a common cold. The fear is if we displease enough patients who want their pills and shots it will eventually come back on us with consequences. Also it often seems better to give some patients what they want and to get them out of the office rather than to deal with the inevitable blow-back.
There is definitely an art to this aspect of medicine as well as a very fine balancing act to consider. To err in either direction of this question can be catastrophic. This is why patient education should be a preeminent priority for clinicians. We need to help patients understand the characteristics of disease patterns that do and do not require medical intervention. We also need to reassure them of nature's healing wisdom and power. We need to tell them why it is okay not to have “a pill for every ill and a potion for every emotion." We must do this because we need our patient’s informed input and support. Healthcare is not, nor should it be a one-sided affair. It is a mutually beneficial partnership between patient and clinician. When we all, patients and clinicians, learn to trust nature and to know our proper roles in the clinician-patient dance it will significantly improve outcomes and satisfaction for our patients as well as for ourselves.