A fork in the waters

Sometimes, I think that that guiding principal of the medical profession, “first, do no harm,” is hopelessly out-of-date. Clearly, a physician should understand her limits, and never should she give care, which hurts, more than helps. Nonetheless, this axiom implies that the doctor is in control, and decides the treatment. Some of the time, a modern motto, which recognizes the true position and limits of the modern doc, might be, “you can lead a horse to water, but you cannot make him drink.”

I saw two patients this week, whose disparate responses to serious medical events, illustrates the limits of what even a careful and clear physician to do. Both were lead to the side of the river, told how to get safely cross. One climbed onto the ferry. The other looked left, looked right and plunged into the maelstrom, rapidly beginning to drown.

Steve is a 61-year-old gentleman. On a blood test last winter, I found that his hemoglobin A1C (HgA1C) was slightly elevated. Normal is 5.6 or less and his was 5.7. This test measures the average blood sugar over time and the very slight increase did not mean he has diabetes, but rather was at increased risk for that illness. I informed him of this, six months ago.

Since that time, he has done everything possible to reduce that risk. He began to exercise for an hour, five or six times a week. He lost 15 pounds. He stopped eating all candy, desert and soda. He got more rest. The result is that his HgA1c dropped to 5.2. Steve took aggressive control of his health and life.

The second patient, Ron, is a 52-year-old gentleman. I saw him a year ago, for an elevation of his red blood count, so called Reactive Polycythemia. To what was it reacting? Smoking and sleep apnea from obesity. In addition, he was developing a chronic cough from early lung disease and, a couple months ago, required the placement of his second cardiac stent.

I told Ron, last year, that he was dying. He was dying of smoking. He was dying of overeating. He was dying from a sedentary lifestyle. His chance of surviving to 60 was not great without significant changes in how he was living. I offered him nicotine patches and gum, anti-smoking medication, a nutritional referral, a prescription to a medical exercise program, referral to a hypnotist and the number of a formal smoke ending program at the local university. I counseled him on methods of decreasing his intake of food and cigarettes. I was emphatic, crystal clear, that his was puffing his last years away.

How much did he decrease his smoking? Nada. His is still burning through more than one pack a day. His nails are yellow and he smells of tobacco. He is proceeding to kill himself.

His weight? Up seven pounds. Exercise of any sort? Not at all.   Ron did nothing improve his health or lifestyle.

What makes these patients so different? Sure, tobacco is addictive and therefore naturally harder to quit. However, massive life-style changes, which Steve put in place, also require tremendous focus and discipline. I have seen the reverse just as often, overweight diabetics completely failing to address rapidly rising sugars, while smokers quit, simply because I say things are bad, or maybe even more important, will be bad for their children.

There are many factors that result in such a contrast is health consciousness. Some people feel helpless or fatalistic, unable to take control of their own lives. Others are overwhelmed by personal events and do not have the time or focus for themselves. Many were not raised in health conscious homes or never had the supports to focus on their own bodies. Some do not believe what they are being told, while others, because of depression or anxiety, simply cannot care. Others never are never told about their choices in a definite and clear manner, which they can understand.

For doctors this can be very frustrating, even resulting in burnout. They try to teach, support and give honest guidance, when they wish all along they could take the patient out back to the woodshed and spank some sense into them. The best a doctor can offer is an honest appraisal of realities and in choices for each malady. Then it is up to each patient, each of us, to choose our path. We decide whether to drink the water or not.


  • John Gehr
    As you said, "You can lead a horse to the water but you cannot force it to drink".
  • Correct. I would say that food is just as addicting as cigs. My question would be why doctors burn out over what you can't control. Its a part of life. Focus on those you can.
  • Carolyn Hughes
    Another great blog Jim. One does what one can. But your deep compassion for your patients is what shines through every blog. It's impossible to turn that off. Just please don't burn out.
  • meyati
    Vic, many doctors have their pay tied to getting results of getting compliance from patients that are in medical populations that are at risk. Lots of the burnout is in younger doctors that are under constant scrutiny about how many patients lose weight, how many are on statins for prevention, how many are dieting-vegetables are preferred, glucose levels, stop smoking, blood pressure control. In my state, the population has diabetes, obesity, heart conditions/strokes. That's not in my family
    • I understand. Its one of the things I campaign on, somethings you can't help or do. I have seen an article where they're figuring out you can do so much.
  • Neil n
    Have you ever considered asking him what he has to live for? Making him say that he living for his work or hobbies or family or what his passions are and ask whether he would like to continue living for those things. Making him vocalize what he has to live for May be the best introspection you can offer him as he clearly will not listen to a physician.
  • jane
    I beg to differ ... Having a single HbA1C test 0.1% above the corporate-influenced range specified as "normal" is not a "serious medical event." It is not a medical event, nor is it serious, certainly not in the sense of having any urgency. Nonetheless, congratulations are due to Steve.

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