Oaths and Snake Oil

True confession… I never took the Hippocratic Oath. I was out on a boat. For whatever reason, at the end of med school, instead of graduation, I opted to spend a month in New Bedford on the Schooner Ernestina. It’s a 100+ year old sailboat that takes students and other groups for ocean tours. I guess I just needed some sea air to clear the four year fog.

That said, having skipped the Oath, I don’t feel licensed to do lots of harm now. It’s not like telling a lie with fingers crossed. But sometimes I think about the history of medicine, its rituals and absurdities, its saints and scoundrels, and where I fit in the soup.

Med school begins with a short white coat ceremony, and ends with the Oath and the “hooding.” The former is a happy day for premeds… who spend the next four years learning they’re actually wearing a warning sign. I can’t say much about the latter since I missed that too. But the goal of each is to help doctors feel noble and special, and perhaps to erase some of the less appealing bits of our history.

In those four years, med students perform superhuman feats of sitting, reading, note taking, sleepwalking, retracting, praying and smiling through tears. Of the “vo-techs,” med students are among the elites who aced the marshmallow challenge 20+ years prior. For myself, I lived from test to test, essentially oblivious to my surroundings. (I remember once going on a date, but deciding against a second because of the commute. She was on the other side of campus.)

However, while med school was challenging, it’s not like any of us contracted black lung from our days in the mine, or had to swim a mile under water dodging torpedoes. Actually, in comparing vo-techs, I suspect plumbers have done more for humanity than all doctors combined. Whoever best moves infected poop from the kitchen and bedroom gets the gold in my book. But I digress.

Medicine for me seems to have two converging histories. The first one with the likes of Hippocrates, Osler and Last, is filled with doctors who dedicated themselves fully to their patients and practiced what they preached with cash as an afterthought. In parallel there have been the snake oil peddlers. In the early days of medicine these were folks who sold placebo at best, and poison at worst. Unfortunately, many still exist today. Some you’ve seen on TV.

This came to me in part because of all the news on EpiPens, and also because of a recent meeting where we talked about a couple new meds called Xarelto and Kcentra. Supposedly Xarelto is superior to Coumadin, because its dosing doesn’t have to be monitored as closely. But it is fairly pricey at around $10 a tablet. In the setting of trauma, however, when bleeding is a bad thing, I now can reverse Xarelto with Kcentra, which will run you $13k if I click the right button. Hopefully you have insurance.

Apparently both meds work, but those numbers give me pause. Have we in medicine, who studied for years with best intentions to help people, been coopted over time to do the peddlers’ bidding? And how much am I a cog in a giant money sucking machine?

I think our two competing histories have converged, in part because over time a lot of the snake oil has started to actually work. At the same time systems and layers have been put in place that massively separate doctors from billing and patients. See attached.

There really are an infinite number of directions to take with an MD. Some join MSF and risk their lives. Others do research, or join pharmaceutical companies to invent new pills. Others teach. Others climb corporate ladders. In my case with ER, I consider myself a people mechanic/waiter. I’m not rewarded for creative thought, but rather for pattern recognition, likeability, speed, and ability to follow a “standard of care.” I like what I’ve learned, but many aspects of the field make me nauseous.

Pre-R gives some balance. It permits a little more creativity, offers more follow-up, and lets me do my own shopping… and peddling.

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