Primum Non Nocere

First, do no harm. This is not actually an easy concept. The more I become tied to medicine, the more I realize the practice of something and the theory are very different. Even standards of care, textbook medicine do not always apply. In the classic book of internship The House of God by Samuel Shem, medicine for older patients is to do as little as possible. In the book, the more the characters try to correct abnormal laboratory values and numbers, the sicker their patients get; the less they do, the better they become. This is not far from the truth. For example, the ED recently admitted a 95 year old to the hospital for no good reason. The ED sent a laboratory test that was not indicated, and when it came back positive, she had to be admitted even though she had no complaints that warranted admission. After examining the data, we ended up ignoring that laboratory value and decided to discharge her. But when I looked at her blood pressure regimen, it was not ideal; she was on multiple medications of the same class and wasn't on other medications that were indicated (she had heart failure but was not on a beta blocker or ACE inhibitor). By textbook and standard of care, her blood pressure regimen should be switched. But upon discussion with the attending and team, we decided to do nothing. Why? Because this regimen had worked for her for so many years. She was already 95; how many studies include 95 year olds? How do we know what is best for them? Changing her medications around would have a higher likelihood of harming her with marginal benefit. So I deferred to her outpatient physician - who knows her well, who will follow up - to decide whether to switch her medications to the standard of care. First, do no harm.