Adverse Effects
From my first few months of blogging, in 2008
Doctors hate it when patients say: “Doc, I don’t want to take this medicine, because it causes all these side effects – just look at this list I got from the pharmacist (or off the internet).”
As allopathic physicians, we are at a disadvantage because our medicines come with warnings about every side effect ever reported, even if no one has ever proven it was actually caused by the medication.
Everyone knows about the placebo effect, the healing caused by a patient’s expectation that a medication will work. The package inserts we get today bring on the nocebo effect, which is the creation of discomfort by negative expectations.
Practitioners of alternative medicine have it easy; they can take full advantage of the placebo effect without the nocebo effect caused by pharmacists, the FDA, the legal climate or the Internet.
Adverse effects can be very real and frightening, though. I have seen plenty of them, and it does make me careful. This is the age of information and Informed Consent, and we have to be very careful to tell patients about possible adverse effects when we prescribe.
I have seen a woman’s bone marrow almost shut down from a week of sulfa for a urinary tract infection. One man lost the use of his right arm for months due to rotator cuff inflammation after taking Cipro for a sinus infection. Another man developed horrendous sunburn while taking doxycycline for a prostate infection. Several patients have developed allergic rashes and tongue swelling.
I have seen people go into heart failure from Avandia, a once-popular diabetes medicine and I have seen people use my prescriptions to try to do themselves in.
But adverse effects can be caused by non-pharmacological treatments also. Sometimes a doctor’s words or demeanor can have unintended, even devastating effects.
One successful business woman told me once that she had felt terrible the whole time between two appointments because she had got the impression I thought she was foolish, and I couldn’t even remember what had happened. A few times I have had to undo damage I caused by being in a hurry when dealing with a patient who was afraid or anxious.
A physician’s demeanor is part of the treatment. I know they teach empathy in medical school these days – to the extent this is something that can be taught.
William Sykes was told by his pulmonologist that he had eighteen months to live when he was diagnosed with alpha-1-antitrypsin deficiency. He became severely depressed. The antidepressants and steroids I prescribed made him manic for a while, but we got through it. I promised him the pulmonologist didn’t really know how long he would live. The specialist did fire William as a patient because he cancelled a couple of follow-up appointments, so it was “him and me” and the occasional Hospitalist for a few days of “pulmonary toilet”.
William lived almost ten years longer than predicted, even got married and adopted an old parrot, which learned to imitate the sound of the oxygen truck backing into the driveway. But he never got over the words of the pulmonologist.
Exactly this. Last week I took a tumble down the flagstone steps in our back yard. I landed hard on the edge of the flagstone sticking out, somewhere on the hip I’d had replaced about a year ago so my immediate concern was that I’d damaged it or broken something else. Although I had full range of motion, it hurt to put weight on that leg. So I had my husband trundle me off to ER to get an x-ray to determine if I’d done any bone damage. None thank goodness and when the massive bruise appeared it was closer to the buttock area than the hip. I’m still using my rollator and canes but I was told to expect a 2 to 6 week recovery from such a fall.
But here’s what relates to what you wrote. The x-ray tech was training a new student so a few more x-rays to get it right. They could see the image after each take, and I could not. After the first take, the trainee went “Oh Wow!” I was immediately alarmed, thinking “what damage did I do?!” Turned out he was awestruck at the image of the hip implant, but his reaction of wonder was not the reaction I had to his reaction.. The radiologist cleared me and my claim to fame about having good bones, even in my 70s, remains intact. It wasn’t until I got home that I thought I should have told him the effect his reaction had on me. It was a spontaneous outburst on his part, even though he knew that the reason I was there was to make sure that I hadn’t damaged the implant or the hip. But it would have made a good teaching moment to let him know that he should keep reactions to the x-rays he takes, to himself.
Good thoughts! I’m re-reading How Healing Works. So incredible how much healing is really in the context and culture rather than the treatment itself.