Part of a series.
You know the serenity prayer, written by Reinhold Niebuhr in about 1940:
God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And the wisdom to know the difference.
I saw an elderly woman in the hallway recently with the prayer framed and done in needlepoint by her daughter. It was very beautiful, and it got me to thinking that it has much to say about medical care. Niebuhr also had a somewhat different version of this prayer which in some ways attunes with health care.
Father, give us the courage to change what must be altered,
Serenity to accept what cannot be helped,
And the insight to know one from the other.
There is a Mother Goose rhyme, apparently from the mid-1600s, which gets even closer to medicine:
For every ailment under the sun
There is a remedy,
Or there is none; if there be one try to find it;
If there be none, never mind it.
This seemed to me to get right to the point of what medical practice needs to be, and it took my thoughts to a book by Shannon Brownlee titled Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.
In it, she described what happened to her father during his last weeks of life. He was clear to all that he did not want to go to the hospital. But volvulus with its attendant pain forced a trip to the local community hospital emergency room. Fortunately, the volvulus could be relieved with a simple non-invasive procedure.
But after a few days, it recurred so back to the ER he went. Again it was reversed, but the physician in charge said it was likely to recur again, and it would probably be best to have surgery to prevent its continued recurrence. The ER doctor urged that he be transferred to the larger hospital some miles away. He would need surgery, but first he would also need his heart evaluated to see if he could, in fact, survive the surgery.
Now a whole series of tests were done: stress test, nuclear scan, CT scans and so on. But when the surgeon came to see him without yet having seen the results of the tests, he said it would not be appropriate to do surgery because he clearly could not survive it. So after all of this unnecessary testing, he went home and died peacefully some weeks later. But — and it is a big but — he was subjected to all sorts of unnecessary turmoil in those last weeks of life.
I was also reminded of Dr. Andy Lazris’ book Curing Medicare. Medicare has obviously been a major boon to many elderly individuals but it has some serious deficiencies, and it behooves us to understand them. Dr. Lazris cares principally for geriatric patients and knows his subject firsthand from 25 years of experience.
One of his major points is that it is often best to not diagnose and treat aggressively (or “thoroughly” as he puts it) but to use a more palliative approach. But Medicare in both its payment systems and its regulatory approach essentially dictates aggressive medicine, indicated or not. Whether in the home, an assisted living facility, a nursing home or the hospital, the pressures are for being “thorough,” often to the patients’ detriment if not outright harm.
For example, Medicare quality indicators require that patients have their blood pressure controlled to a predefined level, but this may be too low for some older individuals. Too low and they may fall when they stand up, break a hip and end up in the hospital. The doctor gets positive points for “quality” and no one connects the terrible outcome with its causation. Similarly, blood sugars can be pushed too low for some leading to confusion yet still fitting the quality benchmark.
Both Brownlee and Lazris, it seems to me, are urging that medical professionals need “the insight to know one from the other” and then the “serenity to accept what cannot be helped.” That can be hard; our training urges thoroughness, that death is a failure. Family members persist. Watch ER or Grey’s Anatomy and the message is clear.
As a profession, we need to remember to fix what we can fix, accept what we cannot fix and always strive to recognize one from the other. If we do it can give us and our patients the serenity to accept — “if there be none, never mind it.”
Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO, University of Maryland Medical Center, and senior advisor, Sage Growth Partners. He is the author of Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.