Adverse Effects

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.

5 Responses to “Adverse Effects”

  1. 1 John Morton July 26, 2008 at 4:30 pm

    Dear Doctor,
    As someone who lives with alpha-1 related lung disease I read your post ‘Adverse Effects’ with great interest. You have very clearly identified one of the great and unidentifiable instruments you and those who practice medicine have – your words.
    I appreciate your sensitivity to the power of them and was delighted to read your story of the alpha who was fired by his Pulmonologist and seemingly out of spite – lived 8 and 1/2 years longer than he said he would. Carpe Dium! I love the idea of his parrot mimicking the sound of the oxygen truck backing up. Priceless.

    Anyway… I just wanted to let you know how much I appreciate your taking you time to post your thoughts and even knowing about alpha-1. You are to be credited with being well ahead of the class but I’m sure that you already knew that.
    Kindest regards!
    John Morton

  2. 2 alpha1john July 26, 2008 at 4:42 pm

    I too was diagnosed in 1999 with severe COPD related to Alpha-1 Antitrypsin Deficiency. To his credit, not only has my pulmonologist who said I’d need a transplant in less than 2 years supported me well beyond that time frame – we continue to work together to keep me going the best of my ability. Pulmonary rehab, weekly IV therapy, Oxygen when needed… the works.

    I too have had need to fire clinicians and I’ve been fired. In all cases, I and my family have come out better for the decision.

    Your comments regarding your alpha patient are priceless. We are a stubborn bunch as you have already noticed I’m sure. You are right however, when you say that your words have long term and lasting effects. I appreciate your insight and I’m sure your patients do too.

    Regards and Best Wishes to you.

  3. 3 Bendy Girl August 12, 2008 at 5:15 pm

    I’m working my way through the archives of your blog and enjoying it very much thank you, after Steph from The Biopsy Report linked to one of your posts.
    Like many people with EDS I have suffered from the effects of medical professionals words and behaviour, I’d go so far to say that they have caused far more damage than having EDS ever could.
    Your insight into this is appreciated probably more so than I ever would have known to do if I’d not been on the receiving end of such a lack of insight.
    Bendy Girl

  4. 4 FNP Student January 30, 2011 at 6:43 pm

    I hate the sentence “I looked this up on the internet”.

    As a wise person once said “A little learning is a dangerous thing”, Alexander Pope, I believe.

    The person comes in with a preconceived idea of what should happen, and if you don’t follow that track, even if it is not the right one, they get upset with you. You lose a bunch of time re-educating them that could have been better spent. And, like you said, it is very important to say it all with tact and compassion.

  1. 1 The Art of Prognosis « A Country Doctor Writes: Trackback on January 1, 2013 at 4:22 am

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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