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When evidence says no, but doctors, patients, and the system say yes

doctor_girl-300x293There is an interesting article from ProPublica called When evidence says no, but doctors say yes making the rounds about the number of doctors who disbelieve, or don’t know, or don’t care about the medical evidence to the detriment of patients. I do not find any fault with the article. I rail against this daily. I have my whole professional life. It is actually a big reason why I blog because I hear regularly “I didn’t know that” from providers or “If I had only known,” from patients.  I love when people tell me they took in something I wrote to show their provider. I love when a doctor tells me they turned a post into a handout.

The sad fact is some doctors don’t learn anything new after residency. Yes, they go to continuing medical education (CME) but they do not learn anything.  Here’s one example. I used to lecture very often about herpes testing. It’s a little complex, but mostly because there is so much mythology. I would lay all the evidence out over 45 minutes, dispel the myths that were never even grounded in science to begin with, and then prepare for the always present onslaught of questions and shaking heads. At times I wondered did they not understand, but they were doctors and I didn’t see how that could be possible?  Were they not listening? Possibly, although many of these lectures were pre laptops and smart phones so distractions were minimal. Did they not believe me? Oh yes. Some would argue with me afterwards about how I could not be right, meaning they didn’t believe the irrefutable basic science I presented as well as the clinical studies. As Spock would say, fascinating. Whenever I give a lecture, and I am considered to be an entertaining speaker, I consider myself successful if I can get 2-3 doctors in a room of 30 to change one thing about their practice.

Some doctors didn’t get good information in residency. A good example in OB/GYN is the belief that IUDs are not acceptable for women who have never been pregnant. Studies disproving this are over 20 years old and yet a 2014 study indicated that 32% of doctors did not believe IUDs were safe for women who have not been pregnant. THIRTY TWO PERCENT. I guess they were taught by someone who didn’t know and so on?

Undoing incorrect information is hard. There are articles written about anchoring. getting stuck on the first diagnosis and when treatment fails a doctor assumes the treatment was ineffective and keeps prescribing more and more treatments instead of taking the other road and questioning the diagnosis. As a sub specialist I can tell you the wrong initial diagnosis is most common thing I see in my field.

On top of it the science is not always good and Big Pharma controls a lot of the funding and of course what data gets released, so we may be making decisions with biased information.

Sometimes  doctors are just jerks. Two years ago my then 86-year-old father had a mycotic femoral aneurysm and needed emergency surgery that took 6 hours. The day after surgery there was a concern he may have had a heart attack during the procedure. Was it from the cardiac stress of the long surgery with a lot of blood loss or did he have blocked vessels? He had normal cholesterol, before the surgery could ride his bike for several miles, had normal blood pressure and no one in his family has ever had a heart attack. His dad lived to 98 and he had a 92-year-old brother. I was told he needed a cath by a surgical resident over the phone as I ran to catch the plane to see him. He would have to be transferred to another hospital to have the procedure.  All kinds of complications flew through my head. “Could I just speak with the cardiologist,” I asked? I just wanted to know the complication rate and what would happen if he did and if he did not have the procedure. The cardiologist refused to speak with me. He even refused to see my dad, all of this decision making was made speaking with a resident. Instead of answering my simple questions and seeing my father the cardiologist cancelled the cath. I was furious. All I had done was dare to ask he see my father and give me some information about risks and benefits. What if my dad died because I had just asked for data? Turns out my dad didn’t need the cath because here we are two years later and my dad is 88 and walking a little more slowly because of his femoral nerve injury, but he’s up and about and still has never had any chest pain. However, this is not an ideal way to have this outcome.

Then there is also money. Some surgeons do an awful lot of hysterectomies while others seem to be able to manage their patients with a much lower rate of surgery. I assume this holds in all surgical fields and not just gynecology. I have heard surgeons say about a not indicated surgery, “Well, If I don’t do it someone else well, so I may as well do it right.” And then, “Who knows, maybe it will help?”

Who knows? What if your pilot said, “Who knows, maybe we’ll land the plane safely?”

Some doctors follow guidelines and some do not. The preferred method of hysterectomy is vaginal according to national guidelines, but hey the robot is cool! Hospitals have to pay for them, so they are advertised as state of the art because you have to pay the upkeep. Patients are happy because they think they are getting the best! Insurers don’t seem to balk at the necessary expense. How does this happen?

But there are other issues too.

Sometimes doctors feel pressured to do something when they have no real medical therapy to offer. The art of doing no thing has been lost.  The urge to help can trump the need to sit on our hands and listen. Doctors are also worried about their patient satisfaction scores, either at work on online. An unhappy patient can leave lots of terrible comments and two or three can affect your salary or at the very least leave you answering to your superiors. If you don’t think the drive to make patients or administrators happy changes medical practice then you are wrong.

Pills and surgeries are “easier” for everyone. Providers, patients and insurers. It is my experience that in general people are happier when they leave with something tangible. A prescription validates the symptoms perhaps? Maybe it validates the time off of work ? However, many things have no easy answer. For example, talking about sleep hygiene is hard. When I tell people about turning off the screen or what they need to do if they are staring at the clock I have received eye rolls. How could a behavior change fix something that is so devastating? People who don’t want pills generally don’t come to the doctor, so we do see many people who are biased towards wanting medical interventions. Some people turn to yoga or cognitive behavioral therapy for their insomnia without ever making a doctor’s appointment.

And what about that knee pain? It hurts so much. How could physical therapy help something that painful? So there is that hurdle. Then there is the co payment for physical therapy, it can be $100 or $150 and there may be 8 or 10 visits as well as daily home exercises to see improvement and maybe weight loss is needed too. However, what if someone dangles a surgery with a $250 co payment? The doctor wouldn’t offer it if it wasn’t helpful, right?  It is pretty easy to see how people, including even well-meaning surgeons, convince themselves that surgery is the answer because it is easier to get a unindicated MRI and a unindicated knee or back surgery in almost every single health system than it is physical therapy and cognitive behavioral therapy. The path of least resistance is rarely the right one and that is terrible.

I have spoken with patients who have had a clearly unindicated surgery who are no better and yet many are perfectly satisfied with the unhelpful surgery. In fact they are happy because they equate the surgery with their doctor taking their complaints seriously and trying something. The bigger the intervention the less unhappy people seem about it not working.

We all believe what we want to believe. If patients don’t come back after surgery, it must have helped, right? If your cold or cough went away after antibiotics, they must have helped, right? I was ill for a week or two before I went to the doctor because I didn’t want it to be pneumonia. In my field multiple studies tell us that self diagnosis of yeast infections is very inaccurate and that women are wrong about 70% of the time, which is worse than flipping a coin. Trying to convince someone over the phone they need to be seen when they don’t want to be because they are convinced they are right is hard and time-consuming. Everyone, doctors included, often refuse to believe statistics apply to them. I get the competing pressures of work and co payments and convenience, but I am seeing a rise in resistant yeast and I am scared for my patients and I want to do the right thing medically. Some people yell at me. Some write nasty things. Some doctors just stare at me in disbelief that self diagnosis of yeast infections is wrong. Others thank me for caring and being dedicated to giving them the right therapy.

If blogging for six years has taught me anything it is that everyone, not just doctors, want to believe what they want to believe. When people can reply to you anonymously you hear a lot more than you hear in the office. I delete so many nasty comments from people who accuse me of lying about iodine allergies or vaginal Valium or vaccines. Some people even believe walking around wearing a vaginal jade egg helped them. I often close comments because of that very issue, the rancorous minority claiming a therapy works for them can change the minds of others. Disbelieving evidence, it seems, is a very human trait. If it were not people like the Medical Medium, who gets his health information from a ghost, would not be a best-selling author.

People often want a unifying diagnosis for their symptoms. Some people don’t want to have depression or fibromylagia or hear that sleep hygiene can help, a unifying diagnosis of chronic Lyme disease or heavy metal poisoning or chronic EBV has “real” treatments. It’s taking symptoms seriously, and so charlatans profit.

I have no easy answers. It’s not just medical education that needs overhauling and empathy training and interpersonal skills. We have to stop publishing lower quality articles. Fewer journals with more rigorous peer review would be great, but then how will doctors keep their academic jobs? It’s publish or period, not publish quality or perish. Wouldn’t it be better to have one amazing article that changes lives than a bunch of crappy ones?

The press also needs to stop writing about case reports and articles with seven patients. People read those headlines and insist on that therapy.

We need to do something about direct to consumer advertising. It’s not helpful.

Magazines and life style websites and physicians with platforms, yeah Dr. Oz I’m talking to you, need to stop giving voice to ludicrous therapies and ideas like wheat or EBV or chronic yeast or vitamin D3 or whenever the new whipping boy is that is causing every autoimmune condition. By the way no one seems to have grain brain in France.

We need more government investment in high quality clinical trials, but are we willing to pay more taxes for it?

We need vetted sources of quality information. Again, that will take tax dollars.

We need professional societies to take stronger stances on what constitutes high quality therapy, what is not, and to be honest about gray areas and we need those guidelines to be handed out to patients.

We need investment in health literacy.

We need doctors trained to understand studies, to stay up to date in their fields and who can communicate, and who are also trained when needed to do no thing. They also need more than 15 minutes to listen, communicate, and treat, but again, that will cost more.

Doctors are certainly part of the problem, but saying it’s all on doctors is like saying global warming is only from coal. There are lots of industries involved and every single one of us has a carbon footprint.

Doing the right thing in medicine is almost always the hardest thing. Not because it’s hard medically, but because life and the medical system have set it up that way. Until that changes care will still vary from state to state and office to office and person to person and whether you live or die might depend on what search terms you entered into Google and that is just wrong.

 

 

 

Discussion

22 thoughts on “When evidence says no, but doctors, patients, and the system say yes

  1. Dr. Jen, when you wrote that you had dared to ask for some information from that cardiologist, it reminded me of how risky it can be (if you’re a patient or a family member) to ask some doctors certain questions if they don’t like the question. Nine years ago, before I was sent home with a GERD misdiagnosis (despite textbook heart attack symptoms of central chest pain, nausea, sweating and pain down my left arm), an ER nurse came to take out my IV, unpack monitors, etc but FIRST she sternly scolded me:

    “You’ll have to stop asking questions of the doctor. He is a very good doctor and he does NOT like to be questioned!”

    I felt like a naughty school girl being spanked for my bad behaviour, humiliated and embarrassed. I couldn’t get out of that ER fast enough…

    The question that I’d had the temerity to ask her “very good” ER physician colleague?

    “But doc, what about this pain down my left arm?”

    Thank you for the ongoing heroic work you do towards “undoing incorrect information” wherever you find it!
    regards,
    C.

    Posted by Carolyn Thomas | February 24, 2017, 6:33 pm
  2. A very necessary article. A lot of this is why I never wanted to go to the doctor when I had something wrong. I had a quack who–when I went over painful digestion issues–did no diagnosing, but twitched with his prescription pad and pen in hand, asking me if there was anything, no matter how small, that I didn’t bring up. I mentioned occasional cramping during my TOM, maybe once every six months and before I’d finished he’d written a script. I didn’t even fill the stupid thing. Turns out he was run out of town. me and the nurse figured I was lactose intolerant–she told me to quit drinking caffeine and having dairy until the followup visit. I dropped 9 pounds and my stomach issues were practically gone. Wonderful. All this guy did was write scripts and see us for maybe three minutes max each. I was glad to never give the guy business again.

    Posted by TheChattyIntrovert | February 24, 2017, 6:41 pm
    • This doesn’t surprise me at all. They’re in such a hurry to resolve the situation that they go with the first diagnosis that makes sense and then focus on getting over the appointment. Inconvenient facts get ignored or dismissed as wrong.

      Posted by Loren Pechtel | February 24, 2017, 7:51 pm
  3. Very well written. I agree with many of your points. I also think many people make decision not based on logic or evidence but their emotion or feelings which can be difficult to understand or navigate.

    Posted by drugopinions | February 24, 2017, 11:17 pm
  4. It’s very difficult to get adults to learn new things, a problem well known in adult education. Such new learning is often relatively temporary and needs to be repeated, and not just the ‘tell them what you’re going to say, say it, tell them what you’ve told them’ but also refresher courses.

    To which you can add cognitive bias; there are so many of these, and they are a real problem which so many ignore.

    Refusing to answer questions is a response to the feeling that a person’s ‘armour propre’ is being questioned; think of it as an insecurity.

    As for hysterectomy; it often seems to be a ‘facultative’ operation in a way that general surgical operations aren’t. If you have a hernia, say, the treatment is operation. A truss is only suggested if you are so very frail. If you have (silent) gallstones, operation when you are young is sensible, but not so clever when you are much older. And these are both operations dealing directly with the problem, whereas hysterectomy seems to be an adjunct to another procedure.

    And, where you have a ‘payments by results’ system, such as private practice, the lure of $ is always a problem. You’ll be aware that in the NHS medics are paid a salary, so this incentive to operate barely applies — though different rules apply when you see the same patient privately.

    Posted by korhomme | February 25, 2017, 2:16 am
  5. Right on, Dr. Jen!

    Posted by NurSerial | February 25, 2017, 5:40 am
  6. I teach about “best-evidence” optimal maternity care and legal patient’s rights to clients and colleagues…nurses, doulas, midwives…(see the wonderful Milbank Report about that topic), and wondered about why practitioners are so reluctant/unable to use even the most obviously provable and easily available best-evidence practices. Even ACOG admits that only about 30% of its practice directives are based on Level A evidence ([ LEVEL OF EVIDENCE: IIIC] 2011 The American College of Obstetricians and Gynecologists). Think of all the solid proof that “delayed cord clamping” should be standard practice by now, and that episiotomy shouldn’t be (Practice Bulletin #165 replaces Practice Bulletin #71, “Episiotomy,” and Committee Opinion #647, “Limitations of Perineal Lacerations as an Obstetric Quality Measure). There’s a whole list of practices and protocols that confer no better outcomes and few benefits that are standard care. Just as you, Dr. Jen, wonder why docs are so immovable in their thinking and practice, other have asked and there are studies and articles about this… here’s a bit of what I’ve found:”
    Abstract: In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice”. Concerning comments from this survey included “obstetrics requires manual dexterity more than science”,
    “evidence-based medicine ignores clinical experience”, and that following guidelines could
    result in “erosion of physician autonomy”. These views were described as obstacles to the
    adoption of evidence-based practices, and the authors recommended emphasis of critical
    analysis of the literature as part of medical education. (Olatunbosun OA, Eduoard L Pierson RA.
    Physicians’ attitudes toward evidence based obstetric practice: a questionnaire survey. Br. Med
    1 316, 365-366,1998)
    And this little tidbit from an AMA journal: the title of the article says it best:
    “The Difference between Science and Technology in Birth: Obstetrics seems to be particularly
    resistant to making evidence-based changes to common practice, perhaps because of the
    emotional climate surrounding pregnant women and babies. Aron C. Sousa, MD, and Alice
    Dreger, PhD ., Volume 15, Number 9: 786-790.”

    So it’s the “emotional climate” that makes it difficult for docs to advocate for and adhere to
    best-evidence care? It’s a patient’s right to be offered and treated with
    only best-evidence care and nothing less. If you asked a birthing momma if she’s paying for
    less than optimal care or whether she’s paying for best-evidence care for herself and her baby,
    we all know what the answer would be.

    Posted by Jacqueline Levine | February 25, 2017, 6:53 am
  7. Jen,
    Unfortunately a common story. That cardiologist doesn’t get paid anything to TALK to you! He just wants to do the cath, put in some stents (that don’t do anything) and get PAID (by MEDICARE). I’m a Hospitalist and I see this all the time. It happened to my father too (in Las Vegas) but I wasn’t as effective as you. They whisked him off to CABG (Heart Surgery) before I could intervene. The NNT (Number Needed to Treat) is INFINITE for stents and 3-6 for CABG. The vast majority of people that have these procedures do NOT benefit from them yet suffer all the risks of side effects. Just the lost time in the hospital is enough to dissuade me that they are worth it. Not to mention the cost and the psychological phenomenon of “having a disease” when you really don’t. To quote a lovely 93 year old woman I recently cared for when I asked her “what’s your secret to success?”

    …”Keep your own teeth and stay away from doctors!”

    Nick Sartor
    http://www.nicksartor.com

    Posted by Nick Sartor, M.D. | February 25, 2017, 8:25 am
  8. Reblogged this on things I've read or intend to.

    Posted by donesoverydone | February 25, 2017, 1:28 pm
  9. Dear Dr. Gunter,
    as a med student in Germany I have gotten wind of several of the things you are describing in clinical practice, but of course it makes a bigger bang when you write from experience, and it confirms dreads that I have for my upcoming professional life. On the other side, I feel that my specific university lays a big emphasis on critical thinking, evaluating literature and taking facts for what they are (and what they’re not). In this sense, I’m motivated and have a lot of faith in my peers, and I hope that we will all fight the ridiculous financial influence on medical practice as long and strong as we can.
    t

    Posted by Twyla | February 25, 2017, 4:55 pm
  10. Doctors are certainly part of the problem, but saying it’s all on doctors is like saying

    But doctors are the ones who do the harmful surgeries with unproven benefit. Usually the worst a patient can do is waste their own and insurer’s money but doctors are capable of mistakenly maiming for life or even worse.

    Doctors are capable of doing far more harm than patients.

    Posted by Chris O'Neill | February 25, 2017, 10:30 pm
  11. Glad to see this issue get more attention. I remember getting an ER report on one of my patients, who was diagnosed with a viral URI and then d/c’d with a Z-pak. Riiiiight. Then I recall one patient with neck pain, and poor posture — slouched, head held forward — who would not accept that something as prosaic as posture could be the cause of his pain.

    However, often when patients feel that I’m listening to them, they are more accepting of non-pharmacological or non-surgical interventions. I also like to give personalized handouts, and draw some illustrations of what’s going on physiologically or (say for MSK pain) “mechanically.” And doing this patient education is important when what you’re recommending is different from what a lot of your peers are still doing even though current evidence and guidelines don’t support their management. But listening and explaining take a fair amount of time (at least for me) and make it hard to be as “efficient” with patient load as the suits want us to be. I don’t expect that pressure to alleviate in the current climate.

    Posted by NW Luna | February 25, 2017, 11:47 pm
  12. Thanks for such an insightful article. As someone who suffers physical symptoms as a result of anxiety I often find myself looking to doctors for reassurance. In the past when I haven’t had a GP who understood my mental health in tandem with my physical health I have been simply prescribed a ton of medication or tests which of course I subjected myself to due to my anxiety.

    Posted by Nicole | February 26, 2017, 12:44 am
  13. So many “yes!” moments here. First one was about CME; I was the program manager at two different hospitals, each of which offered 30 free CME activities per month for their physicians. I would go pick up sign-in sheets, or sometimes stay for the lecture, and see people charting, talking to their colleagues, or worse — signing in, grabbing a sandwich, and walking out the door … but still getting credit for having learned something new. As you point out, practice never seemed to change.

    Also … the part about dismissive docs hit home because I spent 10 years on unnecessary anti-depressants that never helped. Because pill A didn’t help, the docs moved me on to pill B … until they deemed me “medically resistant” and cut me loose with nothing to show for it but permanent side effects from the pills. Cut to today: turns out, I have Hashimoto’s disease that went untreated for that entire time because the assumption was that as I was female and in my late 20s to early 30s, I must just be depressed and the right pill would fix it. Ugh. When I think about how a few simple blood tests would have revealed the truth, I get so angry …

    Thank you for this article.

    Posted by sharonecathcart | February 26, 2017, 6:12 am
  14. I agree strongly with much of what you say – and disagree strongly with other things you say. Misdiagnosis is rampant – at least in my experience – severely impacting quality of life and in some cases facilitating death. When my mom was in her 90’s and living to see her first great grandson and get a 4 generation picture we told the facility she was in and that we needed to keep her healthy. She got a yeast infection they didn’t tell us about and didn’t treat. By the time her symptoms were bad enough family noticed them I had to fight to get her antibiotics, then fight again a few days later to get the full dosage. The family diagnosed the type of dementia she had – the doctors never bothered – and then fought to get her off medication that was known to make hallucinations from her type of dementia worse.

    My experience has been equally bad. There have been multiple bad diagnosis (like when I had mono with an enlarged spleen and liver and was diagnosed with the flu and a pulled muscle.) The worst string of misdiagnosis started over 20 years ago. I went to a doctor in the 1990s with a history of unusual fever, and a round ring. She refused to give me antibiotics – I now believe that’s when I contracted Lyme’s disease. It took 6 years to get my hypothyroidism diagnosed – which only happened thanks to my own research and finding a good endocrinologist. Despite that diagnosis, over the years I got more exhausted, and noticed I always felt better and could think better on antibiotics. Over the course of a couple years the doctors concluded I had Sjogren’s – I questioned repeatedly why antibiotics made me feel better, with no answer and eventually I stopped asking. About the time of the diagnosis the exhaustion lead to a divorce. A year later, with doctors telling me to get out of my high stress job and thinking the exhaustion was my new normal I quit – which has been financially devastating. Finally a little over a year ago I went on antibiotics – and immediately felt better, with more energy and better focus. Went to a recommended ENT, whose nurse said I had a fever and whose tests came back high indicating an infection – he insisted I just had environmental allergies and needed shots (apparently he was expecting my test results to come back low and when I said high meant infection he stopped talking.) That lead me to find a naturopath/MD with a biochemistry background. She’s getting noticeable results (according to neighbors and family, not just me.) She found walking pneumonia infection, fungal infection, mold infection, dairy allergy, and suspects lyme’s disease (I have most of the markers but the other problems could be masking the others – the pneumonia treatment should also knock out the Lyme’s.) She is treating me with antibiotics, and supplements (which many say aren’t proven but which help me), and homeopathy, and diet, and herbs. This is why I disagree that publications with inconclusive results or small sample size are a bad thing. People’s lives are affected, if they can find the right treatment sooner because of an article or early test indications it means the world to that person. If a doctor is inconvenienced because they have to explain why it is or is not a good idea that’s a small price to pay in my opinion.

    Posted by sporting4231 | February 26, 2017, 6:59 am
  15. Teaching older hospital staff is much harder than younger staff. I’ve just been teaching a whole bunch of 4th year MDD students about searching Medline/PubMed and giving introduction classes about writing literature reviews. They seem to grasp the concepts much easier than older staff (the students are also working as juniors at our hospitals). Not only is the problem with publish or perish – there is a whole bunch of parasitic publishers out to con clinicians to publish in their shonky journals. Not only will their research disappear into a black hole (terrible fate for good research) their reputations will be soiled as well. So we have this literacy problem with clinicians of all levels to counter as well. There needs basic empathy training as well as how to deliver bad news. But also, there needs communcation training and how to accept that you are wrong. Drs are not infallible! I find it amazing that that that study you mentioned Jacqueline about EBM not considering the clinicians experience is alarming because EBM is all about the trinity – evidence, clinical experience and patient preference.
    My husband has been writing his art criticism blog for 10 years and he has his fair share of trolls – he wrote this about his years of blogging: https://melbourneartcritic.com/2017/02/16/10-things-i-have-learnt-from-my-years-of-blogging/

    Posted by Catherine Voutier | February 26, 2017, 3:31 pm
  16. The 3 most egregious actions modern medical scientist have allowed destroying society:
    1. Believing that a superior race can be designed by killing off the perceived weaker races.
    2. Thinking that nuclear power will keep the peace on Earth and yield good will towards ALL humankind.
    3. The AMA allowing the idea of removing bone, (living, viable, restorable, auto-healing, and rejuvenating) to treat physical pain in muscles easily cured with massage.

    I’m a physician of 33 years, and I have wondered why hundreds of my patients over the decades continue to complain about pain after wrist, thumb, knee, hip, shoulder and back surgery.

    The precise cause-effect answer is that removing bone was never designed to fully and completely benefit pain in the leg.

    NO human can outdo natural living, viable, auto healing bone!
    Bone is the most durable organic material designed by evolution forces!
    Humankind will never be able to beat this perfect design!

    It took me a few years to figure it out.
    Muscle is the organ tissue location of this pain!!

    Skeleton, joints, joint structures, cartilage, meniscus, vertebrae, discs, nerve roots, and peripheral nerves cannot be the first cause physical pain.

    Physical pain is located in the soft, connective and muscle tissues quickly treated with physical therapy, massage, ROM, lots of stretching, pullings, active tissue release, dry and wet needling.

    If you still living with ongoing physical pain, then you can ask your primary care providers to find someone who has those skills within your network. This may be a challenging task because those options had been taken away.

    Wondering how knee replacements can into use? Money and power.
    This insane idea was invented to circumvent the science and evidence for-profits. We all were tricked! 😦

    “First, do no harm” -Hippocrates
    “A physician without a knowledge of Astrology has no right to call himself a physician.” -Hippocrates
    “Whenever a doctor cannot do good, he must be kept from doing harm.”- Hippocrates
    “Wherever the art of medicine is loved, there is also a love of humanity”-Hippocrates

    Posted by Stephen S. Rodrigues | March 6, 2017, 4:56 pm

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