Primum non nocere has always been my medical mantra. Hippocrates is credited with this dictum, and it means First, do no harm.

As I reflect on three decades as a doctor, I am reminded of how much fun I have had and am grateful to have studied and practiced medicine later in life.

Starting in my late thirties allowed me to benefit from past experiences. Younger students do four years of college, four years of medical school, and graduate into residency programs of three to seven more years to learn their specialty. They emerge from their all-consuming educational cocoons with limited life experience.

These years of learning are physically and financially exhausting, stressful, and isolated. There are few chances to experience the birth of a child, death of a loved one, or a job you hate. Patients will present for help with all these issues. Younger physicians are less than fully prepared.

Education does not help a physician understand loneliness, alcoholism, child abuse, bad bosses, financial crisis, addiction, or poverty.

In the age of the internet, there is a vast amount of information for those able to access it. An inquisitive person can often figure out what is wrong with themselves before seeking a doctor’s advice and confirmation.

"Doctor" is a title that establishes credibility with persons in need or distress. That credibility comes with heavy responsibility as disease and psychiatric illnesses are everywhere. Airplanes bring infections. Water and food carry and spread germs, and alcohol, smoking, and sugar cause severe illnesses. Young and old often die too soon. After decades of learning from my patients, I have become a teacher. Doctors, physician assistants (PA) and nurse practitioners (NP) come for advice.

"Do I cut the abscess? Does she need to be in the hospital? Is this EKG showing ischemia? What should I do? Will this medication cause harm?" I have the experience to change lives. To ignore my advice can be harmful – a sin against the institution of healing.

Most physicians are quite good at what they do, but success is limited by what they know, and especially by what they don't know. Knowledge grows with experience, and without constant striving to keep current, a physician’s knowledge becomes outdated. Technology bypasses some. Medical advances blow past what they were taught.

There is an increasing number of physician extenders providing medical care. These physician assistants and nurse practitioners provide needed access in a world with a growing population and not enough doctors.

I regularly encountered misdiagnoses, unnecessary tests, misuse of drugs, or other problems caused by well-intentioned but under-trained medical providers. Urgent care clinics are popping up manned only by physician extenders. A supervising physician might have oversight responsibility for forty to fifty extenders. Some states do not even limit the number of supervised physician extenders. It is a system doomed to failure.

Our health care insurance plans are inefficient and unfair. Insurance companies force providers to use medicines based on price and not on effectiveness. A better way is required - and inevitable.

I have observed doctors practicing in Iraq (the cradle of civilization), and other countries. In 2003, I met Iraqi doctors who had taken advantage of their country's free six-year medical education taught in English. The British had instituted this program in the 1920s after World War I.

Following medical school and an intern year, doctors in Iraq would serve twelve years as a general medical practitioner in outlying areas. They could return to a residency program and learn a specialty after serving and were paid about $100 a month for those first twelve years. There were no nurses or physician extenders.

They lived with their parents or in small clinics far from bigger cities with limited access to medications or specialists. When the U.S. brought more freedom to Iraq, there had been zero access to outside education for the previous twenty-five years. Saddam Hussein had made it illegal for doctors to leave the country as they often never returned. The Internet was forbidden, and libraries had few books.

These doctors learned at the bedside - the honored Hippocratic method. Teachers passed on what they could from memory or notebooks they carried. Iraq had once been the shining star in the Middle East medical world. But, after years of suppression, they practiced the way they had years before.

"Why do you do this?” I inquired of the doctors.

The answer was almost always the same. "I want to help my people." 2

I realized that these physicians were much like our American frontier doctors. In the early 1900s, U.S. doctors did everything. They were obstetricians and surgeons and family doctors. They were paid with pennies and chickens. They did it because they wanted to help others. They were honored and respected and often did their work for free. It was a calling in the highest sense of the word.

Technology continues to make each day more exciting and productive. It also makes it more dangerous. There are more treatment and testing options, and we can do so much more.

But there is much we should not do – just because we can. Pray that physicians continue to seek the wisdom to know the difference.

Primum non nocere.