As Tolerated Jun 8, 2014

by RICK RADER, MD * EDITOR-IN-CHIEF

Medical advice is a tricky thing.

For the most part physicians will provide very specific, well defined directions. "Take two pills (200 mg each pill), three times a day, with food, and stop immediately if you begin to break out in a rash and call the office." Pretty precise (okay the concept of a "rash" might be up for interpretation).

"Holding the red elastic strap between your two hands stretch them out to shoulder width eight times, rest for 30 seconds and repeat. Do this three times a day for 7 days and then progress with the blue elastic strap for an additional 7 days." (No misunderstanding of "two hands," "30 seconds," "red strap," "three times a day," "7 days.")

"Floss after every meal." (Pretty straight forward.)

Even the ancient physicians gave "precise" instructions. The ancient Ebers papyrus (circa 1550 BC) referred to a favorite prescription given by doctors for the purpose of disease prevention, "Wash and shave the body." It left little up to the patient's interpretation. It indeed did have a positive impact on skin infections caused by sand infested insects.

And then they threw in a ringer. They added the "modifier" that changed the playing field. It changed the equation between the physician and the patient. It might have been the first time that the physician looked up from behind his oak roll top desk, or the stack of parchment or the clay tablets they used to provide instructions for the patient.

"AS TOLERATED" changed the dynamic.

Prescriptions, orders, instructions, and dictates now recognized the individuality of the person. (What a concept!)

No one is sure when they first began to appear and influence the medical landscape. Was it a change in the perception of the clinician's role as a partner and not as a patron? Was it simply to shift the onus of a failed treatment regimen? Perhaps it had its underpinnings in "return to work" legal concerns.

"Diet as tolerated." "Weight bearing as tolerated." "Activity as tolerated." Medicine was introduced to a new paradigm, a new construct and perhaps a new approach. There were now two moving parts to the prescription. There was the recommended action followed by the intensity, time and duration. It was now up to the patient to ascertain how compliant, engaged and responsible they would be in defining their index of adhering to the treatment. The future of medicine is all ablaze with the prospect of individualized genomic-pharmaceuticals, drugs that will be genetically tailored for the individual. Perhaps "take as tolerated" beat them to the punch with the inherent recognition of the individual and the prescription.

There is a mistaken belief that the longer the patient could "tolerate" the advice (whether it be a hot compress, treadmill or diet) the faster they could recover. The "no pain no gain" message might have been an effective poster on a gym wall but it had little "evidence" as a therapeutic rule.

It is well appreciated that the rate limiting step for "as tolerated" is simply pain. With that in mind, perhaps the medical instructions should appear as "take it until you can't take it anymore," or "do it until it hurts and it hurts about as much as you can handle it."

The Disability Rights Movement was founded on "as tolerated." Parents, advocates, people with disabilities" had their tolerance levels, their capacities and their thresholds put to the test. When they realized that the pain of being ignored, marginalized, isolated and devalued was "intolerable" they became mechanized and mobilized. They were told by society that they would be tolerated. But it wasn't quite enough. They needed to be included, counted and considered.

They were appropriately tired of simply being given space, time and access. It was always all about being respected, dignified and recognized. The Disability Rights Movement continues to be intolerant of tolerance. They do not want or seek tolerance. There is an inherent apathy about tolerance; it's the moral equivalent of that most annoying term, "whatever." One does not have to be a historian to appreciate Thomas Mann's observation that "Tolerance becomes a crime when applied to evil."

Tolerance, whether it's part of a doctor's orders, or mandated by law is an imperfect term. In fact it has been recognized as being so imperfect that it has given rise to the creation of the new idiomatic expression, "zero tolerance." The term negates the very essence of the idea of tolerance.

Arthur Japin, the Dutch novelist, has captured the significance of the unacceptability of tolerance: "If you accept others as equals, you embrace them unconditionally, now and forever. But if you let them know that you tolerate them, you suggest in the same breath that they are actually an inconvenience, like a nagging pain or an unpleasant odor you are willing to disregard."

And when it comes to nagging pains, in all their expressed forms, you don't have to simply tolerate them.

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