In Manu Medici: The Art of Administering and Prescribing Medications

Hitting machine with hammer: 1.00

Knowing where to hit machine: 999.00

Total: 1,000.00

There are many versions of the story with this punch line. One is about a plumber, another about Thomas Edison and a third is said to be translated from Arabic. There are even claims that it is an old Norwegian anecdote.

My subject is not physician fees or salaries, but physician skill and experience. Just like painting or gourmet cooking, the practice of medicine can seem deceptively easy to the observer, but it can seldom be done well the first time.

Few people would question the value of experience in the surgical specialties, but medication prescribing isn’t always viewed as an equally complex medical service.

In medical school we memorize which drugs are preferred for which conditions, but our training gives us limited practical experience with these medications. That experience comes with use and over time.

A medical school professor of mine said: “Choose a few drugs from a class, get familiar with them, and stick with them. Add new ones only if they offer a clear advantage over the ones you know.” Today, there are often more similar members of many drug classes than most physicians can become thoroughly familiar with. An unfamiliar drug, even if it has a theoretical advantage, can be harmful to the patient if it is less than expertly prescribed.

When I worked in Sweden, we wrote “In Manu Medici” on prescriptions for medications actually administered by the physician. The words mean “In the physician’s hand”. Strictly speaking, though, I think even medications administered by the patient, including most pills and topicals, are used in the physician’ hand, since the same medication can have widely different results depending on how it is dosed, when and how it is administered and how it is suggested and explained to the patient.

I have reflected before on the art of dosing antidepressants and on giving injections. Choosing the right medication in the first place is often complicated and not easily done without experience.

Probably the two most “artful” areas of prescribing I get involved with are heart failure and depression. The placebo effect in depression treatment is almost as big as the proven benefit of antidepressants, and each member of the antidepressant class seems to have a different set of effects and side effects: Fluoxetine is energizing but often not tolerated by very anxious patients, paroxetine can be mind-numbing and may insulate patients from even appropriate degrees of emotional pain, sertraline is quieting but can break down the defenses of tenderhearted, gentle men, and citalopram turned out to have more side effects even though it was marketed as better tolerated. Bupropione is sometimes particularly helpful in depressed patients with anger issues, and duloxetine brings out aggression in those who harbor potential for it.

I once heard of an overworked psychiatrist who told a primary care provider that a consultation wasn’t necessary because both clinicians had the same number of medications to consider for the patient. That reminds me of an amateur Iron Chef contest I saw, where one contestant couldn’t get the skin off a salmon. Having something at your disposal doesn’t guarantee you can do the right thing with it.

Recently a colleague switched a patient with Parkinson’s disease from pramipexole to ropinirole because the patient’s new insurance wouldn’t cover the first drug. Within a week, the patient became psychotic. After stopping ropinirole, the patient recovered. It was then easy to get a Prior Authorization from the insurance company for pramipexole, which in practice has fewer side effects than ropinirole. Reading the official drug information, you would never know one drug was a little safer than the other, yet this type of substitution is now becoming automatic in many hospitals and nursing homes, and may soon take effect also at the pharmacy. In our Parkinson-patient the doctor was the one who switched drugs because of the insurance – what would have happened if the pharmacist had made the switch? When would the doctor have found out about the substitution? Before or after the patient became psychotic?

“In Manu Medici” is not how today’s health care system views prescribing. When insurance companies and pharmacists want a say in the choice and dosing of medications, the artfulness of the physician may have to be partly utilized to navigate the system and to minimize the damage caused by outside influences on the therapeutic relationship and the treatment plan.