A Country Doctor Writes:

“Let food be thy medicine and medicine be thy food.”

                                                                                       Hippocrates

“I saw few die of hunger; of eating, a hundred thousand.”

                                                                                      Benjamin Franklin

“The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”

                                                                                       Sir William Osler

The US Pharmacopeia is a tempting smörgåsbord of medications for every conceivable disease, ailment and risk factor. It can be approached either as a well-stocked holiday table for careful sampling or as an all-you-can-eat affair. Too much of anything can be deleterious to our health.

At a Swedish smörgåsbord, you typically don’t try to eat everything offered, and you avoid putting too many different things on your plate at the same time. On formal occasions you make several trips to the buffet table and use a clean plate each time. The smörgåsbord is just like a multi-course dinner with a choice of self-serve selections for each course. Etiquette suggests that the first plate includes your choice of pickled herrings and sharp cheeses, the second plate your choice of smoked salmon and other cold fish dishes, the third one cold meats and sausages, the fourth one warm dishes and the fifth one cheeses or sweet desserts.

Polypharmacy has become a buzzword in recent years. Most dictionaries have two definitions of the word, one neutral and one derogatory. The word can simply mean administration of a large number of medications, or it can imply administration of unnecessary medications.

A patient with several chronic conditions may end up taking a large number of perfectly appropriate medications. Even such “appropriate” polypharmacy can cause problems, particularly in the elderly, who are more prone to suffer medication side effects. Also, our understanding of drug metabolism and drug-drug interactions continues to evolve. For example, just within the past few months there have been new warnings about interactions between decades-old medications like simvastatin and amlodipine.

A recent example of how prescribing multiple medications can be fraught with problems is combination therapy for lipid disorders. Well-meaning doctors have combined statins with fibrates and even niacin in order to make each measurement in their patients’ lipid profiles normal. To this day there is no evidence that anything added to a statin regimen further decreases risk, even if a patient’s triglycerides and HDL are off the chart, including several studies published in the last 18 months.

No prescriber thinks they are prescribing too many medications. Since there is disagreement over exactly what number of medications constitutes polypharmacy, and since the word has become so derogatory, I suggest we instead speak of what we should strive for.

I suggest we use the term OLIGOPHARMACY to mean the administration of as few medications as possible to achieve our therapeutic goal.

Just the way a Swede may choose only one or two flavors of pickled herring for his first course at the smörgåsbord and leave some room for the next several courses, physicians may want to choose only a few of the best evidenced drugs for each of their complex patients’ primary diseases in order to also leave room to treat their multiple other medical conditions.

Years ago, I read an article, written in jest, suggesting that a fistful of medications, each with a certain proven percentage of risk reduction, could eliminate heart disease completely. Even when there is statistical evidence that a number of different medications can decrease risk or improve outcomes, we cannot assume their effects are multiplicative or even additive; sometimes all they do is increase the risk of side effects.

Let us think and act like polite Swedes at the smörgåsbord. Pick and choose among the favorites. Let’s not overindulge.

Last weekend I sat down to look at some of the journals I receive at home in the mail. A couple of articles caught my interest, all touching on how we use the medical record.

Dr. Aldebra Schroll describes in an article in Medical Economics how her meticulous medical records were used to deny her patients new insurance coverage after some of her patients lost their jobs and their health insurance. One new patient didn’t tell Dr. Schroll for a whole year that she had Multiple Sclerosis for fear that she would lose her insurance because of her illness.

Dr. Ranjana Srivastava, in her article, Complicated Lives – Taking the Social History in the New England Journal of Medicine tells of when she sat down with a clinic patient in her oncology department. Several doctors rotating through the clinic had seen this woman, but Dr. Srivastava had never seen her before. The woman becomes increasingly upset as the visit goes on. Frantically, the doctor searches through the electronic medical record for a clue. Finally, the patient blurts out:

“Didn’t they tell you? My husband, he died from cancer last week. He died in that hospice of yours.”

The nurse, it turns out, knew what had happened. The doctor asks how.

“Because I talk to her”, the nurse answers.

Also in the New England Journal of Medicine, Dr. John J. Frey III writes about the days when there was no such thing as a “routine HIV test”. I remember in my clinic, we called it a “Special Draw”. Patients usually paid in cash and no claim was submitted to their insurance. We usually stored the results in a special “XYZ” record to protect each such patient’s privacy.

The Journal of the American Medical Association has a commentary about a new Florida law that makes it illegal for physicians to note in a patient’s medical record whether there is a firearm in their household. This standard part of health risk screening in the U.S. is now punishable with a $10,000 fine and disciplinary action by the Florida Board of Medicine.

Why do we write things in our patients’ medical records? It used to be that doctors wrote brief notes to document their treatment. I remember two pediatricians I rotated with during my residency. They knew each other’s styles and preferences inside out. Their office notes might read:

“LOM. Amox”

(Left otitis media, amoxicillin). For a busy pediatrician, an ear infection usually requires no further introduction or explanation. They occasionally scribbled something about their patients’ social histories in the margin or on a problem list that later jogged their own memory, but would be meaningless to other readers.

The world has changed a lot since then, but only the uninitiated expect medical records to be complete and accurate. Patients, doctors, administrators, government, malpractice lawyers and insurance companies all have different expectations from the medical record. Whether we have records scribbled on 4×6 inch cards, typed notes or electronic medical records, their purpose is in the eye of the beholder.

Ironically, I see more and more often that slick, boiler-plate, pre-populated electronic record notes brimming with data that appear to support high-level professional Evaluation and Management coding still have a brief free-text note by the recording physician, explaining in three sentences or less what really happened in the visit. Those brief notes harken back to the brevity of old, but since today’s records are viewed by many more eyes than those of the past, not even those notes always reveal the true essence of the patient-physician encounter.

“The conflict between evidence-based medicine and individuals is at the core of the struggle to reduce the cost of care.  I fear it is intractable and will remain so… We need to talk about the tensions and uncertainty, with respect for each other and with open minds. I’m not sure what solutions are possible but without an ongoing, messy discussion, we won’t find out.”

Jessie Gruman

“In a recent experiment, the average effects of the opioid remifentanil were either doubled or extinguished by manipulating subject expectations; functional magnetic resonance imaging scans showed that regulatory brain mechanisms differed as a function of these expectations. Does this mean that we might double our gas mileage if we wished for it hard enough? Well, no. But people are not machines, and we shouldn’t treat them as such.”

Daniel E. Moerman, Ph.D.

“Patient Centered Medicine” sounds ethical and humane. It almost seems like an obvious thing to strive for, but it is far from universally accepted. Many stakeholders and quite a few opportunists in today’s health care system are working hard to shift power further and further away from the patient-physician decision-making that takes place in the exam room.

In every patient visit there are at least two more parties represented besides the doctor and the patient:

Since the majority of patients are covered by health insurance, the insurance company is always present in any decision that involves money. It would be naïve to expect anything else; that is what happens when someone else pays the tab.

In recent years we have also started seeing “experts” of various kinds judging or prejudicing the medical provider’s performance. Most of the time, these “experts” make recommendations and publish “guidelines” without much authority behind them, since there are often competing guidelines for doctors to choose between. Lately, though, through stronger associations between payors and “experts”, “guidelines”, now re-introduced as “Evidence Based Medicine”, are increasingly used to control what happens in the exam room.

The notion of practicing “Evidence Based Medicine” is not new; doctors study the basic sciences in medical school, read scientific journals and attend continuing education courses to keep up with new developments in their field. What is new is the notion that doctors somehow cannot be trusted to weigh all the available evidence, like other professionals, and sit down with individual patients to discuss how the evidence applies to each unique case.

The “Evidence” seems to have lost its plurality, which is more consistent with the thinking of statisticians and insurance actuaries than with science. The more we learn about diseases and the human body, the more we understand that people are different. Genetics and neurobiology are beginning to explain why treatments that work in some patients may not work in others, and may even be harmful to some.

Jesse Gruman, in her springboard article for Better Health’s Grand Rounds, writes about the inherent conflict between Patient Centered and Evidence Based Medicine in cancer treatment. In each such case, the personal and financial stakes can be enormous.

On July 14, The New England Journal of Medicine published a study comparing inhaled albuterol, the Evidence Based, time-honored treatment for mild asthma attacks, with placebo inhalers, sham acupuncture and doing nothing. Only the albuterol inhalers improved patients’ breathing test performance, but the patients who received placebo inhalers and sham acupuncture experienced the same amount of symptom relief. Only the patients who received nothing were unimproved.

Daniel Moerman, in his editorial, comments on the study:

“For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson’s disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician… Usually the control is designed to convince the doctor yet is irrelevant for the patient and patient-centered care. Often the very assumption that there is a correct control simply is not the case… Maybe it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects over the short or long term. This is, after all, the first tenet of medicine: “Do no harm.”

Moerman’s words challenge us practicing physicians and scientists to be prepared to reconsider the purpose and priorities of many of the things we do on a daily basis. His words must be even more unsettling to all the non-clinicians who make their living trying to tell us what to do.

Dear Patient,

You and I have been working together for many years now, and we have had both triumphs and disappointments. You have looked to me for guidance and advice about many different medical issues, and sometimes also about life’s other challenges.

I hope I have been helpful most of the time, but I know there have been times when I have misled you. In the years since I came to this area, fresh out of residency, many things have changed – in medicine as in life in general.

I told you to put your first baby to sleep on her belly, because that was what medical science thought was best then. Now we believe that to have been bad advice, but Emily still grew up to be a healthy young woman, who now has a beautiful little girl of her own.

I told your husband to go on a low fat diet and to eat less salt to help manage his weight and high blood pressure. It seemed like such obvious, medically sound and commonsensical advice at the time, but it turned out to perhaps be the wrong thing to do. As I learned more, I told him to cut the carbohydrates and increase his intake of heart-healthy fats and that did seem to help his numbers. Eventually, Jim ended up on blood pressure and cholesterol pills as we both entered middle age. I am proud that the two older medications we started have stood the test of time and both proven themselves again and again to lower heart attack risk. I hope they will help Jim stay well and avoid his father’s fate.

I told your mother to consider estrogen replacement in her fifties, because it seemed to offer so many benefits beyond just relief of hot flashes. We will never know if that is why Sandra developed breast cancer. I am just grateful we caught it early and that she has stayed healthy and cancer free through her eightieth birthday.

I am grateful that your father never suffered any harm from Duract or Vioxx, the two arthritis medications I prescribed for him in the belief they were safer and more effective than ibuprofen. I had him stop taking them long before they were withdrawn from the market, because I followed the literature, but I know now I was too quick to prescribe them for him.

Your mother-in-law’s diabetes seemed difficult to control and she wanted to try the newest medications. I should have been more conservative, but thought Rezulin seemed reasonable to try. Just like your father’s arthritis medication, it was eventually taken off the market. When I shared my concerns about it, she accepted my suggestion to start insulin. Her blood sugars have been well controlled since then.

When we first met, I seemed to be the one who provided you with background information on your family’s medical issues, but now you have already read up on symptoms, diagnosis and treatment on the Internet before you see me. These days I feel more like an interpreter than a repository of medical information. I have enjoyed the transition, even if it has exposed how much more there is for all of us to know. I think I can help you look at different sources of information and help you weigh them against each other when they seem to be in conflict.

Over the years I have become more humble about my medical knowledge, even as I have learned many new things and gained more experience. When I first came to this country I had to quickly adapt to the relatively slight differences between medical practice in Sweden and in the US. I quickly realized there was more than one truth, more than one way of doing things. Now, after watching dozens of seemingly immutable truths shatter or fall in and out of fashion several times during my thirty years of practice, I know not to take any fact as absolutely certain.

I appreciate you staying with me as I have tried to apply what I have learned to your and my other patients’ benefit. As medical knowledge expands and treatment options multiply, I will do my very best to stay current without being swept away by unfounded enthusiasm for ideas and medications that may turn out to be short-lived fads.

I am not old yet, but my line of work is ancient. One of my medical school professors told my class we were there to learn how to learn. I never imagined then how many things I would learn, unlearn and relearn in the years to come.

You know by now I am not infallible, but I try very hard to do right by you. Thanks again for trusting me to be

Your

Country Doctor