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.