For Every New Medication 2 Need To Be Removed

One of Donald Trump’s campaign promises is:  “I will formulate a rule which says that for every one new regulation, two old regulations must be eliminated.” No matter what you personally feel about the new president this idea makes a lot of sense.  Many would be happy with just “no new rules, period!” But the 2 for 1 rule (a two-fer) can easily be transmitted to multiple other areas of consideration, especially in pharmaceutical realm regarding prescribing of endless medications without making the critical decision to eliminate any.

Problems with side effects and medication reactions plague the elderly and/or chronically ill patient who carry or store suitcase full bins of pharmaceuticals. Compounding this, when more than one doctor is involved, they rarely decide in concert what to use, and multiple treatments from a stack of practitioners often lead to serious consequences.

The article Adverse drug reactions in the elderly author quotes, “Medications probably are the single most important health care technology in preventing illness, disability, and death in the geriatric population. Age-related changes in drug disposition and pharmacodynamics responses have significant clinical implications; increased use of a number of medications raises the risk that medicine-related problems may occur. “

The number of patients suffering from polypharmacy, significant adverse reactions, and admissions to the hospital is significant and radically increases with age. Many are dose related which alter blood levels of potentially beneficial medication; these can then become life threatening. A good example is blood thinners whose pharmacology can be affected by multiple contemporaneous common medications like antibiotics or ulcer medications.

In a prior blog, a semi-tongue-in-cheek approach was suggested: if the medication bag was too complicated to list easily then the bag should be weighed, discarded and start new treatment plans from scratch. It is not a bad idea. Why weight it though? Some kind of list should be made before tossing that considers what symptom or problem the pharmaceutical is supposed to address. Then after tossing the bag, one can see if each problem still exists, and if a therapeutic avenue has been taken with the new medications.

In conclusion: many seriously ill patients need multiple medications to survive but after too many, a situation of diminishing returns sets in, and side effects often become more serious than the original problem. Maybe, after 5-6 medications are prescribed for chronic complaints, a serious analysis of the need for “all” of these treatments needs to be done. Taking unnecessary medications can be dangerous, create new clinical problems, and dramatically increase the expense of care. Adopting a policy similar to the regulation policy suggested in the beginning may be a good start.  In fact, any individual on more than 5 medications deserves a review on a regular basis, with the intent of eliminating any that are either ineffective, dangerous, or in excess.

Deterioration of the House of Medicine

Today's guest blog by Dr. Donald Kamens, discusses the top ten things that have led to the destruction of medical care in the 21st century. Unfortunately, the list is endless. These are in no particular order, except to say, that the next item is often more odious than the previous.  Here, then are some of things that have gone terribly wrong, and from which we seem unable to turn back.

From a doc of four decades, these are some of the forces that have served in the continual and progressive plight of medical care. Here is what I think needs to be eliminated from the House of Medicine: What do you think?

1.            DTC (Direct to consumer) pharma ads.  Think of it.  Can you remember when such a thing was actually a heresy?  Illegal?  If so, you are older (like me!). Then, the sound of a jazz guitar did not conjure up male performance anxiety and a reach for the pill. Then, all the side-effects of any drug were not spouted off by fast-talking actors, and “tell your doctor if…” were not fare for a commercial break.  Most of you know that the doctor-patient relationship is totally undermined by this crass pharma commercialism.  Ads for pharmaceuticals needs to be made illegal again. Let the doctor do the analytics and the deciding. This does not need to be a patient activity, one more closely related to recreational substances than to therapeutic medicines. At least allow the patient to choose whether to have to listen, to hear, that baloney or not. And choose whether to explore through research online or not.  In the meantime, we could let football games be football games, instead of marketing venues for various chemicals. Sure, beer is a chemical, but it is fine.  What to do:  pull the plug on greedy pharmaceutical manipulations that do well to nothing but confuse patients, and distort the role of the doctor.

2.            Barriers to doctor-patient relationship:  The prime examples here are EHR screens, creating ridiculous busy-work that makes seeing patients like filling out tax forms, and increasing pressure to see more patients in less time. Seriously?! Despite being an advocate of EHR from long ago, and an early developer, they have gone to another universe. Now we have complexity after complexity.  The EHR is such a pain, we have an ever increasing presence of scribes and other assistants assigned to deal with the clerical. Does this not attest to the progressive marginalization of the physician from the therapeutic relationship?  What to do:  eliminate documentation criteria; eliminate reimbursement based on completed charting items.  A one line should be good enough.  “Put her on antibiotics for the pneumonia, and told her to see her doctor and/or come back if not better in two-three days, or if worse. “ Not much more needed.

3.            Liability. Little more needs to be said about that nasty word, but just to be clear….here I am, on the way to work; here I am going to go help someone today.  And they often need help it seems. But wait!  I have to worry about being sued. Alost forgot! I have to think about being hurt-back by the one I am trying to help-out. Seriously?  What to do:  tort reform is not a good plan.  Why? The complexity of work-arounds would be just as overwhelming.  Simply do this: eliminate liability.  If you are there to help, you are there to help.  If you screw up, you screw up.  It is going to happen at times. The house of medicine should not allow overwhelming vulnerability, hurt to the one trying to help. Do it Shakespeare’s way, or make suing doctors illegal.  If done, the costs of medicine will go down, down, down.

4.            Reset the goals: Make patient outcome goals vastly more important than economic goals. More important than throughput statistics. Outcomes do not have to be specific (e.g. cure of coronary syndrome)...BUT Can be non-negative intermediate outcome based.  EG—the patient did not die in the ED; or the patient feels better, now, though we do not have a definitive diagnosis.  Other examples of how this has gone awry include readmission criteria -an economic goal gone haywire, causing care to be stopped before its time 2. Inpatient census monitoring - the goal should be zero census, as everyone would then be well   3- etc., etc.)

5.            Role confusion - (no one more confused than patients: who REALLY does what...doctor, nurse, PA, NP, pharmacist, unit secretary............and the ubiquitous "I never got to see the doctor"). Eliminate the vague uniforms.  Make it consistent with consistent name tags. 

6.            Stating Lies, such as health insurance = healthcare.   (Being "insured" in 2016 guarantees neither care, nor an affordable bill) 

7.            Middle men (modern medicine has seen an ascendency of middle men, not only for pharmaceuticals, but also for devices, services, etc. Too many hands in the pie, means the cost goes up, and up).  Why (Why???) do you have to have 100’s of companies trying to get a piece of the ACA or Medicare pie by offering to find YOU the right plan? Why.  Make is simple, stop this stupid spending on overhead.

8.            Fostering of unrealistic expectations - patients, very often, expect to have something available that has actually not yet been invented.  It can be a world of science fiction.  “What do you mean that your hospital cannot get/read the record from that place I was at over vacation??? “  You mean you cannot reverse my husband’s stroke?   On and on.

9.            Blindness: Here we are: what you might see does not really matter; what is recorded does.   Hard evidence (numbers & testing) has displaced observation, history-taking, examination. (Ask any plaintiff's attorney).  

10.        Stabilize the rapidly shifting medical model Pick a recent approach; stay with it as long as possible. Get ready for change.  Why?  (During the time from symptom to diagnosis may be enough time for accepted criteria for a given entity to change).  Too fast to keep up with.

#11 – 1000+ Get the EHR thing right: Look it is ridiculous to have an ever increasing percentage of time spent on wrestling with these things, time that could be used for patient care.  There are not getting better. Even the good companies know it. Government criteria are getting more and more burdensome. The absence of true interoperability is not tolerable, especially to patients who simply cannot understand why hospital X does not have the information from hospital Z. Let alone why doctor A does not have the information from doctor B at the same facility.  It is a mess. Acknowledge it.  No problem was ever solved without admitting it exists.