DB’s Medical Rants

Awareness: Doctors Prescribe More Than They Explain

Although there were variations, depending on the type of medicine prescribed, 74 percent of the doctors mentioned the trade or generic name of the medicine, and 87 percent stated its purpose. Sixty-six percent said nothing about how long to take the medicine, 45 percent did not say what dosage to take and 42 percent failed to mention the timing or frequency of doses. Physicians mentioned adverse side effects only 35 percent of the time.

The authors noted that the results may not be applicable to other groups of patients, and that the presence of recording equipment may have influenced what doctors said during the patient visits.

Still, Dr. Neil S. Wenger, the senior author on the study, said, “The problems we’re seeing are exactly the things we see going wrong in clinical practice.

“You prescribe a cholesterol-lowering medicine, a medicine that has to be taken for a lifetime, and the person never refills the first prescription. And we wonder why. Now it’s clear why: we never told them that they were supposed to keep taking it.”

Explaining medicines takes time. I hate to sound like a broken record, but physicians need to take time with patients. There are no shortcuts. Our reimbursement encourages shorter visits, thus many physicians do not take the time to explain medications clearly.

Recalling a patient that I discussed a couple of weeks ago - Preventing diabetes. While we were asked to address this patients diabetes, I also discussed his cardiac medications with him. At that time, his cardiologist had apparently not explained the reason he was now on 4 new cardiac medications.

I often call them the 4 pack - ASA, an ACE, a beta blocker and a statin. So I went into the spiel that has almost become second nature. I spend around 10-15 minutes explaining why each medicine is so important. I try to meet the Charlie Mingus ideal - Anyone can make the simple complicated. Creativity is making the complicated simple.

Almost regardless of how long the patient has had those medications prescribed, when I finish, the patient thanks me for “finally explaining” the medications.

Now there are several possibilities here. First, patients like to flatter their physicians. I know that students and residents “suck up” to me, and perhaps patients do also. Second, physicians explain at times during which patients are not prepared to listen. Thus, the patient has heard the explanation previously, but has not absorbed the information. Third, physicians do not explain medical issues clearly. We rarely specifically teach this important skill. Fourth, physicians just prescribe medications and do not bother to explain what and why.

I suspect that all of this explanations are correct for different patients. Regardless of the reasons, “Houston, we have a problem.”

It actually is even more complicated, as this article points out - Medication ditched too early

It took only one month after leaving the hospital for one out of eight heart-attack patients to quit taking the lifesaving drugs prescribed to them, a study of 1,521 patients found.

“One month is very surprising,” said study co-author Dr. Michael Ho of the Denver Veterans Affairs Medical Center.

The heart patients who stopped taking three proven drugs — aspirin, beta blockers and statins — were three times more likely to die during the next year than patients who stayed on the pills.

The study did not examine why people stopped taking their medicine, but the patients who quit were more likely to be older, single and less educated.

They are in good company. Former President Clinton — a younger, married and well-educated patient — was prescribed a statin for high cholesterol when he left office. But he stopped taking it at some point. At age 58, he had to have quadruple bypass surgery because of severely clogged arteries that doctors said put him in danger of a heart attack.

This article explores the problem and adds this important consideration. Sometimes it is about the money.

The research suggests that patients and their doctors must work harder, said Dr. Patrick O’Connor of HealthPartners Research Foundation in Minneapolis, who wrote an editorial in the journal.

“Patients need to ask, `What are the most important medicines in my treatment, the ones that will help me live long enough to see my grandchildren grow up?’ ” O’Connor said.

Doctors, he said, need to tell patients more about the drugs they prescribe and then follow up with them.

“You think they know what a statin is from watching television, but they don’t know that Lipitor is a statin or that Zocor is a statin,” O’Connor said of doctors.

He also said that if a patient is taking six different pills, doctors should give advice about which ones to stop if the cost gets too high.

Some patients assume they quit their pills if the doctor says their cholesterol looks good, said Dr. Kim Eagle of the University of Michigan.

“Generally, these medications need to be continued to have their benefit,” he said of drugs that fight heart disease. But many factors, he said, conspire against regular drug-taking: cost, side effects, depression, carelessness and a desire not to be someone who takes a lot of pills.

Our responsibility does not end when we (physicians) understand what the patient should do. Writing prescriptions starts the process. We must commit to explaining each medication in more depth.

This rant does not excuse physicians. However, we should not blame physicians, but rather understand why we do not do a great job.

We must reform health care to encourage physicians to spend the appropriate time with patients. We must teach students and residents how to talk to patient, how to explain medications to patients, how to gauge our patients understanding. We reimburse actions rather than words. We reimburse procedures much better than talking. We are getting the health care that our system has emphasized.

Now some will shout for a single payer system. I believe that the Canadian and British systems do not encourage careful explanations. They too have severe time constraints.

We must reconsider our priorities in health care. We must consider ideal medical care, and then develop a reimbursement system which rewards the ideal. This should be our challenge.