Patients May Get Better When They Stop the Treatment
There was an article in the 24 January 2015 edition of The British Medical Journal (BMJ 2015;350:h176) which I read with a growing sense of incredulity and dismay. I found myself repeatedly muttering Of course! and Obviously!
It’s called Managing patients with multimorbidity in primary care. Multimorbidity means two or more chronic (long-term) illnesses suffered concomitantly. For illustrative purposes a hypothetical 78 year old woman is described:
…with a previous myocardial infarction, type 2 diabetes, osteoarthritis, chronic obstructive pulmonary disease, and depression. She would be prescribed [according to UK clinical guidelines] a minimum of 11 drugs, with potentially up to 10 others…and would be advised to engage in at least nine lifestyle modifications. In addition to unplanned appointments, she would be expected to attend 8-10 routine primary care appointments for her physical conditions and 8-30 psychosocial intervention appointments for depression and advised to attend multiple (that word again; what’s wrong with ‘many’?) appointments for smoking cessation support and pulmonary rehabilitation.
No wonder she’s depressed.
Depression is a symptom, not a diagnosis; one might start with that and work backwards.
This hypothetical poor lady is being treated according to guidelines and the above description is the mess you get into as a result.
Are doctors these days afraid to do anything unless they follow guidelines? What about their medical knowledge? What about their experience? What about common sense?
It’s absurd that any patient should be taking ‘a minimum of 11 drugs…with potentially up to 10 others’. Presumably her long list includes a statin (to reduce cholesterol), a beta-blocker (to regulate the heart rhythm), an angiotensin converting enzyme inhibitor (to lower blood pressure), two oral anti-diabetic agents, paracetamol (pain-killer), a non-steroidal anti-inflammatory drug (for arthritis) and a serotonin reuptake inhibitor (for depression) – and that’s only eight.
One of the arts of general practice is helping patients with multimorbidities. Every GP should aspire to be good at this. Drugs may have been started by a specialist but that need not mean the GP is bound to continue them. It should be constantly kept in mind that all drugs can have side-effects and harmful interactions. Chemical drugs are not magic cures – they are just that – chemicals. Are they doing her more good than harm? The watchword should be: if in doubt, stop them (or ‘de-prescribe’, as the unnecessary neologism has it.) Therefore, the first thing to do for this hypothetical patient, in my view, would be to stop as many of her drugs as possible. For example, I cannot see the point of a 78 year old woman taking a statin even if she has had a heart attack. And maybe she should be left in peace to continue smoking if she seems disinclined to stop.
Perhaps the drug she doesn’t get in the right dose is the one, described as long ago as 1957 by Michael Balint (The Doctor, His patient and The Illness), called ‘doctor’. The most important aspect of this is that there is one doctor – her own doctor – who is like the conductor of the orchestra. If enough time and care are taken over her – as they should be as a matter of course – then perhaps she wouldn’t be depressed, so the anti-depressant(s) could be stopped. Give her the minimum of drugs that are needed to treat specific conditions or control symptoms. Polypharmacy (the use of several drugs or treatments) in an effort to delay the inevitable – death – needs to be very carefully considered. Or maybe she’s being overdosed on doctors with many (not multiple, please) follow-up appointments – which inevitably involve worry, loss of time, inconvenience and expense.
The article suggests that ‘future developers of guidelines (there we go again) consider addressing more common clusters of chronic conditions. As this is unlikely to be achieved the value of clinical judgment should be recognised and supported.’
Has this only just been thought of? When did clinical judgment cease to be valued? And ‘supported’ – by whom and in what way? Clinical judgment in such a situation is the basic and essential approach to such a patient, or indeed, to any patient. This seems reluctantly to be recognised because the writers go on to say what it should be unnecessary to say:
At times clinical judgment may mean an acceptance that in certain circumstances pursuing stringent disease specific targets is unlikely to be beneficial and may in fact be harmful.
Here we have the problem in a nutshell. It seems clinical judgement is the poor relation of guidelines but ‘at times’ it may have to be resurrected when pursuing targets that may do more harm than good. Obviously! But why should it even be necessary to say this?
Maybe it’s because of doctors feeling they are beholden to another sacred cow: ‘…the potential importance of a multidisciplinary approach in management and a focus on generic outcomes relevant across conditions’ as they wordily put it. (Emphasis added.) This is the conclusion of a paragraph headed ‘Targeting function not disease’, although the preceding sentence in the article makes no sense:
One randomised controlled trial delivered by occupational therapists and physiotherapists targeted functional difficulties of 319 patients aged 70 years or older with multimorbidity and improved health outcomes including a statistically significant reduction in mortality two years post-intervention.
Presumably the second occurrence of the word ‘and’ should be replaced by ‘found’. Even so, I think it highlights a fundamental problem with this sort of approach. You can just hear the patient pleading: ‘I don’t want to be looked after by a team – I want to be looked after by my doctor!’
Even drugs ‘that are not indicated, have inadequate prognostic benefit, or are causing side-effects’, it seems cannot just be stopped by the GP. Well, why not? Because:
…prescribing criteria have [only] recently been developed. Although yet to be validated, these criteria are important steps in recognising and dealing with the treatment burden in those aged less than 65 years. (The word ‘steps’ is redundant.)
Are doctors these days no longer taught pharmacology and therapeutics? (The study of drugs and their use in treating disease.) Do GPs no longer undergo training in prescribing drugs to patients and stopping them when they are actually or potentially doing more harm than good? Surely, good prescribing should be based on minimalism: the smallest dose for the minimum time – if a drug is needed at all.
On the other hand we are encouragingly, if verbosely, told:
General practitioners are uniquely positioned to provide the necessary relational, informational, and managerial continuity of care, and the importance of this function should not be underestimated.
Indeed. But have we not had it drummed into us that general practice is all about continuity of care? Yet the six general practitioner academics who wrote this piece take it upon themselves to remind us that ‘the importance of this function should not be underestimated.’
The same patronising attitude continues as we are told:
Clinicians are encouraged to identify patients as having complex multimorbidity and adopt a practice policy of continuity of care for these patients by assigning them a named doctor. (Emphasis added.)
This makes me almost want to cry. What have GPs been doing all these years if not providing continuity of care to all their patients, and obviously especially to those with ‘complex multimorbidity’ (as opposed to the simple kind of multimorbidity, presumably)?
Why has everything got to be driven by evidence rather than common sense? And what are you supposed to do when the evidence is lacking? Towards the end of the article a trial is reported of UK general practice staff who ‘were trained about available resources including an assessment tool for the support needs of patients, guidebooks on self- management, and a web based directory of local resources.’ Unfortunately, but perhaps not suprisingly, ‘At 12 months follow up there were no reported improvements in shared decision-making, self-efficacy (whatever that is), or generic health related quality of life.’
It seems to me part of the problem is jargon like ‘assessment tool for the support needs of patients’ and, near the end of the piece, gobbledegook:
Having robust systems in place to ensure appropriate monitoring…Practice nurses or other multidisciplinary team members can contribute in specific ways including undertaking target assessment of chronic disease and psychological or functional capacity assessments that can support doctor and patient shared decision making. Multidisciplinary input is an essential component of care…
So now we know.
Of course! Obviously! Part II
Then in The British Medical Journal of 14 March 2015 we have an editorial entitled Guidelines, polypharmacy, multimorbidity, and drug-drug interactions. You can see what’s coming from the subheading: A cascade of failure. Indeed.
The article starts by telling us that polypharmacy often happens because ‘of the application of disease specific guidelines, targeting disease specific goals’ and one result of this is ‘the high rate of adverse drug reactions, mainly from drug-drug interactions.’
A medical student should know that.
What to do about it? An international workshop was convened (I will spare their blushes by not mentioning by whom) which called for:
…more research on potential interactions between a comorbidity and a drug for the index disease, between a drug for a comorbidity and a drug for the index disease, between the index disease and a drug for a comorbidity, and also between recommendations for non-pharmacological treatments.
All clear now?
Then another amazing fact is revealed:
Drugs often have effects that go well beyond a single specific drug target, particularly in patients with comorbidity.
And a question is posed:
How should doctors manage patients with multiple diseases to help to prevent a cascade of problems that start with inadequate guidelines and move through polypharmacy to an increased risk of drug-drug interactions?
One proposed answer to this difficulty is to develop ‘online tools to create multilayered interactive guidelines’, but what to do in the meantime?
I believe the answer is as I have indicated above:
- Don’t be tied to guidelines – use your knowledge, experience and common sense
- Use the minimum of drugs in the minimum dose for the minimum time
- Use drugs only if necessary to treat a defined condition, relieve symptoms or prevent progression of a disease
- Keep constantly in mind the possibility of drug interactions and the risk of side-effects
And finally, and most importantly:
- Remember that patients may get better when they stop the treatment
Note: this post should not be taken as advice for patients to stop any prescribed drug.
Text © Gabriel Symonds