On the Perils of Prescribing

Jan, 2017

Before my daughter entered medical school I urged her to study hard and read widely so as to kill as few patients as possible. Her eyes grew wide – but we save lives! Yes, but we also kill, both through human error and by following the standard of care –which may or may not be good medicine. You will remember the faces of those you killed, not the faces of the ones you saved. The medicines we prescribe are powerful and dangerous, capable of producing both good and harm. Supposedly, the first principle in medicine is to “do no harm,” but this is a canard. Perhaps the ancient Greek Hippocrates could apply this principle, though I doubt it. Nowadays when we use a medicine we play the odds as well as we can estimate them and hope things turn out well. For example, I recommended baby aspirin (in accordance with current accepted recommendations) to a female patient of mine to help prevent ischemic (non-bleeding) stroke. About 85% of strokes are ischemic and only about 15 % are hemorrhagic (brain bleeds). At age 73 she had a hemorrhagic stroke and died. The aspirin did not cause her to bleed, but it most certainly exacerbated the bleeding, which then led to her death.

Most elderly patients are on multiple medications and we really do not know how they interact. We usually know how any two medicines will combine, but when you add a third we do not know; when you add a fourth we do not know, and so on. We are creating these chemical soups without having any real idea how each individual will respond. So the addition of each medication is actually an experiment. I once had an 80-year-old patient who came in with his wife complaining of weakness. I had seen him about 4 months before for a routine physical exam and he was fine. Now he was having trouble getting out of a chair or walking up steps. I ordered blood work and radiologic studies and I stopped his statin knowing it could cause muscle problems. He returned the next week in a wheelchair; he had worsened and all his testing proved normal. I suspected his 6 medication chemical soup as the culprit, so I stopped the last medication that I had put him on. No improvement. In desperation I stopped all of his medications, and a week later he returned to clinic having fully recovered his strength. I tried to put him back on medication, but of course he refused and lived for about 2 more years.

Our task as primary care providers is further complicated by two factors. Specialists can and do alter the medication regimen without our consent, even though we are responsible for coordinating care. For example a cardiologist will add a Beta-blocker hypertensive medication that may worsen the patient’s asthma or COPD. Except in emergencies, every medication or procedure should be ordered by the primary care provider for an outpatient, or by the primary hospitalist for an inpatient. Our current system leads to uncoordinated care and a plethora of mistakes that hurt and kill patients. Secondly, herbal medications and supplements are unregulated thanks to Senators Orrin Hatch and Tom Harkins; so we have no idea what is really in those bottles, and no idea as to efficacy or safety.

– Gary Gallo, MD