A little over ten years ago, while on vacation, I brought my son to a walk in clinic for an earache. The physician working that day was very old. As I discussed my son’s symptoms, we were both confused when the physician pulled out a crumbled piece of paper with a list of ten drug names written on it.
Apparently this aging physician had limited himself to the prescribing the ten drugs he had written on this paper, regardless of the problem. Well he wrote a prescription from the list for a rather strong generic antibiotic. We went home and I threw out the prescription. My son’s health issues resolved and we went back to vacation.
The idea of using a short list of medications regardless of the problem is still alive.
The Archives of Internal Medicine recently published a slightly revised version of an old Journal of the American Medical Association (JAMA) article, with the same lead author—Gordon Schiff, a past president of Physicians for a National Health Program (PHNP)—and same content, replete with PNHP press release. Most would consider this publication fraud. Apparently, it is business as usual for these authors.
The article asserts that physicians should use a limited number of generic drugs—a “short list”—and ignore any new innovation. Of course, the media picked up on this with an article in the Chicago Tribune titled “Hold those drugs, doctor” based on a journal article by single payer proponent. Specifically, the article offers six principles that urge clinicians to:
Physicians and Prescribing Medications
Physicians frequently turn to medications to relieve suffering and prolong life, with more than 60% of people younger than 65 years receiving a prescription drug each year. As the authors recognize, it is “unimaginable for most doctors not to turn to the most up-to-date drugs in trying to do the right thing for the patient.”
Yet the authors take issue with physician’s ethical and rational desire to want to help patients, by asserting that their desire to help patients with the “latest and greatest” drugs “is congruent with the messages and interests of the pharmaceutical industry. The authors claim that “medications are commonly used inappropriately,
overused, and associated with significant harm—suggesting the need to more thoughtfully weigh claims for drugs, especially new drugs.”
As a result, the authors note an “alternate paradigm that represents a radical shift in prescribing attitudes and behaviors,” known as conservative prescribing. They explain that, conservative prescribing embodies an important new construct—the precautionary principle—an ecologic paradigm that stresses forecaring, the practice of anticipating potential adverse effects, even when cause-effect relationships are not fully established scientifically.
This approach places the burden of proving safety on the proponents of introducing a new chemical into the human ecosystem and thus encourages exploring alternatives to new drugs. However, Cass Sunstein devastates the precautionary principle in his book The Laws of Fear (2005). The authors omit it from their bibliography. They also ignore that newly marketed ideas may be more lethal than newly marketed drugs.
Nevertheless, the authors assert that “mastering conservative prescribing is especially important for young physicians and trainees, who lack historical knowledge of past drug harms and withdrawals from the market. Early in their careers, when prescribing habits are being formed, they may rarely have encountered patients with serious drug-related problems or rarely experienced the anguish of realizing that a drug they prescribed harmed or even killed a patient.”
To counterbalance these prescribing pressures, which include often unrealistic patient expectations, practice time constraints, and paucity of data and practical guidance, the authors identified six principles for safer and more evidence-based prescribing.
Think beyond drugs
The authors assert that physicians should consider nondrug therapy, treatable underlying causes, and prevention rather than mainly prescribing drugs. They also assert that clinicians should broaden their repertoire to become more skilled and effective at counseling and prescribing exercise, physical therapy, diet changes, smoking cessation, orthotics, or surgery when appropriate. The authors claim that, “substantial literature supports initiating nonpharmacologic measures as initial or preferred therapy for a range of conditions commonly treated with drugs, such as hypertension, diabetes, insomnia, back pain, arthritis, and headache.”
Practice more strategic prescribing
The article recommends that physicians “use only a few drugs and learn to use them well. Specifically, the article recommends that physicians:
- Defer nonurgent drug treatment;
- Avoid unwarranted drug switching;
- Be circumspect about unproven drug uses; and
- Start treatment with only 1 new drug at a time
In addition, the authors noted that, by becoming familiar with a limited number of drugs, learning in depth how to use a more limited subset of indications and mastering dosing, adverse effects, and interactions, physicians knowledge and experience with those medications will increase dramatically and those physicians will be in a better position to prevent errors and anticipate problems.
This principle also tells physicians to “Be Skeptical About Individualizing Therapy,” even though the authors recognize this runs “counter to the patient-centered care physicians seek to practice.” In fact, the authors claim that “individualization is a mantra of the pharmaceutical industry when it wishes to dismiss disappointing trial results, arguing that they apply only to average patients and not necessarily to the individual patient.”
Maintain heightened vigilance regarding adverse effects
Under this principle, the authors note that physician should:
- Suspect drug reactions;
- Be aware of withdrawal syndromes; and
- Educate patients to anticipate reactions)
Approach New drugs and Indications cautiously and skeptically
The authors recommend that physicians:
- Seek out information from trustworthy, unbiased sources;
- Wait to die until drugs have sufficient time on the market;
- Be skeptical about surrogate rather than true clinical outcomes;
- Avoid stretching indications;
- Avoid seduction by elegant molecular pharmacology; (not sure who is seduced) and
- Beware of selective drug trial reporting
Specifically, the authors assert that physicians should “avoid education from pharmaceutical representatives or “experts” with conflicts of interest, and instead turn to independent drug bulletins or specialists with reputations for integrity and conservative approaches.” They also recommended that physicians “evaluate claims for new drugs skeptically, insisting on evidence that they are demonstrably better than existing (drug or nondrug) therapy.”
In addition, the authors also recommended that physicians not “rush to use newly market drugs,” and instead, suggested the use of generics or a 7-year rule (i.e. wait 7 years before using a new drug). However, if everyone followed that rule of thumb, no new medicine would last that long on the market.
Work with patients for a shared agenda
The authors recommend that physicians:
- Do not automatically accede to drug requests;
- Consider nonadherence before adding drugs to regimen;
- Avoid restarting previously unsuccessful drug treatment;
- Discontinue treatment with unneeded medications; and
- Respect patients’ reservations about drugs
Consider long-term, broader impacts
Finally, the authors assert that physicians should:
- Weigh long-term outcomes, and
- Recognize that improved systems may outweigh marginal benefits of new drugs
Discussion
The authors acknowledge that “none of these principles is particularly novel,” but rather, taken together, they represent a shift in “prescribing paradigm from “newer and more is better” to “fewer and more time tested is best. Consequently, based on several incidents involving drugs with adverse events, the authors urge clinicians to take a more cautious approach to prescribing and administering chemicals whose effects are imperfectly understood.
The reasoning behind the authors assertions and principles however, is flawed. Many professional organizations and medical societies recognize the importance of physicians using new medicines and treatments to advance patient care and improve patient outcomes.
For example, the American Association of Clinical Endocrinologists (AACE) recognized that endocrinologists have a greater responsibility than ever to educate physician colleagues, allied health professionals, and patients on the most up-to-date treatments and guidelines in endocrinology. This is in response to the worsening national epidemic of poorly controlled diabetes and metabolic diseases, the shortage of endocrinologists to treat these conditions, and the rapid expansion of therapeutic innovations that can improve patient outcomes.
Moreover, the article is listed as a “Review Article,” suggesting that the authors conducted a broad and balanced survey of scientific literature. However, the authors merely published opinions, with a bibliography to keep up appearances. Reviews should not promote a singular point of view, but provide readers with the full range of data and interpretations on a topic. This article clearly does not meet these criteria.
Additionally, the article does more than simply promote “conservative prescribing,” it advocates for incompetent care. For example, the authors suggest limiting the number of drugs physicians prescribe, not because more may be better for patients, but because it may be too hard for physicians to know how to prescribe a large number of medicines. So rather than promoting improved education, they promote simply abandoning an arbitrary set of valuable medicines.
Conclusion
Ultimately, the authors “conservative” rationale is extremely flawed, and patients and consumers alike should be extremely concerned with any suggestions to follow such ideas.
Americans need to ask themselves whether they want to live with yesterday’s medicines and treatments, or today’s technological advances and medical breakthroughs. Case in point: suppose that physicians had been adherent to author’s advice, “Do Not Rush to Use Newly Marketed Drugs,” when Lilly began marketing insulin. How many people today would have died and suffered from diabetes?