Conservative Drug Prescribing:
A Plea for Principles and Action

Does the concept of “conservative drug prescribing,” where doctors evaluate your medical history, examine you thoroughly, and think of ways to help you, without reaching for the latest new pill, mean much to you? If your experience is anything like mine—and I am in basically good health with no serious conditions, I have seen doctors offer the latest sleep and asthma medicines as a first step.

But maybe I would do well to think more long-term: can I develop better sleep hygiene first, consider stress reduction or meditation,  and if that didn’t work, try a  medicine with a long-term track record. Of course, newer medicines sometimes do offer advantages, but the deluge of drug promotions make me skeptical.

There is a pill for just about everything these days: real, serious conditions and some, well, you have to wonder. If you watch television, you see the ads constantly, and if you don’t watch tv, you won’t miss out either: in far too many doctors’ offices, you will find a dizzying array of mementoes from drug companies.

I nearly left a doctor’s office in protest recently, but I was sick. I went into the examining room, and found the examining table had bright yellow paper advertising the erectile dysfunction medication Cialis. I felt like I wanted to say a big: “EXCUSE ME, do I have to sit on you? Are you f-*$%ing kidding me?”

You mean that they cannot afford examining paper! Oh, I have read that drug use for ED is leveling off, so I guess that explains the examining table paper.

Any chance to put the idea for the drug in a patient’s or doctor’s mind – well, why not? Besides maybe a guy didn’t even come to see the doctor thinking he remotely had ED. Here’s just the prop to get that guy thinking, “why not try Cialis? –and get hooked to a new drug?

I am not a doctor, but I have seen first hand as a patient, and with family members and friends– how reaching for the next drug can be a big mistake. At worst, inappropriate prescribing and a lack of heightened vigilance can cause a complication, even death, that is related to use of the drug or a procedure that would not have occurred had the medicine been withheld. Timely adverse event reporting is nonexistent. The FDA may promote it, but patients and doctors find it too cumbersome to do.

Contemporary Medical Teaching Promotes Meds

Promotions for new drugs abound in medical education, starting in medical school, residency, and later on, at the annual medical meetings. As a result, many physicians think that they are doing the patient a favor in reaching for a new drug, rather than taking a more comprehensive look at what’s up with the patient.  Maybe the solution to a specific health problem doesn’t even reside with taking a pill at all.

That’s why I was pleased to read an article by Gordon D. Schiff, MD, Harvard Medical School, and William L. Galanter, MD, PhD, University of Illinois Chicago  in Archives of Internal Medicine, on June 13 2011 . Originally published in JAMA, on February 25, 2009, apparently, the editors found it important enough to republish in Archives now.

In their commentary, Schiff and Galanter , state that : “[conservative drug prescribing skills] are “absent or underemphasized in current medical and pharmacy education.”

Now that’s a wowser to me as a patient. But,why?  Drugs are the answer that is blasted on television and in DTC marketing. Schiff pointed out how pharmaceutical companies are in most medical schools, during training, and of course, in Continuing Medical Education, going forwards.

Principles of Conservative Drug Prescribing

In setting forth recommendations that together could help physicians prescribe more appropriately and more conservatively, Schiff and  Galanter recognize that their recommendations come in an atmosphere where pharmaceutical promotions are huge in medical training, continuing medical education, and direct-to-consumer marketing.

From the outset, Schiff and Galanter state that appropriate prescribing and skepticism must be grounded in more learning about the emergence of new drugs and safety. Doctors all too soon forget about adverse events that may have driven drugs off the market. Drugs like thalidomide, phen-fen, or rofecoxib (Vioxx) are cases in point, according to Schiff. They were tested “in limited numbers of patients with few comorbidities, typically for a relatively short time,” write the authors. “Promotional activities distort what prescribers learn about drugs.”

Years ago, I heard a leading diabetes and patient safety thinker lament how quickly some drugs go from the next best thing to off the market because of safety issues learned in the first few years of use. He said: “Remember how once it seemed like it [that new diabetes drug] was all that was out there, everyone was prescribing it, and then two years after it is pulled, and you can barely remember its name.”

A Checklist Intended for Your Doctor

Schiff and Galanter urge doctors to revamp their approach to patient care, and their approach may seem radical in a climate where medications are the center of medical education.
1.    Think Beyond Drugs
2.    Prescribe More Strategically
3.    Have a Heightened Adverse Effects Vigilance
4.    Use Caution and Skepticism Before Selecting New Drugs
5.    Forge a Shared Agenda with Patients
6.    Weigh Long-Term, Broader Impacts of Your Treatment

I wonder: do we need Atul Gawande, MD, to put this into a checklist that physicians in training and community and academic physicians use in practice?

The categories seem like pretty obvious principles of good medical practice.

Direct-to-Consumer Ads Omnipresent

Schiff acknowledges that in a climate where big pharma is omnipresent, it may not be easy to encourage patients to try behavioral changes, or try old, tried-and-true medications with an excellent track record.

Patients are encouraged to think in fragments when they see an ad for one thing after another all night long on the television. Taken in as they come, you would never get the potential for drug interactions.  You’d never think that maybe losing weight and going on a diet might be something to try before rushing to meds to assist.

Short, online quizzes are all over the web, courtesy of big pharma, that are designed to aid you in proving that you’ve got a new condition that you may never have thought about. The drugs are the answer.

Also, often misleading links to government websites and physician organizations, suggesting inaccurately that these groups support the recommended drug. What about links to the American Cancer Society, the government website MedlinePlus, which pharma increasingly makes on line, even though, what you might find there is not an endorsement at all, just some sort of background information on a condition. Many drug companies are doing this now and I wish authorities would crack down on this practice.

Curbing Pharma Messaging

There is a growing movement in medicine, in medical schools, among faculty, medical students, and residents to limit pharma involvement in teaching. It’s healthy for us all.
Schiff told me about the American Medical Students Association PharmFree Initiative a national educational medical student campaign, described on its website as “targeted at medical students in order to continue teaching the qualities of honesty, humility, and accountability in graduate medical education and beyond. Without these qualities, both the credibility of the medical community-and the public trust given to it-will erode.”

A year ago, the University of Michigan Medical School became the first medical school to say that it will no longer take money from drug and device manufacturers for coursework for doctors studying to renew their medical licenses. The project started in January, and I hope to take a look at it. This topic is controversial for sure.

Indeed, many medical leaders take exception to pharma involvement, claiming that industry is really not out to increase prescriptions, but to improve patient care overall. I’d sure like to know if my doctor is taking money from pharma and how s/he sees it.

There are more lessons here. Could the FDA and Federal Trade Commission more aggressively pursue misleading ad campaigns linking pharmaceutical promotions to “trusted” groups like Medline Plus or the National Cancer Institute—groups that never said that they promote a specific drug? I hope so.

Then there are patient satisfaction surveys. They never cover this ground. I’d like to see my doctors take a PharmFree pledge. I don’t want to ever have to sit on Cialis paper in the examining room again.
This article is the first of (probably) three on drug prescribing and you. This first one introduces the concept of conservative prescribing and the barriers to it. Others will examine efforts to control drug promotion in medical school teaching and education. A third will address a specific case of overuse of medicine.

Conflict of Interest, Health Advocacy Organizations, and Patients

As a follow-up to my post yesterday addressing disclosure and health advocacy groups and nonprofits, I have looked into this further online.  And it is not that I think that advocates or advocacy groups are corrupt: I think advocates are important. I just think we ought to know if a pain group has huge dollars from Medtronic, Eli Lilly gives to mental health advocacy, or electronic health record suppliers are giving dollars to advocacy organizations or advocates pressing for them. Then, we can listen, keeping that in mind.

I have turned to advocacy organizations for advice sorting out health problems for myself, family, and friends. I’d rather not be caught by surprise that someone might be promoting a treatment, a facility, or a medical device, only to learn later that they have stock options or receive dollars for touting them. I want to see this up front. And it is not so much that I want a pure situation. I am not sure that this is possible. It turns out that I am not the only one out there who has flagged this as worrisome.

In January, Sheila Rothman and coauthors from Columbia University, wrote an article about mental health advocacy groups’ relationships with Eli Lilly in the American Journal of Public Health. Rothman raises important questions about variation in disclosure in relation to mental health advocacy groups. In health policy, we talk about variation as a problem, with overuse, underuse, and appropriate use of science-based practices. It’s a key concept among health reformers who are trying to make medical care based on the best available concept. Variation in disclosure practices needs to be examined and standardized practices need to be adopted for the public’s health

What Rothman reports is that 161 health advocacy groups received $3.2 million in payments from Eli Lilly, yet only one-quarter of those groups disclosed it at all on public websites that we turn to daily in a Google search. Further, only 1 in 10 identified Lilly as a sponsor; not a single one revealed the amount of dollars received. Like Rothman, I am not saying taking money is corrupt, but there should be a transparent way to see the exact dollars that the nonprofit, health advocacy group or patient advocate gets, so that the public and government can decide for themselves.

Rothman is not the only one to raise this issue. You can find articles in the medical literature on this, dating back years. Some bloggers have been critical as well.

My heart goes out to people who have terrible diseases or conditions. I admire people who devote themselves to outreach and organizing stellar programs for patients like them. In the course of caring for themselves, some have started nonprofits dedicated to advancing care. I am not entirely certain, though, that parents or family members can simply say that they are not affected by grants by the drug and device manufacturers.

I am raising this because it is an important issue as I continue blogging. I’ll undoubtedly return to this issue. I am interested in your views on this situation.