Letting go

I recently attended the funeral of a patient. He was lucky to have lived both long and well. It was an honor to have known him and to be a participant in his life at an important point. With much input from specialists, thought and prayer on my part, and numerous conversations with family members, it was decided to let him go - to stop the life-sustaining treatments in favor of a better quality of life. What a gift his family gave him - to be at peace at the end, to take death on his own terms, as he would have wanted.

Save the Beans

This isn't exactly along the lines of this blog's themes, but it is my issue of the day. You know how one think kind of sticks in your mind all day. Well today, my issue is kidneys and the heaps of abuse they take before they finally throw in the towel for good. In the U.S. diabetes and high blood pressure are the 2 leading causes of kidney failure (and need for dialysis). I had at least 3 patients today who have chosen not to do their part to control these diseases (like take their medications). They range in age from their 20's to their 60's and they are all along the path from normal kidney function to complete dependence on a dialysis machine. What is it about our society that we have these great medications (I know the irony of posting this after my last rant about pills) but still fail to take them? How hard do I push medication compliance with patients? Should I be gentle or firm, threatening or low-key? Ultimately, it is the patient's choice what they do with the recommendations I make, but I think they would make different choices if they saw the end result as clearly as I can.

The problem with pills

This issue comes to mind when considering a patient's request for phenteramine (a stimulant weight-loss pill). Wisconsin actually limits prescribing of this type of medication and has very specific requirements that must be met in order for it to be legally prescribed. Pills (or medications) are of wonderful benefit to many, many people with a variety of ailments. However, our country now counts on "pills" to solve every problem of deficient health (even in the absence of true disease).

Why is this? Well, in all fairness, there are a number of medications out there that do what no measure of diet, exercise, or "living well" can do - think of chemotherapy, blood pressure medications, antibiotics, etc. So, pills often do work. Second, drug companies market their product - to doctors and patients alike. While I have ethical concerns about direct to consumer advertising of medications, I also think these ads sometimes backfire. In my experience it makes patients even more aware of and concerned about potential side-effects. Next, we live in an era of instant gratification and pills can provide that, often more easily than lifestyle changes. Why make all those changes to your routine, diet and exercise habits, as well as deal with your stress if you can just take a pill to help you sleep? And finally, it is easy. It takes me about one-quarter the time to write and even explain the use of a medication than it does to talk about "therapeutic lifestyle changes" - eating right, exercising, dealing with stress and emotional drains, getting adequate sleep and rest, stopping smoking, not drinking alcohol to excess.

So, what is the problem with pills or medications? Well, for one they are rarely a "miracle cure". I have only been out of medical school for about 8 years, but even in my short tenure in the medical field, I have seen a number of medications touted as the next greatest thing or truly revolutionary only to be just one more potential treatment with a focused, but limited benefit. So, patients (and doctors) get frustrated that the medication didn't completely solve or cure the disease. Second, they are often costly. Generic medications fall out of favor quickly, and often unfairly. "Updated" medications - ones that are the next generation of a commonly used medication (like the next generation of anti-depressants, pain pills, anti-psychotics, etc) often offer advantages such as less frequent dosing or fewer side effects. However, they may not be more effective than the cheaper, older option. Using older medications may be perceived as being behind the times by physician colleagues, or be seen as not providing the best care by patients. As mentioned above, it is easier for me to prescribe a pill than discuss lifestyle changes. It is also easier for a patient to take a pill than make lifestyle changes. If lifestyle changes have an effect on a disease (and almost all diseases are affected to some extent by diet, exercise, sleep (or lack), smoking, alcohol, or stress) then lifestyle changes should take precedence over a prescription.

This "problem with pills" is not limited to prescriptions either. Herbal supplements and remedies also offer hopes of a miracle cure or 100% effective treatment and do so under a (sometimes false) umbrella of safety.

Diseases have been created once a pill exists to treat it.

As a stock holder of Pfizer, I clearly believe in the strength and benefit of pharmaceuticals. But, I believe more strongly in the benefit and importance of lifestyle changes first. This must be preached by doctors, but also sought by patients. Exercise is cheap!

The Change our health care system needs

As a family physician, I've tried to cut medication costs for my patients. Even if patients are only paying a portion of the costs, I've noticed that most are concerned about how expensive a medication is. I think many people realize that the health care gravy train can't last forever. As part of comprehensive health reform, I think that any government sponsored health care needs to only pay for generic medications (if available). We just cannot afford to pay for the fanciest (or sometimes even the best) med out there.

A second part of health care reform needs to judge the cost-effectiveness of any test that is paid for by big-daddy government. If it is not cost-effective (like PSA testing for prostate cancer) it is not funded. People can still get PSA testing if they want, but it won't be guaranteed. This would free up more dollars to pay for proven-beneficial tests, like mammograms for women aged 50-79.

Medical work-ups need to make sense - medically, financially, and practically. Testing guidelines that are reasonable should be paid for (checking blood sugar levels in diabetics) but over-the-top, test-for-everything-so-I-don't-get-sued testing is paid for by the patient (if they choose to get it).

Treatments need to be made available universally as we can afford it. This probably will mean that not every patient will get dialysis, the organ transplant, or elective surgery. But, we (as a country) have a budget and what we can pay for should be clear. The money we have should be used for maximal impact and benefit.

And finally, we need to introduce a little healthy capitalism to this process. Let doctors, labs, hospitals, etc. compete for the consumer dollar.