Where there’s a pill, there’s a way

If everything in medicine were cut and dried, it wouldn’t be nearly as interesting a profession. A recent article in the Daily Telegraph highlighted a real dilemma that often faces clinical staff today.

We live in an age of “evidence-based medicine”. All our prescribing is based on evidence. The targets that we try to achieve are based on evidence. The basis of the article is that we should not blindly follow guidelines without giving thought to the well-being of the patient. The contrast was posed between, on the one hand, evidence and targets and, on the other, the physical well-being of the patient.

The gist of the argument was that people in their old age should, according to evidence, be taking many tablets. Statins to reduce cholesterol, aspirin to block platelet activity, ACE inhibitors and calcium channel blockers to reduce blood pressure, maybe some for type 2 diabetes. The effectiveness of all these remedies in preventing disease is now beyond doubt even in the very old.

And yet…

The more drugs a person takes, the more likely it is that they will suffer side effects which may well cause them to feel unwell where previously, they had felt perfectly alright. Remember neither hypertension, dyslipidæmia nor type 2 diabetes usually cause any symptoms (although as health care professionals we know that complications can arise from all of these conditions).

And yet …

GMS QOF points say that drugs should be prescribed and “Points mean MONEY”.

So what is the answer? The most important thing is that, if there is a choice between hitting a target and patient well-being, the patient wins every time.

Perhaps the bottom line is to ask ourselves, “What are we trying to achieve?” There are two opposite ends of a spectrum.

  1. At one end is the 90-year old person with nothing wrong except for a mildly raised serum cholesterol. What would be achieved by treating this? In life expectancy? In disease prevention?
  2. At the other end is a 75-year old person who has just had a myocardial infarction and has raised blood pressure, raised serum cholesterol and Type 2 Diabetes. What would be achieved by treating this? In life expectancy? In disease prevention?

In the first case, the answer is probably that little would achieved by withholding therapy but, in the other, it is vital to do all one can to prevent a further infarction, or worse, a stroke and this will, undoubtedly, result in the prescription of several different drugs.

Everything in medicine is not cut and dried. We have to consider what we think is in the patient’s best interests. We can put the alternatives to a patient and seek their opinion. But as health care professionals we should not shirk from advising the patient who considers everything and, replies, “Well, what do you think, doctor/ nurse?”

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