Canadians are a well-mannered bunch.
We don't show up for dinner empty handed and we don't
let a patient leave our office empty-handed. It would
seem rude and uncaring after they've come all this way
and waited so long....
The prescription seals the deal,
says Chicago geriatrician Dr Holly Holmes. The framework
she and her colleagues developed to help doctors decide
when a medication is no longer necessary for a given
patient appears this month in the Archives of Internal
Medicine (see "Know
when it's time to nix an Rx"). Dr Holmes' mission
is a tough one. Refusing to write a new script isn't
enough, she says — though antibiotic over-prescribing
is largely being curbed this way. Dr Holmes says it's
time for physicians to put a stop on a prescription
the patient may have been refilling since, well before
the doc was a doc. The antibiotic resistance message
that worked so well to appease patients sent home to
their chicken soup won't work here. The reason you should
refuse a refill is a little harder to justify: the patient's
too old or too sick to benefit from therapy anymore.
Drugs that are taken longterm to
treat risk factors or chronic conditions present many
dilemmas for equitable and affordable healthcare. Doctors
need better strategies to assess what level of benefit
justifies keeping a patient on a drug. They could also
do with some tools more humane than actuarial tables
to help them talk about it with their patients. With
better information it may be one of those decisions
that patients can make for themselves.
It's a dilemma that also plays
out in provincial formulary committees that decide which
drugs will be covered. There have been many calls for
a strategy to remove older drugs from the listing to
make room for new drugs, but as yet very little has
been done. The challenge of weeding out older and less
effective therapies has been left to doctors dealing
with one change-resistant patient at a time to replace
one medication with another. The conservatism seen in
family physicians about adopting new therapies (see
"Add a new drug to your arsenal" on page 16) may be
far more situational than inherent. — Susan
Usher, health policy editor
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