Several years ago, when prescribed a single medication to be taken daily for several months, I found it very difficult to remember to take it every day. I knew it was important and I knew why I was taking it, but even then I forgot. That experience got me thinking about the many people who are asked to take six, seven, ten drugs a day…forever. I have no idea how they remember to take all of these drugs correctly, and the fact is, most people don’t. This was made clear to me as early as my residency, when it was not uncommon for people to bring in garbage bags full of medicines. When asked how they determined which ones to take and when, these patients often seemed to go by the pill color of the day rather than any set schedule or plan.
In fact, the data on this issue—known as medical compliance—reveal an abysmal record of patients’ taking medications “as prescribed.” Reportedly less than one third of diabetic patients take metformin correctly. An
d only half the patients with high blood pressure take even 80% of their medications as prescribed. The end result is a multi-billion-dollar expense with unpredictable and often dangerous outcomes. How does this happen?
Unfortunately, when it comes to prescriptions, providers are required to be compulsive. We are trained not only to address every problem with a solution, but also to do so on an individual basis. If you have asthma, there’s a treatment for that. If it’s heart disease, here’s another pill. Diabetes? Take three more. The list grows quickly, adding expense and, more alarmingly, often resulting in untoward drug-drug interactions. It’s gotten so bad you’d be justified in thinking certain providers delusional for even believing the patient could take the list of medications “as prescribed.” Yet, when you talk to physicians about this issue, many simply shrug their shoulders. They’ll tell you they have little choice. The current medical legal climate requires a response to each identified problem.
One solution to this quagmire is personalized medicine, a topic I’ve discussed in prior posts. I should note that personalized medicine means different things to different people, but for many, America’s love affair with technology often translates personalized medicine into genomic medicine. Eric Topol wrote extensively about this in his book , explaining how, through sequencing the genome, doctors will be able to predict how each individual will respond to a particular drug. Equipped with such powerful tools, it’s not hard to imagine a future pharmaceutical industry that could customize medications, rather than simply produce mass quantities that work “well” for the average person.
Until that particular biotech future arrives, I think there is a far simpler and immediate opportunity open to personalized medicine: by identifying a patient’s ability to participate in her own care and then matching the medication regimen not only to her needs and preferences, but to subjective criteria such as mental clarity, alertness, daily routines, family support, etc. Two people with exactly the same list of problems may have very different abilities and willingness to take a complex regimen of medications. A 50-year-old executive may have the same problem list as an 80-year-old nursing home patient, but will clearly have different organizational skills, financial resources as well as an understanding of why the regimen matters. For physicians to write prescriptions they know deep down their patients cannot take borders on the absurd and certainly does not constitute good care.
Although I’d like to think physicians would read this and suddenly change the way they write prescriptions, I am not that naïve. Without a significant change in how we’re trained as well as appropriate protections from medical legal risk, it’s unlikely doctors will suddenly change the way they practice. However, you as the patient have an opportunity to ask the questions. Are all of these medicines necessary? And if I only take a portion of the drugs, what is the overall increased risk to my health? If you find yourself simply unable to follow the regimen, have an honest conversation about alternatives. Remind your doctor that you are not a “problem list” but an individual with specific medical requirements and concerns.
Ultimately, treating problem lists instead of people may be “right” but it’s not reasonable.