"The new American standard"

Another sign of an overmedicated society:

The breakfast buffet at Camp Echo starts at a picnic table covered in gingham-patterned oil cloth. Here, children jostle for their morning medications: Zoloft for depression, Abilify for bipolar disorder, Guanfacine for twitchy eyes and a host of medications for attention deficit disorder.
A quick gulp of water, a greeting from the nurse, and the youngsters move on to the next table for orange juice, Special K and chocolate chip pancakes. The dispensing of pills and pancakes is over in minutes, all part of a typical day at a typical sleep-away camp in the Catskills.

Comments

Anonymous
Sad.
Anonymous
So where is the responsibility of the prescribers of all these pills?
Anonymous
Responsibility? What responsibility? It is about privilage, not responsibility. I can only imagine the handwringing that is sure to come. “The patient made me do it because of some commercial they saw.” Or, we are going to here that each and every patient actually needed the medication.
Anonymous
On the other hand, I have a 53-year-old male employee who actually brags about how many prescriptions he’s on (seven)…like it’s a status symbol. I tend to hold doctors accountable for their actions, but hey, equal time to patients. Nobody’s forcing us to swallow the pills or feed them to our kids.
Anonymous
No. In most cases, nobody is forcing anybody to pop pills like candy. The access to these pills, however, is relegated to the gatekeepers. Unless you are getting your pills on the black market it is incumbent upon the ones with the responsiblity for the gatekeeping to be held to a level of responsibility commensurate with their position. This includes telling pill seaking patients for whom there is no definitive diagnostic indication to take a hike. If they are unable or unwilling to judiciously utilize their responsibility, then we need to have measures enacted to correct the problem.
Anonymous
What about schools who pressure parents to give medication to their kids to control their behavior? Or you think this never happens any more? Google for “school pressure parents to medicalize kids”, read some of the links.
Or doctors using meaningless relative numbers to convince us that the benefit of taking a preventive medication X is much larger than it actually is? This never happens to? Are benefits always exceed risks when you use absolute numbers. How about Evista that increases risk of strokes and heart attacks to a 70-something overweight woman with osteopenia and no history of fractures and (controlled) high blood pressure. Is her reduction in the absolute risk of fractures clearly higher than the increase in her absolute risk of blood clots? What about statins for middle-aged slim women with high HDL and normal ratio and 10-year heart attack risk of less than 1%? Is this something patients ask for?
Diora
I’d like to point out that the doctors’ use of meaningless relative risk reduction numbers (as Kevin recently did in this blog) often cause more patients to take drugs than wouldn’t have taken them otherwise. Sometimes there really is a huge benefit in taking these drugs, but sometimes the balance of benefit/risk is not quite as clear when one considers absolulte numbers. I am talking about primary prevention here, of course.
I would venture a guess that the majority of the US population don’t understand the difference between absolute risk and relative risk. So when a doctor says “this will decrease your risk of some-scary-outcome by 50%” most people would not only think that this is huge, but will also think that they are in imminent danger of this outcome without the drug. Very few would be smart enough to ask “exactly how high is my 10-year risk of this-scary-outcome?”. So yes, in my humble opinion the doctors share the responsibility for overprescribing. They don’t force us to take drugs but they often pressure us to do it or provide misleading information. So before you blame the patients’ asking for drugs, ask yourself if you use RRR instead of ARR when you talk about preventive medications and if you always consider ARR. And before you cite “defensive reasons” – you do it also in your blogs and websites, and last time I checked nobody has sued a doctor for his blog.
jb
Inappropriate prescribing can occur because of a combination of defensive medicine issues and standard of care issues, often interrelated. Concern about being sued for not prescribing the latest new thing (think statins at present) leads a lot of docs to prescribe them for even the smallest indication. This then becomes the de facto standard of care, reinforcing the tendency to prescribe it for any docs who might otherwise be reluctant. No executive wants to be the only one in his foursome not on Lipitor, so the patient is only too eager to take the med when recommended. God help the internist who resists prescribing a statin to the VP of the local bank with a slightly elevated LDL who then has a crippling MI. It’s harder to not write the prescription than it is to write it, especially if there is even slight justification for doing it.
Anonymous
So in other words, you’re blaming someone else for your own failures?
Diora
jb – I do understand defensive reasons: if it is recommended that X gets lipitor because of guidelines or if a patient requests it you have to do it because you are afraid to get sued. But if a patient is reluctant, do you have to deliberately mislead him/her with meaningless numbers? Say if you believe that a patient can really benefit of lipitor because his 10-year risk of heart attack is 10% and if based on his LDL, Lipitor can decrease this risk by 30%, why can’t you honestly say something like “your 10-year risk of heart attack is 10%; if you take this drug it’ll reduce this risk by 3 percentage points, it doesn’t sound like much but you just may end up in this 3%” — this is in cases when benefits clearly outweight the risks. If a patient’s risk is less, you should still express the information in honest terms; you can even mention that it is recommended. But using 30% reduction is misleading because most people immediately think “this is huge”.
Also what risk is there in writing this information on blogs or websites? I even saw websites where these 30% (or 40% or 50%)are accompanied by “whopping” – a “whopping 30%” even “a whopping 20%” — this creates an impression that the medical community thinks this number is huge. Even if it can be really tiny.
And sometimes the risk of getting sued is the same — like in 70-something woman on Evista. If the woman doesn’t yet has osteoporosis but osteopenia, if she is overweight even borderline obese, if she has never had a fracture in her life, her risk of fracture is not that high. Yet the recent study on Evista showed increase in risk of heart attacks (contrary to what was previously thought) and strokes. If the same woman has high blood pressure, even controlled, her chance of stroke may be much higher. So you can get sued if she gets a fracture and you can get sued if she has a stroke. Which is more likely? I am not 100% sure of the answer by the way because I haven’t had time to look absolute risks yet.
Anonymous
Diora, you keep excusing the physicians’ unwillingness to play the gatekeeper of presecriptions by saying that this hypothetical risk of getting sued is what drives their conduct. What is the actual risk of getting sued in those situations you mention? And what is the actual risk of such a suit being successful?
Before we give them a free pass on this “we might get sued” claim, don’t you think we ought to know how likely it is?
Diora
Anon at 10:06 – I think you misunderstood my point. The point I was trying to make is that the fear of getting sued cannot always explain overprescribing, and that
some overprescribing is caused by misleading presentation of benefits not only in doctors’ offices but also on blogs and websites. Also, that sometimes it is unclear if the risk of getting sued is higher with prescribing or with not prescribing.
As far as the risk of getting sued, it is probably tiny in both situations – since the risk of both outcomes is probably small, and most people wouldn’t sue. I’d imagine it is less than 1 in a 1000. But a) if you see a 1000 patients and prescribe multiple drugs your probability of getting sued at least once is not that small 2) it is the perception of the risk’s existence that matters, not the actual risk. Case in point — you probably take some preventive measures, maybe drugs maybe screening tests. Do you know how small the probability that any of these measures will benefit you personally? With the exception of non smoking, controlling diabetes and to a smaller extent not being obese, the probability you’ll benefit is often smaller than 1 in 1000; often it is 1 in 10000. Yet you take these measures. Because you are afraid to be this one person. Same with doctors’ fear of being sued.
The other thing about overprescribing – doctors usually need to follow guideines otherwise they’d be violating “standard of care”. And these guidelines include more and more people. What used to be “normal” yesterday becomes abnormal, pre-condition becomes desease. Which is why what I want is accurate information about the chance of me personally benefitting so that I can make an informed choice. Than I can say “no, thanks” and it’ll be my decision for which I am responsible.
Anon at 10:06, what do you want? Do you want doctors to provide you with clear information about drug’s benefits and risks in meaningful terms, you want them to make decisions for you based on the most recent guidelines or do you just want to cast blame? Will bitching about doctors change their prescribing habits? I don’t think so. So what is the point?
I’d rather ask them for meaningful information.
jb
Diora-
All of your observations are valid, and sometimes there is no good answer. When a patient declines a well justified intervention, all we can do is explain the likely and worse case outcomes as clearly as possible, document everything in the chart, and hope for the best. In extreme cases, such as a woman who declines investigation of a breast lump, we are advised by our attorneys to send a letter certified, return receipt requested, to documented that we did our absolute best to make sure that the patient understands the implications of her choice. It gets a lot more ambiguous when you’re dealing with a medical intervention such as Lipitor, which has a well-defined effect of decreasing heart attacks by a certain percentage, and explain it as plainly as possible. There are a lot of physicians to do not really understand the difference between relative and absolute risk (hence, a lot of the marketing done to physicians by drug companies); and I suspect that the percentage of people in the general population who would understand, even with a brief education session, is in the single digits. The message that they hear is: “Heart attacks are bad. This drug decreases the risk of a heart attack, I want it.” It becomes even more difficult if the patient has to pay a substantial amount for a drug like Lipitor, which can cost over $100 per month in higher doses. Is this really the best use of a patient’s dollar?. It depends on multiple factors, few of which are within the realm of medicine. To make matters even more confusing, received wisdom today is the stuff of lawsuits tomorrow, as anyone who watches cable TV at night will tell you. The average doc who neglected to prescribe Fosamax for an osteoporotic woman last year would be concerned about a lawsuit if she breaks her hip. This year, he will tell her that she has been protected from a terrible jaw disease by his not prescribing the same drug.
As your anonymous responder implied, a lot of this concern is not rational. We know of all sorts of ridiculous lawsuits being filed left and right, (overlawyered.com), and we know about suits that we and our colleagues have been dragged into for absolutely no justifiable reason. Our legal colleagues will point out that the vast majority of groundless lawsuits are dropped at some point in the process, but they really don’t have any idea how stressful and career threatening it is to go through a lawsuit as a defendant. An apt analogy would subjecting one of them to a laparotomy, and then trying to convince him that it’s nothing to be concerned about because I didn’t find cancer.
Anonymous
“We know of all sorts of ridiculous lawsuits being filed left and right, (overlawyered.com),”
That’s all well and good that Overlawyered is your source, but is that really how you accurately assess risk? When deciding whether to provide a drug, do you go to some internet site run by lobbyists which cites stories from all over the world, many of which have nothing to do with the drug in question?
“and we know about suits that we and our colleagues have been dragged into for absolutely no justifiable reason.”
How do you know it’s not justifiable? Because they told you so?
“but they really don’t have any idea how stressful and career threatening it is to go through a lawsuit as a defendant.”
So because you feel an amount of stress out of proportion to the actual risk to you, a risk you have failed to adequately assess to any degree of certainty (you rely on anecdotes), you ignore your professional judgment and prescribe things that you feel may not be necessary? Why even come to you then? Why not just let the people buy them direct from the provider if you’re nothing more than a rubber stamp because you are needlessly frightened of something you don’t understand?
Dr. Steve
Diora –
I find you example interesting because you pitch it as an example of obvious, justified intervention.
However, a 3% reduction in risk is another way of saying that the drug has a 97% chance of doing nothing at all.
I know what the guidelines say but if that’s me with the high cholesterol my answer is “thanks but no thanks”
Diora
Dr Steve,
I think my wording was a bit unclear: I didn’t intend to pitch this as an example of an obvious justified intervention, only of an explanation based on absolute risk in cases doctor believes he/she should prescribe statins so that patients can make informed choice.
I gave it as an example of honest wording as opposed to misleading wording “it reduces risk of heart attacks by 30%”.
jb your point about people not understanding absolute risk vs relative risk may be valid, although I’d imagine it depends on the explanation and people’s level of education. I am surprised though that some doctors don’t understand it. I thought someone mentioned on this blogs that all of you had many courses in probabiity and statistics. It seems though more like elementary school math to me, though – it is not like you need to take a triple integral, only multiply a couple of numbers. I can see myself being able to figure this one out at the age of 9, and I wasn’t that brilliant a kid, only a bit above average in math.
You are right about what is true today being wrong tomorrow… which is why primary prevention seems so tricky to a layperson like me.