The problem with an anti-medication bias

“I don’t like taking medicines.”

All physicians hear some form of this opinion very frequently. Even more frequently, patients don’t state this view outright but rely on it to completely subvert their doctor’s plans.

When I was new to practice such an utterance would shock and confuse me.

“I don’t want to take any medicines,” a patient would declare.

“That’s fine,” I would reassure my interlocutor. “It’s a free country. No one is going to force you to take medicines. But you should know that I’m a primary care doctor. I don’t do surgeries or procedures. I diagnose and treat medical problems, usually with medications. I’m not saying you have to change your opinion. I’m just saying you might be in the wrong place. You’re like the vegan bursting into the butcher shop to declare that you don’t want to buy meat.”

I’ve heard some version of this aversion to medications hundreds of times. Over the years I’ve also realized that it is usually adopted by patients without any serious reflection.

“I’d like to be on the fewest medications as possible,” a patient with diabetes, heart disease, high cholesterol, and high blood pressure would announce.

“Well, the fewest medications you can take is zero. Should we just stop them all?”

Lots of patients adopt this anti-medication preference in the absence of any evidence or serious thought. A strong preference without analysis or evidence is simply a bias. (When I have a strong preference in the absence of evidence, it’s a philosophy; when other people have it, it’s a bias.)

Now, some biases are harmless. I like Folgers instant coffee (black), and you like a vanilla frappuccino. I bicycle; you jog. That’s all great. But if a bias threatens to worsen your health, it deserves a little attention. Some thinking might be useful to either confirm it as a belief you want to live by, or discard it to the cognitive ash heap.

The problem with the anti-medication bias is that most doctors are too busy to argue with you. Let’s say your cholesterol is extremely high. Your doctor might recommend attempts at exercise and weight loss for a few months. After that if your cholesterol is unimproved she may recommend a cholesterol-lowering medication. She may or may not have time to mention that this medication has been proven to prevent strokes and heart attacks in patients with high cholesterol. She might or might not mention the rare and usually tolerable side effects you might expect. But if all she hears from you is, “I’m already taking too many medicines,” she may do the expedient thing, which is to document your refusal to take cholesterol medicine and leave it at that. If you’re lucky, she’ll readdress this again in more detail in a future visit. If you’re unlucky the future visit will be when she sees you in the emergency department during a heart attack.

Because I have more time to spend with each patient than most doctors, I have a lot of experience in trying to understand and overcome this anti-medication bias. I certainly don’t advocate compensating with the opposite bias — taking as many medications as possible. (A small number of patients do seem to believe that there is a pill for everything that ails them. That’s a subject for a different post.) My suggestion instead is that each medication be judged on the basis of its own benefits and harms. You don’t want to minimize the medicines that you take; you want to benefit from all the medicines whose benefits to you exceed the harms.

Now, don’t get me wrong. There are certainly good reasons not take a medication. You might develop a side effect. Discuss that with your doctor. Some side effects diminish with time. Some are annoying but not dangerous. But obviously some are intolerable and might be a good reason to stop taking a medication. So by all means balance the risks, the expense, and the side effects of medications against their benefits, but don’t make a decision before even doing the calculation.

Of course balancing these issues takes time and thought. It requires that the patient be willing to ask important questions (“What side effects should I expect?”) and express any apprehensions. It requires that the doctor answer the questions and make sure the patient understands why the medication is being recommended. That is more difficult and less efficient than writing a prescription and bolting to the next patient.

So please help me eradicate the anti-medication bias. Your health might improve, and you’ll save your doctor a headache or two. Which reminds me, I need some ibuprofen.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • NormRx

    I’ve had people tell me “they don’t believe in drugs” yet they consume two packs of smokes and a fifth of whiskey a day.

    • querywoman

      That’s what I’ve found, especially among men. They guzzle beer yet disdain medicine.
      Alcohol is one of the oldest meds; it produces and altered state.
      Prescribed meds have been refined and tested, and an attempt has been made to give the correct amount for a problem.

  • EmilyAnon

    Refusing drugs might be wishful thinking on the part of the patient that there is nothing really wrong with them, or because they don’t feel ill, the diagnosis is exaggerated. They don’t want to believe they are sick.

  • PoliticallyIncorrectMD

    I am frequently taking care of critically ill young (40-50 yo) patients, whose pre admission medication lists are 25 (!) medications long. It is not uncommon that the reason for admission is a side effect or interaction of those medications. It appears that most of this patients have competent well meaning physicians trying to keep up with ever changing guidelines, minor complaints not requiring pharmaceutical interventions and frequent demands for unnecessary medications. Being “anti-medication” is not a bias, it is common sense!

    • RenegadeRN

      THANK YOU! I believe polypharmacy is a FAR larger problem in this country than lack of prescription meds.

      Only one little sentence about recommending a trial of diet or exercise for a few months, instead of a statin, was mentioned in this article.
      As a nurse who is thankfully pretty healthy, I avoid as many meds as possible and will use said lifestyle changes FIRST- every time.
      If that is not effective or possible , I will use ANY meds for as short a period as possible- Rx or OTC.

      I don’t see this as being non- compliant or a bad patient, I EXPECT to have a dialogue with my doc about my rationale. It’s when the doc doesn’t want to listen or consider any other action besides writing a script that i get my knickers in somewhat of a twist.

      • David Wyman

        You didn’t give any reasons for this approach. Like the man said, it’s your philosophy, not science. We see plenty of polypharmacy in psych. What we see more of are excuses to take no medications.

        • RenegadeRN

          True is IS my philosophy. But I also believe this constitutes basic common sense. Thus I was agreeing with PoliticallyIncorrectMD.

          As an ex chemical dependency/ psych nurse, I was stunned at the levels of polypharmacy! As I was dispensing a 6 Oz cup of meds before breakfast to most in the unit, I would often joke with some that I was serving them their breakfast! Just for a bit of levity and get a smile out of them.

          Yes, there are undoubtedly some patients who refuse to stay on prescribed meds, bipolar patients immediately come to mind- but I still maintain that polypharmacy is a serious problem across the board in medicine today.

    • guest

      Mostly, I take my physician’s advice, but I have opted out of a few medications over the years. I was told I had PCOS, was in the pre-diabetic range, and was prescribed Metformin. Instead, I lost 20 pounds, changed my diet, and my HbA1C is now WNL. Nexium, was another one I decided against. I saw how expensive it was and decided to stick with OTC meds PRN. I was prescribed a drug for abnormal hair growth that goes along with the PCOS, and I decided I didn’t really want to take a medication just for vanity reasons – but would opt for electrolysis.

      If a physician said I absolutely needed a particular medication, then I wouldn’t argue about it. But, if it’s something prescribed to ease a symptom or not absolutely necessary, then I don’t always take it..

      • Guest

        To be clear, I am in No way saying people should not be taking a medicine with a clear indication and that a lifestyle change has failed to help or has no indication for.

        I have no functioning thyroid, is I take replacement hormone, everyday and always will.
        Nothing else will replace that for me but a prescription med. No quibbles here from me.

        I use this as an example of when not to refuse a medically necessary script. In the other hand, when someone wanted to prescribe a hypertension drug one day when I had rushed in, had a zillion things going on and my bp was a little high , I said thanks, but no thanks- it’s situational, and my home testing demonstrates it is regularly below normal. Just a couple examples of my personal rationales for what I accept and don’t accept for my personal health.

  • penguin50

    I sometimes hesitate to accept medications for the following reasons: the doctor is unable to explain how it will act in my body (“We don’t really understand the mechanism by which this drug works”—this is not a deal breaker, but it does make me nervous), the doctor is quite uncertain it will help at all but wants me to try it anyway, and/or the side effects are intolerable. The latter is a particularly strong concern of mine. I have often felt that doctors are unaware of how awful certain side effects can be—they do not experience them in their own body, and perhaps they deeply and unconsciously just don’t want to believe that they are causing suffering as an inadvertent consequence of their larger goal of helping a patient, and so they quickly dismiss a patient’s complaints about severe fatigue, etc.

  • eqvet2015

    Those aren’t medications, those are candy. Or poppy-based nutraceuticals. All-natural (can synthetic opioids be organic?).

    • T H

      Of course they are: they have a basis in carbon.

      • eqvet2015

        I was joking because some anti-medicine people are into herbs because they’re all-natural, buying organic food, etc.

  • SarahJ89

    In my lifetime I’ve had probably hundreds of pills pushed at me. Only two of them (antibiotics for bacterial infections and levothyroxin) have actually been efficacious. Many of the rest were later taken off the market or now have black box warnings. Side effects were rarely, if ever, mentioned.

    I’ll continue to avoid medications whenever possible. I go to the doctor, not for medication, but for information and advice about non-pharmaceutical approaches first.Medications are a last resort. I take the ONE med I need faithfully. It is, for me, the least medication possible. But had I listened to doctors I’d be fat, out of shape and on tons of meds.

    I’ve made many lifestyle changes, all on my own since I’ve yet to have a doctor bring up the topic or display any interest. No doctor has ever asked how I achieved significant weight loss or maintained my activity level.

    Over the years I have been taught–by doctors–to mistrust their faith in medications. I did not come out of the box this way. There’s a trail of “new, improved” medications now discredited that I refused to take that one can follow to figure out how I got to this place. I’ve been my own best advocate in turning down these prescriptions and time has proven me correct.

    As for the narcotics? You need to stop handing them out like candy. Where on earth do you think your patients developed the taste for them? I ended up tearing up prescriptions for 50 oxy and vicodin I neither wanted nor asked for. They were prescribed in a totally knee jerk manner, with no questions asked. I was appalled to have them given to me in such a blithe manner by two doctors within less than a week of one another. In a system with shared EMR, no less.

  • Karen Ronk

    It seems that most medications today are being used to treat things that are drastically different from their original intent. If you go to unbiased sources for information, such as the NIH, you will see the cold hard facts without the hype. It is a big deal to put these things in your system if there is really little actual data to show that they will help you more than harm you. Lifestyle changes can and do make a difference in some cases. When medication is the only/last resort, the doctor and patient need to make an informed decision together.

  • Jennifer Jonsson

    I take eight prescription meds. Some people look like they’re going to faint when I tell them that. I have bipolar disorder, and nobody’s come up with a drug that treats it yet. So people like me take something to stabilize moods, some kind of antidepressant, something for anxiety, something to address grandiose thinking, and in my case, something that blocks the side effects of some of the other drugs (dizziness, shaking hands, weight gain or loss, nausea, etc.) However, I’ve taken drugs with side effects that simply couldn’t be dealt with (such as one that made me think about carving my arms up with a kitchen knife; I wasn’t depressed, or suicidal, it just seemed like a good idea for some reason). If a patient doesn’t want to “take medications”, there’s probably a bad experience with a medication lurking in the background. Physicians who ask the gentle but probing questions can get to the bottom of this faster, and maybe get the patient on a medication that will help without harming. Or at least put themselves in the position to say, “Fine, I won’t prescribe statins to you, but you have to understand that you need to make a major change in your eating and exercise habits.”