Sunday, October 19, 2008

Magic Pills

I think it's interesting that, while it seems that many patients do not trust doctors, many seem to have absolute faith in what we prescribe. I could do the world's greatest ankle exam, according to the Ottawa Ankle Rules, and determine that it's a mild sprain and just needs an Ace wrap, but until we've given that therapeutic x-ray, many patients don't feel better. The Ottawa Rules are actually to determine who needs an x-ray, and they are very good at ruling out fracture. Yet, most people I've seen (observer bias) would much rather believe the x-ray than me. Then again, that could be wise, since I'm just the intern, but still.

I had a depressed, anxious patient who'd suffered a trauma in the past ask me about "the new medicine that will cure everything, you know, the one on TV. Why did my therapist tell me it would take years?" That one stopped me in my tracks. I'm not sure whether this is the fault of DTC advertising, poor education, denial, or all of the above, but that's an awful lot of faith in a medicine advertised by the people who make money off it.

I had a patient who requested an antibiotic by name for a sore throat. Said throat wasn't even red. Patient was a bit hoarse, and had post-nasal drip, so I made a diagnosis of allergies with post-nasal drip throat irritation and prescribed allergy medicine and over the counter throat spray or lozenges. "But why can't I take antibiotics?" "Because your throat isn't infected." "But it HURTS!" "Antibiotics aren't pain medicine. Use the spray at the store."

There seems to be something magic about that prescription, written on the pad. Writing ibuprofen 800 mg tabs is somehow so much more official than saying "take four Advil or Motrin from the store". Perhaps the reason the antibiotics relieve the pain more is simply because they're written on the prescription pad. After all, the expensive placebo is more effective than the cheap one.

Also, we want pills instead of other forms of medicine. Intranasal steroids sprays are front-line for chronic allergies, but don't seem (observer bias) to be very popular. I personally don't use mine as often as I should. Of course, nasal irrigation with saline is also extremely effective, but very few people do it (of those who even know about it). It's just not very sexy to run salt water through your nose (I did it tonight--I recommend pulling your hair back first), and much less messy to take a pill.

In some ways, I think we over-rely on medicine to cure what ails us. How many patients really try to get their cholesterol down with diet or their blood pressure down by cutting out salt? I think we need to re-think "preventative medicine". True prevention isn't about catching disease early by screening, it's about actually preventing disease. We're so focused on the pills that we forget that the best prevention means not to take any. Preventative medicine should actually be about encouraging exercise and healthy diet, but those aren't very sexy on a prescription pad. They're vital to preventing disease, but how much of our national healthcare budget is spent on exercise? We're doing better at smoking cessation, but of course, there are pills for that.

Preventative Medicine: A Way to Avoid Taking Pills. Will it catch on? I doubt it. We like our pills too much.


The MSILF said...

The only cold remedy I use myself is the nasal wash. Washing away those inflammatory mediators is the only thing that gives an hour or two of relief. It is, however, messy and hilarious. I think I blogged about getting caught doing it once.

Tiny Shrink said...

Yeah, my husband watched me do it last night and it was pretty embarrassing. I must admit, I feel much better today, though.

Anonymous said...

It is nice to hear someone else with this opinion on "magic pills"...especially from a doctor.