Tuesday, April 5, 2011

A doctor's practical guide to prescription drugs

When I was in residency training, one of my more challenging patients was a woman in her sixties who ended up in the hospital again and again with complications from heart failure and diabetes. I and her other physicians prescribed a dozen powerful medications to keep her conditions under control, but nothing seemed to work. Her blood sugar level was always too high or too low, and, despite our repeated instructions and reminders, it wasn't clear that she understood what each of her medications was for or how to take them on schedule.

Finally, I made a house call in the hope of sorting things out. As soon as I entered my patient's apartment, I realized just how big the problem was. A jumble of prescription bottles sat on a table in her living room. But when I compared this collection to the copy of her medication list that I had brought with me, mismatches emerged. She had been taking a few medications twice or three times as often as prescribed, and several not at all. It turned out she had been confused by the instructions printed on the labels. Did "take three times daily" mean the same as "take once every eight hours"? And when was it okay to take medications labeled "as needed"?

Some medications made her feel weak or lightheaded, so she used them less often or stopped taking them altogether. And she admitted she had been unable to afford one particularly expensive drug, but had been too embarrassed to tell me before.

In medical school, my classmates and I spent long hours memorizing the right drugs to prescribe for patients with particular diagnoses. We assumed that this would be the hardest part of our jobs, and that once it was done, the patient would obediently take the drug and get better. Since much of medical training takes place in hospitals, where drug supplies are plentiful and nurses administer correct doses at appropriate intervals, our assumption wasn't completely wrong.

But it isn't entirely correct, either—especially when the patient isn't in the hospital. A study of nearly 200,000 outpatient electronic prescriptions published last year in the Journal of General Internal Medicine drew a stunning conclusion: nearly 3 in 10 new prescriptions were never filled at the pharmacy.

To make matters worse, patients who pick up their medications frequently find the instructions difficult to understand. There is little consistency in how pharmacies format their prescription labels, which can lead to confusion if a patient uses more than one pharmacy. Taking several medications is even more challenging. According to a report last month in the journal Archives of Internal Medicine, only 15 percent of older adults were able to correctly consolidate a 7-drug regimen into 4 doses per day, and adults with lower literacy or less formal education were even less capable of doing so. Although researchers have developed quick questionnaires to help family doctors judge a patient's literacy level, I don't have any colleagues who routinely use them in practice.

The good news is that efforts are underway to design standard prescription labels that are easier to read and follow; the bad news is that these commonsense changes probably won't be coming to your pharmacy any time soon. So what can you do to make sure that you and your doctor are on the same page regarding your prescriptions?

First, don't be afraid to ask how much a new medication costs. If you can't afford it, chances are you won't take it. A previous blog post discusses several options for saving money on medications, including substituting older medications or generics. Also, make a point to communicate concerns about unwanted side effects; your doctor can usually manage these by lowering the dose or switching to a different drug.

Most importantly, go over your dosing schedule with your doctor, nurse, or pharmacist as often as it takes to be confident that you know exactly how much medicine to take, and at what times of the day. Commonly prescribed drugs for conditions such as high blood pressure and diabetes can be harmful, even fatal, in excessive doses. I encourage patients who take 3 or more medications to bring all their prescription bottles to office visits, so doctors or medical staff can compare them to the office record and correct any discrepancies.

These simple steps should go a long way toward improving your health—just what the doctor ordered.


The above post was first published on my Healthcare Headaches blog at USNews.com.


  1. I believe that medications are an important component of therapy. It seems though that polypharmacy is a growing issue especially in the elderly which unfortunately also leads to frequent falls. As a side note, adoption of healthy lifestyles are becoming first line therapy for many conditions including diabetes and cardiovascular diseases. The American Heart Association has now defined an ideal cardiovascular profile which consists of seven lifestyle-related components (Lifes' simple 7). Unfortunately, a recent study - the heart SCORE study shows that only 0.1% of people have all 7 components of the ideal cardiovascular profile. Simple changes to one's lifestyle goes a long way and might avoid medications all together.

  2. House call? There are unfortunately not that many house calls done these days.

    However, if house calls were made, I think that the physician-patient relationship would be greatly strengthened and adherence improved. Not only because of the attention paid, but because (as you experienced) the doctor would find out first hand the obstacles the patient was facing.

    Unfortunately, time is an enemy; or the lack of time. As @dialdoctors commented, “Drs can help w/ adherence unfortunately not everyone can take the time bc the system doesn’t help. Good intentions go so far” -- http://wp.me/p1fYJ7-hn

    One suggestion I received to my post (Are doctors the forgotten factor in improving patient adherence? - http://wp.me/p1fYJ7-hn) was "Rather than burdening the MD's dayplanner any further, it would seem to me that adding an Adherence Specialist to the MD's practice would be more prudent." I think that would be unworkable because of added cost to the physician.

    But, what's the answer to get physicians more engaged or, rather, more able to be engaged?

  3. This is such an important subject and post. One of the nicest things you can do for a patient is to clarify their meds for them. Take a sheet of paper or cardboard. Use clear scotch tape and tape each pill on the page with the instructions next to it. For instance: Diovan 10mg for blood pressure. Take one in AM and PM.

    This way the patient can easily see the med and know when to take it. I have patients who bring the sheet in to me at their visit. I can change it or verify it easily.

    It works great.

  4. Thank you all for the feedback and valuable additional information on this challenging issue!