What's A Poor Doctor To Do?

I was skimming through a recent issue of the Journal of the American Medical Society this morning and I came across an article analyzing trends in prescription drug use in adults from 1999 until 2012. It initially caught my attention because I misread the title and thought it was an analysis of prescription drug misuse, which is something I encounter frequently as a psychiatrist. On closer reading though, it was simply an analysis of prescription drug use, which has increased by 8 % over the two time periods in the analysis (from 51% of adults to 59% of adults). The prevalence of polypharmacy (use of five or more prescription medications) increased from 8.2% to 15.0% between the same two time periods.

The article itself was factual and neutral but I started to get hot under the collar as I read it. Polypharmacy is considered a negative thing in medicine. It exposes patients to more side effects and drug drug interactions, and it’s considered dangerous. And I’ve read many news articles about how doctors prescribe too many drugs for too many conditions, and how it’s terrible and expensive and dangerous. At the same time, there are multiple published standards for treating different conditions. There are specific, numeric goals for screening and treating hypertension, diabetes and high cholesterol, just to name a few. There are standards for screening for and treating depression and pain; to remain accredited with certain quality agencies you have to document that you are doing both.

The publication of specific standards for treating conditions and the publication of critiques of polypharmacy and overutilization of prescription medication creates a double-bind for physicians. A double bind is a situation in which no matter which option you take, you fail. You are given two conditions that you must meet, but they are mutually exclusive. There is no possible way to succeed.

For example, when I was a primary care doctor, I might have a patient come in who had hypertension, diabetes, high cholesterol and depression. Many of these illnesses run in packs, so that’s a pretty common scenario. I evaluate the patient and talk to her about treatment. My treatment is likely to be medication based, because even though I encourage her to exercise regularly (which would help all of her conditions) and to change her diet (ditto) and to reduce stress and get more sleep, my patient lets me know that these kinds of changes just aren’t realistic for her. So I start to work with prescriptions. Chances are, it will take two or three medications each to control her diabetes and hypertension and one or two each to get her high cholesterol and depression under control. Not to mention the “add-ons” like prescribing a baby aspirin a day for certain age and risk groups that are published as standards of care. I might succeed brilliantly in controlling her medical problems, but I’m a failure because my patient is taking 5 or more medications.

Double binds are incredibly bad for your psychological health. They create pain, depression and confusion because when you are in a double bind you are always wrong. The only way to “win” in a double bind is to stop playing the game; to refuse one or the other of the conditions that have been placed on you. However, double binds occur in situations in which you can’t just leave the problem; the classic example is between a parent and a child (the parent is the one inflicting the double bind on the child) and of course the child can’t just leave the parent. I would suggest that after the amount of money, time and energy most doctors spend acquiring their professional credentials they are equally unable to leave medicine. So what’s a poor doctor to do?

Most of us seem to muddle along focusing primarily on the patient in front of us at the moment, the one who needs multiple medications to get their chronic health problems under control. We keep our heads down and try to ignore all the criticism, implicit and explicit, that we get for trying our best to do our jobs. I notice though, that there seem to be more and more depressed doctors around. So that strategy doesn’t seem to be working. 

I don’t know if we, as doctors, can speak up for each other and ourselves. I don’t know if we can begin naming and refusing the double binds that are placed upon us. I’m starting to think that we need to try.