Well, Dan and Joseph both have good points.The recent posting about "correcting" labelling brought this to mind.I had a relative, an LPN, who went around with a PDR, dug up all the drugs a person was taking, and terrorized them about the worst things that could possibly happen. And of course, since she is a nurse , more people listened to her than ought to have.It wasn't even good, educated, or informed and balanced advice; and in any case she wasn't trained, qualified, or legally able to give it.Growing up in a medical household, I think I saw all sides of it.But my sympathies generally lie with the physician.My stepfather dreaded news features, and then later on when drug companies were allowed to advertise, because, we heard at the dinner table, "WELL, you KNOW, the next month or so, EVERYBODY is going to want a presription for XYZ whether they need it or not, or whether it's safe for them or not." And boy was he right. He was, although not perfect, (nobody is) a stickler against prescribing anything he didn't feel a patient needed, and also, unlike many colleagues of his time, doing enough testing and studies to ensure the medication would be safe for the patient, AND, imagine this, extensively counselling them on how to take and use the medicine, what it was for, things to watch out for, and if or when they could stop taking it in an emergency.My former internist did much the same thing, but skipped most of it for obvious reasons in my case and just cut to the chase if it were really important, like, "Now that you're taking 600 mg of Inderal a day, you DO know you cannot suddenly stop it or miss a day's dose, right?". That was just like an obligatory reminder, he knew I taught pharmacology. But it was nice, and appropriate.The purpose of the poll, sadly unresponded to as it was, was to divine a sense of when enough is enough, or too much, or not enough."Here, I'm writing you an Rx, take one of these at breakfast time every morning and come see me in two weeks.", isn't good enough (hell, I'd pitch a fit if a doctor ever tried to pull that with me, after correcting his mistakes in the Rx, first, and then most likely tearing it up and walking out of the office.)Between capitation and other cost-control measures due to HMO's, insurance, Medicare / Medicaid, DVA, TriCare, I think the old fashioned doctor is being pushed out of the way he/she used to practice. Time limits on patient visits and consults, a limited formulary/compendium from which you are allowed to prescribe, DRG's, ICD's, all seem to be colliding (seem to be, who am I kidding? are colliding) in a way that is ending up with poorer quality health care, increased adverse drug reactions, misdiagnoses and consequent inappropriate treatment and iatrogenic consequences, and more lawsuits and adverse media for the med/pharma/biotech industry.The sort of things the old country doctor who did house calls generally would not contribute to. He / she knew their patients without needing a chart, and what their real and imagined woes were.So, a particular drug. Let's pick Ritalin. It has 8 million warnings and side effects and is Schedule II. A week's worth was prescribed for my grandmother after her husband died, because she was suicidally depressed. It worked miraculously.The prescriber told my grandmother, "I know how badly you're feeling right now, and your husband was a good man; I can't do anything to replace him, but you ought to remember the many years you had together and the wonderful children you raised.Now, I'm a little worried about you dealing with all this, so I'm going to prescribe something to perk you up a little, because I can see you are so down in the dumps, and we can't have that right now, can we?It's only for a little while, you'll be on your feet in no time, though I know it's hard for you to feel that right just now.And if you have any problems, you just call me anytime, here or at home."Especially then, she didn't need "if you have hypertension, this can be addictive, blah blah blah". One or two weeks, hell, either amphetamine or methylphenidate would have been perfectly safe for her. My grandma the dope fiend.The LPN from Hell would have cheerfully scared her off her week or two of pills, to a great detriment. Thank God she didn't get her claws into her before she was better. Alternatives at the time, there weren't any that would be effectual in a timely manner; tricyclics and MAOI's would have been disasters, apart from their onset of action.So my grandmother lived so she could die of cancer. Okay, maybe not the best story, or maybe so.She'd been on Aldomet forever and did well on it (for hypertension) and HCTZ and took K-Lyte (don't know if it is still made), an oral tasty potassium supplement that was like a fruit-flavored Alka-Seltzer tablet you put in a glass of cold water. But the key is, a soluble K dosage form that is taken orally after it's dissolved.Enter new know-it-all doctor.Even though slow release K tablet formulations were pulled off the market at least once previously, correlated with GI bleeding, GI Ca, that's what she gets. And gets bowel Ca from a specific focal lesion that closely correlates with all the reasons the FDA yanked this stuff the first time.Concentrated potassium ions aren't good for you in the space the size of a pea, anywhere in the GI tract.So, she died, eventually. After metastases to everywhere.And I had to manage her pain care.The consult amounted to "Irma, take these instead; they are released more gradually and I think they will be better for you."So, what is the balance between, "There's a hundred reasons you might be hurt taking this pill" and "Here's your prescription. Any problems, have your coroner call me."?Scaring off patients from treatment they need and is generally accepted as safe and appropriate, is bad.Having patients blindly accept medications and treatment without a thorough risk assessment, is bad.But, where do you draw the line? In the old, take all the time you want, non-HMO days, the physicians made that call, and more often than not did it right.All patients are entitled to counseling and informed consent, but how much is too much and how little is too little?That was the purpose of the poll.RSH.
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