Focus
Student Scene
May 27, 2002
 Photo by Graham Ramsay |
Treating Patients One at a Time
Prescription drugs impose an increasing burden on health care costs. Because both the supply and the demand are growing, Americans are paying more for drugs than ever before. Patients are sometimes compelled to go to extremes to obtain the medications they need. Some elderly New Englanders, for example, are forced to make trips to Canada to take advantage of the lower drug prices across the border. Similarly, the expense of drugs has become so great that in order to meet everyday expenses, some couples have to alternate the months they take their prescription drugs.This lack of affordability presents today's and tomorrow's health care professionals with complex issues, such as how to assist in reducing the cost of drugs while maximizing care for patients. Given an individual with limited resources, how should a physician approach treatment regimens? Should a patient's medicines be put into priority so that she or he can select those that are most essential?
During my pediatrics rotation, a question arose that in a roundabout way addresses what must happen for health care providers to be able to address this idea of prioritizing medications. While discussing sickle cell disease with an intern, he mentioned a senior physician who once said, "If I had one drug to prescribe it would beÉ." And he named the medication. Since that discussion, this question about finding the one best drug has replayed numerous times in my mind.
As a person who has seen a fair amount of sad stories over the last three years of medical school, the thought of a single miracle potion is calming, exciting, and almost therapeutic. But in no way do I think there exists a cure-all that would allow thoughtless drug-pushing. On the contrary, this "one drug" question draws us into considering the population as one patient. And for that patient, disease probabilities, disease virulence, and medicine's ability to manage diseases with currently available drugs must be contemplated. The question demands establishing priorities.
Straight to the Heart
The extensive morbidity and mortality caused by cardiovascular disease is matched by few other conditions. A logical candidate for the drug would be one that helps to prevent this high-burden disease. That drug is aspirin. Regular aspirin use has been shown to reduce the risk of heart attacks and strokes. Aspirin has the added benefits of acting as an analgesic, an anti-inflammatory, and an antipyretic. But aspirin has problems. First, it does not completely eliminate cardiovascular disease but merely reduces the number of thromboembolic events. Second, it has side effects such as increasing the likelihood of gastrointestinal bleeding and hemorrhagic stroke and predisposes those who take the drug to peptic ulcers.Bug Killing Made Easy
Another choice is the drug that was serendipitously discovered by the Scottish bacteriologist Alexander Fleming. Fleming found that a mold--Penicillium notatum--produces a substance that kills bacteria. Since that discovery, later called penicillin, there has been a dramatic change in the way infections have been treated. Penicillin, like other antibiotics, is used for both treatment of infection and prophylaxis. At first glance, antibiotics like penicillin or levofloxacin appear to be a good choice. But any particular antibiotic is problematic since different microbes have different sorts of defenses, so any single medication could not counter all bugs. Also, microbes that are initially sensitive to an antibiotic often, over time, develop resistance. This would eventually make that antibiotic useless.How Important Is Surgery?
Prior to application of anesthesia, surgical practice was barbaric and limited to mostly orthopedic procedures like amputations. Today, anesthesia (along with antiseptic techniques) has made surgeries that were formerly impossible, routine. Without anesthesia the field of surgery would essentially be eliminated. So the question Which drug would you choose? begs another question--How important is surgery?The Dream Drug
Derived from opium poppies, morphine is one of the most powerful and commonly used analgesics. Derived from the Greek mythological figure Morpheus, the god of dreams, morphine (which was the choice of the senior physician mentioned above) allows a person's body to work towards recovery of a particular illness without the added stress of pain. Also, morphine is a vital component of end-of-life care. But morphine is an addictive narcotic, which causes respiratory depression and constipation, making it an imperfect choice.Aspirin, morphine, antibiotics, and anesthesia all prove to be remarkably inadequate as a single therapy to treat a population. Using one drug fails to account for individual physiologic variation and remarkable societal diversity. Essentially the same flaw is seen when patients are prescribed drugs that they cannot or will not take. In both cases there is a failure to approach each patient as a unique person who happens to have a disease.
Medicine is, in fact, moving in the direction of treatment directed toward targeting individuals at a biochemical and genetic level. With the wave of both rational drug design and gene therapy, drugs will be specific to individual diseases and individual genetic makeups. As these pharmacological and genetic advances transform medicine, the one constant must not be identification of a single best medication for everyone but, instead, consideration of the patient as a person first.
--Sean Amos, a third-year medical student at HMS
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.