For our tools, the meds are the core
I used to use way less than a score
Is a need demanded
Drugs that were branded?
Saying “no” is really a chore.
Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. I just returned from a road trip, to visit family and friends and attend a Continuing Medical Education conference.
After the Continuing Medical Education ended, two daughters and one son-in-law accompanied me to sushi lunch, followed, naturally, by dessert.
The ice cream parlor sat in a building that had previously housed a drug store. Closed in 1979, the interior stayed intact until the building sold to new owners who rehabilitated it and decorated it with stuff that had remained from the pharmacy years.
We observed the lack of variety in the drugs that graced the shelves, and soon the two physicians (my daughter and I) dominated the conversation with the question: If you were Minister of Health for an impoverished, small island nation, what drugs would you have on your formulary if you could only have twelve?
We started with pain relief, my younger colleague wanted ibuprofen and acetaminophen (Motrin and Tylenol); and for high blood pressure lisinopril and metoprolol. I agreed with acetaminophen and lisinopril, allowed as how I could live with metoprolol but would prefer carvedilol (in the same class of high blood pressure meds, but also useful in heart failure), and didn’t want ibuprofen at all. “Too many side effects,” I said, “Ulcers and kidney damage and such.”
Diabetes, I declared, should be met with metformin; she would prefer a long-acting insulin. And I could see her point. A long-acting insulin would at least keep the Type I diabetics alive.
I kept looking over her shoulder at the few shelves lined with medication bottles. I remembered, during residency, checking out the 1979 Physician’s Desk Reference and comparing it to the 1980 edition and thinking how small the earlier version looked. With more than 4,000 pages verging on folio size, the current edition dwarfs both put together.
What about antidepressants? We agreed on citalopram. Antipsychotics? Haloperidol (brand name Haldol). Sleeping pills? I voted for trazodone as a triple function drug, useful for depression, chronic pain and sleep.
For antibiotics, we agreed that if we only used amoxicillin sparingly, resistance to it would fade. I wanted another one in addition, such as doxycycline or azithromycin. And I shook my head; doxycycline has gone from $.04 per pill to $3.50 per pill. I asked, What about mupirocin (a topical antibiotic) but the question went unanswered.
If we hadn’t forgotten about thyroid disease, I would have suggested levothyroxine. But we finished our ice cream and went out into the afternoon sunshine. “You know,” I said to my daughter, “In the last three years, working at a Community Health Center, I know there are a lot of really neat new drugs out there, but I don’t prescribe many. Do you write for much in the way of branded meds?”
“No,” she replied, “About the only drug that’s on patent that I prescribe is Plavix (which helps prevent blood clots).” She recounted a conversation with a salesman representing Oxycontin; neither of us prescribe it at all. The rep had asserted the new reformulation made it less addictive. We laughed. A drug like that doesn’t need a rep.
During residency, I clearly remember the program director teaching us that most doctors use fewer than 20 drugs. Pick one from each class, he said, and get familiar with their side effects and their interactions. But he taught us those things before the Information Age and the Internet.
We got in the car. “What about asthma?” I asked.
“We’d have to have albuterol,” she said.
“Yeah, I guess we’d have to have prednisone,” she said.
I suggested single 20 mg tablets scored with three lines on one side and four on the other.