Treatment burdens and time to do a bit more…..nothing?Rob Walker - 24 Jan, 2019
How are the New Year Resolutions going? They may be in full flow, stalling or never started (as in my case…) But is doing nothing sometimes such a bad thing? It inherently goes against our natural human desire to DO something, and this is a problem we constantly face in medicine. We want to DO something for our patients, in part driven by guidelines - get their blood pressure down, improve their HbA1c, improve their life expectancy, but have we forgotten to ask - is this what you really want? And at what point are we doing more harm than good with the treatments we prescribe?
John is 65, he has had type 2 diabetes for 12 years, had an ACS 5 years ago from which he has recovered well, and also has gout and hypertension. He continues to work part time as gardener and has really tried to increase his exercise doing parkrun most Saturdays. His list of medications reads - metformin, linagliptin, aspirin, omeprazole, atorvastatin, amlodipine, ramipril, bisoprolol, allopurinol. You see him after his annual checks and everything is looking pretty good apart from an Hba1c that has crept up slightly to 7.6% (~60mmol/mol); you are aware of the new evidence supporting SGLT2 inhibitors in people with known IHD so prescribe empagliflozin and suggest a repeat Hba1c in 3 months.
However, John doesn’t come back until his annual checks the following year; his blood pressure is through the roof and his Hba1c has shot up to 9% (75 mmol/mol). What has happened you ask? A quick look at his repeat medications tells the story - he hasn’t taken any of his medications for about 6 months, although he has been buying an aspirin from the pharmacy. John started developing some balanoposthitis (inflammation of the penis/foreskin, probably from the empagliflozin), he had had a bad day at work, was getting fed up with all the pills, and just thought ‘sod it’ and stopped everything.
We will all have had variations of cases similar to John and what it highlights is that it is easy to underestimate the pressure and burdens we place on patients with treatments. The concept of ‘treatment burdens’ is a relatively new one and was discussed in the BMJ towards the end of 2018 . Based on the guidelines John has had gold star treatment, but everyone has their tipping point, and that one final side effect from the empagliflozin has caused the whole pack of cards to come down, leading to a far worse outcome for John. One study has shown that in order to comply with 3 disease specific guidelines patients would take between 6-13 medications daily, visit health professionals 1.2-5.9 times/month and spend 49.6-71 hours/month on health related activities. Is it any wonder that sometimes our patients can’t cope with this? The BMJ article had some important points for us to reflect on. First, it suggests most of us are likely to underestimate the workload we place on patients with treatments and overestimate their capacity for more intervention. Second, we need to make sure our patients values and preferences are at the heart of any discussions on treatment, not the clinicians agenda. Finally this needs to be wrapped up with shared decision making and coming back to that important question - ‘what is most important to you?’. We all strive to do this but the pressure to ‘do the right thing’ based on guidelines (and that QoF box bleeping at you) makes it difficult.
Those of you, like me, who had to do ‘trial by video’ with live patient consultations for MRCGP will remember we had to make sure we offered patients a choice of treatment options in the consultation. I was taught a valuable lesson by a trainer that option 1 should always be ‘do nothing’, and in John’s case may well have been a better option than burdening him with more treatment. Overburdening our patients with treatments is part of a wider spectrum we are grappling with now - over-investigating and over-diagnosis are also aspects to this problem, and the Too Much Medicine initiative, run by the BMJ, has become a crucial balancer to the inexorable drive to keep doing more. So as we go head long into 2019, why not just take a moment before adding yet another treatment and consider what a wise owl recently told me ‘Don’t just do something, stand there!’