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The Best Prescription

Dec 12, 2022 6:03 pm

The craziest question that you can ask any doctor is “what is your best therapy for __?”.    Crazy, because there are an exponential number of replies, with added layers of provisos that make each decision uniquely that doctors. Each doctor has her own cha-cha-cha algorithm to a particular problem. The problem is, we each dance to a different cha-cha-cha tune in the practice of medicine.

While most declare the headache to be simply treated, its still a multiple choice of acetaminophen, OTC NSAID or aspirin.  Never mind the other needed “plus” measures (cold compresses, stress avoidance, etc.) to complete the coverage.

Arriving at the best solution (drug) for a particular problem (illness or symptom) can be circuitous or strategy-driven.  Without smart rules, a simple task is easily complexified. Here are my “rules” that guide and simplify my process - a  few basic tenets that help to frame the approach and find the solution.

  • Is this a problem that you can solve (or that’s worth treating)?  The best prescription could be the one you don’t write. (Remember the best surgeons are the ones who know when not to cut! The worst being those who believe a chance to cut, is a chance to cure)
  • Complicated/complex problems may ultimately involve numerous interventions and players, but it’s always best to begin with the biggest most solvable problem first. Then work on your next chance at success!
  • Those asking for your help will need to understand that the solution to a problem may have tradeoffs.  Understanding tradeoff equals better buy in.
  • If you minimize (or gas-light) the problem, you undermine your reputation as a problem solver.
  • “Interesting” problems are seldom interesting and are often high risk-low reward scenarios.

What follows are my “prescribing rules” for most clinical scenarios.  Hence you should consider:

  1. Best drug first: in a perfect world, cost is not an excuse.
  2. Best (optimal) dose first: the sooner you get to good, the gooder you’ll get (this is about the trajectory of control).
  3. Zero-sum additions: DO NOT prescribe a drug unless you stop two drugs. Otherwise, you’re compounding and complicating the problem(s).
  4. The Quest for "Just right" means you are either slowly escalating your bag of tricks or over-treating till the desired benefit is achieved. Which do you want to define you?
  5. Quality of life trumps remission: the former is quite attainable; the latter a holy grail (for good reason).
  6. Every person needs – Hope, Goals & Rules (“yes this will work”; “a response is expected in this time frame”; “take only at night or call me when boils the size of fondue pots appear”)
  7. Provide a Medication List and Handouts for the problem: no one remembers what you said, no one writes it down – BUT you do! Write it, provide it, and educate from it! 
  8. Follow the money: Always know the cost implications of your choices and how this applies to your subject. (Best doesn't have to be expensive & cheap could be a good choice)
  9. Forestall potential failures: prepare the recipient with knowledge about Who/What/How/When your prescription plan will go wrong be undermined or screw up.
  10. It’s your prescription – only you are responsible. Don’t let other cooks mess with your soup!
  11. Don’t fall in love with your solution – the disease will often work to prove you wrong.

What are your "Rules" that should be added to this list?

Disclosures
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
  
Dr. Cush's interests include medical education, novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
 
He can be followed on twitter: @RheumNow

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