Patient outcomes – it’s a patient thing

I was tempted to write this blog after sitting through a discussion on antibiotics. I know that antibiotic resistance is a huge issue and we desperately need to get a handle on it. But the speaker said that simple antibiotics in urinary tract infections reduce the symptoms by about a day so were not ‘worth it’. A very interesting statement to make to someone who may be feeling unwell, with a pain in their tummy and tell me that they are ‘pissing razor blades’ or ‘their urine is burning them like lava’. I also know how easy it is for someone who is elderly to drift from a slight urine infection to being acutely confused. I rather think that this decision should be made by the patient.

Do we really think about the patient when we prescribe a treatment?

It takes me back to the days when I worked in dermatology. The starting point was ‘we want you to use an emollient regularly’. So with the patient in mind we handed a selection of 5 emollients across and said – “go and tell the GP which one you get on with and ask him/her to prescribe enough”. The most economical emollient is the one that the patient will use to improve and maintain the quality of the skin. I am happy to smile when they say that ‘this one is the best – because the pump works upside down’. Al least it has a chance.

I was also involved in “taste tests” for calcium and vitamin D tablets. Another example where the individual patient’s view is important. How many tablets are sitting in patient’s cupboards and they say “well I don’t really like them”.

Sometimes we are really silly:

  • We prescribe z drugs for insomnia when the problem is daytime functioning
  • We prescribe metformin at a dose which causes indigestion or sulphonylureas which cause ‘minor’ hypos, knowing that the two most common solutions is dose reduction by the patient or snacking. And don’t get caught on the snacking issue – several times I have been thinking two rich tea biscuits at approximately 80 calories – not 9 custard creams at your total daily saturated fat intake and 600 calories or the super latte and a chock chip muffin (because the supersized coffee is a free upgrade) at 800 calories – so nearly half the daily load! Don’t get me started on this one….
  • We prescribe two inhalers when one is what they want

It is not unusual for a patient to get a diagnosis and a prescription within a 8 minute appointment for a completely different problem. The patient arrives at the pharmacy with a totally bemused face.

I could go on, but it is clear that we have to think differently.

As a starter it’s your life, your disease and your treatment – so it’s your responsibility. I am there to inform you, help you, direct you and support you in making the most appropriate decisions. And the community pharmacist will answer a few more when you have thought of them. If you don’t want to then that’s fine. Please don’t absorb valuable NHS resources when you have no intention of using them.  I hate to think how many “nurse equivalents” of money are sitting in the bathroom cabinet as unused medicines.

I will still be there when you change your mind and when you are ready. Also be sure you know why you are stopping a medicine before you do.

Now – let’s discuss your problems and understand what you need to achieve – what will you use the medicines for. I will be honest about the medicines – so we can set some realistic goals. I will never promise ‘complete pain relief’, but discuss with you how you would cope if we could reduce the pain by 2 points on the VAS. I do like to give the medicines a fair chance. So it all becomes a balance between medicines and lifestyle, anchored in reality. They are medicines not magic potions.

You can ask when you feel the effects of the medicine in your body – or when you don’t. You can discuss how long you need to take the medicines for when to start thinking about it. You can explain what you intend to do and I will give you some advice.

It is true that medicines can empower people to take control of their lives and it is also true that medicines can change pathways of care. Medicines can provide you with greater security and help you get back to or stay at work. They may help you to get out a bit more and reduce social isolation. Some medicines can cure you, but most reduce symptoms or are a safety belt that reduces the chances of your life becoming a ‘car-crash’.

I have listened to you; I have discussed treatment options; we have agreed realistic goals; we have designed the treatment package. Please don’t be surprised when I then ask – “what’s your skin in the deal” – “what are you going to do to improve your outcomes?” That is the little section in the care plan that I make you fill in – the bit that you commit to.

Please don’t just rely on a pill to achieve your outcomes.


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