‘A Fool for a Patient’

“A physician who treats himself has a fool for a patient.” — Sir William Osler Walk into any pharmacy or grocery store, and you will find shelf upon shelf stocked with over-the-counter medications that can treat indigestion, cold symptoms, pain, fever, lice, and myriad other common ailments. The consumer makes the diagnosis, chooses the treatment, and makes certain that the OTC medicine is safe to take. Pharmacists might be able to help, but they are often difficult to find when the medication aisle is next to the frozen food section. Now the U.S. Food and Drug Administration is looking at expanding the types of medications available without a prescription to treat common diseases like high blood pressure, cholesterol, and diabetes. The dilemma as I see it, after looking after tens of thousands of patients in the ED, is that patients may not get the treatment they need because it takes time and money to see a doctor, and first-step treatments for many chronic conditions are pretty straightforward. Being able to walk up to a pharmacist, get a diagnosis, and begin treatment almost immediately is a great start to prevent heart disease and stroke and to control diseases like diabetes and asthma. The other side of the equation is just as compelling. Medications help control diseases, but education, monitoring, and lifestyle changes are key elements in improving the quality of people's lives. The American Pharmacists Association agrees that expanding the types of medication needed without a prescription is the way to go, and pharmacists are available to take the front line in screening patients, making diagnoses, and providing medication. They also agree to collaboration with other medical providers to provide quality health care. Not all pharmacists will have to participate, and it goes without saying that they want to be compensated for their efforts. The American Medical Association is concerned that allowing patients to self-diagnose and self-medicate is not the best way to achieve quality health care.ImageThe FDA measures not only patient outcomes but whether they take their medications appropriately. Physicians worry that the OTC changes would cause patient outcomes to suffer. Of course, the physician would like to be compensated for his efforts. Big organizations continue to fight over who might be able to charge fees, but a hidden financial component also affects the patient. Many insurance plans help pay for prescription medications, but few reimburse the cost of those over-the-counter medications. No doubt, over-the-counter medicines have made life easier for a mother who uses acetaminophen to treat her child's fever or for the athlete whose pain is relieved with ibuprofen. Some things in medicine are easy, but prescribing medications can be tough. Just because it's over-the-counter doesn't mean that it's always safe. Acetaminophen should be used with caution by people with liver problems, including chronic alcohol abuse. Ibuprofen can cause stomach irritation and bleeding, and may not be the best drug for a patient with ulcers or who is taking blood thinners. And who bothers to read the fine print warnings on the cold medication bottle or know that some of the ingredients are dangerous for people with high blood pressure? As new drugs are added to the over-the-counter list, the patient will have to become his own doctor. Albuterol inhalers are used to rescue patients from acute asthma attacks, but it's important to recognize that all wheezing isn't asthma; it could be congestive heart failure. The cough may not be pneumonia, but cough variant asthma instead. Finding blood on the toilet tissue after wiping may be just hemorrhoids, but blood where it doesn't belong should not be ignored. It may not require a doctor's visit, but a phone call to touch base seems reasonable, unless you don't have a doctor to call. Patients should already know the common complications of their medications, but getting the drug without a prescription increases that responsibility. Diuretics, or water pills prescribed as first-line therapy for high blood pressure, can cause potassium levels in the body to fall. Statins, used to treat high cholesterol, can inflame the liver. We live in a very chemical world and every medication, prescription or not, has the potential to cause a side effect, complication or interaction with another medicine. The AMA and the APhA agree that best quality care requires coordination between doctor, pharmacist, and patient. I expect the pharmacist to review my prescriptions, and it's not unusual to get a call recommending a different drug or a change in dose. It's all about teamwork, but in an age where we routinely outsource tasks to make our lives easier, it is surprising to have a push to cut a teammate. From laundry to computer repairs and car repair to plumbing, we invite people with knowledge and expertise into our day. The patient needs to be responsible for being an active partner in his health and not an object of medical care, but it seems that making the patient take on the role of physician may be a little foolish.ImageDr. Wedropractices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, WI. He is a diplomat of the American Board of Emergency Medicine, a fellow of the American Academy of Emergency Medicine, and a Life Fellow of the American College of Emergency Physicians. He is also a clinical professor in the School of Medicine and Public Health at the University of Wisconsin-Madison and adjunct faculty at the University of Wisconsin-La Crosse. Dr. Wedro has been a commentator on the Olympic Games in Albertville, Lillehammer, and Nagano with CBS and in Salt Lake City, Athens, and Turin with the Canadian Broadcasting Corp. He frequently lectures in the United States and Europe on topics related to emergency medicine, exercise physiology, and athletic injuries and illness. He is a contributing author and editor for WebMD, and posts weekly articles on sports and medicine on his website,http://www.MDdirect.org/blog.

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