To Prescribe or Not Prescribe:
The Go-To Tool in the Medical Bag May Not Always Be the Right One
By; Ashvin Nair
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Praccho Muna-McQuay had been awake for almost twenty-four hours straight. The sun had risen almost three hours before. In the last ten hours, he had visited the local emergency department twice and seen several medical professionals.
For a few days before, Muna-McQuay had felt shortness of breath, but today, this symptom evolved into a feeling of “tightness in my body and stomach burning,” he says. He began to experience paranoia.
Today, after almost twelve hours at the hospital, a doctor prescribed Muna-McQuay stool softener and iron pills. In response, Muna-McQuay says, he felt confused and upset. A well-educated student who started college wanting to pursue medicine, he’d researched his symptoms and initially believed he might have gastritis, a condition in which one’s stomach lining becomes inflamed.
Still, he picked up the Colace and iron pills from a CVS on his way home—the iron because the doctor had seen low iron readings in Muna-McQuay’s bloodwork.
It was noon on the weekend, and he finally closed his eyes, exhausted. The light blue bottle and pills would sit forever unopened on Muna-McQuay’s desk.
Over the next few months, Muna-McQuay would visit specialists whose answers would only prove more confusing. Eventually, he says, he turned to taking a PPI (proton pump inhibitor) to manage his gut symptoms, despite an initial hesitancy; he’d heard stories about patients becoming dependent. PPIs work in many patients by decreasing stomach acid production, but Muna-McQhay felt that his condition was more complex: he’d been taking other medications and the timings of his symptoms were irregular. He also knew, he says, that some research suggests that regular use of PPIs is linked to higher rates of conditions like inflammatory bowel disease and Crohn's Disease, which are serious risks, especially if a patients doesn’t respond to PPI treatment.
Over time Muna-McQuay’s nausea resolved, but his other symptoms persisted.
Muna-McQuay turned back to researching on his own. He turned his attention to a separate drug he’d been taking for hair loss, Finasteride. He found a study that showed a connection between Finasteride and gut inflammation in animal models. He mentioned this research to a doctor, but the physician rejected the drug as a potential cause of Muna-McQuay’s gut trouble.
Muna-McQuay had stopped taking the Finasteride months before on his own. He says he fell unbearably ill when he tried to start taking it again.
Muna-McQuay still takes a PPI but is particularly careful about what he eats. He has completely stopped taking Finasteride, sacrificing potential hair loss for a manageable gut condition, and he doesn’t intend on getting back on it anytime soon. Although research about this connection is still evolving, he felt from personal experience that taking Finasteride contributed heavily to the severity of his symptoms.
Since that visit to the emergency department in Maryland, Muna-McQuay says he has felt unsatisfied with the care he has received. He wishes his physicians had better considered how drugs interact with one another, and wonders whether the PPIs were a “crutch” that the doctors used that potentially prevented him from more tailored care.
Studies have found that doctors are historically quick to give proton pump inhibitors to patients, even when it may not be the best solution. A 2018 study of over 800 patients presenting to a Quebec ER, and taking a PPI at the time of admission, found that over thirty percent did not meet Canadian prescription guidelines.
Taking PPIs can pose health risks and can significantly hurt everyone’s pockets when doctors are not aligned on what conditions require a PPI. In the Quebec study, an estimated $20-30 million dollars were spent on these inappropriate PPI prescriptions, presenting a significant burden to the healthcare system.
A number of older studies have also found overuse of PPIs in the United States and globally.
Medicines work in many cases, can ease suffering, and save lives. But in some cases, as with PPIs, the prescribed medications may not align with their need and purpose in medicine. “At the end of the day,” says Rhode Island psychiatrist Dr. Zobeida Diaz, “you want people…not relying on a medication to help them feel better.”
For some patients, not just prescriptions but medical advice seems out of touch.
Karen Ellis was diagnosed with multiple sclerosis ten years ago. Before she was diagnosed, she says, she rarely took medications. But now, every time she goes to the doctor, her prescriptions and diagnoses change:
“They would have had me on a whole lot of different medicine,” she says.
One early morning a few years ago, Ellis received a message from her doctor, telling her that she had celiac disease; the diagnosis was based on what tests showed in her gut.
She was in disbelief. She “had spaghetti for dinner one night… and raisin bran bread with butter and jelly for breakfast the following morning… and didn’t get sick,” she says.
Patients with celiac disease may experience nausea and diarrhea when consuming even trace amounts of gluten, but Ellis hadn’t noticed any reaction to gluten-containing foods. She says she knew the diagnosis had to be wrong. After she called back and explained her situation, she received an apology for a misdiagnosis.
In another instance of misdiagnosis, Ellis learned from nurses she was seeing for care that they believed she had PVD, or peripheral vascular disease. Her care team insisted that they do an ultrasound on Ellis’ feet; they suspected a lack of blood flow to her extremities and wanted to start a new medication. Ellis says that the doctors, however, did not have sufficient evidence to justify an ultrasound, so first they ordered blood tests.
Poor blood test results would justify the ultrasound, and poor blood flow via the ultrasound would justify the medication for PVD. She says she knew they would find neither because she could walk and perform daily activities with her feet without any issues.
A much simpler way to confirm whether one has PVD is to check the skin of the area where the reduced blood flow is suspected. If blood doesn’t flow to the feet, then the tissue will reflect this by turning dark and scaly; it may start to die.
Finally, a nurse did pull off Karen’s socks; her skin was completely normal. The nurse quickly corrected herself, taking back her statement about the need for an ultrasound or any medication.
In addition to cases where doctors may mistakenly resort to medication, there are cases where natural alternatives can serve as substitutes. Patients like Ellis, however, wonder why doctors rely on them less than on prescribed drugs.
A few years ago, Karen saw her neurologist who told her she had low thyroid levels and needed to start medication.
Karen, who says she is passionate about holistic medicine, insisted that the doctor provide a natural alternative instead. The physician recommended trying kelp as a supplement. Ellis did, and a year later her thyroid levels were no longer low.
At Ellis’ most recent physician visit, bloodwork found low levels of white blood cells. She asked her doctor about natural treatments and was advised to begin taking Manuka honey.
Multiple studies have suggested a link between taking Manuka honey and boosts in immune response in cell line models, including increases in different factors like chemicals and genes related to immune cell recruitment.
Ellis sees her neurologist only yearly and will find out in early 2025 whether the honey worked to increase her white blood cell levels.
Sarita Warrier, dean at Brown’s Alpert Warren medical school, explains that in the second semester of the first year and during the second year of a medical student’s training, students dig into theories of disease and treatment.
Students study, Warrier says, the normal organ and how the normal organ functions. “How can things go awry and lead to disease processes? And then, what are the treatments for those?”
Warrier says the management of patients is an aspect of care fully tackled only at the end of medical school. Students choose and rotate through clinical rotations at different institutions. Depending on where a student completes their rotations, some of their fundamentals of prescription practices could look different.
This way of introducing medicines and prescriptions has drawn criticism, especially from physicians interested in natural solutions like Dr. Diaz.
Diaz explains that current medical school pedagogy has potentially steered treatment in the direction of using medication. From her experience, she says that medical schools “don’t do an amazing job of teaching us…preventative measures or alternative medications, definitely not supplements or nutrition…it’s all drug-based, unfortunately.”
Other disparities in prescription practices include factors about the patient, including socioeconomic status.
One study found that women with early-stage breast cancer in Georgia were more likely to get recommended for standard chemotherapy, irradiation, and hormonal therapy if they were more highly educated or had higher income.
In this study, patients with specific types of government insurance were also more likely to receive standard treatment; studies suggest that outside players like one’s insurance also have an established role in not only granting patients access to treatment but also sometimes determining what treatments they receive.
For example, after the Medicare Prescription Drug, Improvement, and Modernization Act in 2003, which lowered payments to doctors for outpatient chemotherapy drugs, one study found that doctors switched from low to highly-profitable drugs for chemotherapy treatment like docetaxel and gave more chemotherapy.
Insurance isn’t the only outside player that affects prescription practices, as one analysis suggests that pharmaceuticals can significantly affect the way certain drugs are prescribed. One study found that Myrbetriq, a drug for overactive bladders, was prescribed 64% more by physicians with financial compensation from pharmaceutical companies. These compensations often take the form of travel or meals.
Of the 50 brand-name drugs analyzed in the study, 38 percent of which cost more than $1000, more than half were being prescribed by doctors who had financial ties to the makers. The United States is also one of the only countries where these pharmaceutical companies can directly advertise their drugs to consumers to justify their need.
The idea that medical professionals and students can benefit from prescription education is not new. Research implementing training workshops at medical schools has shown improved prescription practices among medical school students and increased their confidence in their ability to make prescriptions.
Physicians do have power to resolve many of these situations.
In a study of patients admitted to a military hospital system, 66% were found to be incorrectly taking PPIs. After an intervention involving physicians calling and re-advising patients about the downsides of taking PPIs and safer alternatives, the number of patients taking PPIs incorrectly decreased by 44% of its original amount.
The same ideas apply to medical residency.
Diaz says medical residencies differ in terms of how they view pharmaceuticals. Diaz chose Brown because of the program’s focus on psychotherapies; other schools prioritize pharmacological treatments, she says.
She recognizes that there are cases where patients need medical support but also takes joy in finding alternatives, she says. She believes there are natural ways to improve her patients’ lives.
“Less is more sometimes…I work to try to minimize or optimize what they’re on so they can get by with less meds or…hopefully no meds at all,” she says.
Diaz says her desire to find safe treatments for patients has influenced her interest in psychiatry and training, but she also says that general practitioners might not have the same approach and often resort to prescribing medications they feel comfortable with.
“General practitioners… they have to see like 30 patients a day… in like, 15 to 20 minutes, they have to see that patient and figure out what they need to do,” she says.
Diaz says that until a patient can see a psychiatrist comfortable and experienced with exploring alternatives, they are limited to these medications.
“It's not uncommon for people to have to wait months to get in to see a psychiatrist. So that's why general practitioners end up…usually feeling the need to start a medication,” she says.
Brown student Jed Kim has experienced this firsthand.
Kim has ADHD, was prescribed an amphetamine by his general practitioner, and has taken this drug for multiple years. His sister suffers from ADHD as well, sees a separate psychiatrist, and has discussed more options with her doctor.
She told her brother about a dermal patch she was prescribed for her ADHD; it has created fewer side effects in patients during clinical trials. Kim says he wonders whether his general practitioner knows about the latest treatments and whether Kim’s care would be more effective if he saw someone with better prescription training.
Medicines do work. Diaz, for example, says she recognizes the need to give medication for certain mental health conditions, particularly “if someone’s anxiety is so high they can’t even engage in doing therapy or using coping skills.”
Brown student Meg Talikoff experienced this reality and was recently prescribed medication for her OCD.
During her first two years of college, she says she struggled with thoughts like having “to drop a class” because she “couldn’t convince” herself that taking the class was the “right thing to do.” Because of her OCD, Talikoff derived equal stress from small daily decisions to larger problems like recently having her identity stolen.
She tried exposure therapy on her own but still found herself very anxious. These therapies consisted of her pushing herself to engage in discomforting activities even when they caused her significant anxiety. She was able to attend school and talk to friends but always felt underlying stress.
She felt that she had exhausted all of her options. This past summer, she sought care from a psychiatrist, who prescribed Prozac.
The doctor would later call Talikoff a “perfect case” in terms of her response to the drug. Talikoff says that the Prozac has helped her return to her old self; she says she can “do stuff without feeling uncomfortable” and can “just be calm.” For some patients like Talikoff, medication offers a new quality of life.
The path to get this care, however, was arduous, Talikoff says. Some of the medical professionals she saw dismissed her symptoms, she says including a specialist at UNC Chapel Hill, whom her sister sees for her OCD.
Talikoff says she sees now that finding the right medication is complicated. It can seem like “throwing spaghetti at a wall and seeing what sticks.”
For cases like Talikoff, the need for medication is clear. Her prescription for 40 milligrams helped her feel that she has herself “back 100%.” She takes the blue and white capsules daily.
Professionals like Dr. Diaz echo this idea for similar patients, but she also seeks to strike a balance particularly when it’s possible to find alternatives or avoid medication entirely. She strives to prescribe drugs only when needed. She says in the field of medicine that doctors “sometimes lose sight that you don’t always have to prescribe a medication” or even “find an issue” at all.
Audio Piece: Access a short audio piece about challenges related to prescribing drugs for psychiatric illness here.
Commentary:
Before this project, I had some hesitancies about writing healthcare pieces related to accurately addressing perspectives and overgeneralizing. Although this piece is about prescription practices, my original topic was slightly different. I was interested in how research shapes medical practice and how scientific training can prepare a physician for more difficult patient situations. Although I recognized a difference, I was unable to find tangible examples to support it. I then adjusted my topic to focus on a particular facet of medical decision-making: prescription practices. After this piece, I can recognize where I overgeneralize. I don't feel that the task of including multiple perspectives is easy, but I do feel more equipped to do it.
I similarly felt that I had an abundance of personal anecdotes to include when writing this piece. I struggled, however, with finding professional opinions. I emailed around fifty psychiatrists within the Providence area, and Dr. Diaz was the only one who got back to me. I can imagine that many see risks in talking about this subject. In my interview with her, I not only learned that there are differences in training depending on one's institution, but I also learned that I may be interested in psychiatry as a potential career in the future.
Overall, my largest takeaway from this process is that I feel ready to grapple with, reflect on, and write about medical issues independently, which was my primary goal for taking this course.
Interviews:
Sarita Warrier 11/5
Karen Ellis: 11/19
Praccho Muna-McQuay: 11/10
Zobedia Diaz: 11/21
Meg Talikoff: 11/22
Xia, B., Yang, M., Nguyen, L. H., He, Q., Zhen, J., Yu, Y., Di, M., Qin, X., Lu, K., Kuo, Z. C., He, Y., Zhang, C., Meng, W., & Yuan, J. (2021). Regular use of proton pump inhibitor and the risk of inflammatory bowel disease: Pooled analysis of 3 prospective cohorts. Gastroenterology, 161(6), 1842–1852.e10. https://doi.org/10.1053/j.gastro.2021.08.005
Nguyen, P. V., & Tamaz, R. (2018). Inappropriate prescription of proton pump inhibitors in a community setting. Canadian Journal of Hospital Pharmacy, 71(4), 267–271. https://doi.org/10.4212/cjhp.v71i4.1802
Masad, R. J., Nasser, R. A., Bashir, G., Mohamed, Y. A., Al-Sbiei, A., Al-Saafeen, B. H., Fernandez-Cabezudo, M. J., & Al-Ramadi, B. K. (2022). Characterization of immunomodulatory responses induced by manuka honey. Frontiers in Immunology, 13, 1020574. https://doi.org/10.3389/fimmu.2022.1020574
Guy, G. P., Jr, Lipscomb, J., Gillespie, T. W., Goodman, M., Richardson, L. C., & Ward, K. C. (2015). Variations in guideline-concordant breast cancer adjuvant therapy in rural Georgia. Health Services Research, 50(4), 1088–1108. https://doi.org/10.1111/1475-6773.12269
Jacobson, M., Earle, C. C., Price, M., & Newhouse, J. P. (2010). How Medicare's payment cuts for cancer chemotherapy drugs changed patterns of treatment. Health Affairs (Project Hope), 29(7), 1391–1399. https://doi.org/10.1377/hlthaff.2009.0563
Fresques, H. (2019, December 20). Doctors prescribe more of a drug if they receive money from a pharma company tied to it. ProPublica. https://www.propublica.org/article/doctors-prescribe-more-of-a-drug-if-they-receive-money-from-a-pharma-company-tied-to-it
Boster, J., Lowry, L. E., Bezzant, M. L., Kuiper, B., & Surry, L. (2020). Reducing the inappropriate use of proton pump inhibitors in an internal medicine residency clinic. Cureus, 12(1), e6609. https://doi.org/10.7759/cureus.6609
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