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Points for Consideration by the Physician

Outcomes, benchmarking, and managed care. Three simple phrases that have significantly changed the way physicians practice medicine today. If you also add closed formularies and critical paths, in some senses clinical decision making has become more focused. I believe that a renewed focus on outcomes simply creates an atmosphere of continuous improvement and is just good medicine. One of the best colleagues to have in attaining the best results from any medicine is a fully informed patient.

Michael Weintraub, M.D., recognized this in 1991, when in his introduction to the Yearbook of Drug Therapy he stated, "In looking for trends in the medical literature, it is apparent that the need for the physician to be an educator of patients and their families is becoming greater and greater." In addition, citing an increased need for patient education, he summarized with the following opinion: "Treatment principles correctly applied by patients educated about their condition and involved in its management seem to be the wave of the future." More than ever before, the volume and characteristics of the drugs in use today require deliberate individualization of treatment. The overall effectiveness of any drug therapy depends on how carefully the drug is selected, dispensed, and administered. Responsible communication between physician, pharmacist, nurse, and patient must be achieved to the greatest extent possible. This process begins with the physician. It is absolutely unacceptable that current estimates put the expense of adverse drug events at some 136 billion dollars a year ... more than is spent on diabetes in the United States.

When You Evaluate a Patient for Drug Therapy

• Review the patient's drug history for known drug allergies and prior drug-induced adverse reactions.
• Ask if the patient is currently under treatment by other health care providers.
• Ask about all drugs used currently-prescription and over-thecounter. Remember that many over-the-counter agents were once prescription medicines. Make certain that you do not gloss over this aspect of the medicines your patient can take without ever obtaining your guidance.
• Remember the prevalence of herbal remedy and nutriceutical use. Include these substances in your questions.
• Consider a patient's history and lifestyle, think about diseases or conditions for which the patient is at risk, and vitamins (such as folic acid for heart disease) or minerals (calcium to prevent osteoporosis) that may be used to prevent the process. Rybacki's first recommendation: "It is always better to prevent a disease or condition than to have to treat it."
• Make certain that you are absolutely current. Many daily fax services are available which can be individualized to your practice and can easily be read after your morning rounds.
• Establish the nature and severity of the disorder under consideration for drug treatment.
• Elicit significant coexisting disorders-possible absolute contraindications for certain drugs.