Introduction

Reviews

Before Taking a Drug, Make Sure the Diagnosis Is Correct

Timothy B. McCall, M.D.

Whenever possible the doctor should attempt to make a diagnosis before prescribing drugs. A thorough interview and exam should therefore almost always precede drug therapy. Lab tests may also be necessary. Unfortunately, not all doctors take the time to do the job right. And given the financial incentives in managed care these days, the problem of inappropriate drug prescribing may be getting worse.

Researchers at Harvard Medical School surveyed over 500 doctors nationwide to see how well they interviewed a patient before prescribing drug therapy. The doctors were presented a hypothetical case of a man with sharp pain in the stomach area, relieved by eating but worse on an empty stomach. They were told the man had a test a month earlier which showed some irritation of the stomach lining but no ulcer. The doctors were asked if they would choose a therapy at this point or whether they would like additional information.

Without asking any further questions, more than a third of the doctors were ready to start drug therapy usually opting for ulcer drugs like Tagamet or Zantac (This study was done before the role of the bacteria H. pylori in causing ulcers was discovered). Had they asked more questions, these doctors would have learned that the man took eight aspirin per day for stomach pain, drank five cups of coffee per day, smoked two packs of cigarettes per day and drank two cocktails at lunch and two glasses of wine each evening—all of which contributed to his stomach problems.

Had the doctors asked about stress, they would have learned that the man’s son was killed in a car crash two months earlier. On average, the doctors asked less than two questions. Only one in six doctors asked about stress. An inadequate interview by the doctor correlated strongly with the recommendation of a prescription drug.

Be concerned if your doctor turns too quickly to the prescription pad. If your doctor seems to be simply treating a symptom, rather than looking for an underlying cause, you can ask what could be causing your symptom. Would any further questions, exams or tests help sort it out? The risk of not looking for a cause and merely suppressing a symptom is that you could delay the diagnosis of a serious condition like cancer.

Before starting a medicine, particularly when therapy will be prolonged or when side effects are likely, try to determine how certain the diagnosis is. Find out how confidant your doctor feels about the diagnosis and on what basis it was made.

When the diagnosis is unclear, sometimes drug therapy only serves to muddy the water. If your condition improves, did the drug do it or was it going to happen anyway? What do you do if the symptoms recur? If the diagnosis is in doubt and the situation is not critical, it's often best to hold off on drug therapy and see what happens. Many doctors seem to have the opposite attitude: The drug won't hurt and might help, so why not use it?

As we will see in the next column, given the potential for side effects with ANY prescription drug, that attitude could lead to all kinds of problems.

Next: Avoiding Unnecessary Prescriptions

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