April 23rd, 2019
The Lown Institute’s recent report, Medication Overload: America’s Other Drug Problem, highlights the harm to older Americans from the increasing use of multiple medications. Over the past several months, the Lown Institute has convened working groups of patients, doctors, nurses, advocates, researchers, and pharmacists to develop a “National Action Plan for Addressing Medication Overload,” which will be published in early 2020.
In this new blog series, Deprescribing Champions, we are highlighting some of these working group members, who are role models for deprescribing, to show how they are making an impact at their institutions.
Our latest profile is of Dr. Brandon Combs, Associate Professor of Medicine at the University of Colorado and an editor of the Teachable Moments section at JAMA Internal Medicine. (Read our previous profile featuring Dr. Emily McDonald!)
Lown Institute: How big an impact do you think institutional culture has on prescribing?
Institutional culture has a substantial impact on prescribing, that can’t be overstated. We’ve seen time and again that culture eats everything else for lunch. The people working at an institution set the tone, especially attending physicians who are leading the team and teaching trainees how to optimally care for patients.
How have you made an impact in your institution?
In the hospital, I always ask what medications patients are taking during daily rounds. This is one of the most important things we can do on rounds. I make sure to find out which medications patients are taking, at what dose, and how often they’re receiving them.
Something I tell trainees is that, as internists, medications are a powerful tool we can use to help our patients, or to hurt them. Imagine if a surgeon went into surgery not knowing what tools they would have in the operating room, it would be unacceptable. And yet it’s not uncommon that clinicians lose track of the medications patients are receiving in the hospital.
I’m not sure why this information gets lost in the shuffle, but I believe one reason is that the importance of medications has been deemphasized in training. So on rounds I always inquire about the medications patients are on. We usually learn something surprising from that experience. For example, we might find out yesterday a patient was on an antibiotic, but today they’re not — why? It can also be an opportunity for deprescribing, when the patient has redundant medications or medications that aren’t clearly indicated. Sometimes you also find that a patient isn’t getting an important medication, which can be dangerous as well.
In the ambulatory setting, I almost always ask patients about what medications they are taking and whether they are effective. Could this medication be leading to problems the patient is describing today? Can they afford the medication? I always find it is a useful learning opportunity.
Another way I’ve had an impact on local culture is through the Do No Harm project, a reflective writing exercise where trainees are encouraged to write about times that overuse or underuse occurs. Each story also includes a “Teachable Moment” where they ask, how might we do better for the patient going forward, given the best available evidence we have? The “Teachable Moments” series in JAMA Internal Medicine, which is an outgrowth of this initiative, has several examples of harm from polypharmacy.
One example was Dr. Ricardo Nieves’ story, in which a 78-year-old patient had become unresponsive because she had received too many doses of “magic mouthwash,” a mouth rinse containing sedating ingredients. We might think, “What could be bad about magic mouthwash, it’s just a mouth rinse?” But mouth tissues are permeable, and some of these drugs have sedating effects and compound each other.
What advice would you give for other attendings or leaders for how to promote a culture of deprescribing at their institution?
The role we play in setting the tone and culture, does not have to be on an institutional level. Being a voice for right care on a medical team, or in a resident clinic, is very helpful as well.
Trainees need to see physicians that acknowledge that some of the things we prescribe with the best of intentions can cause trouble for our patients. We’re not just doing it to be difficult, we’re doing it to be helpful.
When you break it down, I think promoting a culture of safe prescribing is really simple. You need to stand back for a moment and ask, “How does this help the patient?” If the answer is, “We aren’t sure,” that’s probably an opportunity to make a change.