When I was a medical student and resident, my focus was squarely on learning the medicine that I would use to treat patients. I spent far too little time thinking about how my recommendations might be received—or misunderstood by my patients—and the context in which they would receive that information. A little more than a decade into my post-medical school clinical practice--I have an evolving list of ideas that health care professionals – doctors, nurses, pharmacists, and others - need to better explain to their patients. Overcoming these common myths will be challenging given the growing diversity (and variable quality) of media sources about health and wellness—but present an extraordinary opportunity to improve public health and the quality of healthcare delivered. 1. Correlation does not equal causation There’s a memorable article from the New England Journal of Medicinecalled “Chocolate Consumption, Cognitive Function, and Nobel Laureates.” In it, Franz H. Messerli, M.D. notes that the dietary flavonoids found in cocoa plants can improve cognitive abilities. So, he wondered, do countries that consume a lot of chocolate produce more Nobel prize winners? Before you unwrap a Hershey bar and try to solve world peace, I’ll tell you that the answer is a definitive not necessarily. Dr. Messerli discovered that countries where people eat a lot of chocolate do produce a lot of Nobel laureates. This is called correlation. However, that does not mean that Dr. Messeri found a direct link between eating chocolate and winning the Nobel prize — which we would call causation. After all, as Dr. Messerli himself cautioned, “the specific chocolate intake of individual Nobel laureates of the past and present remains unknown.” The chocolate/Nobel theory is a fun one, but it is also useful in illuminating common misconceptions about medicine and health. For example, I recently started a patient with diabetes on a course of metformin. Metformin makes the body more sensitive to its own insulin, decreasing the amount of sugar produced in the liver. Just a few days after starting the medication, the patient called me because his blood sugar was high. Since he’d just taken his first few doses of metformin, he believed the medication had caused the spike in blood sugar. In truth, metformin takes time to reach therapeutic levels and had nothing to do with the rise in his blood sugar. Put another way, my patient observed a correlation between metformin and a rise in his blood sugar. But that correlation did not mean that the medication caused the rise. I explained the difference to him using the example of Nobel laureates and chocolate bars. Though the patient understood the concepts, he suggested I come up with another example. Having type-2 diabetes, he could not eat chocolate bars. That’s a fair criticism, and I’m working on it. 2. Natural isn’t better or worse than chemical. I love nature. I love swimming in the ocean, hiking in forests and biking in the countryside. I also stay healthy by eating vegetarian cuisine. In fact, when in need of a pick-me-up, I’d take a banana over soda any day. Nevertheless, when it comes to medicine, we must be careful about ascribing too much importance to things we deem “natural.” The truth is, thanks to medications created in laboratories, people are living longer, healthier lives than ever before. I have a patient I see regularly who suffers from high blood pressure and who has had several strokes. Were it not for a calcium channel blocker that lowers her blood pressure, it’s not hard to imagine that one of those strokes would have been fatal. In fact, since 1970, the death rates from heart disease and stroke have dropped 60% and 70% respectively, largely due to prescription medications. Put another way, we would lose one million more Americans every year were it not for these non-natural treatments. And yet, when I prescribe a new medication, I’m often asked if instead there’s a “natural cure.” For one thing, I really don’t know what that means. Peanuts are natural. But so is the life-threatening anaphylaxis caused in patients with peanut allergies. So I respond to my patients as every physician should: I’m only interested in prescribing therapies that have been proven to work. This is called evidence-based medicine, and it’s one of the main reasons the average lifespan in America has increased from 69.7 years in 1963 to about 78 years today. So, by all means, we should take that hike and eat that banana. But also take the medication prescribed by your doctor. 3. Doing nothing is sometimes better than doing something. A patient recently came to see me. She had a cold. She was achy, had a low-grade fever, a runny nose and a sore throat. I suspected strep throat, a common bacterial infection. But when we ran a test for strep, it came back negative. I told my patient to go home, get lots of rest, drink lots of fluids and take ibuprofen for her pain and fever. “Wait,” she said before our consult was over. “Aren’t you going to give me an antibiotic?” “Sorry, I can’t do that,” I explained to her. Antibiotics are effective in the treatment of diseases and infections caused by bacteria. But since we’d ruled out strep throat, which is caused by the streptococcus bacterium, her cold was likely caused by a virus, against which antibiotics do not work. Moreover, taking antibiotics unnecessarily can have harmful effects. Antibiotics can kill off the good bacteria that live in our guts and help us digest food, leading to diarrhea and other complications. Moreover, when we look at population health, over-prescription of antibiotics is causing bacteria to become resistant to them. In fact, the Centers for Disease Control and Prevention (CDC) calls this resistance “one of the world’s most pressing public health problems,” noting that the bacteria that cause ear and sinus infections are becoming especially resistant to treatment. About a week later I followed up with my patient. Her cold had passed. She’d spent a couple of crummy days in bed drinking tea and watching bad movies, but her body had indeed fought off what was almost certainly a viral infection. “I guess doing nothing was the right call,” she said. I laughed and reminded her that we hadn’t done nothing. We’d ruled out strep and allowed her body to fight off the virus. 4. Potency is drug-specific I recently prescribed lisinopril for high blood pressure. I started my patient out at a dose of 10 milligrams. “10 milligrams?” she asked. “That’s all?” The same day, I prescribed losartan for another patient with hypertension. I started him out at 50 milligrams. “Wow, 50?” he asked. “Do I really have to take that much?” Many patients assume that when it comes to dosages, all medicines are alike — that ten milligrams of medicine A is similar to ten milligrams of medicine B. This is understandable. Let’s go back to that chocolate bar we talked about earlier. No matter whether you choose a Hershey Bar or a Cadbury Bar a bigger chocolate bar will contain more cocoa, more sugar, and more calories than a smaller bar. But medications are not chocolate bars. Rather, potency is drug-specific. Put another way, every individual medication is only effective at a precise dose unique to that drug. And drug dosing is patient and condition-specific. In fact, different drugs used to treat the exact same ailment are frequently prescribed in very different dosages. 5. Splitting doses won’t make drugs last longer In residency, I saw a memorable patient with type 2 diabetes. I had prescribed a medicine for him that helps lower blood sugars. I had success with other patients on that medicine but my patient wasn’t improving. In fact, his blood sugars were rising, and couldn’t figure out why. I considered prescribing another medication, but I first wanted to see if any other factors were affecting his treatment. After a few minutes of discussion, he teared up and said, “I couldn’t afford all those pills, Dr. Jain. So I broke them in half to make them last longer.” Believe it or not, my patient’s behavior is not uncommon. In an era of rising drug costs, higher deductibles, and Medicare donut holes, many patients — especially seniors on fixed incomes — frequently split doses in order to make their medications last longer. What they don’t know is that they’re rendering their medications ineffective. Many patients may not understand that the effectiveness of a medication depends on its potency — half as much medicine does not mean the medication will be half as effective; more likely, it will have no effect at all. In the case of my patient, we worked to find a generic alternative that was available for a low-price at his local pharmacy. 6. Generic doesn’t equal worse Last but certainly not least, while we are on the topic, I want to address the topic of generic drugs versus their brand name counterparts. Many of my patients believe that generic drugs are inferior to brand name drugs. One particular belief I frequently hear from patients is that they need to take more generic pills to get the same effect that they would get out of a brand name drug. There is no way to address this issue except to be very direct. Generic drugs are the same as brand name drugs. In most cases, it’s that simple. The U.S. Food and Drug Administration has a stringent approval process for generic drugs, which requires the medication to be “the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken and should be used.” Of course, there is one way in which generics diverge from brand name medicines: they’re more affordable. In fact, according to the FDA, generic medications are typically 85 percent less expensive than their brand name counterparts. As a result, these generic drugs are more affordable and patients are more likely to take them — which is why we prescribe them whenever possible. There are occasional instances where a patient is more able to tolerate a brand-name formulation than a generic one—but these are few and far between. …. I want to be very clear that I’m neither surprised by these misconceptions nor upset at having to address them. Rather, I see my job as a physician as learning about how patients receive information and adapting my style and approach to theirs. The common nature of these misconceptions suggests we have a long way to go in our approach to educating our patients about their diseases and their treatments. Source
