Healthy Skepticism Library item: 61

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Zuger A.
We Love Them. We Hate Them. We Take Them.
The New York Times 2004 Dec 14

Full text:

There were eight of us crowded into the exam room as an exasperated patient and I tried to figure out why he was feeling weak and tired and itchy and nauseated and almost fainted in the subway Thursday night.

Two of us, the patient and I, were human beings. The rest had no voices, bodies or personalities in the ordinary sense of the word, but they played a role in the discussion that was just as vigorous and important as if they did.

They were, of course, my patient’s pills. Or rather, they were my pills:
the pills I gave him. Or rather, they were Merck’s pills and Pfizer’s and GlaxoSmithKline’s and a couple of generic manufacturers’. They were the Food and Drug Administration’s pills, too, released into our little sphere only with that agency’s blessing.

But mostly, the pills were the patient’s and mine, and we tussled over them with all the wishful thinking and hidden agenda of estranged parents haggling over the kids. The blue capsule? He’d been taking it for years, with good results. It seemed unlikely to be causing problems now. The new white capsule I gave him last month, the one I figured was making him sick?

“I love it,” he said. “Makes me feel like myself. Can’t live without it.”

The big white tablet from last spring?

“I just look at one and I feel sick,” he said. “I hate them and I’m not taking them anymore. The end.”

“You’ll wind up in the hospital without them,” I said for the sixth time in six months. “Please, bear with them. There’s nothing else to use.”

But I knew perfectly well he had probably stopped taking them regularly months ago, and would never swallow one again.

When he left the room, I gazed for a few moments at the single prescription he had left sitting on the desk. The big white tablet. Such a good pill. Cheap, safe and effective, if a little hard on the stomach.
How I loved that modest, hardworking pill. Of course, I had never put one into my mouth, but it was still one of my favorites. How could he reject it, reject me, out of hand like that?
The nation’s use of prescription drugs is soaring, a government report said this month, and the relationships we all have with those little pieces of matter, our pills, are becoming ridiculously tangled.

Medical anthropologists have written at length about how medications “commodify” health, fostering the illusion that it is something bought and sold at market. In doctors’ offices and in medicine cabinets, though, a reverse process takes place: we all anthropomorphize pills right back from commodities to willful agents of good or evil.

For patients, they can be saviors, or assassins. For doctors, the voodoo is even stronger. Medicines are our prosthetics, at once utterly foreign (we are unlikely to take them ourselves, and may not even know what they look like) yet so much a part of us that we can barely function without them.

For those of us in specialties without scalpels or scopes, they are our only tools (if you don’t count all the good advice). Inevitably, we evolve idiosyncratic patterns of prescribing, favorite combinations, pills we love or hate. The pills become our friends, our servants, our agents, ourselves.

Of course, that artistry and control is all an illusion. We flex our dosing muscles at a remove too far from the actual ingestion to be in control of anything, and we are in turn controlled by forces we never see. One moment we are signing for Vioxx, confident and enthusiastic; the next moment, it disappears, and we are left to explain why. One moment we are prescribing a patient’s big white tablet, happy that we are practicing medicine of the highest quality by protecting him from bad things. The next, we discover once again that little known fact:
There is a placebo effect for doctors, too.

Pity the doctor who thinks that prescribing a drug is the same thing as treating a patient, and the patient who agrees. Some never learn otherwise. The rest of us slowly wake up to the fact that the prescription is just the beginning, sometimes not even that. Without constant discussion and re-evaluation, we might as well all be writing poetry on those prescription forms.

After a month without the big white pills my patient said he felt a lot better. I, of course, was no longer practicing quality medicine, and felt a lot worse. His stomach talked to him. The statistics of what would happen to him without the pills talked to me. The pills, for once, were silent. Perhaps the best we could do, under the circumstances, was keep talking to each other.