Map of life expectancy at birth from Global Education Project.

Friday, March 02, 2007


Polypharmacy is the term we use when people who have ridiculous numbers of prescriptions, which creates all sorts of problems -- drug interactions, side effects, difficulty in adherence, cost. It's often hard to sort out what particular drug or combination of drugs might be causing a side effect, how one drug may affect the potency of another (a very common occurrence because the drugs compete for the liver enzyme systems that break them down and remove them from the blood stream), what's really working . . .

An equally, probably more serious problem these days is that people have multiple doctors. Medicine has become more and more specialized; the systems of medical and so-called behavioral health care (mental health and substance abuse treatment) are largely separate; and now we have the phenomenon of the hospitalist.

It used to be that primary care physicians would have "admitting privileges" at local hospitals. If you needed to be hospitalized, your personal Marcus Welby M.D. would sign you in and visit you while you were there, consulting closely with whatever surgeon was responsible for slicing and dicing you. I remember my own pediatrician handing me a bowl of ice cream after I'd had my tonsils out. No more. The chance that your primary care physician will see you while you're in the hospital, or even have the least clue what is going on there, is nil. Instead, your care will be overseen by a hospitalist -- or probably several, actually, as shifts change -- a doctor who meets you when you are admitted and will never see you again after you are discharged.

Your doctor is supposed to get what's called a discharge summary from the hospital, a document that gives your test results, results of your surgery or other procedures, follow up plans, prescribed medications, etc. But Sunil Kripalani and colleagues, in the new JAMA, find based on a literature review that it just ain't happening. At the first visit with your primary care provider after hospital discharge, the chance that she or he will have that discharge summary is somewhere around 25%. Even four weeks later, it's still not there something like 1/4 to 1/2 of the time. Obviously, this can be very dangerous.

For people with serious comorbidities -- such as the large percentage of people with HIV who have substance abuse disorders or mental health problems -- the lack of communication among providers is a continuing problem. Most medical doctors, as far as I can tell, have never even seen one of their patient's mental health records. (Any M.D.s out there care to comment?) Conversely, mental health and substance abuse treatment providers have great difficulty in keeping up-to-date on their client's medical condition and treatment. Elderly people often go to specialists such as cardiologists, who do not communicate with their primary care doctors, who don't even know what prescriptions their patients have. This can actually kill people.

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