Pop artist Andy Warhol was famously quoted as saying, “In the future, everyone in the world will get a chance to be famous for 15 minutes.” Maybe he was predicting the future of health care, where everyone would get 15 minutes with their primary care physician. Because that’s the reality of our health care system today.
“The 15-minute appointment is a huge problem for older adults, especially individuals who have several chronic conditions and are taking multiple medications,” said Dr. Nick Schneeman, MD, Lifespark Chief Medical Officer. In a recent article he wrote for TIME magazine, Dr. Schneeman talked about the growing incidence of polypharmacy—the regular use of five or more prescription drugs—as an “underpublicized American tragedy” that contributes to premature deaths and hundreds of hospitalizations every day. (For more on this topic, read Polypharmacy and Seniors: Health Crisis with a Cure.)
From integrated to siloed
Earlier in his career as a primary care physician, Dr. Schneeman would occasionally refer clients to a urologist, pulmonologist, oncologist, or cardiologist. After meeting with the client, the subspecialist would send a letter to Dr. Schneeman outlining their recommendations, including any new medications. Most often, he would take their recommendations and prescribe the beta blocker or diuretic, but not before considering his client’s current medications, medical history, and goals of care.
“As the primary prescriber, I was fully integrated into the decision-making process and in the ownership of the risk-and-benefit discussion about everything related to my clients’ care,” he said. “That model of care doesn’t exist anymore.”
One of the consequences of decentralized care is an increase in what Dr. Schneeman calls “drug cascading.” This phenomenon refers to the prescribing of a medication by one doctor, which then causes a side effect, which is then treated with another medication, which causes a new side effect, and so on. “If you’ve been prescribed medications for insomnia, fatigue, erectile dysfunction, swelling of your ankles, confusion, incontinence, and many other complaints, be wary that your symptoms could be due to one of your medications,” he said.
Complexities of deprescribing
Eliminating drugs is a complex decision that can be as risky as adding them, but few doctors or specialists have been trained in the practice of deprescribing, Dr. Schneeman said. A study published in the Annals of Family Medicine found that, in general, physicians tend to avoid deprescribing, describing it as “swimming against the tide” of patient expectations and the medical culture of prescribing.
Still, Dr. Schneeman cautioned clients never to attempt to pare down their drug list on their own. “Always consult a medical professional,” he said, adding that some larger health systems now allow their physicians to consult with a pharmacist. At Lifespark, senior-savvy pharmacists are integrated into provider teams to advise and consult on the ways certain medications affect the body as it ages.
Tips for working within the system
Given the limitations of the 15-minute appointment, Dr. Schneeman shared a few tips to help seniors and their families make the most of their doctor visits, so they can stay healthy at home:
- Schedule an appointment specifically focused on medications and deprescribing. “If you try to slip such an important topic into a routine follow-up or an appointment for a different concern, it’s not going to go well.”
- When making the appointment, it’s important to clearly state the purpose of the visit. “Tell them in advance that you want to discuss polypharmacy—this will give your doctor a chance to do research, consider talking to your subspecialists and, importantly, reflect on how your medications may work for or against each other,” he said. “If you blindside them, they’ll probably refer you back to your cardiologist or urologist or whoever prescribed the drug in the first place.”
- Questions to ask your doctor during your visit: How strong is the evidence that the medication will provide a benefit? What the risks are in the near term and over time? What is the specific reason I’m taking each of these medications? “If you’re a senior, don’t be too proud to ask if the medication or the dose is still appropriate for you, given your age and life goals,” he said.
- Consider asking a family member to accompany you to the appointment. “It can be helpful to have another pair of eyes and ears at this discussion and to have an advocate by your side.”
“Paring down your drug list may require some self-advocacy and an extra doctor’s appointment, but it’s so worth it,” Dr. Schneeman said.
To learn how Lifespark helps people age more magnificently, visit Lifespark.com.
