Not so long ago, it was common for people to be in the dark about how doctors prescribe medicine and other treatment options that were available for their condition. They often did not even know anything about the medicines they were taking. Doctors wrote out prescriptions, gave instructions on how to take the medicine, talked a little about side effects, and that was it. Today, people have become more savvy about their health care and are more involved in making decisions about their treatment. To work more effectively with your doctor in choosing the best medicines for you, it helps to understand how a doctor makes a diagnosis, considers the particular circumstances of a patient, and finally prescribes a drug.
On the surface, the process seems very simple. You arrive at the doctor’s office with a problem, the doctor examines you and makes a diagnosis, and you leave the office with a prescription for a medicine that you expect will make you better. Although it may seem straightforward to you, for your doctor, the process of prescribing the right medicine is a bit more complicated, and it can be a real challenge.
The right drug for the right diagnosis
Before deciding what medicine to give you, the doctor must make a diagnosis. It is the diagnosis that determines the treatment, but diagnosing arthritis is far from an easy task. To start, the doctor will ask you lots of questions about your symptoms. Which joints are painful? When are they most painful? How long have you had symptoms? Are there any activities that make the pain worse? The answers to all these questions, together with a thorough physical exam and possibly x-rays, blood work, or other diagnostic tests, can help your doctor come to a diagnosis.
In recent years, improved understanding of the signs and symptoms of the more than 100 types of arthritis has made it easier to diagnose them. In addition, advances in diagnostic testing have helped doctors make quicker and more accurate diagnoses. For example, a new blood test that detects substances called anti-CCP antibodies has made it possible for doctors to diagnose rheumatoid arthritis (RA) sooner in some cases. Magnetic resonance imaging (MRI) tests allow doctors to see changes in joint cartilage before they appear on x-rays.
However, the doctor’s work is not done once the diagnosis is made — then it’s time to prescribe a treatment. Until several years ago, doctors had only a few drugs available to treat conditions such as osteoarthritis (OA), RA, fibromyalgia, ankylosing spondylitis, juvenile idiopathic arthritis, and osteoporosis. Nowadays there are many more. It is very exciting to have so many more drugs to choose from, but it also makes prescribing one more difficult, particularly because many of them are so new. Whether to prescribe a newly available drug can be a difficult decision. Although some doctors prefer to stick with tried-and-true treatments, others are comfortable prescribing newly approved drugs or even asking patients to participate in studies of not-yet-approved medicines. Sometimes doctors will prescribe drugs approved for a similar health condition but not for your particular diagnosis. This is called “off-label” prescribing. (See Your Medicines and the FDA for more information on the categories of drugs your doctor can prescribe.)
The doctor will also consider how severe your symptoms are when prescribing a medicine. If, for example, you have many inflamed joints, the doctor may prescribe a stronger medicine to control the more serious inflammation.
Of course, a trip to the doctor’s office doesn’t always result in a diagnosis. Sometimes, it will not be clear from your symptoms or the diagnostic tests exactly what condition you have. In this case, the doctor may opt to “watch and wait,” keeping close tabs on the situation until a diagnosis becomes clear. But even without a diagnosis, the doctor may still prescribe drugs to treat your symptoms.
Other times, you may be seeing the doctor about an existing diagnosis — perhaps your joints are hurting more during the day, or you are experiencing more stiffness in the morning. In this case, the doctor may want to change the dose of a drug you are taking or switch you to a different drug entirely.
Reviewing your history
The goal of the office visit is to develop the best possible treatment plan for you. To do this, the doctor needs to know more than just your diagnosis; he or she also must know your medical history. This does not just include the history of your arthritis. Other health problems you have or have had may determine which medicine the doctor recommends. For instance, a person with osteoporosis, a condition in which bones lose mass and are easily broken, will usually not be prescribed an anti-inflammatory corticosteroid drug, which can cause bone loss.
The doctor must also learn from you (or your health record) what medicines you have taken and whether they worked well. Because each person is different, your individual response to each medicine is important. Your treatment history should include information on whether the drugs you took had unwanted side effects, such as allergies or stomach irritation. In addition, the doctor should know if you’ve had other difficulties taking any medicine in the past. For example, you might have a problem swallowing large pills or remembering to take a medicine four times a day. With this knowledge, the doctor can prescribe, for example, a pill that comes in an easy-to-swallow capsule or a medicine that needs to be taken only twice a day.
All about you
A doctor who understands you well is better able to prescribe the best medicine. Your preferences, personality, concerns, and habits should influence the doctor’s recommendation. He or she may therefore find it helpful to know the answers to the questions below. Of course, your doctor may not ask you all these questions. But you should read them over and think about your answers so you will be ready to volunteer any important information during the office visit.
- Do you ever have trouble taking your medicines regularly and as prescribed? Why?
- Do you prefer taking a medicine by pill or liquid?
- Are you able and willing to give yourself an injection?
- Are you afraid of needles?
- If administering or monitoring the effects of the drug requires regular doctor visits, will you have trouble making it to these appointments for any reason?
- Are you able to follow through with tests, such as blood or urine tests, that may be needed to ensure your medicine is not causing any ill effects?
- Are you able to observe your body’s reaction to a medicine to see if it is working or if any problems are developing?
- Do you have any health problems that your doctor isn’t aware of?
- Are you worried about the medicine’s side effects? Are you so worried that you may not take it as prescribed?
- Are you worried about the medicine for any other reason?
- Are there times when it is easier for you to remember to take your medicine, such as in the morning, at night, or at noon?
- Do you travel a lot? Do you need a medicine that you can easily use when you’re traveling?
- Are you willing to take a drug that has only recently become available?
- How do you feel about the idea of participating in a drug trial?
The doctor will use the information you provide to help select a medicine for you. For example, if you are very concerned about side effects, you and your doctor may decide on a lower dose or a drug with a lower risk of complications. If you are fearful of a new medicine, the doctor may be able to start with one that has been on the market longer.
Several other considerations, such as finances, the availability of transportation and other assistance, and even pharmaceutical advertising can come into play when a doctor prescribes a drug.
Finances. Although we all wish every medicine were affordable for everyone, in reality doctors often need to take costs into account. You and your doctor should discuss the cost of the medicine and whether your health insurance plan covers it, whether you can afford to pay for it out of pocket, or whether you qualify for a drug company’s assistance program. The doctor should also consider whether there is available, or will soon be available, a generic version of the drug. When a drug’s patent expires, less expensive and equally effective generic versions of the drug often come on the market. (See What Is a Generic Drug?)
Transportation. Some medicines, such as intravenous infusions, need to be administered at a medical facility. If you don’t have access to or can’t afford transportation to the facility, the doctor may need to adjust your prescription or help you find transportation resources.
Assistance. If you need assistance (for example, if you need help giving yourself an injection at home), you should discuss the issue with your doctor, who may be able to recommend an alternative plan.
Pharmaceutical advertising. Adding to the complexity of the process of prescribing the right drug is the issue of pharmaceutical companies advertising their medicines to the public. It used to be that the advertising and promotion of prescription medicines was directed only toward health professionals, especially physicians. Now, medicines are also widely advertised on television, on the Internet, and in magazines. As a result, doctors find that many patients ask about — or ask to be put on — a drug because they heard or read about it in an advertisement. While educating yourself about available treatments is generally a good thing, relying only on advertisements for information can have a negative effect on your treatment.
Imagine this scenario: A man with RA has seen an advertisement for a powerful new drug. He brings the information with him to his next doctor visit and asks the doctor to prescribe the medicine. The doctor had already prescribed a medicine that has been calming the inflammation of RA well. But despite his improved health, the patient hopes the newer medicine can do more or even be the “cure.”
The doctor is now in a difficult position. If the new drug does not work as well as the one the patient is already taking, the RA could flare up and become more difficult to control. The patient could also develop a harmful side effect from the new drug. On the other hand, if the doctor does not respond to the request, the patient may be upset and may even think the doctor is being unresponsive, uncaring, or unknowledgeable.
Clearly, it is best if the doctor’s prescription is based on experience and good judgment rather than patient pressure or, even worse, fear of possible litigation. However you learn about a new medicine, you should discuss it with your physician. Fully consider his or her opinion before you decide that the drug’s for you.
Putting it together
It’s clear that a physician has a lot to think about when making a prescription. It’s certainly not enough to know what drugs are available and what they treat. The doctor must also have an understanding of your symptoms and an in-depth knowledge of your medical history, personality, and finances. When you appreciate the intricacies of this complex decision-making process, you’ll be better able to work with your doctor to maintain good communication and achieve good results.