Funny… De-diagnosing (&de-prescribing)

It’s funny – well, at least to me, in my world of not so funny things; I was going to start this with, ‘Most people will have heard of de-prescribing…’ Then, I realised I didn’t know what I was talking about.

This is groupthink & being a specialist all congealed into one.

I’ll start at the beginning.

And, in the beginning, there was de-prescribing.

This is the relatively new concept (outside of the world of Geriatricians) that says that it is often better to stop medicines than to start them; although there are many wonderful drugs out there, making pharmaceutical companies and stock-holders rich; there are also pills, potions and lotions which are not only ineffective, but harmful.

One of the joys of graduating from medical school relates to the pleasure of prescribing drugs – especially those which people can’t ordinarily access without a doctor’s say so. (or a non-medical prescriber, but, let’s not go there just now) (I think my first script was for Morphine on the HDU at Raigmore Hospital)

And so, it goes – doctors are the folk you approach if you want medicine; antibiotics, pain-killers, antidepressants or antipsychotics. They are the gate-keepers. It you aren’t busy prescribing, as a doctor, what are you doing?

Anyone who has visited the installation in the British Museum which displays the pills/tablets/drugs/medicines tableau of what a person might take in a lifetime to ensure their wellbeing, will understand that we, that is, society, are drowning underneath a mountain of enteric-coated, water-soluble products.

And, to de-prescribing.

This is the art of stopping those medicines that are no longer necessary to maintain health – for example, the 96-year-old’s Simvastatin.

Yes, when I have my heart attack, load me with these agents – saturate my bloodstream with reductase inhibitors; bombard my kidneys with agents to inhibit enzymatic and microcellular pathways, but, when I have reaped the benefit, let me move on. Grant me more than day-release from the prescriptions; set me free.

This is when I take my Bic and stop the statin, the ace-inhibitor, analgesic, anxiolytic, antihypertensive or sedative. When I set people free from the constraints of care.

On most occasions – that is, something like 99.9% of the time, patients are grateful. They appreciate that someone has stopped and considered their therapeutic burden, who has talked with them, involved them and their families in decision-making about the extent to which medicines control life.

And on to de-diagnosing.

I haven’t heard this term before – it came-out during a meeting this afternoon with colleagues who are looking with me at strategies to expand the knowledge and awareness of delirium.

A funny thing; well, not necessarily funny if you are the patient, but funny in an ironic sort of way, is the eagerness of doctors to provide diagnoses.

I suspect patients are complicit in this.

No one likes to deal with uncertainty –

– Can I have a bunch of those things?… What are they?

– Oh, I don’t really know, I am sure they taste good

That sort of thing.

We seek assurance, orientation and guidance.

– Doctor, what is causing my pain?

– Oh, it must be your sciatica.

– Ah… sciatica. I have sciatica.

This is different to –

– Doctor, I am struggling to sleep

– Oh…

The onus often falls on the doctor to deliver. To perform.

De-diagnosing comes from this;

– Doctor, why is my mother so very confused

– She has dementia

– Oh dear, I didn’t realise that.

Three months later… Memory clinic at local mental health organisation –

– How can I help you?

– The doctor asked us to see you about mum’s dementia

>>>Tests>>>

– Your mum doesn’t have dementia. Mrs A, you don’t have dementia, I think you were delirious.

– Oh – so, no dementia?

– No

This is de-diagnosis; when one doctor provides a watertight diagnosis that is adopted by patient, family and friends, which is then overturned because of the actions of time and, the thoroughness of the assessment conducted by someone who knows what they are doing.

How many of us could be de-diagnosed?

How many asthmatic, depressive, arthritics at some point in time had a wheeze followed by sadness and stiff joints.

A dance macabre.

There is so much urgency within our health service and our 24/7 society that the immediacy of results, diagnosis and prognosis is considered core business.

Time is a component of health and social care that people have tried to sweep under the carpet.

What we need is time and space to breathe, think and recover.

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