I recently stumbled upon a very interesting editorial opinion in the ‘European Journal of Clinical Pharmacology’: ‘The use of drugs is not as rational as we believe…but it can’t be! The emotional roots of prescribing’, authored by Albert Figueras, from Fundació Institut Català de Farmacologia (Catalonia Institute of Pharmacology Foundation at Vall d’Hebron Hospital, in Barcelona).
Since more than 40 years ago when Archie Cochrane said that “there must be solid scientific evidence behind any statement, decision and prescription made by medical staff”, and all the way until today’s WHO promotion of rational medicine utilization, both developing and industrialised countries have been striving to increase sound knowledge about prescription and thus spread the kind of rational thinking necessary to foster evidence-based medicine in drug use.
Keeping your skills up to date has never been an easy task but nowadays we have newsletters and other Internet tools that can grant any MD state-of-the-art knowledge on any subject he or she may need, accessible anywhere and for any medical speciality. Nevertheless, drug use in the “real world” is far from this high quality. Not only in Spain: it has been noted in France, Greece and other countries that, despite widespread knowledge of risk factors that may cause gastrointestinal toxicity in patients under nonsteroidal anti-inflammatory drugs (NSAID) treatment, there is a massive use of proton-pump inhibitors in individuals that show no significant risk.
Changing well-established drugs for newer, less-known products is not consistent with the need of a well-grounded comparative evaluation. We are not raising concern on the influence of gifts or invitations from pharmaceutical companies. Many doctors really want to make rational decisions… but can’t.
Neurologist Antonio Damasio carried out research into interactions between emotion and reasoning, breaking away from the classic Cartesian idea that human decisions are the result of an invariable logical process (‘cogito ergo sum’). The way our decisions are affected by our feelings has already been deeply researched, specially in fields where a wrong choice can have fatal consequences, such as aviation… or finance. Is drug prescription safe from this emotional influences? A bias in favor of a particular medicine can come from empathy, marketing or even trust and be triggered by factors such as “making use of an innovation” or “this is an optimal safety profile”.
Negative perceptions can also arise due to insights such as “generic drugs are worse than branded ones”, “rational prescription is for poor countries only” or “looking after costs when prescribing reduces my freedom as a physician”. Or bad feelings can come just out of fear of the unknown, even though uncertainty comes along with every medical decision.
This theory is well established, but campaigns to improve drug use or medical tuition are still aimed at clinical and pharmacological knowledge and ignore emotional factors that should complete this information. Factors that pharma industry does not forget in its promotional efforts, by the way.
The emotional roots of drug prescription in clinical practice constitute a complex field of study, but maybe this is the right moment to take advance of modern neuroscience and identify what make us prescribe drugs the way we do. This would not only contribute to a better drug use but would help avoiding a financial over-spending that our society cannot bear anymore.
Albert Figueras. The use of drugs is not as rational as we believe… but it can’t be! The emotional roots of prescribing. EUROPEAN JOURNAL OF CLINICAL PHARMACOLOGY Volume 67, Number 5, 433-435, DOI: 10.1007/s00228-011-1024-5
*This post was originally published in Spanish at El Supositorio*
*This blog post was originally published at Diario Medico*