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One Doctor TRIES To Implement The Hippocratic Oath!

[Karl Note:  What an amazing comment on the level of ethics amongst doctors -- that one doctor would try to reduce unnecessary and harmful drugs, and run into complaints from his fellows!  Here is a sign of the degradation of modern medicine!]

Page One Feature

New York Doctor Creates a Rift
With Radical Notion: Fewer Pills

By MICHAEL OREY
Staff Reporter of THE WALL STREET JOURNAL
 

NEW YORK -- Last July, David Morris, a newly hired physician at the prestigious Hebrew Home for the Aged here, did something daring: He began weaning residents in his care off many of their medications.

One was 89-year-old Oscar Cohen, who was taking six medications for a variety of maladies, ranging from anemia to congestive heart failure. By this spring, he was down to two.

As Dr. Morris methodically evaluated his patients' drug regimens, he was especially apt to eliminate drugs for diabetes, hypertension, high cholesterol, depression and other chronic illnesses. In many cases, he felt these medications were doing nothing at all for his patients. In certain instances, he worried they might even be dangerous.

A year later, Dr. Morris's unusual crusade has proved divisive. A number of residents and family members have vehemently objected to his decisions. Not one of the nine other doctors on the Hebrew Home's staff has followed his lead. Susy Abraham, the home's medical chief, complains that Dr. Morris has been "overzealous" in his campaign and at times has had to override his orders. "I thought he was practicing dangerous medicine," she says. Dr. Morris denies that.

Still, Dr. Morris does have allies -- including Daniel A. Reingold, who runs the not-for-profit facility. The elderly, Mr. Reingold says, including those at the Hebrew Home, are routinely "overmedicated." In his efforts to cut back on drugs, Dr. Morris is "challenging a lot of notions," he says. "And I like the way he's challenging them." Some leading geriatricians also endorse Dr. Morris's approach. Jerry Avorn, a researcher at Brigham and Women's Hospital in Boston, says systematically reviewing patients' medications "may be one of the most important medical interventions you can do."

Drug Dilemma

The battle playing out inside the Hebrew Home spotlights a dilemma facing the entire country. On the one hand, the drug industry's spectacular breakthroughs in recent decades have dramatically improved the quality of life and extended the longevity of Americans, who now are popping more pills than ever. U.S. pharmacists filled more than three billion prescriptions last year, up from about two billion in 1990. Congress is now considering a prescription-drug benefit for Medicare, the government's health program for the elderly, which would only add to the drug avalanche. But the very same pills can also cause surprising harm.

In 1999, the Centers for Disease Control and Prevention reported more than 600,000 hospital admissions and 700,000 emergency-room visits resulting from medications that were correctly administered, but nonetheless produced side effects -- from intestinal bleeding to seizures -- and even death. A study published in the Journal of the American Medical Association in 1998 estimated that about 100,000 people die from such adverse reactions every year in the U.S.

Many patients clearly need to be on multiple medications. Treating a single chronic ailment such as heart disease can require as many as four different drugs. Even so, researchers say that keeping the number of pills as low as possible is critical. A person taking seven medications is about 14 times more likely to have a problem than a person taking one, estimates Mark Beers, a geriatrician and editor-in-chief of medical manuals published by drug giant Merck & Co.

Adverse Reactions

Because the elderly take the most drugs, they are at the greatest risk. On average, Americans who are 65 or older take six medications, including prescription and over-the-counter drugs, according to a number of studies. For residents of nursing homes and other long-term-care facilities, that average rises to eight. One man who showed up for admission to the Hebrew Home in 1993 was taking 42.

Especially for the elderly, the hazards of pill pile-on aren't merely a function of the number of drugs. Because seniors metabolize drugs more slowly, they often should take lower doses than younger adults -- or avoid some drugs entirely. A study published last August in the American Journal of Medicine projected that each year there are about 350,000 adverse drug reactions in nursing homes, of which about 20,000 are life-threatening or fatal.

Soaring drug costs also take an economic toll. Prescription sales in 2000 totaled $145 billion, up from $65 billion in 1995, according to IMS Health, which compiles health-care data. A recent report by the Washington, D.C., nonprofit National Institute for Health Care Management foundation notes that prescription drugs account for only about 9% of all health care spending, but were responsible for 44% of the increase in total health-care expenditures in 1999. About 65 million Americans, including 12 million seniors, have no prescription-drug insurance.

Dr. Morris blames drug makers for America's ever increasing proclivity for pills. With their legions of sales representatives, sponsorship of the vast majority of drug research and massive consumer advertising campaigns, the pharmaceuticals industry "is driving the practice of medicine," he says. Last year, drug makers spent about $2.5 billion on direct-to-consumer advertising, according to IMS Health. Sixty percent of doctor visits now end with the writing of a prescription, the CDC says.

The drug industry acknowledges that pill overload is a problem for older Americans but plays down its direct responsibility. Daniel Vasella, chief executive of Novartis AG, the world's No. 6-ranked drug company, sums up the prevailing view: Managing a patient's mix of medications "is fundamentally the responsibility of the physician," he says.

But patients in America often see multiple doctors, with no single physician monitoring the overall medication regimen. Patients also self-medicate with myriad over-the-counter pills and herbal supplements. What's more, when it comes to prescribing for the elderly, doctors are often flying blind: Information about dosing and how certain drugs affect the elderly can be impossible to come by. At the Hebrew Home, where the average resident is 88, Dr. Morris says that, at times, "I feel like I'm walking in uncharted territory, and that makes me uneasy."

Geriatricians say drug companies have failed to include enough older Americans -- particularly the growing ranks of those over 75 -- in clinical trials and to gather information about how seniors are affected by a drug after it has gone on the market. "We still have a gaping hole in our knowledge about how drugs behave in the elderly," says Dr. Avorn, who is a leading expert on this subject.

While in 1997 Congress gave drug makers extended patent protection for drugs they test in children, no similar incentive exists for testing among the elderly. Rachel Behrman, deputy director of the Food and Drug Administration's office of medical policy, argues that incentives are already in place since the elderly "are the ones for whom the blockbuster drugs are developed." While acknowledging that the oldest Americans are seldom recruited for clinical trials, in general, she says, "the elderly are pretty well represented."

When Dr. Morris showed up at the Hebrew Home, few would have marked him as a renegade. Gentle and, at 75, slightly stooped, he simply began applying to his patients the knowledge amassed during his almost three-decade tenure teaching medicine at schools including Albert Einstein College of Medicine. During that time, Dr. Morris had devoured medical journals, recording key points on tapes that he listened to repeatedly while brushing his teeth, driving or walking around.

To be closer to his daughter, Dr. Morris had moved to this city's Riverdale section, which is also the location of the Hebrew Home's main campus. Perched on 19 acres with views of the Hudson River, the Hebrew Home for the Aged at Riverdale -- as it is formally known -- is one of the nation's most highly regarded elder-care institutions. It has 1,000 beds at three nursing facilities in the New York area. Last year its pharmacy filled 76,000 prescriptions.

Phase Out

In Dr. Morris's first meeting with Mr. Cohen, he decided his new patient was receiving a number of superfluous medications. Mr. Cohen was taking Coumadin, a blood thinner, to treat an irregular heart rhythm. But after a series of checkups and cardiograms, Dr. Morris couldn't detect any evidence of this problem. So he halted the drug, whose label warns of potential interactions with more than 100 other medications. The doctor also discontinued Mr. Cohen's prescription-level doses of iron when lab tests showed he wasn't anemic. He phased out blood-pressure pills when it looked like they had lowered Mr. Cohen's pulse too drastically. (The doctor now closely monitors the pressure.)

One adverse reaction caught Dr. Morris by surprise. Mr. Cohen was taking two medications for his congestive heart failure: a diuretic to treat the condition and potassium supplements to counteract reduced potassium levels that are a common side effect of diuretics. In March, Mr. Cohen's potassium levels suddenly soared to potentially fatal levels. "It scared me to death," says Dr. Morris, who immediately discontinued the supplements.

A brief stint on a low-potassium diet led Mr. Cohen to gripe that he couldn't eat potatoes or bananas, but he says he is otherwise happy with Dr. Morris's care.

As he did with Mr. Cohen, Dr. Morris took a hard look at the drug regimens of his other patients. He halted diabetes medication for about 10 residents, concluding that the weight gain it caused presented a greater risk than letting blood-sugar levels rise a bit. And he took roughly 25 patients off psychotropic drugs, which treat conditions such as anxiety and depression.

In August, the doctor examined 87-year-old Sidney Zucker, who was complaining of frequent dizziness. When Dr. Morris checked Mr. Zucker's blood pressure, it was so low that he couldn't even get a reading when Mr. Zucker made a wobbly effort to stand. That explained the dizziness, which Dr. Morris worried could put his patient at risk for a fall. Looking at the drugs Mr. Zucker was taking, Dr. Morris noted that some of them, including the antipsychotic Risperdal, could lower blood pressure. (Psychotropic drugs are linked to more than 32,000 hip fractures in elderly adults each year, says a report issued last year by the Department of Health and Human Services.)

"Detailed discussion with the nurses concerning Mr. Zucker's mental status did not reveal any delusions, nor did they think he needed Risperdal," Dr. Morris noted in Mr. Zucker's chart. The next day, Dr. Morris wrote, "patient has less dizziness." He also took Mr. Zucker off a drug for acid reflux and Lescol, a cholesterol-lowering drug.

Lois Stroger, Mr. Zucker's daughter, says her father's condition has dramatically improved, and that the result of Dr. Morris's treatment has been "wonderful."

Others are less enthusiastic. While Dr. Abraham, the Hebrew Home's medical director, praises Dr. Morris for his efforts, she complains that in a number of instances "he was cutting medications too drastically, two and three medications at a time." That, she notes, makes it hard to trace the cause of any change in the patient's condition. She also disagreed with some of his calls.

Dr. Abraham points to Mr. Zucker as a case in point. Besides stopping several medicines at once, Dr. Morris shouldn't have taken Mr. Zucker off the cholesterol-lowering drug, she says, because he had coronary bypass surgery in 1987. In January, Mr. Zucker spent a night in a hospital emergency room after complaining of chest pains. Although Dr. Morris continued to believe that a cholesterol-lowering drug would not "make an iota of difference," that incident, and pressure from Dr. Abraham, prompted him to resume anticholesterol therapy.

Concern over cholesterol also led to a clash with dietitian Jane Charon, who objected when he discontinued Lescol for Yetta Zipper, a 95-year-old resident. Dr. Morris persisted anyway, arguing that there is no scientific support showing that cholesterol-lowering pills benefit someone this old who has no cardiac risk factors. Ms. Charon confirms this exchange.

Dr. Morris also took broadsides from residents' families. One of his patients was taking Mestinon to control myasthenia gravis, a serious neuromuscular disease. Since he detected no sign of the disease, he halted the drug. The woman remained without symptoms for a month, he says. But when the woman's family learned the drug had been halted, "they really exploded," Dr. Morris recalls. They called in Michael Swerdlow, a neurologist at Montefiore Hospital, who ordered the drug restarted. While praising the idea of eliminating medications, Dr. Swerdlow says that it was a mistake in this case. The family, which declined to allow the Hebrew Home to release its name or the name of the patient, also insisted that Dr. Morris no longer be in charge of the woman's care.

"People are more fearful of stopping drugs than they are of starting them," Dr. Morris says.

By January, seven months after Dr. Morris arrived at the Hebrew Home, the run-ins with patients, families, and staff began to take their toll. Dr. Morris says he realized that his in-depth review of patients' medications, and the individualized minitrials he conducted by discontinuing them, amounted to practicing "academic medicine" in a nonacademic setting.

In a meeting in Mr. Reingold's office, Dr. Morris told the home's chief, "I'm just going to be a nursing-home doctor. I'm going to fall in line. I assure you, you won't get any more complaints." Mr. Reingold's reply, the two men recall: "No, I'm not going to let you do that. You do the right thing, that's all that matters."

Mr. Reingold's support for Dr. Morris was partly born of pragmatism. The former health-care attorney and social worker says he watched with dismay as the Hebrew Home's pharmacy expenses soared in the 1990s. Last year, he says, they reached $2 million, up from about $1.5 million five years ago. Although the Hebrew Home enjoys the support of big-name benefactors such as Sanford I. Weill, chairman of Citigroup Inc., 92% of its residents are on Medicaid, the federal health-insurance program for the poor. Medicaid pays nursing homes a flat rate per resident to cover expenses, including drugs.

As he fought to hold down costs, Mr. Reingold came to believe that fewer drugs might even improve patient care. In theory, nursing homes should be well positioned to curtail the flow of drugs. Residents are in the care of a single physician and one pharmacy dispenses all the medications. And federal regulations require that a "consultant pharmacist" review residents' medical records each month. Mr. Reingold's discovery: All of these systems "do more to make sure that the residents get the medications than to make sure they don't."

Small Incentive

For instance, Mr. Reingold, who is 46, says that Chem Rx, the Oceanside, N.Y., company that provides pharmacy services to the Hebrew Home, does a good job of alerting physicians to drug allergies or interactions but isn't likely to suggest that a drug is unnecessary. Nor does Chem Rx have any incentive to cut back on medication, Mr. Reingold says, since it makes money on every prescription. Steven Silva, vice president of sales and servicing for Chem Rx, counters that his company actually loses money on some prescriptions. In any case, he says it falls to the "consultant pharmacist," not the dispensing pharmacist, to badger doctors about potentially unnecessary medications.

But Robert Accetta, who serves as the consultant pharmacist for the Hebrew Home and 15 other nursing facilities, says that having those conversations with physicians can be difficult and that "perhaps we could be overstepping the boundary" by raising such a question. Most "physicians will tend to stabilize a patient and then continue with the regimen that stabilized them," Mr. Accetta adds.

To break this cycle, Mr. Reingold hopes soon to hire a staff pharmacist whose primary job will be to help physicians zero in on unnecessary prescribing. For his part, Dr. Morris knows such efforts face limits.

Two patients, for example, have adamantly rebuffed his overtures to get them to drop nightly sleeping pills, which are notoriously addictive if used long-term. "I stayed awake all night," Sylvia Schwartz recalls of her brief effort to quit. "I can't stop."

Write to Michael Orey at michael.orey@wsj.com¹

URL for this Article:
http://interactive.wsj.com/archive/retrieve.cgi?id=SB993155813874254556.djm

Hyperlinks in this Article:
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