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CHAPTER 6 — The First Script
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medication may be indicated, providing an ample introduction to its
pros and cons, collaboratively arriving at a decision as to its use, and
delineating directions for its use while checking to make sure the patient
understands these directions.
Later in the book, we will be examining many useful techniques for
the sound implementation of the multitiered third step above, but in this
chapter our focus will be on the first and second steps – (1) uncovering
the patient’s feelings about his or her medications and (2) introducing our
personal philosophy of how we approach the use of medications. As hinted
above, without a successful navigation of these first two steps, Step 3 is
often doomed for failure.
Eliciting the Patient’s Views on Current Medications:
The Medication Passport
Many of the patients entering our offices, or appearing on our inpatient
units, have been on a long journey regarding the medications that they
have taken for illnesses ranging from the common (diabetes, hyperten-
sion, and depression) to the less frequent (multiple sclerosis, rheumatoid
arthritis, and epilepsy) to the infrequent or rare (carcinoid syndrome and
amoebic meningoencephalitis). Many patients have seen many clinicians,
many offices, and, in some instances, many inpatient units.
Our elderly patients are often walking pharmacies with 10 or more
medications on board. Indeed, a survey of 17,000 Medicare patients
demonstrated that two out of every five patients reported taking five or
more medications.
2
In a Canadian study with patients averaging 81 years
of age, the patients were juggling a disturbing 15 medications daily (range
6 to 28).
3
Except for the young, many patients have had a long list of en-
counters with physicians, nurses, physician assistants, clinical pharmacists,
and case managers.
Some of these encounters have been good and some not so good. Thus,
patients enter our offices with preconceptions, expectations, and fears of
what and whom they are about to encounter behind the exam room door.
Sometimes they have every right to be worried, for our patients have encoun-
tered pill-pushers who have had little interest in what they want or believe.
Other times they have been fortunate to have met talented clinicians, who
have listened carefully and shared decision making with them. So much
the better for us, for these patients are anticipating good care. Nevertheless,
all patients have a track record with prescribers and the medications they
prescribe. Each patient arrives at our office for a first appointment with