Sunday, January 30, 2005

Is Effexor the Best Medication for Me to Be On?

Or: What Would Osler Do?

A couple of weeks ago, a patient asked me this question: "Do you think Effexor is the best medication for me to be on?"

I had to think about that for a few moments.  Honestly, it had not occurred to me to cast that question, but it seemed like an obvious and reasonable thing to ask. 

I can't recall exactly what I said, but it was something like this:
The fact is, there is no way for us to know what the best medication is for you.  Since we cannot know the answer to that question, I don't ask it.  You see, when we [the non-royal we, meaning "members of the medical profession"] think about a medication strategy, we try to build a strategy based upon questions that can be answered. 

The only way to know what the best medication for you is, would be to try them all, one at a time.  They would have to be adequate trials, which means at least six weeks each at the maximum dose.  That would take years, would be miserable to go through, and would not be ethical for me to do. 

Instead, when I think of a medication strategy, I ask, at every decision point: what is the most reasonable thing to do now?  That is a very different question than asking: what is the best thing to do now? 
You might be wondering, do I really talk like that? Yes.  There are many dialects of English.  Some people talk in newyorkerese.  Some people talk in bumperstickerese.  I talk in lecturese. 

The second point is the most important.  Base your strategy on questions that can be answered.  Of course, that assumes that you know what questions can be answered, and which cannot.  That is not always obvious. 

I've noticed, over the years, that many persons are surprised by how much is not known about medicine.  Indeed, not only is there much we don't know, there is much that cannot be known

What I mean, is that there are some things that we really would like to know, but for various reasons, it is impossible to know.  For example, there is much we do not know about the safety of medication during pregnancy.  This surprises people.  But think about it.  In order to really know if a medication is safe during pregnancy, we would have to get a large number of women, randomize them, have half take medication; the other half, placebo; have them all get pregnant, and see what happens in both groups.  Obviously, that would be unethical.  Therefore, the experiments will not be done.  At least not in the USA, as it currently is constituted.  Thus, we are left in the position of having to make very important, potentially life-altering decisions, knowing full well that we do not have the information we would like to have.

This does not mean that such decisions cannot be made.  Rather, it means that the process of making decisions has to be structured carefully, taking into account the fact that there are huge gaps in our knowledge.  This is one reason why William Osler wrote of aequanimitas.
The complementary "mental" virtue is aequanimitas, which is the personal quality of calmly accepting whatever comes in life.
The full text of Aequanimitas is here.