Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE

Narrative medicine (NM) centers on understanding patients’ lives, caring for the caregivers (including the clinicians), and giving voice to the suffering.¹ It is an antidote for medical “progress,” which often stresses technology and pharmacologic interventions, leaving the patient out of his/her own medical story—with negative consequences.

This missing patient narrative goes beyond the template information solicited and recorded in the history of present illness (HPI) and review of systems (ROS). It is well expressed by Francis W. Peabody, MD, (1881-1927) in a published lecture for Harvard Medical School students: “One of the essential qualities of the clinician is an interest in humanity, for the secret of the care of the patient is in caring for the patient.”²

This article serves as an introduction to NM, its evolution, and its power to improve medical diagnoses and reduce clinician burnout. While its roots are in palliative and chronic care, NM has a place in the day-to-day care of patients in acute settings as well.

VIGNETTE

It’s been a busy day in clinic; the clock ticks toward closing. Scanning the monitor, you permit a brief moment of relief as you spy the perfect end-of-shift, quickie patient case: “Sore throat x 2 days,” with a rapid strep test under way. You quickly check lab coat pockets for examination tools and hasten down the hall noting age 22, white female, self-pay. Vitals reveal a low-grade fever. Maybe this sore throat will be bacterial; all the easier as there will be no need to do the “antibiotics don’t work for viruses” sermon.

You knock briefly, enter the exam room, place the laptop on the counter, and immediately recognize the patient from multiple visits over the past 2 years, mostly for gynecologic issues. You recall treating her for gonorrhea and discussing her worry about HIV. She told you that she’s a graduate student, although she is overdressed for a week night, wearing a silk blouse, short skirt, and high heels. She offers a winning smile and tells you with her pleasant accent that she is running late for an appointment.

The patient describes her symptoms: unrelenting sore throat for 2 days and pain with swallowing. She complains of feeling feverish and fatigued, with no appetite and “swollen glands.” She denies cough and runny nose; she looks and sounds exhausted. She denies smoking and excessive alcohol intake. You vaguely hone in on the accent, thinking it might be South African. Her HPI and ROS completed, you record her physical findings of pharyngeal erythema, no exudates, and moderate anterior lymphadenopathy.

You have a nagging thought about her “story.” As an urgent care clinician, you know you are likely her only health care provider and you feel some connection. It is late, and the patient is in a rush, so you promise yourself to delve deeper the next time she presents.

Continue to: You confirm the negative strep test results...

You confirm the negative strep test results and deliver the well-rehearsed sermon. She appears surprised, asking if you are sure. You suggest that she schedule a full physical in the near future. She hops off the table, heels clicking on the tile floor, as you complete your note. You do not suspect she is off to meet her scheduled man of the evening as assigned by her escort service.

Before you clock out, you check the extended patient appointment schedule and do not see her name. You vow to call her the next day and discover that she has no listed phone number. An uncomfortable feeling settles in: Are you missing something?

IN URGENT CARE

NM is an interactive patient approach more often applied to seriously ill or chronic disease patients, for whom it meaningfully supports a patient’s existence as central to the diagnostic testing and treatment of health care concerns. One can professionally debate that NM has no place in urgent care; however, this is where many patients’ acute and chronic conditions are discovered. It is where elevated blood glucose becomes type 2 diabetes and abnormal complete blood counts become blood cancer. With deeper application of NM’s principles, our simple-appearing acute pharyngitis case might have received a different workup.

NM practitioners subscribe to careful listening. Rita Charon, MD, a leading proponent of NM, describes this approach to patient care as a “rigorous intellectual and clinical discipline to fortify health care with its capacity to skillfully receive the accounts persons give of themselves—to recognize, absorb, interpret, and be moved to action by the stories of others.”³ It is a patient care revival that helps clinicians recognize and shield themselves from the powerful stampede of tech­nology, templated patient interviews, digital documentation, and diminution of clinician and patient bonding.

The clinician in this patient encounter has functionally intact radar, sensing something awry, but communication falls short. NM’s strength is to bond the clinician to the patient, enhancing subtle, and at times pivotal, information exchange. It generates patient trust even in brief encounters, fostering improved clinical decision-making. A stronger NM focus might have encouraged this clinician to investigate more deeply the patient’s fancy clothing and surprised response to the negative strep test results by posing a simple query, such as ”What do you think might be going on?”

Continue to: MEDICAL ERROR

Pharyngitis is common, making it prime territory for medical error—even for experienced clinicians—because of 3 human tendencies that NM recognizes and seeks to avoid.⁴ These human tendencies, insightfully delineated decades ago by experimental psychologists Amos Tversky and Daniel Kahneman, authors of Anchoring, Availability and Attribution, appear most commonly under uncertain conditions and time pressures, such as in urgent care. How does this patient encounter reflect these tendencies?⁵

Anchoring refers to the tendency to grasp the first symptom, physical finding, or laboratory abnormality, and hold onto it tightly.⁵ Such initial diagnostic impressions/information may prove true; however, other unconsidered diagnoses may include the correct one. In this encounter, the clinician entered the exam room with an early fixed diagnosis and applied the rapid strep results to diagnose viral pharyngitis. Other, conflicting hints were fleetingly noted and not addressed.

Availability refers to the tendency to assume that a quickly recalled experience explains a novel situation.⁵ Clinicians regularly diagnose viral pharyngitis, leading to familiarity and availability. This is contrary to NM’s view of every patient having a unique and noteworthy story.

Attribution refers to the tendency to invoke stereotypical images and assign symptoms and findings to the stereotype, which is often negative (eg, hypochondriac, drinker).⁵

In this encounter, the clinician would have benefited from considering other categories of diagnoses that could occur in this patient, expanding the differential diagnosis list, by soliciting a deeper patient story, fostering trust, and following clinical intuition. Had this bond been cultivated over prior visits, even in an urgent care setting, the graduate student ruse would have been discovered and the patient’s true occupation—female sex worker—revealed. The clinician would have modified the laboratory testing, discovering human herpesvirus type 8 (HHV-8) as the pharyngitis etiology, which is disproportionately linked to HIV co-infection and increases the risk for Kaposi sarcoma (KS) 20,000-fold. The prevalence of HHV-8 is 17% in the United States and is much higher (50%) in South Africa, the origin of the patient’s accent.⁶ 
Deeper patient relationships enable uncomfortable history-taking questions, with improved reliability. This missed diagnosis has wide-ranging negative consequences for the patient and her escort encounters.⁶

Continue to: THE FLEXNER REPORT

THE FLEXNER REPORT: NARRATIVE MEDICINE'S EXCISION

It is clear that the scientific revolution prompted the removal of NM from clinical practice. The 1910 Flexner Report, funded by the Carnegie Foundation for the Advancement of Teaching Science and authored by research scholar and physician Abraham Flexner, analyzed the functioning of 155 US and Canadian medical schools.⁷ His report supported the socially desirable goal of reforming medical education by exposing mediocre quality, unsavory profit motives, inadequate facilities, and nonscientific approaches, and publishing a list of those falling below the gold standard (which was the German medical education system). Harvard and Johns Hopkins received a gold seal, many other medical schools closed, and several responded to the challenge and excelled.⁸

Medical school curricula transitioned to exclusively theoretical and scientific teaching, objectifying values and rewarding research and efficiency. The subjective patient story was surgically excised and replaced with objective science. Not all change is good, however, and years later, Flexner reflected that scientific medicine was “sadly deficient in cultural and philosophic background.”⁸ His report also dramatically suppressed the use of complementary and alternative medicine and psychiatry, another medical boomerang.⁹ Scientific rigor is desirable—but not to the exclusion of the central patient role and other potential health care modalities.

THE PROBLEM-ORIENTED MEDICAL RECORD AND EHR

Decades after Flexner’s report on medical education curricula, another reformer, Lawrence Weed, MD, trained his eye on medical documentation’s organization and structure. He published a seminal article, “Medical Records that Guide and Teach” in the New England Journal of Medicine.¹⁰ Truly a pioneer, he demonstrated how typical medical record case documentation circa 1967 could be more efficient and espoused the problem-oriented medical record. He conceptualized designs for reorganizing medical records, prophetically promoted use of “paramedical” personnel, and encouraged computer integration.¹⁰

Coinciding with the birth of the PA profession and the recent inception of the NP profession, Weed endorsed the use of trained interviewers who would ­apply a “branching” question algorithm with associated computer data entry designed to protect expensive physician time. The patient story would be a jigsaw puzzle, as physicians could fill in missing information.¹⁰

Weed’s goals had merit by stressing structure for the disorganized, then-handwritten medical record, benefitting the growth of team-based patient care. However, efficiency and precision continued to marginalize a key component of the patient’s illness narrative in favor of speed, objectivity, and achievable billing essentials.¹¹ His recommendations have eradicated the free-text box, replacing it with a selection of pull-down choices or prewritten templates. With a series of clicks, the subjective patient’s own narrative is sterilized, removing valuable details from the team’s view.¹¹ The “s” of the Subjective Objective Assessment and Plan note is washed away (Table 1).

Continue to: Weed's clinical documentation...

Weed’s clinical documentation efficiency system caught fire. However, similar to Flexner’s later second thoughts, Weed also cast doubt on the full effect of his recommendations. In a 2009 interview conducted by a former medical student of his, Weed revealed views that more closely resemble our current competency-based medical education and stress the value of interpersonal skills in patient care¹²:

1. Computerization of the medical record—with its vast amount of information and physician-processing capacity—“inevitably” leads to dangerous cognitive shortcuts. Medical education seeks to instill “medical knowledge and clinical judgment,” giving students “misplaced faith in the completeness and accuracy of their own intellects and is the antithesis of a truly scientific education.”¹²
2. Medical student recruitment and instruction have long emphasized memory and regurgitation of facts, while students should be selected for their hands-on and interpersonal skills. Medical school should be “teaching a core of behavior instead of a core of knowledge.”¹² These are areas in which NM helps.

FLEXNER, WEED, AND NOW, CHARON

Medicine’s history is blemished by errors, some significant. Flexner neatly compartmentalized medical education, Weed digitized the clinician/patient interaction, and Charon revitalizes the reason clinicians chose a health care profession. Charon—as a practicing internist, as well as a professor in the Department of Medicine and Executive Director of the Program in Narrative Medicine at Columbia University’s Vagelos College of Physicians and Surgeons in New York City—is fully qualified to speak to the importance of NM in medical education and medical practice. Her 2006 book reminds us that sore throats are not always simple, boring, and routine; each one is as unique as the person housing that particular pharynx.¹³

How does NM drive clinicians to be better, countering cognitive errors while incorporating the patient’s cultural and philosophic background? According to Charon, the NM concept results from conversation among scholars and clinicians teaching and practicing at Columbia University in early 2000, fueled by decades of insight from literature, medical (health care) humanities, ethics, health care communication, and primary care medicine.³ NM supports patient-centric teaching and care, reminding us that it combines the historical doctor-at-bedside, who exhibited careful, empathetic questioning and listening, with the benefits of modern medical science.

Charon describes 3 main clinician-to-patient interactions, allowing us to regain some of what we have lost: attention, representation, and affiliation (Table 2). In addition to medical error reduction, these 3 interactive behaviors counter the aforementioned 3As (anchoring, availability, and attribution) of cognitive error.⁵Attention initiates the clinician’s heightened and committed listening to the patient.³ In our patient encounter, essential information is undisclosed, leading to a missed diagnosis and an incomplete representation in the written note. The clinician, due to insufficient attention, missed important clues such as the patient’s dress, accent, and profession, which limited the representation. This almost seems nonsensical; who would care about a patient’s dress or accent and, of practical concern today, where would one record it? And could another urgent care clinician or specialist find these notes? How might a more serious future medical outcome be averted? Affiliation results in a connection of careful listening and full documentation as the clinician becomes invested in the whole patient, not just the sore throat.³

PREPROFESSIONAL AND PROFESSIONAL EDUCATION

Preprofessional humanities education may result in stronger NM conceptualization. The Association of American Medical Colleges (AAMC) recognizes the value of arts and humanities in medical education in developing qualities of professionalism, communication skills, and emotional intelligence in physicians. The AAMC Curriculum Inventory and Reports (2015-2016) shows that 119 medical schools require humanities education, including

• Visual arts to improve observational skills
• History education to frame modern-day Ebola outbreaks (eg, using the framework of the Black Death),
• Literature and poetry to enhance insight into different ways of living and thinking, fostering critical thinking.¹⁴

Continue to: NM has been offered in...

NM has been offered in medical schools with positive outcomes. Published results of a 2010 qualitative study of 130 Columbia University medical students who completed a required intensive half-semester of NM seminars testify to its salience.¹⁵ Students articulated NM’s importance to critical thinking and reflection, through improved attention and affiliation with their patients, improved ability to examine assumptions and develop new skills, and improved clarity of communication.¹⁵

A small number of PA programs, far fewer than medical schools, are incorporating NM coursework, through application of literature, visual media, creative writing, and other approaches based on the humanities.¹⁶ The nursing profession, which prefers the term narrative health care to narrative medicine, endorses its inclusion in nursing education. A 2018 article in Nursing Education Perspectives supports the study of humanities to complement technical competencies such as the ability to “absorb, analyze, and interpret complex artifacts” and to “participate effectively in deliberative conversations.”¹⁷

THE PRACTICING CLINICIAN: MENTAL HEALTH AND NARRATIVE MEDICINE

The value of NM extends beyond the patient to embrace caregivers as well; this is important, in light of increased attention to mental health status among clinicians. Although the term used most frequently is physician burnout, data indicate that patient management by MDs, NPs, and PAs is becoming indistinguishable—and thus risk for associated negative mental health consequences may be shared across professions.¹⁸ Physician burnout has been described as “emotional exhaustion, depersonalization, and a sense of reduced accomplishment” and has a documented prevalence of about 50%.¹⁹ It has also been described as a “progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the condition of their work with three key characteristics: physical exhaustion, cynicism, and inefficiency.”²⁰ The medical community is deeply concerned about and seeks methods to better understand and prevent this phenomenon. A meta-analysis by West et al supports positive outcomes in addressing burnout through mindfulness training, stress management, and small-group discussions.¹⁹

The National Academy of Medicine is also addressing the issues of clinician well-being (see https://nam.edu/initiatives/clinician-resilience-and-well-being/). Former US Surgeon General Vivek Murthy, MD, has spoken about the epidemic of loneliness that affects clinicians. This can result from playing the physician role, lack of family support, and increased dependency on technology—yet, on a basic level, lack of interpersonal communication and connection are at the core.²¹ Communication between clinicians can lead to greater social cohesion and compassion, and effective uninterrupted listening and expression of their feelings helps. This begs the question: If physicians need to communicate better and practice active listening among themselves, how does this translate to the physician-to-patient bond?

THE CLINICIANS' PERSONAL BALM

Caruso Brown and Garden describe how the illness experiences of physicians, through their own reflective writing, create an empathy bridge between the professional healer and a sick patient, allowing them to be better and healthier clinicians.²² Recent best-selling physician narratives such as those by Atul Gawande,²³ Siddhartha Mukherjee,²⁴ and Paul Kalanithi²⁵ support the similarities between the sick physician and the sick patient. Illness narratives written by physicians-turned-patients are not dissimilar to illness narratives written by patients. Reflective writing by clinicians fosters a deeper understanding not only of how patients feel, but also of the relationship they desire and deserve.²²

Continue to: Writing a novel...

Writing a novel is beyond the time and ability of many clinicians. However, they can closely read literature (another NM tool), discuss books and other types of writing, participate in a book club, establish a hospital or office support group, and find a buddy or trustworthy confidant with whom to decompress and vent.³ Active journal clubs can alternate clinical guidelines with literature to expand their perspectives. An international voice, Maria Giulia Marini, Research and Health Director of the Fondazione ISTUD in Milan, Italy, and European proponent of NM, offers similar suggestions, indicating that making nonmedical works parts of a clinician’s life encourages empathy and promotes understanding between clinician and patient, as well as a holistic management approach, encourages personal and collegial reflection (eg, sharing tough experiences), sets a patient-centered agenda, and challenges the norm.²⁶

NARRATIVE MEDICINE'S FUTURE ROLE

The field of medical humanities has experienced growth through publications, national and international conferences, and formal discussion between executives of the AAMC and the National Endowment for the Humanities to design and incorporate joint programs teaching humanities in medical schools.²⁷ As of March 2019, there were 85 established baccalaureate health humanities programs in the US, with additional programs in development.²⁸

Clinicians and professional organizations cannot help but see the suffering of patients, with its concomitant provider burden. The urgent care patient encounter in our example met the standard of care of the typical interaction that achieves billing protocols; the HPI, ROS, and physical exam would not raise an eyebrow. Yet, an NM approach provides more. Asking the atypical questions about accents, out-of-the-ordinary dress and behavior, and wondering about the mentioned late-night appointment attends to NM’s focused active listening, with resultant quality documentation and a whole patient encounter, even in an acute care case.

Don’t be afraid. Consider that as in novels and movies, strange things happen. The iconic book The House of God reminds clinicians that, upon hearing hoof beats, we should first think of horses—however, sometimes a zebra is correct.²⁹ When an urgent care clinician interprets the hoof beats, a zebra may be in the differential diagnosis; in the case presented, the patient might fortunately be spared a future KS diagnosis. And the clinician may avoid personal anguish at what could have been a better outcome. NM can help clinicians remember that sore throats are as unique as people.

Narrative medicine (NM) centers on understanding patients’ lives, caring for the caregivers (including the clinicians), and giving voice to the suffering.¹ It is an antidote for medical “progress,” which often stresses technology and pharmacologic interventions, leaving the patient out of his/her own medical story—with negative consequences.

This missing patient narrative goes beyond the template information solicited and recorded in the history of present illness (HPI) and review of systems (ROS). It is well expressed by Francis W. Peabody, MD, (1881-1927) in a published lecture for Harvard Medical School students: “One of the essential qualities of the clinician is an interest in humanity, for the secret of the care of the patient is in caring for the patient.”²

This article serves as an introduction to NM, its evolution, and its power to improve medical diagnoses and reduce clinician burnout. While its roots are in palliative and chronic care, NM has a place in the day-to-day care of patients in acute settings as well.

VIGNETTE

It’s been a busy day in clinic; the clock ticks toward closing. Scanning the monitor, you permit a brief moment of relief as you spy the perfect end-of-shift, quickie patient case: “Sore throat x 2 days,” with a rapid strep test under way. You quickly check lab coat pockets for examination tools and hasten down the hall noting age 22, white female, self-pay. Vitals reveal a low-grade fever. Maybe this sore throat will be bacterial; all the easier as there will be no need to do the “antibiotics don’t work for viruses” sermon.

You knock briefly, enter the exam room, place the laptop on the counter, and immediately recognize the patient from multiple visits over the past 2 years, mostly for gynecologic issues. You recall treating her for gonorrhea and discussing her worry about HIV. She told you that she’s a graduate student, although she is overdressed for a week night, wearing a silk blouse, short skirt, and high heels. She offers a winning smile and tells you with her pleasant accent that she is running late for an appointment.

The patient describes her symptoms: unrelenting sore throat for 2 days and pain with swallowing. She complains of feeling feverish and fatigued, with no appetite and “swollen glands.” She denies cough and runny nose; she looks and sounds exhausted. She denies smoking and excessive alcohol intake. You vaguely hone in on the accent, thinking it might be South African. Her HPI and ROS completed, you record her physical findings of pharyngeal erythema, no exudates, and moderate anterior lymphadenopathy.

You have a nagging thought about her “story.” As an urgent care clinician, you know you are likely her only health care provider and you feel some connection. It is late, and the patient is in a rush, so you promise yourself to delve deeper the next time she presents.

Continue to: You confirm the negative strep test results...

You confirm the negative strep test results and deliver the well-rehearsed sermon. She appears surprised, asking if you are sure. You suggest that she schedule a full physical in the near future. She hops off the table, heels clicking on the tile floor, as you complete your note. You do not suspect she is off to meet her scheduled man of the evening as assigned by her escort service.

Before you clock out, you check the extended patient appointment schedule and do not see her name. You vow to call her the next day and discover that she has no listed phone number. An uncomfortable feeling settles in: Are you missing something?

IN URGENT CARE

NM is an interactive patient approach more often applied to seriously ill or chronic disease patients, for whom it meaningfully supports a patient’s existence as central to the diagnostic testing and treatment of health care concerns. One can professionally debate that NM has no place in urgent care; however, this is where many patients’ acute and chronic conditions are discovered. It is where elevated blood glucose becomes type 2 diabetes and abnormal complete blood counts become blood cancer. With deeper application of NM’s principles, our simple-appearing acute pharyngitis case might have received a different workup.

NM practitioners subscribe to careful listening. Rita Charon, MD, a leading proponent of NM, describes this approach to patient care as a “rigorous intellectual and clinical discipline to fortify health care with its capacity to skillfully receive the accounts persons give of themselves—to recognize, absorb, interpret, and be moved to action by the stories of others.”³ It is a patient care revival that helps clinicians recognize and shield themselves from the powerful stampede of tech­nology, templated patient interviews, digital documentation, and diminution of clinician and patient bonding.

The clinician in this patient encounter has functionally intact radar, sensing something awry, but communication falls short. NM’s strength is to bond the clinician to the patient, enhancing subtle, and at times pivotal, information exchange. It generates patient trust even in brief encounters, fostering improved clinical decision-making. A stronger NM focus might have encouraged this clinician to investigate more deeply the patient’s fancy clothing and surprised response to the negative strep test results by posing a simple query, such as ”What do you think might be going on?”

Continue to: MEDICAL ERROR

Pharyngitis is common, making it prime territory for medical error—even for experienced clinicians—because of 3 human tendencies that NM recognizes and seeks to avoid.⁴ These human tendencies, insightfully delineated decades ago by experimental psychologists Amos Tversky and Daniel Kahneman, authors of Anchoring, Availability and Attribution, appear most commonly under uncertain conditions and time pressures, such as in urgent care. How does this patient encounter reflect these tendencies?⁵

Anchoring refers to the tendency to grasp the first symptom, physical finding, or laboratory abnormality, and hold onto it tightly.⁵ Such initial diagnostic impressions/information may prove true; however, other unconsidered diagnoses may include the correct one. In this encounter, the clinician entered the exam room with an early fixed diagnosis and applied the rapid strep results to diagnose viral pharyngitis. Other, conflicting hints were fleetingly noted and not addressed.

Availability refers to the tendency to assume that a quickly recalled experience explains a novel situation.⁵ Clinicians regularly diagnose viral pharyngitis, leading to familiarity and availability. This is contrary to NM’s view of every patient having a unique and noteworthy story.

Attribution refers to the tendency to invoke stereotypical images and assign symptoms and findings to the stereotype, which is often negative (eg, hypochondriac, drinker).⁵

In this encounter, the clinician would have benefited from considering other categories of diagnoses that could occur in this patient, expanding the differential diagnosis list, by soliciting a deeper patient story, fostering trust, and following clinical intuition. Had this bond been cultivated over prior visits, even in an urgent care setting, the graduate student ruse would have been discovered and the patient’s true occupation—female sex worker—revealed. The clinician would have modified the laboratory testing, discovering human herpesvirus type 8 (HHV-8) as the pharyngitis etiology, which is disproportionately linked to HIV co-infection and increases the risk for Kaposi sarcoma (KS) 20,000-fold. The prevalence of HHV-8 is 17% in the United States and is much higher (50%) in South Africa, the origin of the patient’s accent.⁶ 
Deeper patient relationships enable uncomfortable history-taking questions, with improved reliability. This missed diagnosis has wide-ranging negative consequences for the patient and her escort encounters.⁶

Continue to: THE FLEXNER REPORT

THE FLEXNER REPORT: NARRATIVE MEDICINE'S EXCISION

It is clear that the scientific revolution prompted the removal of NM from clinical practice. The 1910 Flexner Report, funded by the Carnegie Foundation for the Advancement of Teaching Science and authored by research scholar and physician Abraham Flexner, analyzed the functioning of 155 US and Canadian medical schools.⁷ His report supported the socially desirable goal of reforming medical education by exposing mediocre quality, unsavory profit motives, inadequate facilities, and nonscientific approaches, and publishing a list of those falling below the gold standard (which was the German medical education system). Harvard and Johns Hopkins received a gold seal, many other medical schools closed, and several responded to the challenge and excelled.⁸

Medical school curricula transitioned to exclusively theoretical and scientific teaching, objectifying values and rewarding research and efficiency. The subjective patient story was surgically excised and replaced with objective science. Not all change is good, however, and years later, Flexner reflected that scientific medicine was “sadly deficient in cultural and philosophic background.”⁸ His report also dramatically suppressed the use of complementary and alternative medicine and psychiatry, another medical boomerang.⁹ Scientific rigor is desirable—but not to the exclusion of the central patient role and other potential health care modalities.

THE PROBLEM-ORIENTED MEDICAL RECORD AND EHR

Decades after Flexner’s report on medical education curricula, another reformer, Lawrence Weed, MD, trained his eye on medical documentation’s organization and structure. He published a seminal article, “Medical Records that Guide and Teach” in the New England Journal of Medicine.¹⁰ Truly a pioneer, he demonstrated how typical medical record case documentation circa 1967 could be more efficient and espoused the problem-oriented medical record. He conceptualized designs for reorganizing medical records, prophetically promoted use of “paramedical” personnel, and encouraged computer integration.¹⁰

Coinciding with the birth of the PA profession and the recent inception of the NP profession, Weed endorsed the use of trained interviewers who would ­apply a “branching” question algorithm with associated computer data entry designed to protect expensive physician time. The patient story would be a jigsaw puzzle, as physicians could fill in missing information.¹⁰

Weed’s goals had merit by stressing structure for the disorganized, then-handwritten medical record, benefitting the growth of team-based patient care. However, efficiency and precision continued to marginalize a key component of the patient’s illness narrative in favor of speed, objectivity, and achievable billing essentials.¹¹ His recommendations have eradicated the free-text box, replacing it with a selection of pull-down choices or prewritten templates. With a series of clicks, the subjective patient’s own narrative is sterilized, removing valuable details from the team’s view.¹¹ The “s” of the Subjective Objective Assessment and Plan note is washed away (Table 1).

Continue to: Weed's clinical documentation...

Weed’s clinical documentation efficiency system caught fire. However, similar to Flexner’s later second thoughts, Weed also cast doubt on the full effect of his recommendations. In a 2009 interview conducted by a former medical student of his, Weed revealed views that more closely resemble our current competency-based medical education and stress the value of interpersonal skills in patient care¹²:

1. Computerization of the medical record—with its vast amount of information and physician-processing capacity—“inevitably” leads to dangerous cognitive shortcuts. Medical education seeks to instill “medical knowledge and clinical judgment,” giving students “misplaced faith in the completeness and accuracy of their own intellects and is the antithesis of a truly scientific education.”¹²
2. Medical student recruitment and instruction have long emphasized memory and regurgitation of facts, while students should be selected for their hands-on and interpersonal skills. Medical school should be “teaching a core of behavior instead of a core of knowledge.”¹² These are areas in which NM helps.

FLEXNER, WEED, AND NOW, CHARON

Medicine’s history is blemished by errors, some significant. Flexner neatly compartmentalized medical education, Weed digitized the clinician/patient interaction, and Charon revitalizes the reason clinicians chose a health care profession. Charon—as a practicing internist, as well as a professor in the Department of Medicine and Executive Director of the Program in Narrative Medicine at Columbia University’s Vagelos College of Physicians and Surgeons in New York City—is fully qualified to speak to the importance of NM in medical education and medical practice. Her 2006 book reminds us that sore throats are not always simple, boring, and routine; each one is as unique as the person housing that particular pharynx.¹³

How does NM drive clinicians to be better, countering cognitive errors while incorporating the patient’s cultural and philosophic background? According to Charon, the NM concept results from conversation among scholars and clinicians teaching and practicing at Columbia University in early 2000, fueled by decades of insight from literature, medical (health care) humanities, ethics, health care communication, and primary care medicine.³ NM supports patient-centric teaching and care, reminding us that it combines the historical doctor-at-bedside, who exhibited careful, empathetic questioning and listening, with the benefits of modern medical science.

Charon describes 3 main clinician-to-patient interactions, allowing us to regain some of what we have lost: attention, representation, and affiliation (Table 2). In addition to medical error reduction, these 3 interactive behaviors counter the aforementioned 3As (anchoring, availability, and attribution) of cognitive error.⁵Attention initiates the clinician’s heightened and committed listening to the patient.³ In our patient encounter, essential information is undisclosed, leading to a missed diagnosis and an incomplete representation in the written note. The clinician, due to insufficient attention, missed important clues such as the patient’s dress, accent, and profession, which limited the representation. This almost seems nonsensical; who would care about a patient’s dress or accent and, of practical concern today, where would one record it? And could another urgent care clinician or specialist find these notes? How might a more serious future medical outcome be averted? Affiliation results in a connection of careful listening and full documentation as the clinician becomes invested in the whole patient, not just the sore throat.³

PREPROFESSIONAL AND PROFESSIONAL EDUCATION

Preprofessional humanities education may result in stronger NM conceptualization. The Association of American Medical Colleges (AAMC) recognizes the value of arts and humanities in medical education in developing qualities of professionalism, communication skills, and emotional intelligence in physicians. The AAMC Curriculum Inventory and Reports (2015-2016) shows that 119 medical schools require humanities education, including

• Visual arts to improve observational skills
• History education to frame modern-day Ebola outbreaks (eg, using the framework of the Black Death),
• Literature and poetry to enhance insight into different ways of living and thinking, fostering critical thinking.¹⁴

Continue to: NM has been offered in...

NM has been offered in medical schools with positive outcomes. Published results of a 2010 qualitative study of 130 Columbia University medical students who completed a required intensive half-semester of NM seminars testify to its salience.¹⁵ Students articulated NM’s importance to critical thinking and reflection, through improved attention and affiliation with their patients, improved ability to examine assumptions and develop new skills, and improved clarity of communication.¹⁵

A small number of PA programs, far fewer than medical schools, are incorporating NM coursework, through application of literature, visual media, creative writing, and other approaches based on the humanities.¹⁶ The nursing profession, which prefers the term narrative health care to narrative medicine, endorses its inclusion in nursing education. A 2018 article in Nursing Education Perspectives supports the study of humanities to complement technical competencies such as the ability to “absorb, analyze, and interpret complex artifacts” and to “participate effectively in deliberative conversations.”¹⁷

THE PRACTICING CLINICIAN: MENTAL HEALTH AND NARRATIVE MEDICINE

The value of NM extends beyond the patient to embrace caregivers as well; this is important, in light of increased attention to mental health status among clinicians. Although the term used most frequently is physician burnout, data indicate that patient management by MDs, NPs, and PAs is becoming indistinguishable—and thus risk for associated negative mental health consequences may be shared across professions.¹⁸ Physician burnout has been described as “emotional exhaustion, depersonalization, and a sense of reduced accomplishment” and has a documented prevalence of about 50%.¹⁹ It has also been described as a “progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the condition of their work with three key characteristics: physical exhaustion, cynicism, and inefficiency.”²⁰ The medical community is deeply concerned about and seeks methods to better understand and prevent this phenomenon. A meta-analysis by West et al supports positive outcomes in addressing burnout through mindfulness training, stress management, and small-group discussions.¹⁹

The National Academy of Medicine is also addressing the issues of clinician well-being (see https://nam.edu/initiatives/clinician-resilience-and-well-being/). Former US Surgeon General Vivek Murthy, MD, has spoken about the epidemic of loneliness that affects clinicians. This can result from playing the physician role, lack of family support, and increased dependency on technology—yet, on a basic level, lack of interpersonal communication and connection are at the core.²¹ Communication between clinicians can lead to greater social cohesion and compassion, and effective uninterrupted listening and expression of their feelings helps. This begs the question: If physicians need to communicate better and practice active listening among themselves, how does this translate to the physician-to-patient bond?

THE CLINICIANS' PERSONAL BALM

Caruso Brown and Garden describe how the illness experiences of physicians, through their own reflective writing, create an empathy bridge between the professional healer and a sick patient, allowing them to be better and healthier clinicians.²² Recent best-selling physician narratives such as those by Atul Gawande,²³ Siddhartha Mukherjee,²⁴ and Paul Kalanithi²⁵ support the similarities between the sick physician and the sick patient. Illness narratives written by physicians-turned-patients are not dissimilar to illness narratives written by patients. Reflective writing by clinicians fosters a deeper understanding not only of how patients feel, but also of the relationship they desire and deserve.²²

Continue to: Writing a novel...

Writing a novel is beyond the time and ability of many clinicians. However, they can closely read literature (another NM tool), discuss books and other types of writing, participate in a book club, establish a hospital or office support group, and find a buddy or trustworthy confidant with whom to decompress and vent.³ Active journal clubs can alternate clinical guidelines with literature to expand their perspectives. An international voice, Maria Giulia Marini, Research and Health Director of the Fondazione ISTUD in Milan, Italy, and European proponent of NM, offers similar suggestions, indicating that making nonmedical works parts of a clinician’s life encourages empathy and promotes understanding between clinician and patient, as well as a holistic management approach, encourages personal and collegial reflection (eg, sharing tough experiences), sets a patient-centered agenda, and challenges the norm.²⁶

NARRATIVE MEDICINE'S FUTURE ROLE

The field of medical humanities has experienced growth through publications, national and international conferences, and formal discussion between executives of the AAMC and the National Endowment for the Humanities to design and incorporate joint programs teaching humanities in medical schools.²⁷ As of March 2019, there were 85 established baccalaureate health humanities programs in the US, with additional programs in development.²⁸

Clinicians and professional organizations cannot help but see the suffering of patients, with its concomitant provider burden. The urgent care patient encounter in our example met the standard of care of the typical interaction that achieves billing protocols; the HPI, ROS, and physical exam would not raise an eyebrow. Yet, an NM approach provides more. Asking the atypical questions about accents, out-of-the-ordinary dress and behavior, and wondering about the mentioned late-night appointment attends to NM’s focused active listening, with resultant quality documentation and a whole patient encounter, even in an acute care case.

Don’t be afraid. Consider that as in novels and movies, strange things happen. The iconic book The House of God reminds clinicians that, upon hearing hoof beats, we should first think of horses—however, sometimes a zebra is correct.²⁹ When an urgent care clinician interprets the hoof beats, a zebra may be in the differential diagnosis; in the case presented, the patient might fortunately be spared a future KS diagnosis. And the clinician may avoid personal anguish at what could have been a better outcome. NM can help clinicians remember that sore throats are as unique as people.

Narrative medicine (NM) centers on understanding patients’ lives, caring for the caregivers (including the clinicians), and giving voice to the suffering.¹ It is an antidote for medical “progress,” which often stresses technology and pharmacologic interventions, leaving the patient out of his/her own medical story—with negative consequences.

This missing patient narrative goes beyond the template information solicited and recorded in the history of present illness (HPI) and review of systems (ROS). It is well expressed by Francis W. Peabody, MD, (1881-1927) in a published lecture for Harvard Medical School students: “One of the essential qualities of the clinician is an interest in humanity, for the secret of the care of the patient is in caring for the patient.”²

This article serves as an introduction to NM, its evolution, and its power to improve medical diagnoses and reduce clinician burnout. While its roots are in palliative and chronic care, NM has a place in the day-to-day care of patients in acute settings as well.

VIGNETTE

It’s been a busy day in clinic; the clock ticks toward closing. Scanning the monitor, you permit a brief moment of relief as you spy the perfect end-of-shift, quickie patient case: “Sore throat x 2 days,” with a rapid strep test under way. You quickly check lab coat pockets for examination tools and hasten down the hall noting age 22, white female, self-pay. Vitals reveal a low-grade fever. Maybe this sore throat will be bacterial; all the easier as there will be no need to do the “antibiotics don’t work for viruses” sermon.

You knock briefly, enter the exam room, place the laptop on the counter, and immediately recognize the patient from multiple visits over the past 2 years, mostly for gynecologic issues. You recall treating her for gonorrhea and discussing her worry about HIV. She told you that she’s a graduate student, although she is overdressed for a week night, wearing a silk blouse, short skirt, and high heels. She offers a winning smile and tells you with her pleasant accent that she is running late for an appointment.

The patient describes her symptoms: unrelenting sore throat for 2 days and pain with swallowing. She complains of feeling feverish and fatigued, with no appetite and “swollen glands.” She denies cough and runny nose; she looks and sounds exhausted. She denies smoking and excessive alcohol intake. You vaguely hone in on the accent, thinking it might be South African. Her HPI and ROS completed, you record her physical findings of pharyngeal erythema, no exudates, and moderate anterior lymphadenopathy.

You have a nagging thought about her “story.” As an urgent care clinician, you know you are likely her only health care provider and you feel some connection. It is late, and the patient is in a rush, so you promise yourself to delve deeper the next time she presents.

Continue to: You confirm the negative strep test results...

You confirm the negative strep test results and deliver the well-rehearsed sermon. She appears surprised, asking if you are sure. You suggest that she schedule a full physical in the near future. She hops off the table, heels clicking on the tile floor, as you complete your note. You do not suspect she is off to meet her scheduled man of the evening as assigned by her escort service.

Before you clock out, you check the extended patient appointment schedule and do not see her name. You vow to call her the next day and discover that she has no listed phone number. An uncomfortable feeling settles in: Are you missing something?

IN URGENT CARE

NM is an interactive patient approach more often applied to seriously ill or chronic disease patients, for whom it meaningfully supports a patient’s existence as central to the diagnostic testing and treatment of health care concerns. One can professionally debate that NM has no place in urgent care; however, this is where many patients’ acute and chronic conditions are discovered. It is where elevated blood glucose becomes type 2 diabetes and abnormal complete blood counts become blood cancer. With deeper application of NM’s principles, our simple-appearing acute pharyngitis case might have received a different workup.

NM practitioners subscribe to careful listening. Rita Charon, MD, a leading proponent of NM, describes this approach to patient care as a “rigorous intellectual and clinical discipline to fortify health care with its capacity to skillfully receive the accounts persons give of themselves—to recognize, absorb, interpret, and be moved to action by the stories of others.”³ It is a patient care revival that helps clinicians recognize and shield themselves from the powerful stampede of tech­nology, templated patient interviews, digital documentation, and diminution of clinician and patient bonding.

The clinician in this patient encounter has functionally intact radar, sensing something awry, but communication falls short. NM’s strength is to bond the clinician to the patient, enhancing subtle, and at times pivotal, information exchange. It generates patient trust even in brief encounters, fostering improved clinical decision-making. A stronger NM focus might have encouraged this clinician to investigate more deeply the patient’s fancy clothing and surprised response to the negative strep test results by posing a simple query, such as ”What do you think might be going on?”

Continue to: MEDICAL ERROR

Pharyngitis is common, making it prime territory for medical error—even for experienced clinicians—because of 3 human tendencies that NM recognizes and seeks to avoid.⁴ These human tendencies, insightfully delineated decades ago by experimental psychologists Amos Tversky and Daniel Kahneman, authors of Anchoring, Availability and Attribution, appear most commonly under uncertain conditions and time pressures, such as in urgent care. How does this patient encounter reflect these tendencies?⁵

Anchoring refers to the tendency to grasp the first symptom, physical finding, or laboratory abnormality, and hold onto it tightly.⁵ Such initial diagnostic impressions/information may prove true; however, other unconsidered diagnoses may include the correct one. In this encounter, the clinician entered the exam room with an early fixed diagnosis and applied the rapid strep results to diagnose viral pharyngitis. Other, conflicting hints were fleetingly noted and not addressed.

Availability refers to the tendency to assume that a quickly recalled experience explains a novel situation.⁵ Clinicians regularly diagnose viral pharyngitis, leading to familiarity and availability. This is contrary to NM’s view of every patient having a unique and noteworthy story.

Attribution refers to the tendency to invoke stereotypical images and assign symptoms and findings to the stereotype, which is often negative (eg, hypochondriac, drinker).⁵

In this encounter, the clinician would have benefited from considering other categories of diagnoses that could occur in this patient, expanding the differential diagnosis list, by soliciting a deeper patient story, fostering trust, and following clinical intuition. Had this bond been cultivated over prior visits, even in an urgent care setting, the graduate student ruse would have been discovered and the patient’s true occupation—female sex worker—revealed. The clinician would have modified the laboratory testing, discovering human herpesvirus type 8 (HHV-8) as the pharyngitis etiology, which is disproportionately linked to HIV co-infection and increases the risk for Kaposi sarcoma (KS) 20,000-fold. The prevalence of HHV-8 is 17% in the United States and is much higher (50%) in South Africa, the origin of the patient’s accent.⁶ 
Deeper patient relationships enable uncomfortable history-taking questions, with improved reliability. This missed diagnosis has wide-ranging negative consequences for the patient and her escort encounters.⁶

Continue to: THE FLEXNER REPORT

THE FLEXNER REPORT: NARRATIVE MEDICINE'S EXCISION

It is clear that the scientific revolution prompted the removal of NM from clinical practice. The 1910 Flexner Report, funded by the Carnegie Foundation for the Advancement of Teaching Science and authored by research scholar and physician Abraham Flexner, analyzed the functioning of 155 US and Canadian medical schools.⁷ His report supported the socially desirable goal of reforming medical education by exposing mediocre quality, unsavory profit motives, inadequate facilities, and nonscientific approaches, and publishing a list of those falling below the gold standard (which was the German medical education system). Harvard and Johns Hopkins received a gold seal, many other medical schools closed, and several responded to the challenge and excelled.⁸

Medical school curricula transitioned to exclusively theoretical and scientific teaching, objectifying values and rewarding research and efficiency. The subjective patient story was surgically excised and replaced with objective science. Not all change is good, however, and years later, Flexner reflected that scientific medicine was “sadly deficient in cultural and philosophic background.”⁸ His report also dramatically suppressed the use of complementary and alternative medicine and psychiatry, another medical boomerang.⁹ Scientific rigor is desirable—but not to the exclusion of the central patient role and other potential health care modalities.

THE PROBLEM-ORIENTED MEDICAL RECORD AND EHR

Decades after Flexner’s report on medical education curricula, another reformer, Lawrence Weed, MD, trained his eye on medical documentation’s organization and structure. He published a seminal article, “Medical Records that Guide and Teach” in the New England Journal of Medicine.¹⁰ Truly a pioneer, he demonstrated how typical medical record case documentation circa 1967 could be more efficient and espoused the problem-oriented medical record. He conceptualized designs for reorganizing medical records, prophetically promoted use of “paramedical” personnel, and encouraged computer integration.¹⁰

Coinciding with the birth of the PA profession and the recent inception of the NP profession, Weed endorsed the use of trained interviewers who would ­apply a “branching” question algorithm with associated computer data entry designed to protect expensive physician time. The patient story would be a jigsaw puzzle, as physicians could fill in missing information.¹⁰

Weed’s goals had merit by stressing structure for the disorganized, then-handwritten medical record, benefitting the growth of team-based patient care. However, efficiency and precision continued to marginalize a key component of the patient’s illness narrative in favor of speed, objectivity, and achievable billing essentials.¹¹ His recommendations have eradicated the free-text box, replacing it with a selection of pull-down choices or prewritten templates. With a series of clicks, the subjective patient’s own narrative is sterilized, removing valuable details from the team’s view.¹¹ The “s” of the Subjective Objective Assessment and Plan note is washed away (Table 1).

Continue to: Weed's clinical documentation...

Weed’s clinical documentation efficiency system caught fire. However, similar to Flexner’s later second thoughts, Weed also cast doubt on the full effect of his recommendations. In a 2009 interview conducted by a former medical student of his, Weed revealed views that more closely resemble our current competency-based medical education and stress the value of interpersonal skills in patient care¹²:

1. Computerization of the medical record—with its vast amount of information and physician-processing capacity—“inevitably” leads to dangerous cognitive shortcuts. Medical education seeks to instill “medical knowledge and clinical judgment,” giving students “misplaced faith in the completeness and accuracy of their own intellects and is the antithesis of a truly scientific education.”¹²
2. Medical student recruitment and instruction have long emphasized memory and regurgitation of facts, while students should be selected for their hands-on and interpersonal skills. Medical school should be “teaching a core of behavior instead of a core of knowledge.”¹² These are areas in which NM helps.

FLEXNER, WEED, AND NOW, CHARON

Medicine’s history is blemished by errors, some significant. Flexner neatly compartmentalized medical education, Weed digitized the clinician/patient interaction, and Charon revitalizes the reason clinicians chose a health care profession. Charon—as a practicing internist, as well as a professor in the Department of Medicine and Executive Director of the Program in Narrative Medicine at Columbia University’s Vagelos College of Physicians and Surgeons in New York City—is fully qualified to speak to the importance of NM in medical education and medical practice. Her 2006 book reminds us that sore throats are not always simple, boring, and routine; each one is as unique as the person housing that particular pharynx.¹³

How does NM drive clinicians to be better, countering cognitive errors while incorporating the patient’s cultural and philosophic background? According to Charon, the NM concept results from conversation among scholars and clinicians teaching and practicing at Columbia University in early 2000, fueled by decades of insight from literature, medical (health care) humanities, ethics, health care communication, and primary care medicine.³ NM supports patient-centric teaching and care, reminding us that it combines the historical doctor-at-bedside, who exhibited careful, empathetic questioning and listening, with the benefits of modern medical science.

Charon describes 3 main clinician-to-patient interactions, allowing us to regain some of what we have lost: attention, representation, and affiliation (Table 2). In addition to medical error reduction, these 3 interactive behaviors counter the aforementioned 3As (anchoring, availability, and attribution) of cognitive error.⁵Attention initiates the clinician’s heightened and committed listening to the patient.³ In our patient encounter, essential information is undisclosed, leading to a missed diagnosis and an incomplete representation in the written note. The clinician, due to insufficient attention, missed important clues such as the patient’s dress, accent, and profession, which limited the representation. This almost seems nonsensical; who would care about a patient’s dress or accent and, of practical concern today, where would one record it? And could another urgent care clinician or specialist find these notes? How might a more serious future medical outcome be averted? Affiliation results in a connection of careful listening and full documentation as the clinician becomes invested in the whole patient, not just the sore throat.³

PREPROFESSIONAL AND PROFESSIONAL EDUCATION

Preprofessional humanities education may result in stronger NM conceptualization. The Association of American Medical Colleges (AAMC) recognizes the value of arts and humanities in medical education in developing qualities of professionalism, communication skills, and emotional intelligence in physicians. The AAMC Curriculum Inventory and Reports (2015-2016) shows that 119 medical schools require humanities education, including

• Visual arts to improve observational skills
• History education to frame modern-day Ebola outbreaks (eg, using the framework of the Black Death),
• Literature and poetry to enhance insight into different ways of living and thinking, fostering critical thinking.¹⁴

Continue to: NM has been offered in...

NM has been offered in medical schools with positive outcomes. Published results of a 2010 qualitative study of 130 Columbia University medical students who completed a required intensive half-semester of NM seminars testify to its salience.¹⁵ Students articulated NM’s importance to critical thinking and reflection, through improved attention and affiliation with their patients, improved ability to examine assumptions and develop new skills, and improved clarity of communication.¹⁵

A small number of PA programs, far fewer than medical schools, are incorporating NM coursework, through application of literature, visual media, creative writing, and other approaches based on the humanities.¹⁶ The nursing profession, which prefers the term narrative health care to narrative medicine, endorses its inclusion in nursing education. A 2018 article in Nursing Education Perspectives supports the study of humanities to complement technical competencies such as the ability to “absorb, analyze, and interpret complex artifacts” and to “participate effectively in deliberative conversations.”¹⁷

THE PRACTICING CLINICIAN: MENTAL HEALTH AND NARRATIVE MEDICINE

The value of NM extends beyond the patient to embrace caregivers as well; this is important, in light of increased attention to mental health status among clinicians. Although the term used most frequently is physician burnout, data indicate that patient management by MDs, NPs, and PAs is becoming indistinguishable—and thus risk for associated negative mental health consequences may be shared across professions.¹⁸ Physician burnout has been described as “emotional exhaustion, depersonalization, and a sense of reduced accomplishment” and has a documented prevalence of about 50%.¹⁹ It has also been described as a “progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the condition of their work with three key characteristics: physical exhaustion, cynicism, and inefficiency.”²⁰ The medical community is deeply concerned about and seeks methods to better understand and prevent this phenomenon. A meta-analysis by West et al supports positive outcomes in addressing burnout through mindfulness training, stress management, and small-group discussions.¹⁹

The National Academy of Medicine is also addressing the issues of clinician well-being (see https://nam.edu/initiatives/clinician-resilience-and-well-being/). Former US Surgeon General Vivek Murthy, MD, has spoken about the epidemic of loneliness that affects clinicians. This can result from playing the physician role, lack of family support, and increased dependency on technology—yet, on a basic level, lack of interpersonal communication and connection are at the core.²¹ Communication between clinicians can lead to greater social cohesion and compassion, and effective uninterrupted listening and expression of their feelings helps. This begs the question: If physicians need to communicate better and practice active listening among themselves, how does this translate to the physician-to-patient bond?

THE CLINICIANS' PERSONAL BALM

Caruso Brown and Garden describe how the illness experiences of physicians, through their own reflective writing, create an empathy bridge between the professional healer and a sick patient, allowing them to be better and healthier clinicians.²² Recent best-selling physician narratives such as those by Atul Gawande,²³ Siddhartha Mukherjee,²⁴ and Paul Kalanithi²⁵ support the similarities between the sick physician and the sick patient. Illness narratives written by physicians-turned-patients are not dissimilar to illness narratives written by patients. Reflective writing by clinicians fosters a deeper understanding not only of how patients feel, but also of the relationship they desire and deserve.²²

Continue to: Writing a novel...

Writing a novel is beyond the time and ability of many clinicians. However, they can closely read literature (another NM tool), discuss books and other types of writing, participate in a book club, establish a hospital or office support group, and find a buddy or trustworthy confidant with whom to decompress and vent.³ Active journal clubs can alternate clinical guidelines with literature to expand their perspectives. An international voice, Maria Giulia Marini, Research and Health Director of the Fondazione ISTUD in Milan, Italy, and European proponent of NM, offers similar suggestions, indicating that making nonmedical works parts of a clinician’s life encourages empathy and promotes understanding between clinician and patient, as well as a holistic management approach, encourages personal and collegial reflection (eg, sharing tough experiences), sets a patient-centered agenda, and challenges the norm.²⁶

NARRATIVE MEDICINE'S FUTURE ROLE

The field of medical humanities has experienced growth through publications, national and international conferences, and formal discussion between executives of the AAMC and the National Endowment for the Humanities to design and incorporate joint programs teaching humanities in medical schools.²⁷ As of March 2019, there were 85 established baccalaureate health humanities programs in the US, with additional programs in development.²⁸

Clinicians and professional organizations cannot help but see the suffering of patients, with its concomitant provider burden. The urgent care patient encounter in our example met the standard of care of the typical interaction that achieves billing protocols; the HPI, ROS, and physical exam would not raise an eyebrow. Yet, an NM approach provides more. Asking the atypical questions about accents, out-of-the-ordinary dress and behavior, and wondering about the mentioned late-night appointment attends to NM’s focused active listening, with resultant quality documentation and a whole patient encounter, even in an acute care case.

Don’t be afraid. Consider that as in novels and movies, strange things happen. The iconic book The House of God reminds clinicians that, upon hearing hoof beats, we should first think of horses—however, sometimes a zebra is correct.²⁹ When an urgent care clinician interprets the hoof beats, a zebra may be in the differential diagnosis; in the case presented, the patient might fortunately be spared a future KS diagnosis. And the clinician may avoid personal anguish at what could have been a better outcome. NM can help clinicians remember that sore throats are as unique as people.

CE/CME No: CR-1802

PROGRAM OVERVIEW
Earn credit by reading this article and successfully completing the posttest and evaluation. Successful completion is defined as a cumulative score of at least 70% correct.

EDUCATIONAL OBJECTIVES
• Identify patients who are at the greatest risk for the effects of polypharmacy.
• Recognize which medications are most likely to cause adverse drug events (ADEs) in the elderly population.
• Understand the effects of aging on the pharmacokinetics and pharmacodynamics of medications.
• Learn strategies to reduce the risk for polypharmacy and ADEs, including use of the Beers Criteria and the STOPP/START Criteria.

FACULTY
Kelsey Barclay practices in orthopedic surgery at Stanford Medical Center in Palo Alto, California. Amy Frassetto practices in Ob-Gyn at NewYork-Presbyterian in New York City. Julie Robb practices in emergency medicine at South Nassau Communities Hospital in Oceanside, New York. Ellen D. Mandel is a Clinical Professor in the Department of PA Studies at Pace University-Lenox Hill Hospital in New York City.

ACCREDITATION STATEMENT

This program has been reviewed and is approved for a maximum of 1.0 hour of American Academy of Physician Assistants (AAPA) Category 1 CME credit by the Physician Assistant Review Panel. [NPs: Both ANCC and the AANP Certification Program recognize AAPA as an approved provider of Category 1 credit.] Approval is valid through January 31, 2019.

Article begins on next page >>

Managing medications in the elderly can be complicated by the physiologic effects of aging and the prevalence of comorbidities. Consistent use of tools such as the Beers criteria and the STOPP/START criteria, as well as medication reconciliation, can reduce polypharmacy and its adverse drug effects, improving health outcomes in this population.

Older adults (those 65 and older) often have a number of comorbidities requiring pharmacologic intervention, making medication management a complicated but essential part of caring for the elderly. A recent analysis of trends in prescription drug use by community-dwelling adults found that 39% of older adults used five or more prescribed medications.¹ Furthermore, about 72% of older adults also take a nonprescription medication (OTC or supplement); while OTC medication use has declined in this population in recent years, dietary supplement use has increased.²

These patients are also more susceptible to adverse drug events (ADEs)—including adverse drug reactions (ADRs)—resulting from the physiologic changes of aging. By one estimate, ADRs are about seven times more common in those older than 70 than in younger persons.³ One out of every 30 urgent hospital admissions in patients ages 65 and older is related to an ADR.⁴

Providers must therefore be cognizant of drug indications, dosing, and drug interactions when prescribing medications to elderly patients. Fortunately, tools and methods to avoid polypharmacy and the adverse effects of commonly prescribed medications—such as anticholinergics and psychotropic drugs—are available.

POLYPHARMACY AND PRESCRIPTION CASCADING

While there is no specific number of medications required to define polypharmacy, the term is generally used when a nonhospitalized individual is taking five or more medications.⁵ The more medications a patient is taking, the more at risk he or she will be for ADRs, drug interactions, and prescription cascading.

Prescription cascading begins when an ADR is thought to be a new symptom and a new drug is prescribed to control it. Ultimately, a cascade of prescriptions occurs to control avoidable ADRs, resulting in polypharmacy. As many as 57% of women older than 65 in the United States are currently prescribed five or more medications, with 12% prescribed nine or more drugs.⁶ Not only do these medications cause independent ADRs, but there is also increased risk for drug interactions—and potentially, additional avoidable ADRs.

The elderly population is at greater risk for ADEs because these patients are more likely to have multiple comorbidities and chronic diseases, requiring multiple therapies.⁷ Polypharmacy is also more dangerous in the elderly because the physiologic changes that occur during natural aging can affect both the pharmacokinetics and pharmacodynamics of medications. The absorption, distribution, metabolism, and excretion of drugs within the human body changes as a person ages, while certain drug classes can alter the way the body functions. For example, muscle mass naturally declines and the proportion of body fat to muscle increases; this change affects the distribution of drugs such as benzodiazepines or lithium.⁷ If the medication dosage is not corrected, the toxicity of the drug will be increased.⁷

Medication excretion is largely controlled by the kidneys. Renal perfusion and function decline with age, leading to a decrease in glomerular filtration rate—which requires closer monitoring of medication selection and dosing. The risk is heightened when the elderly patient becomes acutely ill. An acute decrease in kidney function results in decreased excretion of medications, leading to an increase in ADRs.⁷

Ultimately, the safety of many medications in the elderly patient is unknown.⁸ But there is a growing body of knowledge on the adverse effects of some classes of medication in this population.

COMMONLY PRESCRIBED MEDICATIONS—AND RISKS

ADEs result from medication errors, ADRs, allergic reactions, and overdoses. The incidence of ADEs—specifically ADRs and medication errors—is elevated in elderly patients who are prescribed certain classes of medications or multiple drugs simultaneously.⁸ Anticholinergic drugs and psychotropic drugs (specifically antipsychotics and benzodiazepines) are among the medications most commonly prescribed to elderly patients—and among the most likely to contribute to ADEs.⁹ Diabetes is a chronic condition whose treatment may also put elderly patients at risk for ADEs.¹⁰

Anticholinergic medications

Anticholinergic drugs—commonly prescribed for Parkinson disease, depression, urinary incontinence, pulmonary disorders, intestinal motility, and muscle spasms—competitively inhibit the binding of acetylcholine to muscarinic acetylcholine receptors.⁹ Because this mechanism tends to be nonselective, the adverse effects may be widespread. Central adverse effects include cognitive impairment, confusion, and delirium; peripheral adverse effects include constipation, urinary retention, dry mouth, blurred vision, peristaltic reduction, and tachycardia.⁹

Anticholinergic drugs are commonly prescribed to elderly patients for cardiovascular (CV) and neurologic disorders. (Medications for the former include ß-blockers, calcium channel blockers, diuretics, and ACE inhibitors; for the latter, amitriptyline, quetiapine, nortriptyline, prochlorperazine, haloperidol, and paroxetine.) An assessment of anticholinergic activity classified most neurologic medications as high activity and most CV medications as low—however, the latter are usually given in conjunction with other anticholinergic medications, increasing their ability to cause ADRs.¹¹

In many cases, patients are prescribed anticholinergic medications to control symptoms of a disease, not to cure it—which means patients may be taking these medications for years. This cumulative exposure is called the anticholinergic burden. Many studies show that the anticholinergic burden is a predictor of cognitive and physical decline; a 2016 study of adults older than 65 who were exposed to 5 mg/d of oxybutynin for more than three years had a 23% increased risk for dementia, compared to low-risk or no exposure groups.⁹

In a retrospective, population-level study conducted in New Zealand, researchers assessed the anticholinergic effects of delirium, urinary retention, and constipation in 2,248 patients (65 and older) who were admitted to the hospital with at least one prescribed medication. Anticholinergic burden was found to be a significant independent predictor; patients taking five anticholinergic medications were more than three times as likely to develop an anticholinergic effect than those taking just one such medication (adjusted odds ratio, 3.21).¹¹

Psychotropic drugs

Another often-prescribed medication group is psychotropic drugs, specifically antipsychotics and benzodiazepines, for agitation and behavioral disturbances in dementia. A year-long study of 851 patients in two long-term care nursing homes in Boston found that risk for ADRs—specifically, falls—was increased in those who had a change (initiation or dose increase) in psychotropic medication (ie, benzodiazepine, antipsychotic, or antidepressant).¹²

Second-generation antipsychotics, which are more commonly prescribed than first-generation agents, work on a postsynaptic blockade of brain dopamine D₂ receptors and have an increased affinity for serotonin 5-HT_2A receptors (see Table 1 for pharmacology of these medications).^13,14 Adverse effects of these drugs include hypotension, sedation, and anticholinergic effects. Second-generation antipsychotics also carry a “black box warning” for increased risk for death in elderly patients with dementia-related psychosis.¹⁵

Benzodiazepines bind to receptors in the gamma-aminobutyric acid receptor complex, which enhances the binding of this inhibitory neurotransmitter (see Table 2 for pharmacology). Of this class of drugs, lorazepam has the highest potency, whereas midazolam and diazepam have lower potencies. Use of benzodiazepines increases risk for delirium and respiratory depression.¹⁶

Diabetes treatment

People with diabetes have an increased risk for ADEs; this risk is elevated in older adults due to comorbidities such as peripheral neuropathy, retinopathy, coronary artery disease, and peripheral vascular disease.¹⁰ Hypoglycemic agents, such as insulin and insulin secretagogues, confer a higher risk for falls due to their hypoglycemic effect.¹⁰ Furthermore, metformin is known to increase risk for cognitive impairment in patients with diabetes.¹⁰

PREVENTING ADEs AND UNNECESSARY POLYPHARMACY

Predicting and preventing ADEs should be a health care provider’s priority when treating an elderly patient taking multiple medications—but it is often overlooked. Electronic medical records (EMRs) are helpful in preventing ADEs, specifically prescription errors, by flagging the patient’s chart when potentially problematic medications are ordered; however, this captures only a portion of ADEs occurring in this popu­lation.⁷

Other options to evaluate a patient for polypharmacy and possible ADRs include the Beers Criteria and the STOPP/START Criteria.^17,18 Additionally, performing thorough and frequent medication reviews helps ensure that patients are prescribed essential medications to treat their comorbidities with the most opportunistic risk-benefit ratio. Patients’ medication lists across settings (eg, hospital, primary care, urgent care) can be accessed more easily, efficiently, and accurately with the integration of EMRs.

Beers Criteria

First published by Dr. Mark Beers in 1991 and endorsed by the American Geriatrics Society, the Beers Criteria identifies possible harmful effects of certain commonly prescribed medications to help guide and modify pharmacologic treatments, particularly in adults older than 65. The Beers Criteria classifies medications into three categories:

1. Drugs that should be avoided or dose-adjusted
2. Drugs that are potentially inappropriate in patients with certain conditions or syndromes
3. Drugs that should be prescribed with caution in older adults.¹⁷

In the most recent update (2015), possible adverse effects of medications based on a patient’s hepatic or renal function, the effectiveness of the medication, and possible drug interactions were added. For example, nitrofurantoin and antiarrhythmics (eg, amiodarone and digoxin) should be avoided at a lower threshold of hepatic and renal impairment than previously recommended. The criteria suggest avoiding use of zolpidem, a nonbenzodiazepine receptor agonist, because of its elevated risk for adverse effects and minimal effectiveness in treating insomnia. More information about the 2015 criteria is available from the American Geriatrics Society (http://online library.wiley.com/doi/10.1111/jgs. 13702/full).¹⁹

The latest update also takes into account recently published evidence of increased ADEs resulting from drugs such as antipsychotics and proton pump inhibitors (PPIs).²⁰ Antipsychotics are associated with an increased risk for morbidity and mortality, and PPIs are now recommended only for treatment duration of up to two months because of the possible increased risk for Clostridium difficile infection, as well as falls and fractures in patients older than 65.²⁰ (PPIs indirectly reduce calcium absorption, which may lead to an increased fracture risk, particularly in postmenopausal women.²⁰)

As with any guideline, the Beers Criteria was designed to supplement, not replace, clinical expertise and judgment. The risks and benefits of a medication should be weighed for the individual patient.

STOPP/START Criteria

Less widely used is the STOPP/START Criteria, an evidence-based set of guidelines consisting of 65 STOPP (Screening Tool of Older Person’s potentially inappropriate Prescriptions) and 22 START (Screening Tool to Alert doctors to the Right Treatment) criteria. Although they may be used individually, STOPP and START are best used together to determine the most appropriate medications for an elderly patient.

The STOPP guidelines help determine when the risks of a medication may outweigh the benefits in a given patient. STOPP includes recommendations for the appropriate length of time to use a medication; for example, PPIs should not be used for more than eight weeks (similar to the Beers recommendation) and benzodiazepines and neuroleptics for more than four weeks.¹⁸

START helps clinicians recognize potential prescribing omissions and to identify when a medication regimen should be implemented based on a patient’s history.¹⁸ Examples of START criteria include suggestions of when to initiate calcium and vitamin D supplementation for prevention of osteoporosis and when to begin statins in patients with diabetes, coronary artery disease, and cardiovascular disease.¹⁸

STOPP/START is organized by physiologic system, which allows for greater usability, and it addresses medications by class rather than specific medications. (The Beers Criteria was criticized for these reasons, as well as its limited transferability outside the United States.) When assessed in systematic reviews, the STOPP/START criteria were found to be fundamentally more sensitive than the Beers Criteria. Overall, it was concluded that the use of the STOPP/START criteria resulted in an absolute risk reduction of 21.2% to 35.7% and greatly improved the appropriateness of prescribing medication to the elderly. Its use also resulted in fewer follow-up appointments with a primary care physician (PCP).¹⁸

iPhone and Android applications such as iGeriatrics and Medstopper provide clinicians with easy access to Beers Criteria and STOPP/START Criteria, respectively.

Medication reconciliation

Medication reconciliation—in which health care providers review a patient’s medication list at hospital admission and discharge, and even at routine office visits—is an increasingly common practice, especially with the implementation of EMRs. The patient’s prescribed and OTC medications, as well as dose, route, frequency, and indication, are updated, with the goal of maintaining the most accurate list. Health care providers can utilize both the Beers Criteria and the STOPP/START criteria in their reconciliation process to help reduce polypharmacy in the elderly. It is an essential step in maintaining communication between providers and ultimately decreasing the incidence of ADEs.¹⁷

IMPROVE … continuity of care

Polypharmacy can decrease patient likelihood to adhere to the regimen, whether due to confusion or intolerance.⁸ Patients should be included, along with caregivers and all medical providers, in a holistic assessment of the patient’s best interests in terms of long-term care and pharmacologic treatment, since those who have a sense of control in their treatment goals and expectations often achieve a better understanding of their medical status.¹⁰

However, educating patients about their medications is time-consuming, and time is often at a premium during a typical office visit. A pilot study of 28 male veterans (ages 85 and older)—the Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE) project—devised a model to combat this problem.²¹ As an adjunct to a visit with the PCP, a clinical pharmacist trained in patient education and medication management performed face-to-face clinical consults with patients and their caregivers. The results indicated that medical management by both the PCP and the pharmacist resulted in better medication management. The pharmacist was able to spend time with the patient and caregiver, resulting in individualized instructions, education, and strategies for safe and effective medication use. The PCP remained involved by cosigning the note with the pharmacist and was available for consultation, if needed.

In IMPROVE, 79% of patients had at least one medication discontinued and 75% had one or more dosing or timing adjustments made. Potentially inappropriate medications were reduced by 14%.²¹ When the researchers compared the six-month period before the trial with the six-month period afterward, they found an average pharmacy cost savings of $64 per veteran per month. There was also a decreasing trend in phone calls and visits to the PCP. Cost savings were comparable to or greater than those reported for similar interventions.²¹ There has not been sufficient long-term follow-up to assess this method’s effects on ADEs, morbidity, and mortality, however.

CONCLUSION

Managing medications in the elderly population is difficult, and polypharmacy is common due to the prevalence of patients with comorbidities. It is important for providers to be aware of possible drug interactions, prescribing cascades, and ADEs. Medications such as anticholinergics and antipsychotics pose an increased risk for ADEs, but the regular implementation of criteria such as Beers or STOPP/START in clinical practice will minimize overprescribing and improve health outcomes. These criteria should be used to supplement the clinical judgment and expertise of providers as a mainstay of patient care in the elderly.

CE/CME No: CR-1802

PROGRAM OVERVIEW
Earn credit by reading this article and successfully completing the posttest and evaluation. Successful completion is defined as a cumulative score of at least 70% correct.

EDUCATIONAL OBJECTIVES
• Identify patients who are at the greatest risk for the effects of polypharmacy.
• Recognize which medications are most likely to cause adverse drug events (ADEs) in the elderly population.
• Understand the effects of aging on the pharmacokinetics and pharmacodynamics of medications.
• Learn strategies to reduce the risk for polypharmacy and ADEs, including use of the Beers Criteria and the STOPP/START Criteria.

FACULTY
Kelsey Barclay practices in orthopedic surgery at Stanford Medical Center in Palo Alto, California. Amy Frassetto practices in Ob-Gyn at NewYork-Presbyterian in New York City. Julie Robb practices in emergency medicine at South Nassau Communities Hospital in Oceanside, New York. Ellen D. Mandel is a Clinical Professor in the Department of PA Studies at Pace University-Lenox Hill Hospital in New York City.

ACCREDITATION STATEMENT

This program has been reviewed and is approved for a maximum of 1.0 hour of American Academy of Physician Assistants (AAPA) Category 1 CME credit by the Physician Assistant Review Panel. [NPs: Both ANCC and the AANP Certification Program recognize AAPA as an approved provider of Category 1 credit.] Approval is valid through January 31, 2019.

Article begins on next page >>

Managing medications in the elderly can be complicated by the physiologic effects of aging and the prevalence of comorbidities. Consistent use of tools such as the Beers criteria and the STOPP/START criteria, as well as medication reconciliation, can reduce polypharmacy and its adverse drug effects, improving health outcomes in this population.

Older adults (those 65 and older) often have a number of comorbidities requiring pharmacologic intervention, making medication management a complicated but essential part of caring for the elderly. A recent analysis of trends in prescription drug use by community-dwelling adults found that 39% of older adults used five or more prescribed medications.¹ Furthermore, about 72% of older adults also take a nonprescription medication (OTC or supplement); while OTC medication use has declined in this population in recent years, dietary supplement use has increased.²

These patients are also more susceptible to adverse drug events (ADEs)—including adverse drug reactions (ADRs)—resulting from the physiologic changes of aging. By one estimate, ADRs are about seven times more common in those older than 70 than in younger persons.³ One out of every 30 urgent hospital admissions in patients ages 65 and older is related to an ADR.⁴

Providers must therefore be cognizant of drug indications, dosing, and drug interactions when prescribing medications to elderly patients. Fortunately, tools and methods to avoid polypharmacy and the adverse effects of commonly prescribed medications—such as anticholinergics and psychotropic drugs—are available.

POLYPHARMACY AND PRESCRIPTION CASCADING

While there is no specific number of medications required to define polypharmacy, the term is generally used when a nonhospitalized individual is taking five or more medications.⁵ The more medications a patient is taking, the more at risk he or she will be for ADRs, drug interactions, and prescription cascading.

Prescription cascading begins when an ADR is thought to be a new symptom and a new drug is prescribed to control it. Ultimately, a cascade of prescriptions occurs to control avoidable ADRs, resulting in polypharmacy. As many as 57% of women older than 65 in the United States are currently prescribed five or more medications, with 12% prescribed nine or more drugs.⁶ Not only do these medications cause independent ADRs, but there is also increased risk for drug interactions—and potentially, additional avoidable ADRs.

The elderly population is at greater risk for ADEs because these patients are more likely to have multiple comorbidities and chronic diseases, requiring multiple therapies.⁷ Polypharmacy is also more dangerous in the elderly because the physiologic changes that occur during natural aging can affect both the pharmacokinetics and pharmacodynamics of medications. The absorption, distribution, metabolism, and excretion of drugs within the human body changes as a person ages, while certain drug classes can alter the way the body functions. For example, muscle mass naturally declines and the proportion of body fat to muscle increases; this change affects the distribution of drugs such as benzodiazepines or lithium.⁷ If the medication dosage is not corrected, the toxicity of the drug will be increased.⁷

Medication excretion is largely controlled by the kidneys. Renal perfusion and function decline with age, leading to a decrease in glomerular filtration rate—which requires closer monitoring of medication selection and dosing. The risk is heightened when the elderly patient becomes acutely ill. An acute decrease in kidney function results in decreased excretion of medications, leading to an increase in ADRs.⁷

Ultimately, the safety of many medications in the elderly patient is unknown.⁸ But there is a growing body of knowledge on the adverse effects of some classes of medication in this population.

COMMONLY PRESCRIBED MEDICATIONS—AND RISKS

ADEs result from medication errors, ADRs, allergic reactions, and overdoses. The incidence of ADEs—specifically ADRs and medication errors—is elevated in elderly patients who are prescribed certain classes of medications or multiple drugs simultaneously.⁸ Anticholinergic drugs and psychotropic drugs (specifically antipsychotics and benzodiazepines) are among the medications most commonly prescribed to elderly patients—and among the most likely to contribute to ADEs.⁹ Diabetes is a chronic condition whose treatment may also put elderly patients at risk for ADEs.¹⁰

Anticholinergic medications

Anticholinergic drugs—commonly prescribed for Parkinson disease, depression, urinary incontinence, pulmonary disorders, intestinal motility, and muscle spasms—competitively inhibit the binding of acetylcholine to muscarinic acetylcholine receptors.⁹ Because this mechanism tends to be nonselective, the adverse effects may be widespread. Central adverse effects include cognitive impairment, confusion, and delirium; peripheral adverse effects include constipation, urinary retention, dry mouth, blurred vision, peristaltic reduction, and tachycardia.⁹

Anticholinergic drugs are commonly prescribed to elderly patients for cardiovascular (CV) and neurologic disorders. (Medications for the former include ß-blockers, calcium channel blockers, diuretics, and ACE inhibitors; for the latter, amitriptyline, quetiapine, nortriptyline, prochlorperazine, haloperidol, and paroxetine.) An assessment of anticholinergic activity classified most neurologic medications as high activity and most CV medications as low—however, the latter are usually given in conjunction with other anticholinergic medications, increasing their ability to cause ADRs.¹¹

In many cases, patients are prescribed anticholinergic medications to control symptoms of a disease, not to cure it—which means patients may be taking these medications for years. This cumulative exposure is called the anticholinergic burden. Many studies show that the anticholinergic burden is a predictor of cognitive and physical decline; a 2016 study of adults older than 65 who were exposed to 5 mg/d of oxybutynin for more than three years had a 23% increased risk for dementia, compared to low-risk or no exposure groups.⁹

In a retrospective, population-level study conducted in New Zealand, researchers assessed the anticholinergic effects of delirium, urinary retention, and constipation in 2,248 patients (65 and older) who were admitted to the hospital with at least one prescribed medication. Anticholinergic burden was found to be a significant independent predictor; patients taking five anticholinergic medications were more than three times as likely to develop an anticholinergic effect than those taking just one such medication (adjusted odds ratio, 3.21).¹¹

Psychotropic drugs

Another often-prescribed medication group is psychotropic drugs, specifically antipsychotics and benzodiazepines, for agitation and behavioral disturbances in dementia. A year-long study of 851 patients in two long-term care nursing homes in Boston found that risk for ADRs—specifically, falls—was increased in those who had a change (initiation or dose increase) in psychotropic medication (ie, benzodiazepine, antipsychotic, or antidepressant).¹²

Second-generation antipsychotics, which are more commonly prescribed than first-generation agents, work on a postsynaptic blockade of brain dopamine D₂ receptors and have an increased affinity for serotonin 5-HT_2A receptors (see Table 1 for pharmacology of these medications).^13,14 Adverse effects of these drugs include hypotension, sedation, and anticholinergic effects. Second-generation antipsychotics also carry a “black box warning” for increased risk for death in elderly patients with dementia-related psychosis.¹⁵

Benzodiazepines bind to receptors in the gamma-aminobutyric acid receptor complex, which enhances the binding of this inhibitory neurotransmitter (see Table 2 for pharmacology). Of this class of drugs, lorazepam has the highest potency, whereas midazolam and diazepam have lower potencies. Use of benzodiazepines increases risk for delirium and respiratory depression.¹⁶

Diabetes treatment

People with diabetes have an increased risk for ADEs; this risk is elevated in older adults due to comorbidities such as peripheral neuropathy, retinopathy, coronary artery disease, and peripheral vascular disease.¹⁰ Hypoglycemic agents, such as insulin and insulin secretagogues, confer a higher risk for falls due to their hypoglycemic effect.¹⁰ Furthermore, metformin is known to increase risk for cognitive impairment in patients with diabetes.¹⁰

PREVENTING ADEs AND UNNECESSARY POLYPHARMACY

Predicting and preventing ADEs should be a health care provider’s priority when treating an elderly patient taking multiple medications—but it is often overlooked. Electronic medical records (EMRs) are helpful in preventing ADEs, specifically prescription errors, by flagging the patient’s chart when potentially problematic medications are ordered; however, this captures only a portion of ADEs occurring in this popu­lation.⁷

Other options to evaluate a patient for polypharmacy and possible ADRs include the Beers Criteria and the STOPP/START Criteria.^17,18 Additionally, performing thorough and frequent medication reviews helps ensure that patients are prescribed essential medications to treat their comorbidities with the most opportunistic risk-benefit ratio. Patients’ medication lists across settings (eg, hospital, primary care, urgent care) can be accessed more easily, efficiently, and accurately with the integration of EMRs.

Beers Criteria

First published by Dr. Mark Beers in 1991 and endorsed by the American Geriatrics Society, the Beers Criteria identifies possible harmful effects of certain commonly prescribed medications to help guide and modify pharmacologic treatments, particularly in adults older than 65. The Beers Criteria classifies medications into three categories:

1. Drugs that should be avoided or dose-adjusted
2. Drugs that are potentially inappropriate in patients with certain conditions or syndromes
3. Drugs that should be prescribed with caution in older adults.¹⁷

In the most recent update (2015), possible adverse effects of medications based on a patient’s hepatic or renal function, the effectiveness of the medication, and possible drug interactions were added. For example, nitrofurantoin and antiarrhythmics (eg, amiodarone and digoxin) should be avoided at a lower threshold of hepatic and renal impairment than previously recommended. The criteria suggest avoiding use of zolpidem, a nonbenzodiazepine receptor agonist, because of its elevated risk for adverse effects and minimal effectiveness in treating insomnia. More information about the 2015 criteria is available from the American Geriatrics Society (http://online library.wiley.com/doi/10.1111/jgs. 13702/full).¹⁹

The latest update also takes into account recently published evidence of increased ADEs resulting from drugs such as antipsychotics and proton pump inhibitors (PPIs).²⁰ Antipsychotics are associated with an increased risk for morbidity and mortality, and PPIs are now recommended only for treatment duration of up to two months because of the possible increased risk for Clostridium difficile infection, as well as falls and fractures in patients older than 65.²⁰ (PPIs indirectly reduce calcium absorption, which may lead to an increased fracture risk, particularly in postmenopausal women.²⁰)

As with any guideline, the Beers Criteria was designed to supplement, not replace, clinical expertise and judgment. The risks and benefits of a medication should be weighed for the individual patient.

STOPP/START Criteria

Less widely used is the STOPP/START Criteria, an evidence-based set of guidelines consisting of 65 STOPP (Screening Tool of Older Person’s potentially inappropriate Prescriptions) and 22 START (Screening Tool to Alert doctors to the Right Treatment) criteria. Although they may be used individually, STOPP and START are best used together to determine the most appropriate medications for an elderly patient.

The STOPP guidelines help determine when the risks of a medication may outweigh the benefits in a given patient. STOPP includes recommendations for the appropriate length of time to use a medication; for example, PPIs should not be used for more than eight weeks (similar to the Beers recommendation) and benzodiazepines and neuroleptics for more than four weeks.¹⁸

START helps clinicians recognize potential prescribing omissions and to identify when a medication regimen should be implemented based on a patient’s history.¹⁸ Examples of START criteria include suggestions of when to initiate calcium and vitamin D supplementation for prevention of osteoporosis and when to begin statins in patients with diabetes, coronary artery disease, and cardiovascular disease.¹⁸

STOPP/START is organized by physiologic system, which allows for greater usability, and it addresses medications by class rather than specific medications. (The Beers Criteria was criticized for these reasons, as well as its limited transferability outside the United States.) When assessed in systematic reviews, the STOPP/START criteria were found to be fundamentally more sensitive than the Beers Criteria. Overall, it was concluded that the use of the STOPP/START criteria resulted in an absolute risk reduction of 21.2% to 35.7% and greatly improved the appropriateness of prescribing medication to the elderly. Its use also resulted in fewer follow-up appointments with a primary care physician (PCP).¹⁸

iPhone and Android applications such as iGeriatrics and Medstopper provide clinicians with easy access to Beers Criteria and STOPP/START Criteria, respectively.

Medication reconciliation

Medication reconciliation—in which health care providers review a patient’s medication list at hospital admission and discharge, and even at routine office visits—is an increasingly common practice, especially with the implementation of EMRs. The patient’s prescribed and OTC medications, as well as dose, route, frequency, and indication, are updated, with the goal of maintaining the most accurate list. Health care providers can utilize both the Beers Criteria and the STOPP/START criteria in their reconciliation process to help reduce polypharmacy in the elderly. It is an essential step in maintaining communication between providers and ultimately decreasing the incidence of ADEs.¹⁷

IMPROVE … continuity of care

Polypharmacy can decrease patient likelihood to adhere to the regimen, whether due to confusion or intolerance.⁸ Patients should be included, along with caregivers and all medical providers, in a holistic assessment of the patient’s best interests in terms of long-term care and pharmacologic treatment, since those who have a sense of control in their treatment goals and expectations often achieve a better understanding of their medical status.¹⁰

However, educating patients about their medications is time-consuming, and time is often at a premium during a typical office visit. A pilot study of 28 male veterans (ages 85 and older)—the Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE) project—devised a model to combat this problem.²¹ As an adjunct to a visit with the PCP, a clinical pharmacist trained in patient education and medication management performed face-to-face clinical consults with patients and their caregivers. The results indicated that medical management by both the PCP and the pharmacist resulted in better medication management. The pharmacist was able to spend time with the patient and caregiver, resulting in individualized instructions, education, and strategies for safe and effective medication use. The PCP remained involved by cosigning the note with the pharmacist and was available for consultation, if needed.

In IMPROVE, 79% of patients had at least one medication discontinued and 75% had one or more dosing or timing adjustments made. Potentially inappropriate medications were reduced by 14%.²¹ When the researchers compared the six-month period before the trial with the six-month period afterward, they found an average pharmacy cost savings of $64 per veteran per month. There was also a decreasing trend in phone calls and visits to the PCP. Cost savings were comparable to or greater than those reported for similar interventions.²¹ There has not been sufficient long-term follow-up to assess this method’s effects on ADEs, morbidity, and mortality, however.

CONCLUSION

Managing medications in the elderly population is difficult, and polypharmacy is common due to the prevalence of patients with comorbidities. It is important for providers to be aware of possible drug interactions, prescribing cascades, and ADEs. Medications such as anticholinergics and antipsychotics pose an increased risk for ADEs, but the regular implementation of criteria such as Beers or STOPP/START in clinical practice will minimize overprescribing and improve health outcomes. These criteria should be used to supplement the clinical judgment and expertise of providers as a mainstay of patient care in the elderly.

CE/CME No: CR-1802

PROGRAM OVERVIEW
Earn credit by reading this article and successfully completing the posttest and evaluation. Successful completion is defined as a cumulative score of at least 70% correct.

EDUCATIONAL OBJECTIVES
• Identify patients who are at the greatest risk for the effects of polypharmacy.
• Recognize which medications are most likely to cause adverse drug events (ADEs) in the elderly population.
• Understand the effects of aging on the pharmacokinetics and pharmacodynamics of medications.
• Learn strategies to reduce the risk for polypharmacy and ADEs, including use of the Beers Criteria and the STOPP/START Criteria.

FACULTY
Kelsey Barclay practices in orthopedic surgery at Stanford Medical Center in Palo Alto, California. Amy Frassetto practices in Ob-Gyn at NewYork-Presbyterian in New York City. Julie Robb practices in emergency medicine at South Nassau Communities Hospital in Oceanside, New York. Ellen D. Mandel is a Clinical Professor in the Department of PA Studies at Pace University-Lenox Hill Hospital in New York City.

ACCREDITATION STATEMENT

This program has been reviewed and is approved for a maximum of 1.0 hour of American Academy of Physician Assistants (AAPA) Category 1 CME credit by the Physician Assistant Review Panel. [NPs: Both ANCC and the AANP Certification Program recognize AAPA as an approved provider of Category 1 credit.] Approval is valid through January 31, 2019.

Article begins on next page >>

Managing medications in the elderly can be complicated by the physiologic effects of aging and the prevalence of comorbidities. Consistent use of tools such as the Beers criteria and the STOPP/START criteria, as well as medication reconciliation, can reduce polypharmacy and its adverse drug effects, improving health outcomes in this population.

Older adults (those 65 and older) often have a number of comorbidities requiring pharmacologic intervention, making medication management a complicated but essential part of caring for the elderly. A recent analysis of trends in prescription drug use by community-dwelling adults found that 39% of older adults used five or more prescribed medications.¹ Furthermore, about 72% of older adults also take a nonprescription medication (OTC or supplement); while OTC medication use has declined in this population in recent years, dietary supplement use has increased.²

These patients are also more susceptible to adverse drug events (ADEs)—including adverse drug reactions (ADRs)—resulting from the physiologic changes of aging. By one estimate, ADRs are about seven times more common in those older than 70 than in younger persons.³ One out of every 30 urgent hospital admissions in patients ages 65 and older is related to an ADR.⁴

Providers must therefore be cognizant of drug indications, dosing, and drug interactions when prescribing medications to elderly patients. Fortunately, tools and methods to avoid polypharmacy and the adverse effects of commonly prescribed medications—such as anticholinergics and psychotropic drugs—are available.

POLYPHARMACY AND PRESCRIPTION CASCADING

While there is no specific number of medications required to define polypharmacy, the term is generally used when a nonhospitalized individual is taking five or more medications.⁵ The more medications a patient is taking, the more at risk he or she will be for ADRs, drug interactions, and prescription cascading.

Prescription cascading begins when an ADR is thought to be a new symptom and a new drug is prescribed to control it. Ultimately, a cascade of prescriptions occurs to control avoidable ADRs, resulting in polypharmacy. As many as 57% of women older than 65 in the United States are currently prescribed five or more medications, with 12% prescribed nine or more drugs.⁶ Not only do these medications cause independent ADRs, but there is also increased risk for drug interactions—and potentially, additional avoidable ADRs.

The elderly population is at greater risk for ADEs because these patients are more likely to have multiple comorbidities and chronic diseases, requiring multiple therapies.⁷ Polypharmacy is also more dangerous in the elderly because the physiologic changes that occur during natural aging can affect both the pharmacokinetics and pharmacodynamics of medications. The absorption, distribution, metabolism, and excretion of drugs within the human body changes as a person ages, while certain drug classes can alter the way the body functions. For example, muscle mass naturally declines and the proportion of body fat to muscle increases; this change affects the distribution of drugs such as benzodiazepines or lithium.⁷ If the medication dosage is not corrected, the toxicity of the drug will be increased.⁷

Medication excretion is largely controlled by the kidneys. Renal perfusion and function decline with age, leading to a decrease in glomerular filtration rate—which requires closer monitoring of medication selection and dosing. The risk is heightened when the elderly patient becomes acutely ill. An acute decrease in kidney function results in decreased excretion of medications, leading to an increase in ADRs.⁷

Ultimately, the safety of many medications in the elderly patient is unknown.⁸ But there is a growing body of knowledge on the adverse effects of some classes of medication in this population.

COMMONLY PRESCRIBED MEDICATIONS—AND RISKS

ADEs result from medication errors, ADRs, allergic reactions, and overdoses. The incidence of ADEs—specifically ADRs and medication errors—is elevated in elderly patients who are prescribed certain classes of medications or multiple drugs simultaneously.⁸ Anticholinergic drugs and psychotropic drugs (specifically antipsychotics and benzodiazepines) are among the medications most commonly prescribed to elderly patients—and among the most likely to contribute to ADEs.⁹ Diabetes is a chronic condition whose treatment may also put elderly patients at risk for ADEs.¹⁰

Anticholinergic medications

Anticholinergic drugs—commonly prescribed for Parkinson disease, depression, urinary incontinence, pulmonary disorders, intestinal motility, and muscle spasms—competitively inhibit the binding of acetylcholine to muscarinic acetylcholine receptors.⁹ Because this mechanism tends to be nonselective, the adverse effects may be widespread. Central adverse effects include cognitive impairment, confusion, and delirium; peripheral adverse effects include constipation, urinary retention, dry mouth, blurred vision, peristaltic reduction, and tachycardia.⁹

Anticholinergic drugs are commonly prescribed to elderly patients for cardiovascular (CV) and neurologic disorders. (Medications for the former include ß-blockers, calcium channel blockers, diuretics, and ACE inhibitors; for the latter, amitriptyline, quetiapine, nortriptyline, prochlorperazine, haloperidol, and paroxetine.) An assessment of anticholinergic activity classified most neurologic medications as high activity and most CV medications as low—however, the latter are usually given in conjunction with other anticholinergic medications, increasing their ability to cause ADRs.¹¹

In many cases, patients are prescribed anticholinergic medications to control symptoms of a disease, not to cure it—which means patients may be taking these medications for years. This cumulative exposure is called the anticholinergic burden. Many studies show that the anticholinergic burden is a predictor of cognitive and physical decline; a 2016 study of adults older than 65 who were exposed to 5 mg/d of oxybutynin for more than three years had a 23% increased risk for dementia, compared to low-risk or no exposure groups.⁹

In a retrospective, population-level study conducted in New Zealand, researchers assessed the anticholinergic effects of delirium, urinary retention, and constipation in 2,248 patients (65 and older) who were admitted to the hospital with at least one prescribed medication. Anticholinergic burden was found to be a significant independent predictor; patients taking five anticholinergic medications were more than three times as likely to develop an anticholinergic effect than those taking just one such medication (adjusted odds ratio, 3.21).¹¹

Psychotropic drugs

Another often-prescribed medication group is psychotropic drugs, specifically antipsychotics and benzodiazepines, for agitation and behavioral disturbances in dementia. A year-long study of 851 patients in two long-term care nursing homes in Boston found that risk for ADRs—specifically, falls—was increased in those who had a change (initiation or dose increase) in psychotropic medication (ie, benzodiazepine, antipsychotic, or antidepressant).¹²

Second-generation antipsychotics, which are more commonly prescribed than first-generation agents, work on a postsynaptic blockade of brain dopamine D₂ receptors and have an increased affinity for serotonin 5-HT_2A receptors (see Table 1 for pharmacology of these medications).^13,14 Adverse effects of these drugs include hypotension, sedation, and anticholinergic effects. Second-generation antipsychotics also carry a “black box warning” for increased risk for death in elderly patients with dementia-related psychosis.¹⁵

Benzodiazepines bind to receptors in the gamma-aminobutyric acid receptor complex, which enhances the binding of this inhibitory neurotransmitter (see Table 2 for pharmacology). Of this class of drugs, lorazepam has the highest potency, whereas midazolam and diazepam have lower potencies. Use of benzodiazepines increases risk for delirium and respiratory depression.¹⁶

Diabetes treatment

People with diabetes have an increased risk for ADEs; this risk is elevated in older adults due to comorbidities such as peripheral neuropathy, retinopathy, coronary artery disease, and peripheral vascular disease.¹⁰ Hypoglycemic agents, such as insulin and insulin secretagogues, confer a higher risk for falls due to their hypoglycemic effect.¹⁰ Furthermore, metformin is known to increase risk for cognitive impairment in patients with diabetes.¹⁰

PREVENTING ADEs AND UNNECESSARY POLYPHARMACY

Predicting and preventing ADEs should be a health care provider’s priority when treating an elderly patient taking multiple medications—but it is often overlooked. Electronic medical records (EMRs) are helpful in preventing ADEs, specifically prescription errors, by flagging the patient’s chart when potentially problematic medications are ordered; however, this captures only a portion of ADEs occurring in this popu­lation.⁷

Other options to evaluate a patient for polypharmacy and possible ADRs include the Beers Criteria and the STOPP/START Criteria.^17,18 Additionally, performing thorough and frequent medication reviews helps ensure that patients are prescribed essential medications to treat their comorbidities with the most opportunistic risk-benefit ratio. Patients’ medication lists across settings (eg, hospital, primary care, urgent care) can be accessed more easily, efficiently, and accurately with the integration of EMRs.

Beers Criteria

First published by Dr. Mark Beers in 1991 and endorsed by the American Geriatrics Society, the Beers Criteria identifies possible harmful effects of certain commonly prescribed medications to help guide and modify pharmacologic treatments, particularly in adults older than 65. The Beers Criteria classifies medications into three categories:

1. Drugs that should be avoided or dose-adjusted
2. Drugs that are potentially inappropriate in patients with certain conditions or syndromes
3. Drugs that should be prescribed with caution in older adults.¹⁷

In the most recent update (2015), possible adverse effects of medications based on a patient’s hepatic or renal function, the effectiveness of the medication, and possible drug interactions were added. For example, nitrofurantoin and antiarrhythmics (eg, amiodarone and digoxin) should be avoided at a lower threshold of hepatic and renal impairment than previously recommended. The criteria suggest avoiding use of zolpidem, a nonbenzodiazepine receptor agonist, because of its elevated risk for adverse effects and minimal effectiveness in treating insomnia. More information about the 2015 criteria is available from the American Geriatrics Society (http://online library.wiley.com/doi/10.1111/jgs. 13702/full).¹⁹

The latest update also takes into account recently published evidence of increased ADEs resulting from drugs such as antipsychotics and proton pump inhibitors (PPIs).²⁰ Antipsychotics are associated with an increased risk for morbidity and mortality, and PPIs are now recommended only for treatment duration of up to two months because of the possible increased risk for Clostridium difficile infection, as well as falls and fractures in patients older than 65.²⁰ (PPIs indirectly reduce calcium absorption, which may lead to an increased fracture risk, particularly in postmenopausal women.²⁰)

As with any guideline, the Beers Criteria was designed to supplement, not replace, clinical expertise and judgment. The risks and benefits of a medication should be weighed for the individual patient.

STOPP/START Criteria

Less widely used is the STOPP/START Criteria, an evidence-based set of guidelines consisting of 65 STOPP (Screening Tool of Older Person’s potentially inappropriate Prescriptions) and 22 START (Screening Tool to Alert doctors to the Right Treatment) criteria. Although they may be used individually, STOPP and START are best used together to determine the most appropriate medications for an elderly patient.

The STOPP guidelines help determine when the risks of a medication may outweigh the benefits in a given patient. STOPP includes recommendations for the appropriate length of time to use a medication; for example, PPIs should not be used for more than eight weeks (similar to the Beers recommendation) and benzodiazepines and neuroleptics for more than four weeks.¹⁸

START helps clinicians recognize potential prescribing omissions and to identify when a medication regimen should be implemented based on a patient’s history.¹⁸ Examples of START criteria include suggestions of when to initiate calcium and vitamin D supplementation for prevention of osteoporosis and when to begin statins in patients with diabetes, coronary artery disease, and cardiovascular disease.¹⁸

STOPP/START is organized by physiologic system, which allows for greater usability, and it addresses medications by class rather than specific medications. (The Beers Criteria was criticized for these reasons, as well as its limited transferability outside the United States.) When assessed in systematic reviews, the STOPP/START criteria were found to be fundamentally more sensitive than the Beers Criteria. Overall, it was concluded that the use of the STOPP/START criteria resulted in an absolute risk reduction of 21.2% to 35.7% and greatly improved the appropriateness of prescribing medication to the elderly. Its use also resulted in fewer follow-up appointments with a primary care physician (PCP).¹⁸

iPhone and Android applications such as iGeriatrics and Medstopper provide clinicians with easy access to Beers Criteria and STOPP/START Criteria, respectively.

Medication reconciliation

Medication reconciliation—in which health care providers review a patient’s medication list at hospital admission and discharge, and even at routine office visits—is an increasingly common practice, especially with the implementation of EMRs. The patient’s prescribed and OTC medications, as well as dose, route, frequency, and indication, are updated, with the goal of maintaining the most accurate list. Health care providers can utilize both the Beers Criteria and the STOPP/START criteria in their reconciliation process to help reduce polypharmacy in the elderly. It is an essential step in maintaining communication between providers and ultimately decreasing the incidence of ADEs.¹⁷

IMPROVE … continuity of care

Polypharmacy can decrease patient likelihood to adhere to the regimen, whether due to confusion or intolerance.⁸ Patients should be included, along with caregivers and all medical providers, in a holistic assessment of the patient’s best interests in terms of long-term care and pharmacologic treatment, since those who have a sense of control in their treatment goals and expectations often achieve a better understanding of their medical status.¹⁰

However, educating patients about their medications is time-consuming, and time is often at a premium during a typical office visit. A pilot study of 28 male veterans (ages 85 and older)—the Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE) project—devised a model to combat this problem.²¹ As an adjunct to a visit with the PCP, a clinical pharmacist trained in patient education and medication management performed face-to-face clinical consults with patients and their caregivers. The results indicated that medical management by both the PCP and the pharmacist resulted in better medication management. The pharmacist was able to spend time with the patient and caregiver, resulting in individualized instructions, education, and strategies for safe and effective medication use. The PCP remained involved by cosigning the note with the pharmacist and was available for consultation, if needed.

In IMPROVE, 79% of patients had at least one medication discontinued and 75% had one or more dosing or timing adjustments made. Potentially inappropriate medications were reduced by 14%.²¹ When the researchers compared the six-month period before the trial with the six-month period afterward, they found an average pharmacy cost savings of $64 per veteran per month. There was also a decreasing trend in phone calls and visits to the PCP. Cost savings were comparable to or greater than those reported for similar interventions.²¹ There has not been sufficient long-term follow-up to assess this method’s effects on ADEs, morbidity, and mortality, however.

CONCLUSION

Managing medications in the elderly population is difficult, and polypharmacy is common due to the prevalence of patients with comorbidities. It is important for providers to be aware of possible drug interactions, prescribing cascades, and ADEs. Medications such as anticholinergics and antipsychotics pose an increased risk for ADEs, but the regular implementation of criteria such as Beers or STOPP/START in clinical practice will minimize overprescribing and improve health outcomes. These criteria should be used to supplement the clinical judgment and expertise of providers as a mainstay of patient care in the elderly.