I am sure that the ethical physician prescribes what she believes is best for
the individual patient at the time the patient is seen. Whether, from a
societal point of view where limited resources always exist in any health care
system, that choice
is guided by best evidence of effectiveness and cost-effectiveness, is a
completely different question. There is, to my mind, overwhelming evidence from
every jurisdiction examined, that physicians could always improve the
cost-effectiveness of diagnostics they order and drugs that they prescribe.
Generic substitution is the most obvious, easy-to-manage-and-maintain way that
developed countries have of
maintaining quality of therapies while controlling costs. An evidence-based
"essential drugs list" or formulary as it is called here is considered the
cornerstone of encouraging cost-effective prescribing.
There are always "outs" for exceptional circumstances but these need to be
carefully watched. The ease of management of quality generic substitution in
developing countries may be another matter.....
I must admit that, as an active clinician, I despair when I hear other local
physicians complaining about not being able to prescribe whatever they want.
They are usually exactly the ones that need some guidance about rational
prescribing. As a therapeutics expert, I am quite happy to have my prescribing
questioned and corrected, when appropriate. There is far too much medicine for
any of us to know the best evidence all the time. I only wish there was an
equally active group reviewing our diagnostic practices as well! Now that I am
personally losing income through government clawback because of our collective
physician "over"-utilization of health care services, I am all the more
interested in evidence-based guidance.
Center for Evaluation of Medicines, St Joseph's Hospital, and
Department of Medicine, McMaster University, Rm 4X1
Phone: (905) 522-1155 ext 5269 (SJH) or 521-2100 ext 3371 (MUMC)
FAX: 521-6136 (SJH) or 521-4971 (MUMC)