The prescriber’s dilemma

By on April 1, 2011

Photo © Elena Derevtsova


Before prescribing any medicine, a doctor ought to be prepared to answer the following questions to the patient’s satisfaction:


What good will it do?

What harm might it do?

What harm might occur if the medicine is not prescribed?


The patient should thereby be convinced that taking the medicine will do more good than harm. 


If someone is suffering from a serious illness such as pneumonia, and it is proposed to prescribe penicillin, the answers to the above questions are usually obvious:  the medicine has a good chance of curing the infection, it may cause side-effects such as allergic reactions or stomach upsets but these are unlikely, and if it is not prescribed the patient may become very ill and possibly die.  Therefore, the expected advantages of the recommended treatment clearly outweigh the potential disadvantages.


But suppose the purpose of the proposed treatment is to prevent something that may never happen?  This is often the case these days.  For example in treating someone’s blood pressure or cholesterol level, which may be regarded as abnormally high, the idea is to prevent possible future harm.  Well, I should think under these circumstances a doctor needs to have a pretty strong reason to tell someone to take pills for the rest of their life.  Compliance with such advice often seems to be based on fear.  


Now, here is a general knowledge question: what is the world’s best selling drug – ever?  


The answer is Lipitor®, otherwise known as atorvastatin, which is used to lower cholesterol levels in the blood.  


In my experience it is not uncommon that at a routine check-up a cholesterol level is found which is deemed to be too high, and a medicine is prescribed to bring the level down.  This is in spite of the fact that the person may feel perfectly well.  Thus, healthy people are turned into patients and face a lifetime of pill taking with all the anxiety that this entails.  


Cholesterol lowering medicines should not be prescribed in isolation.  The patient’s overall situation needs to be taken into account and careful consideration given as to whether there are other ‘risk factors’, such as:  


Is there a history in parents or siblings of premature death from strokes or heart attacks?

Does the patient suffer from diabetes or high blood pressure?

Is the patient overweight, and does he or she drink excessively or smoke?


If an apparently raised cholesterol is the only ‘risk factor’ in an individual case, it may  be better to accept that the benefit, if any, of prescribing cholesterol lowering drugs is likely to be small, and the patient may be better off without them.  


Similarly, quite often on a routine examination hypertension (high blood pressure) is said to be found.  With the current definition by many authorities of hypertension as a blood pressure equal to or greater than 140/90mmHg, and especially with a new American definition of ‘pre-hypertension’ of 120-139/80-89mmHg, it has been predicted that by 2050 more than one half of adults over 60 in most regions of the world will have high blood pressure.  Can it really be true that such a huge number of older people will suffer from this disease and should be treated indefinitely with chemical drugs? 


This column is not intended as medical advice nor as an indication that anyone should stop taking prescribed medicines.


Dr Gabriel Symonds is the founder and director of the Tokyo British Clinic.  As part of the general medical services provided he advises people about how to manage their risks for cardiovascular disease.

Tel: 03-5468-6099.

About Dr. Gabriel Symonds

Dr. Gabriel Symonds was the director of the Tokyo British Clinic. The clinic closed down in May 2014 after serving the expatriate community for 20+ years. Dr. Symonds has retired and the Tokyo British Clinic is now closed. Dr Symonds will continue to live in Tokyo and may be contacted by e-mail over any questions concerning medical records or related matters: He will be available from another address for: smoking cessation psychotherapy/counselling circumcision information Tel: (03) 5458-6099