Of curing and healing

One of the first duties of the physician is to educate the masses not to take medicines.

Sir William Osler

In his entertaining, concise history of medicine, British medical historian Roy Porter reminds us that in the humoral medical tradition of Western medicine, drugs were not expected to play the decisive role in healing—“banking on heroic remedies was what quacks did.”¹

Traditional therapeutics had many strings to its bow, including regulation of diet and environment … and giving wise counsel. A good drug was expected less to zap a disease than, through purging, sweating, or cleansing the blood, to aid the healing power of Nature.¹

In the past century, things have changed substantially. In the early 1900s the study of materia medica transformed into laboratory-based pharmacology, drugs became mass produced in factories, and the modern-day pharmaceutical industry emerged with its enormous influence. Such is that current influence that writer Thomas Hager begins his book by describing an art exhibit displaying

all the 14,000 doses of prescription drugs an average Briton took in a lifetime. These pills, woven into lengths of fabric … covered a gallery table that stretched for forty-six feet.²

Hager could not believe what he was seeing. “Did people really take that many pills?” No, actually—they take more, way more. The average American takes about 50,000 pills in their lifetime, and the United States spends around $34 billion annually on over-the-counter drugs and $270 billion on prescription drugs, more than any other country.² It is harder to determine how many pills the average Canadian takes in a lifetime, but just over half have taken 1 medication in the previous month, and medication use rises, not surprisingly, with age.³

Two research articles in this month’s issue highlight different areas of prescription drug use in Canada.

Singer et al (page 520) explore primary non-adherence—not taking newly prescribed medication.⁴ They show that it ranges from 15% to 30%, is more likely for non-symptomatic conditions (eg, hypertension), and is less likely with symptomatic conditions (eg, depression). Income is a factor, but not a consistently predictive one. In the end this study raises as many questions as it answers. The poor predictiveness of the models they developed suggests caution is required when considering characteristic-based interventions or prediction tools to improve primary nonadherence.

Ally et al (page e204) address access to a comprehensive selection of essential and effective medications for all Canadians.⁵ This mixed-methods study builds on the CLEAN Meds randomized controlled trial that investigated the effects on patient adherence of free and convenient access to essential medicines.⁶ The current study shows consensus among participants and prescribers that the short list of medicines used in the trial is comprehensive and provides access to commonly prescribed medicines.⁵

But, as our predecessors understood, it can take more than medications to help us heal. A visit to one of my patients in hospital provided a stark reminder. The large east-facing window was gray and opaque, indistinguishable from the dark clouds in the winter sky—but not so dark as to hide the unknown stains on the floor or the desiccated alcohol swabs that littered the tiles like large, dirty, human-made snowflakes. The sounds of the busy nursing station drifted into the room, punctuated by the alarm of an intravenous pump going off nearby. I do not spend much time in hospitals these days, but the visit reminded me that while modern hospitals might be curing places, they are not healing places. In a wonderful commentary (page 487), Agnihotri provides a global and historical tour that reminds us of the untapped potential of our clinics and hospitals to be not just places of curing, but places of healing as well.⁷

Although optimizing accessibility and adherence is crucial, applying nonpharmaceutical approaches to healing is just as important to the art of family medicine.

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