(1994; 115 pages) [French] [Spanish]
Chapter 7. STEP 2: Specify the therapeutic objective
Before choosing a treatment it is essential to specify your therapeutic objective. What do you want to achieve with the treatment? The following exercises enable you to practice this crucial step.
Exercise: patients 9-12
For each of these patients try to define the therapeutic objective. The cases are discussed below.
Girl, 4 years, slightly undernourished. Watery diarrhoea without vomiting for three days. She has not urinated for 24 hours. On examination she has no fever (36.8°C), but a rapid pulse and low elasticity of the skin.Patient 10:
Woman student, 19 years. Complains of a sore throat. Slight redness of the throat, no other findings. After some hesitation she tells you that she is three months overdue. On examination, she is three months pregnant.Patient 11:
Man, 44 years. Sleeplessness during six months, and comes for a refill of diazepam tablets, 5 mg, 1 tablet before sleeping. He wants 60 tablets.Patient 12:
Woman, 24 years. Consulted you 3 weeks ago, complaining of constant tiredness after delivery of her second child. Slightly pale sclerae, but normal Hb. You had already advised her to avoid strenuous exercise. She has now returned because the tiredness persists and a friend told her that a vitamin injection would do her good. This is what she wants.
Patient 9 (diarrhoea)
In this patient the diarrhoea is probably caused by a viral infection, as it is watery (not slimy or bloody) and there is no fever. She has signs of dehydration (listlessness, little urine and decreased skin turgor). This dehydration is the most worrying problem, as she is already slightly undernourished. The therapeutic objective in this case is therefore (1) to prevent further dehydration and (2) to rehydrate. Not: to cure the infection! Antibiotics would be ineffective anyway.
Patient 10 (pregnancy)
In Patient 10 you will have recognized Patient 5 who complained of a sore throat while her real problem was the suspected pregnancy. You will not solve her problem by prescribing something for her throat. The therapeutic objective depends on her attitude towards the pregnancy and she will probably need counselling more than anything else. The therapeutic objective is then to assist her to plan for the future. This will probably not involve drug treatment for her sore throat. Moreover, the fact that she is in early pregnancy should stop you from prescribing any drug at all, unless it is absolutely essential.
Patient 11 (sleeplessness)
In Patient 11 the problem is not which drugs to prescribe, but how to stop prescribing them. Diazepam is not indicated for long term treatment of sleeplessness as tolerance quickly develops. It should only be used for short periods, when strictly necessary. The therapeutic objective in this case is not to treat the patient's sleeplessness but to avoid a possible dependence on diazepam. This could be achieved through a gradual and carefully monitored lowering of the dose to diminish withdrawal symptoms, coupled with more appropriate behavioural techniques for insomnia, which should lead to eventual cessation of the drug.
Patient 12 (tiredness)
In Patient 12 there is no clear cause for the tiredness and it is therefore difficult to make a rational treatment plan. Having excluded anaemia you may guess that as a young mother with small children and perhaps a job outside the home, she is chronically overworked. The therapeutic objective is therefore to help her reduce physical and emotional overload. To achieve this it may be necessary to involve other members of the family. This is a good example of the need for non-drug therapy. Vitamins will not help, and would only act as a placebo. In fact, they would probably act as a placebo for yourself as well, creating the false impression that something is being done.
As you can see, in some cases the therapeutic objective will be straightforward: the treatment of an infection or a condition. Sometimes the picture will be less clear, as in the patient with unexplained tiredness. It may even be misleading, as in the student with the sore throat. You will have noticed that specifying the therapeutic objective is a good way to structure your thinking. It forces you to concentrate on the real problem, which limits the number of treatment possibilities and so makes your final choice much easier.
Specifying your therapeutic objective will prevent a lot of unnecessary drug use. It should stop you from treating two diseases at the same time if you cannot choose between them, like prescribing antimalarial drugs and antibiotics in case of fever, or antifungal and corticosteroid skin ointment when you can not choose between a fungus and eczema.
Specifying your therapeutic objective will also help you avoid unnecessary prophylactic prescribing, for example, the use of antibiotics to prevent wound infection, which is a very common cause of irrational drug use.
It is a good idea to discuss your therapeutic objective with the patient before you start the treatment. This may reveal that (s)he has quite different views about illness causation, diagnosis and treatment. It also makes the patient an informed partner in the therapy and improves adherence to treatment.