The Enemy of Good is Better: Maximizing versus Satisficing in Clinical Medicine

Herbert Simon, Nobel Laureate

Recently I was called to admit a little old lady with a digoxin overdose who had symptomatic bradycardia.  She was in her 70s, had Alzheimer's disease (AD) and a medication list that would not print on one page.  I immediately thought, what benefit does digoxin have that justifies even the occasional admission for toxicity?  That's a good question in its own right, but consider a partial list of her other medications:

1. pantoprazole
2. lisinopril
3. gabapentin
4. raloxifene
5. estradiol
6. donepezil
7. labetolol
8. furosemide
9. glipizide
10. fenofibrate
11. memantine
12. sitagliptin
13. spironolactone
14. amlodipine
15. alprazolam
16. aspirin

One certainly must wonder what goals her providers are trying to achieve with these and indubitably some other medications which aren't listed.  Her husband was frustrated when I told him that many of the medications she is taking are not really doing her any good.  "They why do they have her taking them?" was a question I could not answer, because it doesn't make sense to me either.  Exasperated, he offered a great analogy:  "Suppose you hire me as a contractor to build you a home, and I tell you that you need to build a 14 foot high retaining wall in the back yard, two feet thick, reinforced with rebar and containing 20 yards of concrete.  Would that be responsible unless it were absolutely necessary?  What kind of contractor would recommend something you didn't really need?"

"A physician contractor," came the ready answer in both of our minds, and we simultaneously nodded in understanding.