Modern scientific medicine has given humanity extraordinary tools. Antibiotics transformed once-lethal infections into treatable illnesses. Cardiovascular medications prevent strokes and myocardial infarctions. Insulin, anticoagulants, immunotherapies, psychiatric medications, and countless other treatments have extended and improved millions of lives.
The problem is not medication. The problem begins when our capacity to prescribe becomes greater than our discipline to ask whether every intervention remains necessary. That distinction is increasingly important in an aging population in which a patient may see several specialists, accumulate multiple diagnoses, and gradually acquire a medication list that no single clinician originally intended.
One drug becomes three. Three become seven. Another medication is prescribed to treat a symptom that may actually be an adverse effect of one already being taken. Eventually, we may no longer be treating only disease.
We may also be treating treatment.
Polypharmacy is more than a medication count
Polypharmacy is often defined numerically, commonly as the simultaneous use of five or more medications. But the number alone can be misleading.
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A patient with several serious illnesses may appropriately require numerous medications. Conversely, even two or three medications may constitute excessive treatment if their indications are weak, their interactions are harmful, or they continue long after their original purpose has disappeared.
The more clinically useful question is therefore not simply: How many medications is this patient taking? It is: Does every medication still have a clear indication, meaningful expected benefit, acceptable risk, and continuing biological purpose for this particular patient?
That question becomes especially important with aging. Renal clearance changes. Hepatic metabolism changes. Body composition changes. Receptor sensitivity changes. Homeostatic reserve diminishes. A medication regimen tolerated at age fifty-five may behave quite differently in the same person at eighty.
Yet medication lists often move in only one direction: They grow.
When treatment creates another diagnosis
I once encountered a man whose experience illustrated how easily this can happen. Over time, psychiatric medications had been added and adjusted. His cognitive function deteriorated profoundly enough that he was eventually considered to have Alzheimer’s disease.
But the story did not end there. When his medications were later carefully reassessed and a newer antipsychotic medication was discontinued under appropriate supervision, much of his memory and cognitive function returned.
The lesson is not that psychiatric medications are inherently harmful, nor that cognitive decline should casually be attributed to medication. The lesson is more fundamental. Before concluding that a new symptom represents a new disease, we should ask whether it could represent an effect of treatment.
Confusion may lead to another diagnosis. Dizziness may lead to imaging. A fall may lead to hospitalization. Gastric symptoms may lead to another prescription. Fatigue may trigger another workup.
Each step can be individually defensible. Collectively, however, they can create a cascade. This is one of the most important forms of iatrogenic harm because it can hide within otherwise conscientious medical care.
The prescribing cascade deserves greater attention
Medicine is appropriately trained to recognize disease. We are less consistently trained to recognize when treatment itself has become part of the disease burden.
Consider an older patient who develops pain and begins taking an NSAID. Gastric irritation follows, and acid suppression is added. Blood pressure rises or renal function deteriorates, requiring additional attention. Dizziness develops after further medication adjustments. The patient falls.
At every point, another intervention may appear reasonable. But viewed longitudinally, the more important question may be: Where did the cascade begin?
This is why medication review should not be a clerical exercise performed merely to reconcile a list in the electronic record. It should be a clinical investigation.
- What was this medication originally prescribed for?
- Is that condition still present?
- Is the treatment still producing meaningful benefit?
- Could the dose be lower?
- Could lifestyle, rehabilitation, nutrition, sleep, movement, or another lower-risk intervention reduce the need for it?
- Could one medication be treating the adverse effect of another?
- And most importantly: What happens if we thoughtfully remove something?
Deprescribing, of course, is itself a medical intervention. Many medications must not be stopped abruptly, and withdrawal or disease recurrence can be dangerous. Rational deprescribing therefore requires the same clinical judgment, supervision, and follow-up that rational prescribing requires. But stopping an unnecessary treatment should be considered an active form of good medicine, not therapeutic neglect.
The problem extends beyond the individual patient
There is another dimension of excessive pharmacologic intervention that deserves to be considered alongside polypharmacy: microbial drug resistance. Antibiotics are among the greatest achievements in medical history. Their success, paradoxically, helped create the conditions for their overuse.
Every exposure to an antimicrobial agent creates biological selection pressure. Susceptible organisms are eliminated while organisms possessing survival advantages are more likely to persist and propagate.
Microbes evolve. They do not negotiate with our prescribing habits. This is evolutionary biology occurring in real time.
When antimicrobial drugs are used unnecessarily, incorrectly, or too broadly, the consequences therefore extend beyond the patient receiving the prescription. We exert selective pressure on microbial populations and gradually diminish the effectiveness of therapeutic tools upon which future patients may depend.
Microbial drug resistance is therefore not simply an infectious-disease problem. It is a health care sustainability problem.
Two problems, one underlying principle
Polypharmacy and microbial drug resistance may initially appear to belong to different areas of medicine. One concerns medications accumulating within an individual patient. The other concerns microbial populations adapting across communities and generations.
But at a deeper biological level, they teach a remarkably similar lesson: Intervention has consequences. Human physiology adapts to what we do to it. Microbial populations adapt to what we expose them to. More treatment is not automatically better treatment.
The purpose of medicine should therefore not be to maximize intervention. It should be to achieve the greatest meaningful health benefit with the least unnecessary biological disruption. This principle becomes increasingly important as health care grows technologically sophisticated and pharmacologically powerful.
We need to restore therapeutic restraint
The extraordinary success of modern medicine should make us more thoughtful about using its tools, not less. Before adding another medication, clinicians should ask whether the patient’s biology can be supported in another way. Before treating another symptom, we should ask whether an existing treatment might be contributing to it. Before continuing a longstanding prescription, we should periodically reconsider whether its original indication remains valid. Before prescribing an antimicrobial, we should remember that the biological consequences may extend far beyond the individual encounter. And before assuming that intervention represents action while restraint represents inaction, we should recognize that sometimes the most sophisticated clinical decision is knowing when not to intervene.
Medicine needs prescribing excellence. It also needs deprescribing excellence. It needs antimicrobial treatment. It also needs antimicrobial stewardship. It needs powerful technologies and pharmaceuticals. But it also needs respect for physiology, adaptation, evolutionary biology, and the body’s capacity for recovery and self-regulation.
The future of better health care will not be determined solely by how many new treatments we develop. It may depend equally on learning to use the treatments we already possess with greater precision, restraint, and wisdom.
The goal should not be less medicine. The goal should be the right medicine, for the right reason, for the right duration, and no more than biology requires.
Narinder Singh Parhar is a physician with more than three decades of experience in internal medicine, hospital medicine, and intensive care medicine. Over the course of his career, he cared for a broad spectrum of medically complex and critically ill patients while developing a growing interest in health care systems improvement, prevention, biomechanics, and population health.
Dr. Parhar previously served as an associate clinical professor affiliated with the University of California, Davis, and on the executive board of Sutter Independent Physicians IPA in California. His professional experience spans outpatient medicine, inpatient care, intensive care medicine, and health care leadership, including past affiliations with Sutter Health and Sutter Roseville in California.
Throughout his career, he became increasingly concerned about several structural challenges within the current health care model, including affordability, accessibility, polypharmacy, health care fragmentation, microbial resistance, physician burnout, and the progressive underemphasis of prevention and functional preservation. These observations led him to develop the Health Enhancement Organization (HEO) Framework, a prevention-oriented and biomechanics-aware health care enhancement model designed to complement scientific medicine through earlier biological support, movement preservation, patient empowerment, and health care team well-being.
Dr. Parhar’s current work focuses on health care course correction, scalable prevention strategies, biomechanics education, healthier aging, and improving long-term population health resilience in practical, affordable, and biologically grounded ways. He is the founder of Jeeva Health Systems, and his research includes “Impact of a Novel Plant-Based Treatment Option in Improving Pulmonary Function Markers,” published in Alternative and Integrative Medicine.
