"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
I will be away on vacation for the next two weeks. My laptop has been banned from the trip by a vote of 5 to 1. I was the lone dissenter. Even the five year old, my staunchest ally, voted against me. Blogging will resume on July 1.
In the meantime, I’ve left some toys for you to play with:
MD vs PhD: The Wall Street Journal's Opinion Journal posts the story of the invention of the MRI. Seems two people claim to have invented it: one an MD and the other a PhD. So far, the PhD seems to be getting most of the credit. Neither man comes across as being particularly gracious, but they both seem to have played significant roles in developing the imaging technique. If they could get past their egos, they could just share the credit. posted by Sydney on
6/14/2002 09:10:00 PM
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Stupid Joke: A passenger on an airplane going from San Francisco to Memphis, told someone his rash might be smallpox, which raised a ruckus. Turned out he had hives. posted by Sydney on
6/14/2002 08:31:00 AM
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Bayer Promotes Drug with "Research": A study of one of Bayer's diabetes drugs has been published in The Lancet and has the media abuzz with the news. The drug in question is arcarbose, which basically prevents you from absorbing sugar-producing food from your gut. It hasn't caught on much as a treatment for diabetes because people complain too much about the side effects. It makes you gassy. Very gassy. One of my patients went on a trip with a group of friends and got kicked out of the car because of it. That's how bad it is. Well, now along comes a study, funded by Bayer of course, which suggests the drug can prevent diabetes:
The study, funded by Bayer, involved 1,400 people from nine countries who had pre-diabetes, known scientifically as impaired glucose tolerance. Half were given acarbose pills and half were given fake pills. After more than three years, 32 percent of the patients who were taking acarbose had progressed to diabetes, compared with 42 percent of those taking the dummy tablets. The results mean the people taking acarbose were 25 percent less likely than the others to develop diabetes.
That's the press release take on the study. Now, let's look at the abstract of the actual study:
We randomly allocated 714 patients with impaired glucose tolerance to acarbose and 715 to placebo. We excluded 61 (4%) patients because they did not have impaired glucose tolerance or had no postrandomisation data. 211 (31%) of 682 patients in the acarbose group and 130 (19%) of 686 on placebo discontinued treatment early. 221 (32%) patients randomised to acarbose and 285 (42%) randomised to placebo developed diabetes... Furthermore, acarbose significantly increased reversion of impaired glucose tolerance to normal glucose tolerance. At the end of the study, treatment with placebo for 3 months was associated with an increase in conversion of impaired glucose tolerance to diabetes. The most frequent side-effects to acarbose treatment were flatulence and diarrhoea.
First of all, many more people who were taking the drug dropped out of the study than were taking the placebo, 211 compared to 130. That means that the side effects of the drug must have been frequent and must have been unpleasant. It is also a much greater difference than the difference seen between the two groups in the development of diabetes. 221 patients who took the drug developed diabetes compared to 285 people who did not take the drug. That’s only a difference of 64 people between the two groups. You can also look at the data this way: out of the group who took acarbose, 1/3 stopped it because of side effects, 1/3 developed diabetes, and 1/3 did not develop diabetes. In contrast, in the group who didn't take the drug, only 2/5 of them went on to develop full-blown diabetes. Since the condition in question can be easily remedied with diet modifications and exercise, the whole thing seems senseless, as this diabetic specialist points out:
"It clearly does not make huge sense for people to swallow food and then take tablets to stop them digesting it," said Dr. Edwin Gale, a professor of diabetic medicine at the University of Bristol in England who was not connected with the study. "The best thing you can do is take exercise once or twice a week for 20 minutes. That will halve your risk."
FDA Slap-down: The FDA is trying to put a stop to senior citizens getting their drugs from Canada. The owner of the Canadian prescription mail-order business got a letter from the FDA telling him to cease and desist:
By order of the U.S. Food and Drug Administration, Michael Hunter, owner of Hunter's Pharmacy in Windsor, Ontario, has stopped shipping medications into the United States. Hunter received a letter from the FDA that he said leaves him no choice.
The letter, dated June 5, said shipments "appear to contain unapproved and misbranded prescription drugs" that could not be imported. It said the FDA had issued warnings to U.S. consumers and U.S. Customs regarding possible safety concerns.
A lot of people are skeptical about the claims of "misbranded" and "unapproved" drugs. I share their skepticism. The drugs are made by the same companies who sell them here in the US. The only difference is that the Canadian government has negotiated a better price for drugs in Canada. The FDA is also sending letters to the senior citizens:
Phillip Abookire, 79, of Avon Lake, recently got a warning letter from the FDA after receiving a refill from Hunter's.
"I got this letter from the FDA that said the drugs might be counterfeit and other bogus claims," he said. "It's as phony as the day is long. The prescriptions are exactly the same, the companies are the same, everything is the same."
Hunter said the only difference is the medicines he sells come from the Canadian branch of a drug company.
Remember, the FDA gets a lot of its operating revenues from the drug companies who pay them "user fees" to review their drugs. This sounds suspiciously like pay-back to me.
COMMENT: A reader emails with this take on the issue:
"From my dealings with the FDA it is much more likely that they are defending their own turf than doing anything to help the drug companies.They have never liked the concept of US citizens obtaining drugs that have not been properly through the FDA mill. Allowing Canadian purchase opens that door. Here are some more possible excuses for a claim of mis-branding:
1) Drugs for the Canadian market come with Canadian style use instructions. Wrong paperwork=misbranding.
2) Drugs for Canadian market might be made in a non-FDA inspected factory. This is unlikely to be the case, or to matter, but it is a concern with some other countries. The cleanliness standards in some overseas factories leaves a lot to be desired. (It always concerns me when the factory inspection discusses the filth level on the tarps that protect the instruments from the bird droppings.)
3) Drug labels might not contain tracking lot numbers that match US databases.This doesn't matter unless there is a recall.
These sound like FDA overkill to protect the US turf."
Good point. And probably closer to the truth than my initial knee-jerk reaction. posted by Sydney on
6/14/2002 07:55:00 AM
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Measels,Mumps,Rubella: A recent review of the data on the vaccine against measles, mumps, and rubella has determined that it is safe and in no way connected to such things as autism and bowel problems:
Several groups, including the World Health Organization, the U.S. Institute of Medicine, and Britain's Medical Research Council have reviewed evidence investigating a possible link between the vaccine and autism, but the latest project, published Tuesday in the Internet version of the journal Clinical Evidence, is the most comprehensive.
"We looked through over 2,000 studies on millions of children, covering 50 years of research," said lead investigator Dr. Anna Donald, whose company, Bazian Ltd., analyzes the quality of medical research. The company was contracted by the publishing arm of the British Medical Association to conduct the review.
"The science is very rigorous and this really does give a green light to MMR," she said. "The science on this issue is over; the scientific debate is dead."
The vaccine has never been all that controversial here, but in Britain they are very alarmist about it. There was a minor politcal brouhaha several months ago because Tony Blair wouldn't say whether or not his child had gotten the vaccine. We routinely give the vaccine here, yet we don't have higher rates of the supposed complications (autism, etc.) than they have in Britain. What we do have is a much lower rate of measles, mumps, and rubella.
posted by Sydney on
6/14/2002 07:43:00 AM
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Budget Madness: Do we really have $38 million dollars to spend on this every year for three years? posted by Sydney on
6/13/2002 01:30:00 PM
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"Pharmatactics": I wish I had thought of that term, but it's the coinage of another physician who sent me this email about pharmaceutical sales tactics:
I am an oncologist and a big target for the industry. After all it is common for one of my patients to receive $2-3000 treatments every three weeks. We get offers of "educational" meetings commonly. The company brings in some (often genuine) prominent speaker pays them a nice honorarium, and they give a talk at one of the nicer restaurants in town. Would this seem ok to my patients?
The industry also invites us to become members of their "speakers bureau." This usually entails a weekend somewhere nice and an honorarium. They pay for the flight, room, and meals, and they give you a check! One of the local docs presented some slides that he got at one of these meetings at one of our tumor boards. I respect this person, but I know that he got the slides at one of these events. The honorarium was $500. Are these things ok? What would our patients think?
Many prominent academicians try to minimize the difference between working in science and us private practice moneygrubbers by traveling around for the drug companies. Does this have impacts on the quality of their studies? What would our patients think?
Last Bastion of Integrity Falls:The New England Journal of Medicine is the leading medical journal world wide. The one doctors all over the world turn to for sound, unbiased articles. The last word in medicine. For a long time they have toed a strict line on conflict of interest. They would not publish editorials or papers in which the author had a financial tie to the drug or procedure being covered. They slipped up sometimes, most notably when Redux was given a favorable editorial review by a researcher who had financial ties to the drug company, but most of the time they managed to stick by their rules. Evidently, it was a hard task, for they have given up:
The distinguished New England Journal of Medicine is relaxing its strict conflict-of-interest rules for authors of certain articles because it cannot find enough experts without financial ties to drug companies...
...Since 1990, the journal's rule was that nobody who wrote a review article or editorial could have any financial interest in a company that made a product discussed in the article, or in any competitor of such a product.
Now, instead of forbidding any financial interest, the journal will forbid any "significant" stake. Its definition of significant is that agreed on by the National Institutes of Health and the Association of American Medical Colleges: payments of up to $10,000 a year are insignificant.
However, stock, stock options or patent positions of any value are deemed significant, because their value can rise and there is no limit on their potential for profits.
In addition, authors of such articles cannot have had "major research support or a major proportion of their funding from relevant companies" within two years of the article's publication.
Do What I Say or Else:Moira Breen has some interesting thoughts on the interplay between medical care and personal and institutional biases:
I'll throw in an anecdote here, because I found it food for thought. A friend of mine had her medical insurance through one of the largest U.S. HMOs. She unexpectedly became pregnant at the age of 37, and the nurse-advisor recommended insurance-covered amniocentesis because of the higher risk of age-related genetic disorder, Down syndrome in particular. My friend, because she had no intention of having an abortion in case of Down syndrome, declined the procedure as a waste of time and resources. What followed, according to my friend, was a long bullying lecture on the social irresponsibility of taking the risk of having a child with Down syndrome. The secondary implication was that my friend was of course entirely too stupid or naive to understand the difficulties of caring for such a child.
Knowing my friend, this incident for me has high comic import. At this point in the story, I know what's coming next. No one who is any judge of human beings would have sized up this woman as the sort who could be profitably bullied. The advisor will be subjected to the verbal equivalent of being grabbed by the collar and smashed up against the wall. The advisor will end up stuttering and back-stepping. The subject will not be raised again.
But how often is this sort of thing played out with a less stalwart and less pyrotechnic leading lady? It is in the interest of the HMO, a private company, to promote abortions rather than the birth of children with genetic defects.
This sort of thing is played out all too often, and not just in the realm of abortions. I've seen women who were bullied into taking estrogen when the dogma of the day was that it was all benefit and no risk. I've seen elderly people bullied into cardiac catheterizations they didn't want. I've seen more people than I can count bullied into taking cholesterol lowering medications. Most of us bully smokers, drinkers, and those who are overweight. We're taught to do it in medical school and residency. "Still smoking?" the attending would say. "Read them the riot act." Unfortunately, we are too often likely to use the same riot act technique for anyone who balks at our recommendations. I know I've been guilty of it. I've also been on the receiving end of it as a patient.
This attitude is rarely beneficial. The smoker knows smoking is harmful. He'll quit when he's ready. The overweight person knows he's fat. It's only cruel to treat him with disdain and disapproval. He'll probably only eat more as a result. Ditto the drinker. Bullying people into treatments they don’t want only fosters a loss of autonomy and a contempt for traditional medicine. Both probably have something to do with the popularity of "alternative medicine." But, when we enter the realm of life and death, this can take on an especially sinister tone. It's the main reason we need to be on guard against the movement for physician assisted suicide, for even when a doctor isn't being an out and out bully, his personal biases can have a significant impact on patient decisions.
Moira Breen's friend was lucky. She could defend herself against the bullying of her nurse adviser. Imagine if she had been a frail, elderly woman with no family to support her. Suppose her only social outlet was coming to the doctor. Maybe he reminds her of her deceased husband. Maybe she just finds his company delightful. She needs a reason to come to the doctor, so she complains about her arthritis, or abdominal pain. All the time. The doctor is trained to treat the complaint. He gives her pain medication after pain medication, but she still complains. He sends her to specialists. She still complains. She senses his frustration with the persistence of her symptoms and mistakes it for frustration with her. It makes her feel anxious, and maybe a little sad, because she really likes him. She starts to feel that she's a burden. She suggests one day to the doctor that she would be "better off dead." If physician-assisted suicide were legal and widely accepted, the doctor would be all too likely to seize the option as a good solution. He would likely feel frustrated and anxious about failing to rid her of her pain. If she were silenced, his pain and frustration would be gone. Neither the patient nor the doctor would be overtly aware of their underlying motivations. Once they start down the road to assisted suicide, such a patient would find it difficult to turn back. She wouldn't have the fortitude to risk her doctor's disapproval.
This isn't such a far-fetched scenario. (I think it happened recently in Australia, but in that case it was publicity the patient craved, and it was the influence of family and euthanasia activists that led her down the road to suicide.) Many lonely elderly people come to the doctor to just talk. Sometimes the motivation for their visits is obvious, but a lot of times it isn't. A lot of times, they aren't able to fully acknowledge the motivation for their visits even to themselves. These are the people who are difficult to treat, and they are the ones who would end up being "assisted" to death. They are also the people who would be most susceptible to the suggestions and biases of their doctors. "Bullying" in this case would be too strong a word, but subtle physician influence would certainly be a factor.
Putting You Out of My Misery:Steven Den Beste calls this woman's actions the ultimate sacrifice. The sacrifice that this 63 year old woman made was to take the lives of her two terminally ill sons who were living in a nursing home. They were both in the advanced stages of Huntington's disease. Relatives described their condition as deplorable:
"They were like babies," said Janelle Scott, Carr's sister-in-law.
Their only living sibling, 38-year-old James Scott, is in the early stages of the disease. He said his brothers, riddled with painful bed sores, had been in and out of nursing homes, were miserable and could only mumble to each other.
The news reports don't say whether or not the brother's mumblings were understandable to those around them. No one records how they felt about their condition. We do know, however, how their mother and their executioner felt:
Arrested by the officer responding to the call, the mother said she shot her sons because she didn't want them to suffer anymore, police said.
The key words there are she didn't want. She didn't want to see them suffer anymore, not they didn't want to suffer anymore. It was her pain, not theirs that she was ending. Den Beste sees this as a noble thing, and a justification for assisted suicide. However, even his arguments are more about relieving someone else's pain, than relieving the patient's pain:
This happens a lot more than most people realize. Murder-suicides among old people are common. One old person is caring for another (usually a spouse or sibling) who is severely crippled (quite commonly with Alzheimer's) and eventually reaches the point where the person they knew and loved is gone, leaving an empty-but-breathing body behind. It hurts too much to see what had become of a once-vital person, and so the one who is still competent will murder the other, and then commit suicide afterwards to avoid inevitable prison, and because they can't bear to live without their life-partner. (emphasis mine)
There is no reason to believe that these are malicious murders, or that these people would repeat these crimes. On the contrary, there's every reason to believe that they are acts of love, reactions to specific circumstances. While you may not believe anyone could ever want to kill someone they loved as a loving act, that's an abstract judgment. I think you'd have to actually see, and spend time with, someone you loved who was going through that in order to understand that at a certain point the only thing you want is for them to actually die so that they stop suffering. (I've been through it.) Death is not the worst of all alternatives.
It really isn't. But some people think it is. Such people have been sheltered; they haven't seen the worst that life has to offer. Can you imagine what it must be like to be totally paralyzed, to the point where you can't control any voluntary muscles at all, and to live like that for weeks, months, years? Completely imprisoned inside your body, unable to communicate, living with unrelieved tedium, and slowly going mad? I'd rather be dead. I would do almost anything to avoid that fate.
Mr. Den Beste may rather be dead, but how does he know the other person would? The problem is that we can only imagine what it's like to be in that state, paralyzed, and unable to communicate. We can only project our own feelings and fears on the one who is supposedly suffering. It isn't their suffering we are so keenly aware of, it's our suffering. And he's right, death is not the worst of all alternatives. Hastening death is the worst of all alternatives.
A living will that directed family members to kill you if you were in such a state would seem to be an expression of your own wishes, but would it really? After all, what if you changed your mind while you were lying there helpless? What if a whole new aspect of being opened up to you but you couldn’t express it to your family? There you would be, your family projecting their own suffering onto you, and you helpless to stop them from killing you. True, we honor living wills now that direct us not to take extraordinary measures to prolong life, but that is very different than actively snuffing out a life. The measures we take to prolong a life are often in and of themselves quite painful. In the case of terminal patients, they are ultimately futile, so witholding those in such circumstances is justifiable. But to actively end a life, is to assume more than we have the right to assume.
And Another Thing: It must have been especially traumatic for the other nursing home residents when the two brothers were murdered:
Grief counselors will be on hand Sunday to work with patients, their families and employees, nursing home administrator Chuck Brown said.
"Right now we're just concerned with helping our residents get over this and working with our employees," Brown said.
Imagine yourself helpless and completely dependent on other people. Imagine if someone just like you were killed for being just as helpless as you are. And that killing occurred in what you thought was your safe haven. God, what that must have done to them. I wonder if they'll ever again be able to trust their caretakers to protect them? This is the other argument against physician assisted suicide. It places the doctor in a dual role of healer and killer, and erodes the trust that is the cornerstone of the doctor-patient relationship.
When Hippocrates wrote his oath, he included the injunction that physicians would "not give a fatal draught to anyone if asked, nor suggest such a thing." This was a revolutionary concept back then. Before Hippocrates and his followers, medical care was provided largely by shamans or magicians. They used spells and magic to work their cures. The problem was, they could use good magic to make you better, or bad magic to make you worse. They weren't necessarily committed to your best interests. They could be bribed to give you some bad medicine if someone wanted to be rid of you. That's why Hippocrates put that bit in his oath, to emphasize the committment of his followers to the good of the patient and to the patient's good only. It marked a turning point in medicine and sent us on the road that we've been traveling for over 2,000 years now. Physician assisted suicide would only turn us back to the time of the shaman when a patient had no idea whose interest was being served. It's a road I don't want to go down. posted by Sydney on
6/13/2002 06:23:00 AM
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US officials gave ministers a classified briefing, which one participant said included a stark account of the horrendous consequences of a possible smallpox attack on a US city.
In a simulation exercise '"Dark Winter" in which academics, senators, and administration officials participated last year, smallpox spread within 13 days from Oklahoma City to 25 states and 15 foreign countries.
About one-third of those polled favor making it easier for authorities to access private e-mail and telephone conversations. More than 70% are in favor of requiring U.S. citizens to carry identification cards with fingerprints, and 77% believe all Americans should have smallpox vaccinations
It'll be interesting to see how the CDC's own public opinion polling turns out, especially since no effort was made to publicize it. I'm betting they'll claim far fewer want the vaccine. posted by Sydney on
6/12/2002 07:46:00 AM
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Pharmaceutical Pique: The news lately has been filled with annoying stories about pharmaceutical sales tactics. First, there is this story about a clinic in Washington state that has started charging sales reps for their time. I share their distaste for the salesmen, but charging them sounds terribly close to asking for a bribe. It would be better to just ignore them and refuse to meet with them (my own policy). The drug companies are upset with the Washington clinic:
The Polyclinic's decision, rare among clinics, startled drug-company officials. They warned of a chilling effect on the flow of free drug samples and educational programs aimed at doctors. And the American Medical Association's ethics-committee chairman said such fees may violate ethical guidelines for doctors.
The Polyclinic's medical director, Dr. Richard Clarfeld, said the value of information provided by drug salespeople has been outweighed by the disruption they cause and their promotion of expensive drugs, which undermines the clinic's effort to promote lower-cost alternatives to its doctors.
Drug-industry officials disagreed:
"Physicians receive important information about new medicines and their characteristics, including potential side effects, from technically trained sales representatives," said Jeff Trewhitt, spokesman for PhRMA, a drug-manufacturers trade group.(actually, a lobbying group)
These drug companies are constatnly overstating the value of the information they provide to doctors. It is without exception biased and unreliable. Any doctor who actually relies on them to learn about a new drug is a fool.
Some companies say they won't be visiting the doctors anymore (which is probably what the doctors are hoping), but others are eager to beat down their door:
One saleswoman showed up at the Polyclinic yesterday with both her checkbook and credit card, unsure how to buy some face time with those who hold the prescription pad - but sure she needed to get inside.
The doctors are coming under criticism for charging for the drug rep visits, and rightfully so:
Another Northwest pharmaceutical executive, who requested anonymity, predicted that drug firms will be afraid not to pay entry fees. That's because if they abandon a clinic, their competitors may be better able to sway doctors' prescribing habits.
The executive said he believes the Polyclinic made the decision to boost its cash flow rather than to ban sales reps. But the Polyclinic's David said the clinic will likely bring in only about $3,000 a month from the fees...
...For the American Medical Association, the interactions between drug-company representatives and doctors have been a focus of attention for some time. Recently, the Council on Ethical and Judicial Affairs updated its policies to clarify the problems with payments by drug-company representatives.
Dr. Frank Riddick, chairman of the ethics committee, boils it down: Doctors shouldn't take money, directly or indirectly, to be "educated" by drug reps, nor should they accept gifts. Fees paid to doctors should be for professional services, he said, and drug-company visits don't qualify.
"Either way you slice it, it's in violation of the existing rules on the interaction," he said. "Our decision was: Physicians shouldn't be paid to educate themselves, and if it's not education, then it's a gift."
Riddick emphasized that the AMA's guidelines are voluntary, and meant to apply to doctors. When it comes to a clinic's decision to charge for time, "then it's not all that clear what we've said," Riddick said. "It's somewhat murky. However, by extension, if one doctor can't do it, then 80 doctors shouldn't do it."
A practicing endocrinologist in a 500-physician group in New Orleans, Riddick said he worries about the role of money in the relationship between doctors and drug companies.
"The clinic has a right to make certain business decisions. If they find they're overrun with pharmaceutical reps and patients can't get in, then they have a right to limit hours, or the number. ... I'm not sure I would choose a cash payment," he said.
"If money's changing hands, then the money may create a conflict of interest in making the right decision. That's the real reason we put those little rules out there."
The doctors say they chose to charge the drug reps rather than ban them because they still want to get free samples. The free samples are a powerful carrot for doctors, more so than the little gifts of food and paraphenalia. Doctors rely on them to help out their indigent patients who can't afford drugs. For a long time, this was my sole reason for continuing to see drug reps. However, the samples they provide aren't all that useful. They are invariably the newer, more expensive drugs; drugs that are not necessarily the best choice for what ails the patient. For example, strep throat is still best treated with penicillin, which you can get for less than ten dollars. But a doctor with a sample closet and a patient with no insurance is too often tempted to treat it with Zithromax or Cipro instead because that's what they have in the closet. This may seem to be no big deal, but it is. Overuse of antibiotics like Zithromax and Cipro can foster antibiotic resistance in other bacteria in the body, making future infections more difficult to treat. Since I've stopped seeing the salespeople, I no longer have a sample closet, and I really don't miss it. My patients weren't being served well by it in the long run. My advice to doctors everywhere: Ban the reps! Get your information from credible sources, like The Medical Letter.
Pharmaceutical Pique Part II: The other story of drug company sales tactics regards the annoying letters they send to doctors and patients:
"Patient education" letters from pharmacies that advise consumers to refill a prescription or change to another medication are drawing attacks from drug industry critics who say the letters may undermine patient care, inflate the cost of treatment and violate privacy. As the fine print sometimes acknowledges, many of the letters are funded by drug companies, which stand to gain if patients comply....
...The letters in question range from the comparatively benign - like those reminding patients to refill a prescription for a chronic condition like high blood pressure or heartburn - to more potentially jarring and pernicious notifications that a prescription has been changed by the pharmacy without any doctor-patient consultation. Somewhere in between are commercial pronouncements promoting a new-generation drug, a different brand or a less expensive generic...
....One letter from Walgreens informs patients that the pharmacy has been in touch with their physician, who has already approved a switch from one prescription to another -- in this case, from the brand name Synthroid to the generic levoxyl -- leaving the patient out of the loop. Unless the patient phones his doctor to discuss the matter, he won't know if his medical history was considered in approving the change.
"We sent this - it was not funded by a drug company - just to let patients know [cheaper] levoxyl could be substituted for Synthroid," said Walgreens spokesman Carol Hively. That it not only could be but was substituted in this case, she said, "doesn't seem shocking to us. Pharmacists communicate so much with doctors about patients and their medicines. There was no intent to leave out the patient." She declined to say whether most patients accepted the switch.
While such a switch might save money for many customers - both cash-paying and insured - the pharmacy may make out too, since profit margins can be higher on generic drugs.
David Pearle, a professor of medicine and pharmacology at Georgetown University Hospital, said that a pharmacist may not even call the physician in such cases. The contact about the switch would come via a pharmacy form letter; if the physician doesn't respond, a more strongly worded form letter might follow....
This is exactly what happens. The letters sent to physicians are couched in such a way that they fool them into thinking the change of medicine is mandated by the patient's insurance company formulary. You really do have to read the very very fine print to see that it isn't. I was once fooled by this, but a patient complained and I finally read the fine print. If it's obviously a pharmceutical gimmick, I shred it. If I'm not sure, I call the patient. This, of course, has increased my paperwork time, something that I resent deeply. The worst part of all of this, however, is how the drug companies and pharmacies try to paint the whole thing as "patient education" rather than the profit seeking it is:
Schumer's complaint refers to the pharmacy letters as "marketing campaigns disguised as patient education campaigns."
But NACDS's Wright rejected that idea. "Patient compliance programs are treatment programs that save lives, not marketing programs," she said. "Drug companies pay for the programs so that patients won't have to."
Oh, please. Pharmacies send the letters so patients will be more likely to return to them for refills and in an attempt to get them to buy drugs that are more profitable for the pharmacy. Pharmaceutical companies send them to get the patient to switch to their drug. There is no motivation to "educate the patient." In the past two weeks I have had a flurry of phone calls from patients who are requesting changes from Claritin to Clarinex, which are essentially the same drug, that have been spurred by just such a letter. Such tactics are deplorable, and I applaud Senator Schumer for taking action on the issue.
Judy Garland Pilots: I hope this story isn't true:
"Investigation into why a U.S. F-16 pilot mistakenly bombed - and killed - four Canadian soldiers in Afghanistan in April reportedly finds the American fighter squadron had complained the week before about extreme fatigue, and had been told by higher-ups to ask the flight surgeon for amphetamines to help them keep alert. U.S. Air Force rules allow the use of such drugs, though most often for long transoceanic cargo flights. No evidence so far that the pilot took the drug or that fatigue was the cause of the mistaken bombing."
I have a lot of commercial pilots in my practice who tell me they aren't allowed to fly with any drugs in their systems. They refuse decongestants, non-sedating antihistamines, even nonsteroidal anti-inflammatories for pain because they're afraid they'll be grounded. Can it possibly be true that our Air Force has a lower standard for its pilots than our commercial airlines? posted by Sydney on
6/12/2002 06:28:00 AM
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Overactive Activists: Abortion activists in New York have succeeded in requiring abortion training in New York obstetrics/gynecology residency programs. (link requires NY Times registration). This was one of the goals of the Hillary Clinton health plan, too, and now it looks like it has won out. The story says that residents can pass on the training based on moral and religious grounds, but I wonder how many will feel pressured by their attendings and their fellow residents to do the procedure despite their personal misgivings. Everyone has to pull their share of the load in residency programs. If someone opts out of a procedure then another resident has to do it instead, a circumstance that can foster an awful lot of resentment between co-workers who have to work long, hard hours together. And how many will feel that to refuse to do something an attending asks will label them as a "bad resident," and hamper their careers?
Laws that mandate medical practice never bode well for a society, and in this case it should give everyone pause. Ob/Gyn residents are taught to consider the fetus as their patient just as much as the mother. Now, they are being required to learn to terminate that patient. Can mandated euthanasia in geriatrics programs be far behind?
Malpractice Insurance Crisis Update:Overlawyered has the latest on rising malpractice premiums and their influence on physician supply. posted by Sydney on
6/12/2002 06:15:00 AM
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Smallpox Public Forum Update: New blogger Health Welfare Warfare reports that only about 100 people showed up at the St. Louis forum on Saturday. Jeesh. Do we just not care? Wake up people. Our future is at stake here. posted by Sydney on
6/11/2002 08:42:00 AM
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"In the long term, a dirty bomb would add at most one new case of cancer out of every 100 persons exposed, according to the Federation of American Scientists, a Washington research and advocacy group.
Unlike a nuclear bomb or a nuclear plant fire such as the one at Chernobyl, a dirty bomb would produce radioactive material that would be either too small or too big to stay in people's lungs, said Dallas, who spent a decade studying the health effects of the 1986 Chernobyl accident.
Someone can spend hours unprotected in the aftermath before reaching a dangerous dose, but "you wouldn't want to spend days there," Dallas said."
I believe them. The atomic bombs were much more destructive just because of their powerful explosive force. Their radiation was the lesser evil. The health effects of radioactive contamination from a dirty bomb would be more akin to the radiation exposure after a nuclear power reactor accident, like Chernobyl. As bad as that might have been, it's still better than being leveled by a traditional atomic blast. posted by Sydney on
6/11/2002 08:29:00 AM
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History Lessons: I'm only halfway through Pox Americana : The Great Smallpox Epidemic of 1775-82 by Elizabeth Fenn, but so far it's been a great read. (Life too often gets in the way of my reading, so I'm a little slow). The first third of the book covers the experience of the Continental Army with a smallpox epidemic that raged up and down the eastern seaboard. The Americans had a low level of immunity to the disease and were particularly susceptible, especially those from New England and the South. In those areas, there were fewer immigrants from Europe and more people who had lived in America all their lives. They were thus less likely to have been exposed to smallpox at some point. In addition, the colonies in both regions did not allow inoculation, largely out of fears of its side effects. (In those days, to obtain immunity they would scratch some pus from a smallpox pustule into their skin. It was risky because it gave you a slight case of smallpox. This is different from vaccination which uses the cowpox virus to achieve the same thing. Vaccination is much less risky than inoculation.) Troops from the colonies in the Middle Atlantic area fared much better. Their states allowed inoculation and they had more European immigrants among them who had been exposed in the past. Thus, they had greater levels of immunity. The British were the same. They allowed inoculation and they had more men who had been exposed to the disease in the past.
The beginning of the war corresponded to the beginning of the smallpox epidemic. Washington, fearing that inoculation would spread the disease further, did not allow its use among the troops. The British, however, did just the opposite. It was their policy to identify men among their ranks who had never had smallpox and inoculate them. The result was that the Americans were decimated by the disease and the British hardly noticed it. Fenn blames the disease for the American defeat on the Plains of Abraham. By the time Washington and his troops were gathered in Valley Forge, he realized the folly of his anti-inoculation position. He reversed his stance, and all nonimmune troops and new recruits were inoculated on arrival. Smallpox among the troops declined, and the course of the war turned.
Now let's see, a population with very little immunity, a policy against preventive steps; sounds familiar, no? Maybe the folks at the CDC should read Elizabeth Fenn, or at least ask her to attend their conference this month. And while they're at it, invite some historians with expertise in the conquest of Central America, when smallpox was the great ally of the conquering Spaniards. They could remind the good doctors just what smallpox was like among populations with no immunity. Let's hope our leaders have the wisdom to learn from history.
NOTE: I changed the link for the book to Barne's and Noble, since Amazon seems to only be offering the paperback version now, which hasn't been published yet. (Just in case any of you are anal enough to notice such a thing) posted by Sydney on
6/11/2002 06:13:00 AM
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And Surely Mercy and Goodness:Best of the Web Today had a post yesterday that gave the lie to the assertion that Israel denies medical care to Palestinians:
"Remember the foiled suicide attack last month in which the Israelis used a bomb-disposal robot to examine the would-be terrorist before he was captured? The New York Times has an interview with that terrorist, 18-year-old Zaydan Zaydan of Jenin, who is being treated in an Israeli hospital--a fact that in itself underscores the distinction between Israeli civilization and Arab barbarism. As Sgt. Kfir Levi of the Israeli Defense Forces tells the Times, "He's also a human being, despite all of this. That's the difference between us and them, at least in our thoughts. I don't believe if something like this happened on the other side, they'd be giving this kind of treatment. Just the opposite."
Zayman echoes the sentiment. "This Jewish policeman is better than many, many Arabs," he tells the Times."
Calling Bridget Jones: Remember Bridget Jones' Diary and her obsessive recording of the number of "alcohol units" she had ingested? Well, now the British want their drinks to be clearly labeled in alcohol units. Maybe this is just a British term. I'm not even sure what an "alcohol unit" is. Four ounces of whisky? Eight ounces of wine? Twelve ounces of beer?
UPDATE: Yep, it's something uniquely British. And all this time I thought Helen Fielding was just being cute and clever in using the term. posted by Sydney on
6/11/2002 06:05:00 AM
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Virtual Malpractice: USA today covers a trend to diagnose and treat via email. The biggest problem with this is that there are few cases where an accurate diagnosis can be made without actually laying eyes and hands on a patient. Even something as simple as a red eye, which a patient often thinks is "pink eye" can be easily misdiagnosed if treated without examining the patient. My personal policy is that I don't treat patients over the phone, it's too fraught with dangers. And let's face it, email is just a slow phone call. posted by Sydney on
6/11/2002 06:05:00 AM
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Pox in Pakistan:Glenn Reynolds has a link to this story about a possible "smallpox" outbreak in Pakistan. The story mentions that it has been going on for two years. I doubt it's smallpox. It would have recieved much more attention than it has if it were, especially as long as two years ago. It's probably monkeypox or some other of the many related pox viruses. posted by Sydney on
6/10/2002 01:18:00 PM
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"They have [weapons of mass destruction] and continue to develop them, and they have weaponized chemical weapons. We know that," Rumsfeld said. "They've had an active program to develop nuclear weapons. It's also clear that they are actively developing biological weapons."
Fruits of the Human Genome Project: Researchers find the gene responsible for malignant melanoma. They hope to be able to design drugs that work to switch the mutated gene off in melanoma cancer cells. They are cautious but optimistic about the implications:
"The most exciting thing about this discovery is that it could be a direct lead to new treatments for malignant melanoma," he said. "Because mutated BRAF is permanently stuck in the 'on' position, we have already started searching for drugs that will switch it back off. These drugs would be expected to stop the growth of these cancers.
"We have to be cautious, because cancers are devious and unpredicatable beasts, but my hope and expectation is that we will find something that inhibits the process and stops the cancer from growing."
There is currently no cure for malignant melanoma beyond early and complete excision. Too often, it has already spread by the time it's diagnosed. I wish them luck in their quest. posted by Sydney on
6/10/2002 08:32:00 AM
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Another Argument for Offering Smallpox Vaccine to Everyone:Iraq might have it:
"There are concerns that Russia's smallpox may have been leaked to terrorists, and whether something similar happened with monkeypox is uncertain. Another former U.N. weapons inspector, who requested anonymity, told UPI "There's no confirmation that (monkeypox) leaked out, but the potential exists."
Alibek said he had no idea whether monkeypox had ever been leaked out of the Soviet program. But he noted that from the 1970s until the 1990s, "it was not a problem to get any of the orthopox viruses (smallpox, camelpox and monkeypox)," and many countries had access to them if they wanted them. (emphasis mine)
Iraq is one of the rogue states that may have obtained access to monkeypox. "We've never ever gotten to the bottom of their involvement with camelpox, whether they were really trying to weaponize it or it was a facade for working with smallpox or monkeypox," said the former U.N. inspector, who was a member of the team that went into Iraq.
There is a lot of suspicion that Iraq had access to smallpox, but "there's no such indirect evidence for monkeypox,"the inspector said. Asked if monkeypox was less of a concern than smallpox, the inspector replied, "I wouldn't say it's of less concern ... The fact that we haven't come across evidence from the United Nations doesn't mean it's not there."
Whether it's smallpox (much more fatal and more contagious) or monkeypox (less fatal, less contagious), the Iraqis appear to have been up to something. posted by Sydney on
6/10/2002 06:45:00 AM
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Islamic IVF: Talk about your "reproach among women". In Iran infertility is a reproach by all society, and a justification for divorce. As a result, more women are turning to in vitro fertilization. This, too, has social and religious implications, however (forgive the Enlgish, evidently the translator isn't very handy with the language):
"Since Muslim men's sperm cannot be impregnated with a woman who is not legally his wife, they have to marry for a limited period of time under a special religious dispensation (Siqeh Mahramiat).
However, the father is not allowed to see his temporary wife, who actually functions as a host mother. The host mother cannot see her "guest baby" and it should be delivered immediately to its father.
These unwritten social laws create a secure situation for infertile mothers in which they can have a child without losing their husbands....
...Since mother's genetic features influence the baby, infertile couples always look for beautiful and smart host widow mothers. That can give rise to more problems. For, it is highly probable that a temporary marriage turns to a permanent one.
Apart from the social stigma associated with IVF births, there are legal hurdles that need to be overcome by the prospective parents.
Authorities have refused to issue birth certificate for babies born out of IVF method."
So much for Islam as a tolerant and loving religion.
Internet Activism: Last night I was busy writing letters to politicians about the smallpox vaccine issue. I found this site when I was looking for Tom Ridge's email address. If you've ever had trouble finding out who to contact about a political issue, try e.thePeople. They can give you the email address of just about anyone in government. Now, whether or not the email gets read, that's a whole 'nother can of beans. posted by Sydney on
6/10/2002 06:29:00 AM
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Sunday, June 09, 2002
Men's Health Awareness: It's National Men's Health Week, so expect a lot of stories in the news about prostates, testicles, and other unique male health problems, like this story from ABC News on men who avoid doctors. The story indulges in an awful lot of psychobabble:
"Experts say many men view sickness as a vulnerability, the polar opposite of masculinity. "A physical problem changes a male's sense of self," says Pollack. Acknowledging a need to be protected alters a man's perception that he is the protector.
Women, in contrast, are much more likely to see the doctor because this decision does not affect who they are. Being cared for is viewed as "feminine," so it feels more acceptable. Furthermore, a woman's yearly gynecologic visit may have trained her to understand the importance of preventive health care.
Pollack suggests that physicians be sensitive to a male's need to feel strong and in control. The way a man feels after a visit with the doctor will often determine whether he will follow the advice his doctor gives. In the end, a doctor's attitude and approach is "a matter of life or death," says Pollack.
But experts say one approach to the problem is to appeal to the male's sense of honor and duty by helping family members concerned about him. A wife may try telling her husband, for instance, that she and the kids "love and need him around," making him feel he's seeing a doctor in order to fulfill a familial responsibility."
This has to have been written by a woman. I refuse to believe that some inherent sense of masculinity keeps men from seeking medical care. I can believe they might be too busy, or too fearful of a bad diagnosis, or just not as apt to seek preventative services as women, but I don't think it's because of their "masculinity." Let's face it, women go to the doctor more often because the medical profession has successfully conveyed to them the importance of coming in for pap smears once a year. As far as coming in for treatment of known medical problems, or symptoms of disease, they are no better than men. It's misguided to suggest that we need to treat men differently, to make certain assumptions about their behavior. It's nothing less than stereotyping. We would do much better to treat them as the individuals they are, and just ask them what's on their mind. posted by Sydney on
6/09/2002 11:50:00 AM
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Tom Tomorrow: Tommy Thompson gave a commencement address this weekend about the wonders of medicine future:
"If admitted to the hospital, the patient of tomorrow will not be required to fill out elaborate forms. The use of telemedicine will allow one's whole medical record to be sent from one part of America to another within seconds.
We will carry wallet-sized cards that have our latest EKG, chest x-ray, lab tests, operative reports and other critical data encoded in them. And to protect privacy we will use iris scanners - scanners that evaluate the unique features of the iris in a person's eye - to activate these cards.
Patients will have diagnoses made with non-invasive scanners and most surgical repairs will be performed through laporascopic techniques using robotics.
Medications will be tailored to our own genetic code and delivered safely through bar-coded systems.
Billing will be processed at the time of care. Patients will know the costs and will be satisfied with the quality of care you provide, but will not be encumbered by mountains of confusing paperwork."
Mighty ambitious future, there, and very cold and impersonal, too. I'm not so sure I want robots operating on me any time soon. I'd prefer a human hand directed by a human mind who can make adjustments for my body's individuality. As for that wonderful, portable, paperless system, our government is currently doing everything it can to throw up roadblocks to making that happen. In their efforts to make it possible to send information electronically about patients, they have engineered difficult to follow privacy regulations with stiff penalties for failure to follow them. That sort of thing just makes everyone more leary of using the cybersphere. It's one of the reasons so few physicians use e-mail to communicate with their patients. They're afraid they won't be able to guarantee patient confidentiality. posted by Sydney on
6/09/2002 07:34:00 AM
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Irritable Bowel Drug Reprieve: Lotronex, a drug used for "spastic colon" that was withdrawn a while back for severe side effects, has been lobbied back onto the market. The FDA is putting strict provisions on its use, however:
"Lotronex may be prescribed only by certain doctors enrolled in a special program, and given only to the sickest patients, fewer than 5% of sufferers, who have failed other therapies, the Food and Drug Administration said Friday."
Make it hard enough to prescribe and no one will prescribe it. They did the same thing with a drug called Propulsid about three years ago, and no one uses it anymore. It's unlikely the drug company will be able to continue manufacturing it if its market is going to be so limited. The FDA has effectively banished the drug without seeming to be the bad guy. Score one for them. posted by Sydney on
6/09/2002 07:30:00 AM
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