Wednesday, January 24, 2007

Tying up Loose Ends + Bonus Feature

A friend of mine, in response to my last two posts, emailed me a recent article in the Wall Street Journal entitled "The Case Against Stents: New Studies Hint at Overuse" The title is rather self-explanatory, but it is about the burgeoning trend in medicine of cardiac catheterization and stent placement. Honestly, at this point, calling it a burgeoning trend is probably not the best description - since the procedure has been around for at least 10 years - however, every year more and more people are having it done. The article very accurately identifies one of the problems in medicine my last two posts have hinted towards, hence the reason I bring it up. The fundamental argument of the article, as one might guess from the title, is that new studies are finding that the long-term outcomes of cardiac catheterization is probably not as good as we originally thought and likely have a mortality benefit only in a select population - much like Coronary Artery Bypass Grafting (CABG).

I would love to post the entire article, however, it is quite lengthy. If you have a subscription to WSJ - which is never a bad thing to have - then you can search for the article title above. But, I would like to share with you one 'pithy' remark from the article.
"It's a medicine-for-dollars scenario," says Kevin Graham, director of preventive cardiology at the Minneapolis Heart Institute. "The doctor who practices disciplined medicine makes significantly less money than the doctor who is trying to find some justification for stenting a patient. That's the system. People get paid for doing things."

It is a deplorable idea to think of healthcare in such a way, but unfortunately, seeing it everyday, I would have to agree with Dr. Graham. My friend had this to say "So I guess my basic thought is that medicine, like law and all other supposedly high-minded professions, is really just a business." Again, sadly this is true.

Bonus Feature
I had to share this. I saw a bumper sticker the other day, which I can honestly say was the funniest I've seen in a long time. It was stuck to the back of a Scion xB - a picture of which is shown below...

The bumper sticker read: "Sadly, you've just been passed by a toaster"







thanks to EVN for the article and remarks....

Friday, January 19, 2007

My Frustrations with Medicine 2 - Making the Patient Happy

For some inexplicable reason, the last two days have been extremely light, thus I write again much sooner than I anticipated. I want follow up my last post with a secondary frustration from a recent rotation.

I'd like share with you a story of an encounter I had with a patient, then explore its foundations. Of course with HIPAA being what it is I'll try to be as vague as possible, without blurring the fundamental point of the story. I stepped into the occupied patients room, introduced myself and started the interview portion of the encounter. To make a long story less long, the patient (who I will refer to as 'X') explains, tearfully, that she has gained so much weight recently she doesn't recognize herself and can't walk because her legs are so big and has never looked like this and doesn't eat breakfast or lunch and exercises 20 minutes every day and her daughter's wedding is in 4 months and she doesn't fit in her dress anymore and so on.... At this point, I am trully feeling sorry for her and empathizing as much as possible, but also slightly confused. Anyone who eats one meal a day and exercises everyday does not gain weight, unless there's a metabolic problem. Thus, I go down the hypothyroidism route. In conjunction with the weight gain she's constipated, cold all the time, and fatigued. In the setting of a 'normal' exam, I feel like I have a pretty strong case for hypothyroidism as a diagnosis - at the very least a reason to check a TSH. I mention this to her and say if her thyroid levels are low we can replace it. Then the interview turns sour. She says to me "there's nothing wrong with me, I just need a diet pill... give me a diet pill." I hedged. "If Dr. _____ won't give me a diet pill, I'll just go find another doctor. That's what you are here for, to help me, to give me what I need. How can you say your a doctor and not give someone what they need." I'm a little perturbed at this point. I assured her I (we) wanted to help, but also wanted to do what was best for her. Again she scolded me. So I challenged her a little (my frustration surfacing) about the exercise and find out she sits on her stationary bike and watches T.V. every morning, sometimes actually moving the pedals, but never sweating. Tiring of the tension between us and the energy to persistantly respond kindly, I exited to find the doc and report my findings.

After the doc and I are both in the room, X continues to insist she needs a diet pill today. "When I broke my foot years ago I couldn't do anything for 4-weeks and gained so much weight. I went to my doctor and he gave me a pill and all the weight came off." After going back and forth for a while there is no happy conclusion to be had. X insists on a diet pill she doesn't need and refuses to let us take blood to run basic labs.

So what would I do at this point? Peace out, cheerio, ciao! As a future doc, if my patient is not willing to work with me in their care and is simply using me to get a medication, I don't feel there is any reason to continue our relationship. I'm young, inexperienced, and jaded - heck, I'm not even a real doc yet - but I'm not going to prescribe a medication with a risk-benefit ratio far schewed to the former. That being said, what did happen? The doc prescribes Lasix, which is a diuretic! Are you kidding me?! Her exam was completely unremarkable - no fluid in the lungs, ascites, or edema in the extremities! No indication for a diurectic whatsover, but the patient left happy.

Here is an abridged list of the possible adverse effects of Lasix:
COMMON
Dermatologic: Photosensitivity, Pruritus, Rash, Urticaria
Endocrine metabolic: Electrolyte imbalance (14-60%), Hyperglycemia, Hyperuricemia (40%)
Gastrointestinal: Constipation, Diarrhea, Loss of appetite, Nausea and vomiting
Neurologic: Asthenia, Dizziness, Headache, Vertigo
Renal: Glycosuria
SERIOUS
Cardiovascular: Hypotension
Gastrointestinal: Pancreatitis
Hematologic: Hemolytic anemia, Thrombocytopenia

So I ask the question, how far should we go as docs to make the patient happy?


Two interesting articles from today's news:
http://www.healthday.com/Article.asp?AID=601105

http://news.aol.com/topnews/articles/_a/nicotine-increasing-in-cigarettes-study/20070118122009990001?cid=2194

Thursday, January 18, 2007

My Frustrations with Medicine

Currently, I am doing a 4-week rotation in outpatient adult medicine. For those not comfortable with med school lingo, this essentially means I working at a doctor's office where one would go if they were feeling ill. Those who know me realize I do not particularly enjoy functioning as a doctor in this outpatient setting - mainly because the repetition of titrating a patient's hypertension/hyperlipidemia/diabetes/[insert any other chronic disease] medication bores me - there's no learning new presentations or seeing interesting pathology. Those that choose primary care as a career (whether that be Internal Medicine or Family Medicine) have my respect, because its something I couldn't do. And frankly, to be an excellent primary care doctor is much more difficult than being any kind of specialist in my mind (conversely to be mediocre is tremendously easy). I say all this to share some of my experiences the last few weeks - or rather my frustrations - with the understanding that they come not from my distaste of the outpatient setting, but rather practicing bad medicine.

The practice in which I am working is very busy. It is composed of many docs and subsequently a whole host of patients. Besides the patients, doctors, and office staff there is another group of people that can be seen milling the halls filling cabinets with samples.... that's right, drug reps! Honestly, a day has not gone by when I haven't seen 5 different drug reps in this particular office. They're dropping off samples, bringing lunch, handing out pens, quoting the latest study that supports their medication (often forgetting to quote those that show no benefit), etc. Now, I have nothing personal against drug reps - 75% of them are female and very attractive - but it does bother me the intimate relationship doctors have reciprocated with big pharm. Fundamentally, how can two groups with such different inherent objectives operate together? Axiomatically, doctors are (or should be) concerned first and foremost with the interests of their patient(s) (it's spelled out in the Hippocratic oath we all take). Compare this, to a multi-million dollar company (multi-billion dollar industry) that, bare-bones, consists of investors. You can believe all the sugar-coated PR bull pharmaceuticals exude, but at their heart, their responsibility is to make money for their investors.

Being on the outside, maybe patients don't see a problem with this. Maybe they walk by, notice the hot blond in the tailored business suit talking to the doc and think nothing of it. I think our patients are smarter than that. Maybe they realize physicians are in bed with big pharm and don't think it affects them. I believe it does. Accepting gifts - whether it be pens, lunches, dinners, vacations - does indeed affect prescribing patterns and is certainly a breach of patient-centered ethics. For you are no longer thinking of the best option - physically, emotionally, monetarily - for that patient or for other patients inhabiting this society. That is essentially what we as physicians (I speak from a soapbox 5 months from now) have done in allowing big pharm our ears. Obviously, there are times when only the latest and greatest medication will do, but that is far, far from the norm. Moreover, newer drugs (the only ones pushed by pharmaceutical companies) cost 10x - or more - as much as an alternatives.

As an aside, a study published in the Journal of the American Medical Association last year reported "third-year medical students get one gift or attend one event per week sponsored by the pharmaceutical industry, which spends $12 billion to $18 billion annually on marketing to doctors and medical residents."

That is the ethical side of the argument. Where do samples fit in? Pharm companies are marketing geniuses (not to mention scientific wizards with some of the drugs they make). By ensuring a plentiful supply of free samples in offices, they know, once a patient is started on a medication, likes it, and has negligible side effects they have effectively guaranteed repetitive use. This is not a bad thing if indicated for the best care of a patient, unless of course there was a cheaper alternative that would have done the same thing. Just the other day, the doc I was working with gave a patient a 1 month supply of the newest Type 2 Diabetes medication, Januvia, worth over $300. Now tell me there isn't any repercussions for society when this patient goes on that med long term and lifestyle changes would have achieved similar results.

As with most of the 'problems' I point out, do I have a solution? Not really. I would like to see drug reps no longer roaming the halls of any hospital or practice, along with their free pens and food. I would like to see samples done away with. I would like to see drug prices reduced. But, truthfully, it's a multifaceted problem and one also has to realize that it takes a RIDICULOUS amount of money to make a successful drug. Less than 10% of all compounds patented actually make it to market. And it takes millions and millions of dollars to bring a drug from discovery to FDA-approved. No one is going to spend the money to make a medication if they then can't recoup their investment. Thus is the way a capitalistic society functions. Stories like this are not singular instances. Despite all the fancy drugs our national health-care is mediocre at best - compared to other developed countries - and we spend twice as much. So what do we do? When I figure it out, I'll let you know.

next up: Making The Patient Happy

Tuesday, January 9, 2007

Change is Good?

I have recently found myself enamored with books - reading them, browsing them, and just touching them. I wasn't always like this. Much to the contrary, my mother was at her wits end trying to get me to read when I was younger. I remember this went all the way through high school, with my mom finally giving up on me. I hated reading, I mean what was the point? Back then, I couldn't understand why anyone would read; T.V. provided much more entertainment and, well, best of all you didn't have to READ IT! The worst part was summer vacation. How can you call it vacation when you have to read 5 books in 3 months?! But now, I walk into any bookstore and buy at least one book regardless of whether I need it or not.

I'm sure your reading this, pointing out the fact that a lot of kids hate to read... hold on, I'm getting to the point. So in high school and college what was I obsessed with? Clothes (thus my outward appearance to the world). It sounds really stupid, but man I loved clothes and I spent all my money on them. So in order to be financially responsible I did what any respectable high school student does... I got a job in retail. First it was The Gap. I worked there for over a year, simply for the discounts. Then I moved up the retail ladder and worked a few years at J.Crew. Man it was awesome, I was getting clothes for real cheap. I graduated college, moved on to medical school and left my retail days behind me. Again your wondering, SO WHAT!

It wasn't until after I left retail that I realized how pathetic I was being. The only reason I worked in those stores was to accumulate more stuff - specifically clothes - which I thought by owning would make me more and more admired. It's amazing how immature I can be when I pause to analyze my actions. So what about now? Honestly, I could give a crap about clothes. I haven't bought myself a single article of clothing in over 3 years. That might seem a little extreme, but when one has over 40 button down shirts, its really not. Can I thus say I am cured? Have I finally hurdled over my immature and self-indulging insecurities?

Back to the books. Over the the holidays, during a time of reflecting, I realized that I have not so much 'matured' as I have replaced one stumbling block for another. Namely, books for clothes. While in college, I yearned to be accepted by the 'cool' kids and much to my detriment was indeed accepted. This acceptance was based heavily on superficiality. Indeed, at many "institutes of higher learning," physical appearances are heavily relied upon - essentially mirroring society at large. In medical school, however, a different attribute is praised, that being one's intellect. Thus - and you can see where I'm going with this - books are held at a higher value. Have I not then simply conformed my insecurities to the environment in which I am placed? To a degree I would say yes. For a long time, an area of weakness for myself has been the pathologic emphasis I place on the external. I doubt I am the only one to flounder in this way. God has transformed my life with His grace and without this continual and renewing grace I would truly be doomed.

Do I write all this to say clothes or books are bad?! Of course not! Books are great! And clothes are... well... good too. Nonetheless, it is quite revealing to analyze why I (we) do and emphasize certain things. For it is these exact things that reflect what is important in our lives. Thats enough for now, I need to finish this next chapter.... ;)