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