The Thursday before the unfortunate election in Massachusetts that I am sure will deal the coup de grace to an already paralyzed senate, I saw a 54 year old man, let’s call him Joe, who was sent to me, a cardiologist, by his primary care doctor. By his history and ECG, there was no doubt that the man had suffered a myocardial infarction at home in the middle of December (something his PCP thought he had to confirm by a nuclear stress test probably costing several thousand dollars). It was also clear that Joe was self-employed, uninsured, and  his finances were in shambles. In fact he admitted that he had to “raid” his childrens’ bank accounts in order to pay for heating oil and the state sales taxes he owed, which were due the next day. The opportunity of any myocardial salvage had obviously passed and as the patient did not have angina and no ischemia on his stress test, I thought that medical therapy would be a better option that submitting him to a cardiac catheterization. As I started to tell the patient that as a minumum, he should take aspirin, a beta blocker, an ACE-inhibitor and a statin, the first question was “How much will that cost me?”. After that, further recommended test (such as an echocardiogram) were only going to happen if his care was “free”. Unfortunately, this is a common scenario.

With health care reform on the verge of collapse, I guess all of us have developed a sinking feeling – at least the ones that thought we’d finally had overcome the US malady we call “health care” and were on the way to recovery. It is an angry feeling, and a depressing one. Mostly, I just don’t want to understand, but I am afraid I do. I just read today’s New York Times “Prescription” piece for January 23rd. It seems to confirm what I had suspected and in fact what I have heard from my patients: America has been duped out of believing in health care reform. The opponents of the process that would  insuring most Americans have successfully sown so much doubt and misinformation that many citizens now think it is a bad idea. We live in a scary era – can anyone blame the people? Unfortunately, it is they who will suffer.

The system that has been devised sounds too complicated, too expensive – and critics from the other side complain it does not cover enough people. That’s all good, I can see the point, particularly the one about cost, which is scary, in particular with the backdrop of two ongoing wars, a slowly (or maybe not yet) recovering economy and high unemployment.

It seems, however, that many object on the basis of the principle of liberty, aversion of higher taxes and government mistrust. Coming from Germany to the US now almost 10 years ago, it’s something I’ll never understand. It boggles my mind that free choice (i.e.the choice not to buy insurance) would top the principle of the “common good” and solidarity with the less fortunate. The NYT piece described the opposition ordinary citizens. Charles Burke, a 55 year old man managing a cafe, is reported stating he was against mandatory insurance as he has always paid out of pocket; and Irving Cable, also 55, as saying “I won’t pay it (…) and I’ll shoot the first person that tries to make me go to jail because I will not buy health insurance“. This sort of stance only makes sense if we really are consequential: if you do not have insurance, you pay with you own money. Any sort of subsidy, be it directly to health care consumers or indirectly through government payments for charity care, higher premiums that finance jacked up hospital and health care provider fees, is in fact a form of solidarity payment, though not a just or equal one. If you offered Mr. Burke and Mr. Cable a refund of every cent of any Medicare Tax he ever paid, at the expense of forgoing any government paid health care ever, maybe they’d accept. And maybe it would work for them, as they may never get sick. Maybe they won’t get heart disease or cancer and quickly end up with bills a multiple of what their savings might be. But maybe it won’t work, and they’ll end up just as Joe.

The problem will be that it will be less likely in the future to find someone to provide free care, in particular care that conforms with the standard.  Payments are on the decline, the baby boomers are coming of age and less and less health care providers are willing to work with Medicaid and Medicare patients. This may sound morally objectionable, but they are within their rights and one has to conissr teh economic situation, salary for staff, rent etc.  Others will leave Medicine altogether. At some point coverage will be so thin, it will significantly delay care – already it is said that 45,000 people die yearly due to lack of insurance. Indeed, judging by the fact that even I, a healthy, young, insured man cannot find a primary care doctor that is accepting patients in my city, we may already beyond that point.

Maybe we have to hit rock bottom? When we do,  it will be so more painful.  Many seated members of congress won’t be there anymore, having retired or been voted out. But as they would probably lose many Medicare benefits,  maybe they should be paying attention now.

The national debate on health reform has uncovered innumerable “health care horror stories” in which cancer patients worry more about their bills than their malignancy or where pregnant women are laid off and dropped from their insurance soon before their due date. These stories are tragic, and unconscionable for the richest country in the world, however, as a physician, this is not my typical experience. Instead, what I see every day is patients with private health insurance who cannot afford the copays for their medications, delays in treatment as I grovel for prior authorization with a non-physician utilization reviewer, and patients stuck with huge bills for routine services that they thought they were covered for.

In my practice, patients have a mix of private and public coverage. While I work with some extremely impoverished patients who qualify for public insurance through Medicaid, it is the people with employee sponsored private insurance who are most at risk for roadblocks to care. As a primary care physician, it is hard enough to fit all of the recommended screening, health education, and chronic disease management that complex patients need into a fifteen minute visit. When the burden of battling with insurance companies is added to the equation, there is no way that I can succeed. My patients, especially the ones with private insurance, are forced to deal with the high copays, denials of claims, and delays in care.

Reflecting on the past week, a bunch of cases come to mind. While these stories may lack drama, it is nonetheless troubling to me how frequently my treatment recommendations are impeded by difficulties with health insurance. And I am sure my patients are not alone in suffering the consequences:

Ms. D, came in Wednesday. She has high blood pressure and very high cholesterol. I had not seen her in over six months, but she works a demanding job, so I figured that she had just been busy. In the office, we did not talk about her blood pressure. We did not talk about diet and exercise. She had not followed up for so long because at the prior visit I had sent her for an echocardiogram of the heart and she was billed $800 for the test. Her insurance would only cover $200. We spent the entire visit talking about how she could not afford to pay this bill. I just don’t get it. She has private health insurance. She was having symptoms that had been worsening over several visits and needed further evaluation. Now, she is receiving daily letters from a collections agency, and she is frightened to come to the doctor because of the bills that may show up in the mail.

Mr. D, a security guard with diabetes, hurt his knee while fishing and had severe pain and swelling. When I initially saw him a few weeks ago, there did not seem to be any major structural damage to the ligaments, so I recommended a conservative approach with rest, ice, and anti-inflammatory medications. Now, several weeks later, the pain and swelling had not subsided, so I ordered an MRI to evaluate for more subtle damage to the knee. After several attempts at prior authorization, the private insurance company refused to pay for the test. Baseball players get MRIs the same day for any bump or bruise, but even going through the appropriate prior authorization process, I could not order an MRI for my patient with private health insurance. I am not looking forward to all the phone calls that it will require to protest this denial of necessary diagnostic test.

On Thursday, Mr. F came in to have his blood checked. He requires blood thinners to prevent recurrence of blood clots which could be fatal. He has twice previously had clots in the blood vessels of his calves, and he once had a blood clot travel to his lungs. He has a clotting disorder that makes any break in treatment with the blood thinners extremely dangerous. Warfarin is an effective and inexpensive blood thinner, but it requires frequent monitoring because its activity is affected by numerous interactions with other medications and foods. His blood test showed that the warfarin was not doing its job, so I recommended an increased dose. It takes about three days for the dosage change to have a full effect, so I also recommended injectable blood thinners, which act more rapidly, until we could demonstrate that his warfarin had reached a therapeutic level. However, he could not afford the copay for the injectable blood thinner, so he must hope that he does not develop another blood clot as we wait for the higher dosage of warfarin to take effect.

Yesterday, I saw Ms. E for a follow up appointment. She is only in her 30s but has already had major back surgery for a disk problem. She stands for six hours a day at work and has recently had worsening of her back pain. Her spine specialist had recommended physical therapy, instead of a repeat operation, but she cannot go because her private insurance company requires a copay for every session. She has been unable to work because of the worsening pain, so she cannot afford these copays and has not been able to follow the treatment plan. I do not want her to become dependent on pain killers, but since the treatment recommended by her orthopedist is not a realistic possibility, we are running out of options.

I could fill many pages with stories like these of my patients whom are hard working, have private health insurance through an employer, but just cannot get the care that they need, because of unreliable coverage. It frustrates me that executives of health insurance companies spend millions on advertising to disparage public health insurance, and Republican politicians are stone walling meaningful health care reform because they are afraid that a public health insurance option would put private health insurance companies out of business. I do not care who provides health insurance for my patients. Whether they have public or private insurance, I just want them to get the best care possible. If private health insurance companies provide a high quality product, they will not be “forced” out of business by a public plan. It makes sense that competition between a public plan and private plans would lower costs, improve quality, and guarantee an option to those who do not have employer sponsored coverage. As a physician, I need to advocate for my patients. Private health insurance companies have thousand of lobbyists and millions of dollars to spend. So why do these companies need so many politicians, including Democrats, advocating for them as well? This is not about ideology. It’s about patients who cannot afford their medications or who face bankruptcy due to medical bills.  We need change, and this will only come with a guaranteed public health insurance option.

- Aaron Fox, MD

National Physicians Alliance

Generally, I lack the time to follow much TV, so it’s been a while that I watched Lost, but I thought the show’s basic and primordial premise – being lost on an island, where no one really knows how they got there, or how to get away (ok, for those who are up to date on this, people seems to have gotten off the island in Season 4) – seems so befitting our current economic situation. Now, I am a physician and not a economist, but most analysts seems to agree with me that the current world economic situation is quite similar to the TV series: we seem utterly lost, every day brings a new turn (together with a 500 up or down in the Dow), no one fully undertsands how we got here (some of the villans, subprimes, clearly not being everything), no one really knows how to get out of the hole.

But that is not the only thing lost. Although I just learned that Ed Kennedy is working on comprehensive heallth care reform (bless him, I wish him well but this may be his parting gift to Congress and the American People), I think that people like Bean, Gingrich and Kerry, who just out forward a suggestions to run medicine like baseball, should do a reality check. Here are some things they wrote that bug me:

Studies have shown that most health care is not based on clinical studies of what works best and what does not, be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition (…)  We can do better if doctors have better access to concise, evidence-based medical information (…)  Evidence-based health care would not strip doctors of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that doctors can deliver the best quality care at the lowest possible cost.

First, apart from the fact that a baseball player can hardly be compared with a doctor, it is not like Evidence Based Medicine is a new concept. It has been around for decades. And the barrier to findings new evidence is not primarlily the lack of will of doctors to accept it, it’s the lack of evidence, caused by a lack of studies, especially unbiased studies. The US government and public have sat back, NIH funding has been insufficient, and we have left it to the drug industry to go and find the evidence. Thus there is a lot of (often biased) evidence of the most lucrative conditions (although the FDA’s orphan drug program has made some difference), like the new diseases everybody seems to have (restless legs, social anxiety, ADHD). Meanwhile, it has become more and more expensive to get a medical education, there is a shortage of physcians, particularly in primary care, the doctors that do work often have no time, and sometimes no funds, for continuing education. Furthremore,  the number of un- and underinsured people is at an alltime high. Although I think it is a great idea, adequately funding the NIH, or some new institution, to run large unbiased clinical trials will have no immediate impact on clinical care: evidence will take years to accumulate and be transplated into practice and it will cost billions that Americans unfortunately are not willing  to pay (more taxes, anyone?).

Everyday I deal with the checkbox mentality of doctors: patient has condition X, so I must check Y and order Z. If I don’t, my hospital gets poor marks on the statistics used to judge their performance, and soon will determine their reimbursement. Furthermore, doctors are trained to think that if they do yet another test, they will not get sued and risk their livelihood and job as a result. Meanwhile, they have not time to talk to the patient, take a good history and review the chart. There is little, if any, evidence that increaseing the ‘batting average” of a doctor to run test Z does anything to make a patient better.  What we need NOW (notn in 5 to 10 years), is to get off the island. Not mb checking boxes, or more tax breaks, but by comprehensive health care reform. Let’s get Un-Lost!

This is so interesting. First, read the NLARx piece on Academic Detailing in ME/NH/VT….I think it is great that my state’s medical association has come out in favor of it (e.g., after opposing the ban on the sale of prescriber data).

As you may also know, the new PhRMA guidelines discourage providing gifts to doctors. I quote from NLRAx piece:

Practices that want to be visited by pharmaceutical company representatives still may do so, Smith (note: Gordon Smith, executive vice president of the MMA) said, although many practices already have eliminated such contacts.

Smith noted that ethics programs for doctors and the pharmaceutical industry have virtually eliminated gift-giving and other enticements to physicians.

“We have cleaned up the relationships between the doctors and the companies a lot, and there was a lot to clean up, including the dinners, the golf, the conferences,” said Smith, who has been doing his job for 28 years.

Even freebies like company-branded coffee mugs and notepads no longer are allowed, he said.

Drugs reps can pay for a “modest lunch in conjunction with a bona fide educational presentation,” Smith said, and that’s about it.

Well, as recent as two weeks ago, Sales Reps from AstraZeneca were hovering in our cath lab break room with some lavish breakfast, and they did not try to give me a bona fide educational presentation (read sales pitch – I would not have wanted one, either). I had to wiggle by them to get to our hospital supplied coffee. Another bona fide presentation by Medtronic took place last week at Hollywood Slots. I was not there, but I heard that a local doctor took away a few paraphernalia he won in a “raffle”. So as has been predicted before, the guideline is not working. So, Mr. Smith, the NPA is glad that more physicians are coming around, but much cleanup remains!

I think I am a decent doctor – I guess that what most doctors think of themselves. But sometimes I wonder if I am just not born for the job, due to lack of business sense. Here is why, it is situations like this:

A 76 year old demented patient is referred to me for a transesophegal echocardiogram (TEE, that is when they take an ultrasound picture of your heart from within your food pipe – although pretty low risk, it’s not the most comfortable experience). He was found to have a moderately leaky valve and a large fluid collection around his heart – 2 months ago! Another cardiologist has referred him, but when speaking to that person, he does not know the patient well, having seen him once. This cardiologist states that the primary care doctor wanted the TEE. That primary care provider also claimed that “he is new to me”.

Now if I do the TEE, although it may not be a great indication, I make ~ $400 for my practice (most from the technical fee), and eventually, some for myself. If I do not, I have spent 30 min reviewing the chart and speaking with the patient and his family, for basically nothing (I cannot charge for a consult as the patient has just been seen by one of my partners). A pericardial effusion may require a follow up ‘surface’ echo, for ~ $50. But if I want to do that, I need to spend another 15 to 20 minutes tracking the referring doctor down, changing the order, explaining the whole thing to the patient….. probably as much time as it would take me to do the study.
There is an apparent conflict of interest – patient health (put at risk by the TEE) and his wallet versus my convenience and bank account. It seems to me that this conflict is resolved often in favor of doctors’ income, if you read about the proliferation of heart CT scans for but the most inappropriate indications.

But what else could be going through your mind? Would you do the TEE? Would you be afraid that the referring primary doctor, maybe used to get what he wants, will refer the patient elsewhere? What about if the patient has worsening symptoms? What if the patient’s family wants to have the test because they want to know “what is wrong with him?” Are you afraid the patient is seriously ill and that you will be sued if harm comes to him and you did not do the test? Would he even be a candidate for surgery of the leaking of the valve was found to be severe?

There certainly is not a lot of black and white here. Is defensive medicine justifiable in the current system? Probably, and unfortunately, yes. However we must always consider the patient first. If more harm than good is done, think back to “Primum Non Nocere”. Whoever came up with it (and it seems not to have been Galen, nor Hippocrates, they spoke greek!) had – and made – a point.

And if I may offer some more of my bad Latin: Cura Te Ipsum (de studium percuniae) – Physician, heal thyself first of the striving for money….

The Senate’s Republicans blocked a vote to avoid a cut in Medicare reimbursement starting next week. I hear part of the problem was that money to pay for avoiding the cut was going to come from funding Medicare Advantage Plans. Basically, this is federally subsidized private health insurance for Medicare elegible people and is generally 10 to almost 20% more expensive for tax payers than traditional Medicare. I see that there a probably some profits from donors to protect…. according to the New York Times, Bush has threatened a veto because

 “… it would finance a small increase in payments to doctors next year by reducing payments to insurance companies that care for some Medicare beneficiaries.”

Go figure. Let’s just say the insurance industry has about a 10% profit while my practice’s has been exactly 0.

OK, so many of you may think: doctors make enough money – what is a 11% cut going to do, they can’t buy there second Porsche? No, my friends. I am not clairvoyant, but here are some facts and what (I am pretty sure) will happen:

• Doctors are already working longer hours for less money than a few years ago. Believe it or not, many doctors already provide some free healthcare (maybe not as much as they want you to believe, but my mechanic doesn’t work for free either). While there has been a small increase in average worker’s wages over the past decade, reimbursment of many doctors has dropped by as much as 20% (or even more). Most doctors are dedicated to their patients, but they are also deeply indebted with school loans, and may not want to sell their home or have their kids drop out of college just to be able to do their job. Money is just a reality.
• Doctors offices will reduce costs, which means cutting down on overhead (firing the assistant, the nurse, the receptionist), which means longer waits and worse care.
• Doctors will avoid seeing new Medicare patients – good luck, Baby Boomers (just remember to vote in November!).
• There is already a severe shortage of doctors in poor and rural areas. As these tend to have more people dependent on Medicare and Medicaid, there will be further exodus from these regions – wouldn’t you be at least considering another job if you salary was cut by 10%? There are plenty of opportuities elsewhere.
• Primary Care doctors, already facing probably the lowest reimbursment, may as well be hanging up their coat and go into more lucrative jobs…  like at McDonalds…. ever tried to get preventive healthcare from a Dermatologist?
• The education of resident doctors is tied to Medicare, so we’ll see cuts there, and thus in a few years, probably a decline in quality.

In other words, please do not make a screwed up system worse. What we truly need is an overall reform, like Universal Healthcare, not a patchwork of legislation and rules that is so intransparent, I am sure many legislators have no clue what is going on, especially that they live in cities with pelnty of physicians to choose from and their healthare is paid for!

Earlier this week, I discharged a patient after a 45 day hospitalization. She had been through a lot – a viral infection caused her immune system to go wild, she had a fungal infection, her kidneys failed – but she pulled through and recovered so quickly that we discharged her to home rather than to a nursing home as originally planned.

Today, I called to see how she was doing. It’s a long, slow haul after a month and a half in the hospital, but she’s doing better each day.

Her husband then mentioned that his next biggest task was to get her insurance coverage continued. You see, since she had been hospitalized for so long, and ill before then, she hasn’t been working. And since she hasn’t been working, her employer-sponsored health insurance will soon lapse. She’ll have to enroll in a COBRA plan (and pay the full cost of the insurance), but if her coverage every lapses, she’ll never get insurance again due to her “pre-existing condition.”

Doesn’t her husband have enough things to do? Shouldn’t he be spending time helping her get stronger, rather than fighting the insurance company to fulfill their promise to pay for her medical care? They were sure happy to take her money for years, but now that she needs coverage …

Sadly, this is all to common. For her, it’s the catch-22 that you can’t work if you are sick, and you can’t get insurance if you can’t work. For other patients, it’s the policy ceiling that allows insurers to walk away after paying out a set amount (which is all-to-easy to reach when you have a 45-day hospitalization).

Is there any morality in a system that fails those just when they need it the most?

Addiction is a catchy word. Everyone knows the US is ‘addicted’ to oil. When we think of ‘addicts’, some movie scene with a skinny, disheveled criminal may come to mind. Thankfully, not many physicians have a narcotics problem. Or at least I hope that is the case, there seems to be a paucity of data out there. A study in New South Wales from the 1990′s suggested at least 0.4%. In US Anesthesiologists, it may be as high as 1.6%.
However, if you are about to cancel your upcoming surgery, here is a scary fact: your doctor may be addicted to hand outs from the pharma industry, sometimes called a “pharma whore“. Those are not my words, this is a term some doctors, jokingly acknowledging somewhat inappropriate behavior, describe themselves (it also is used to describe industry friendly politicians who take pharma money). I may have used it to describe myself a few years ago, when during my fellowship I was Chief (Pharma) Fellow, in charge of making a call schedule and the premium champion of arraging dinners for my colleagues and me at Seattle’s premier restaurants like Shiro’s. Even according to guidelines by the AMA and PhRMA, such meals are not OK:

“What do the guidelines say?
In short, the AMA guidelines state physicians should accept only gifts that entail a benefit to patients and that are of modest value. Individual gifts related to the physician’s work, such as pens and notepads are also acceptable. And no gift should be accepted if there are strings attached.” (from AMA FAQ’s).

I ran into a friend yesterday who stated that a few of my former colleagues went out 3 nights in a row at the ACC, to the best steak houses, including one with a 7 course tasting meal. Modest? From experience I can say that a good steak, sides and some wine is at least $100 a head. I my hotel you only needed to go down to the lobby around 7:30 PM to see such dinner parties leaving – always a few salivating docs surrounding a cheerful sales rep.
I arrived at the ACC conference this past weekend, for the whole shebang. Saturday morning I attended a CME course for Cardiac CT, run by The Johns Hopkins University, with support by Toshiba. Now granted, no one expect to hear from such a CME activity that one should NOT use cardiac CT, although the benefit of the test is not undisputed. One can also not expect that the CME activity would be unbiased – the faculty basically admitted it was to demonstrated to possibilities of Toshiba’s new 320 slice CT scanner, Johns Hopkins being the first medical center in the US to have it installed (one speaker made mention of a Siemens product). The other goal of the course was to demonstrate the result of the Core64 trial – needless to say that was Toshiba sponsored, too. This activity is part of an ‘unofficial’ program at the ACC, such satellite symposiums are usually sponsored by Pharma, feature prominent speakers and despite their ‘unofficial-ness’ are featured in the proper ACC meeting brochures.
That night, I returned to my room and found that someone had left some trash in front of my door. It was a white plastic bag that contained 32 glossy promotional fliers (one was a mouse pad; the next day I received 16, then 3) that invited me to visit various pharmaceutical companies booths at the “Exhibition” the next day. Now if you have never been to one of these conferences, this you got to see. The Exhibition is an area that could probably accommodate a few football fields where pharmaceutical and device vendors have set up their displays. Now, in principal, that is not a bad thing. For example, I wanted to learn more about my hospitals radiology software, what features the new update of the software had etc., and I went and talked to the sales reps, who did a great job of answering all my questions.

But the main goal of these companies is to sell their product (a legitimate reason). Their booths are colorful, brightly lighted constructions. The way they do this is by luring you in with some kid of relatively cheap trinket, like a travel mug, a low end USB drive, or the like. To obtain this, one usually has to give out one’s contact information (by swiping a plastic card) and talk to a rep, sometimes answer some questions or fill out a survey. Now imagine 30,000 cardiologists swarming that hall. One would be surprised that people making an average of $300,000 a year (and sometimes much much more), would care to get these plastic gimmicks. When I was a fellow (making far less than the above amount), I did it, been there. I once lined up to get a wooden pen engraved with my name – there must have been a line of 20 to 30 doctors and it took probably 15 min. I have sipped cold Starbucks Coffee at the Pharma trough. I have answered marketing surveys, only to receive a cheap pair of sunglasses….. this year I celebrated my independence by treating myself to a fountain pen which will probably last me a lifetime.

Furthermore, when you pick up your ACC program for the conference, you are handed an impressive array of gifts:

- a black bag prominently displaying the name of a high selling cholesterol drug
- a neck strap for the name tag, with the same label
- a water bottle, featuring a new anti-angina medication
- a clip board with a blood pressure medicine written all over
- a business card holder wit drug company AND ACC label (you can get in engraved at the company booth)
- several glossy brochures
- a pen, labeled with an anti-platelet drug (it’s NOT aspirin)
- a bookmark with incorporated loupe (for those older cardiologists – or is it for the fine print on the medication packet), of course it’s branded

(Read more…)

What a meeting. It was a bit of an geographical, meteorological and figurative journey for me: from Downeast Maine to Houston, TX. Let’s just say I did not need my jacket. I did not need good spirits either, since everybody brought plenty! A 3 day intense, fun and educational 3rd annual meeting. Among others, there were great speakers/bloggers like Howard Brody and Merril Goozner, as well as Marcia Hams (from the Prescription Project) and last but not least, former Surgeon General Joycelyn Elders, who was keynote speaker at the joint AMSA/NPA event. She is hilarious, but clearly not in tune with the Washington establishment, especially the born again kind. Here is just one of her priceless – and true – quotes:

“Condoms will break, but I can assure you that vows of abstinence will break more easily than condoms.”

For the ‘Pharma Taskforce’, the meeting was a success. First of all, it is now called the “Unbranded Doctor” campaign, expanding its original scope of advocating for prescription privacy, to the broader issue of pharma-physicians interaction. It will have its own website, unbrandeddoctor.org, where health care providers can learn about more the campaign and find networking opportunities as well as resources, most importantly the “Unbranded Doctor Toolkit”. There is also an online store where I encourage y’all to buy unbranded T-shirts, mugs, stickers etc.

Missing from the meeting? Pharma Money – it was almost entirely supported by the membership!

We’re excited to host a media/debriefing room at the National Physicians Alliance annual meeting this weekend in Houston. Here, NPA members are live-blogging about their experiences, doing media training, and sharing their stories about the uninsured, their interactions with big pharma, and their personal stories as physicians, through our online surveys!

If you are a physician, we invite you to answer these survey questions. You’ll help us develop our “Faces of the NPA” initiative.