AAMC has finally put out some guidelines regarding industry gifts, etc at med schools – simply its to pretty much ban all gifts. However, I think it could still be stronger in that it doesnt require the ban of industry representatives from campuses/hospitals – they’ve just written out more restrictions – i.e. they should not be in pt care areas for example and also recommending more regulation for drug samples vs. doing away with it (we and pt’s dont really need this – its only that we’ve come to believe the fallacy that there is no other way to get free drugs to patients who need them!). You can see the full report at: AAMC Task Force on Industry Funding of Medical Education

Today’s NY Times has a good piece on it:

Ban Urged on Gifts at Medical Schools

By GARDINER HARRIS
Published: April 28, 2008

Drug and medical device companies should be banned from offering free food, gifts, travel and ghost-writing services to doctors, staff and students in all 129 of the nation’s medical colleges, an influential college association has concluded.”

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!

It’s quiet evening on call (a rare enough occasion), and I just finished watching Invasion, with Nicole Kidman and Daniel Craig, snuggled on the sofa on this cold Maine Winter night. The plot is fairly simple, similar to its predecessors (The Invasion of The Body Snatchers, 1956 and 1978), with a twist: Earth’s Population is infected by an alien spore that turns them into emotionless droids, suppressing all that are immune and infecting those that are still themselves. Far fetched? – maybe (one scene shows a TV clip of President Bush visiting Chavez… c’mon, not even in Science Fiction!!!). But the again…

Something similar seems to be happening with our own Food and Drug Administration (FDA), and the medical profession in general. There are people among us – doctors, legislators, adminstrators, patients – who’s minds have been snatched. They live under the in the influence of a delusion, namely the profit-driven pharmaceutical industry acts first in patients’ interests, while their first priority undoubtedly seems to be increasing shareholder value), and that Big Pharma is the best, most reliable and unbiased source of information about medicines that they are desparate to sell.

What is the latest? ‘Legalizing’ off label advertising of drugs.

A little backgroud: The FDA was founded in 1927, and received more powers over drugs in 1938, when FDR signed the Food, Drug, and Cosmetic Act into law. Basically, the FDA is charged with protecting us (the population of the USA) from harmful drugs. Pharmaceutial companies apply for approval of a drug, pay a ‘user fee (~1.2 million), and – once approved – get to market these drugs for the approved indication. If the medicine is not used for the approved use, it is used ‘off label‘. Any doctor is free to prescribe any medicine for any use, i.e. I could write a script for aspirin and tell the patient to apply it externally for a  wart. While that is completely ineffective (don’t try this at home!), it is absolutely legit. In fact, many medicines are used off label and are considered standard if care. One example is the use of heparin for an acute heart attack. But it is illegal for Bayer to promote aspirin for  warts, as this is not an approved indication. Just remember that in recent years, there have been million dollar judegments against pharma for illegally promoting off label uses, such as in the Neurontin case.

Now that is supposed to change. The FDA proposes that pharmaceutical companies should be able to present doctors with reprints of articles touting unapproved indications (more detail here). While there are some strings attached, like these reprints should “be peer-reviewed“, and should not be “edited or significantly influenced by a drug or device manufacturer “, this is a bad joke. If this was not written by a pharma lobbyist, someone in the FDA is doing a good job substituting. The FDA cannot even do its job of overview of direct to consumer advertising!!!  Now they are supposed to make sure that thousands of pharma sponsored, scientifically questionable articles that will be dumped on doctors desk are up to their guidelines. Whom are they kidding? By the way, dissemintaion of such information is already allowed under section 401 of the Food and Drug Administration Modernization Act , which the FDA proposed in 1998 - however there are probably too many requirements for our pharmaceutical friends to follow? Now we get a copy of some paper, which may be the only data we ever see on the use of that drug for that indication (while Pharma and FDA are free to keep negative trials locked away). And which doctor has a few free hours to research these off label indications himself/herself?

The FDA should do its job, shed the mind snatchers, and protect people, not profits. This rule is open for public comment – stop the FDA from being ‘fed’ its lines and speak out against its advisers from being ‘drugged’ by their financial relations with Pharma. Otherwise, it’s just the Fed and Drugged Administration.

In a recent opinion piece (or here), Betsy McCaughey, former lieutenant governor of New York and current adjunct senior fellow at the Hudson Institute, raves against mandatory health insurance, in fact she claims to know the “Truth About Mandatory Health Insurance”! This is accompanied by a caricature by Chad

Crowe, worthy of a feature in ‘How to Translate Polemics into Art’.

“Requiring catastrophic coverage (our parents called it major medical) probably is smart“, Betsy muses, but, in brief, comprehensive coverage would not solve overcrowded emergency rooms, and anyway many uninsured are immigrants (and – sarcasm intended – we know most of them are illegal = do not deserve health care) and healthy people should not be made to pay premiums covering the risk of sick people.

First, I doubt (and for her sake I hope) that Betsy has set foot in an ‘overcrowded’ ER in an inner city hospital recently, other maybe for a brief cameo appearance. I am not saying that giving everyone health insurance tomorrow would make this problem go away. But as someone who has trained at institutions running such ERs, I can attest to the fact that many (not all) visits are due to lack of preventive care, proper education and the availability of health care providers that actually see patients (the one’s that cannot pay beaucoup $$$).

Second, the notion that healthy young people should not pay more for healthcare than they consume is exactly the problem that has been bogging down the US system. Other countries have widespread or mandatory insurance – backwards places like Western Europe, you know – many of which the WHO rates better than the US on healthcare (France is No 1, Italy No 2, Spain No 7, Austria no 9, Netherlands No 17, UK No 18, Germany No 25, Canada No 30…. the US is a distant 37th). And by the way, the US also is not top of the list when in comes to fairness of financial contribution, as stated in the same report (the front runner here is Colombia, and there are 7 European countries in the Top 10). In Germany, for example, everyone shares the cost of healthcare, insurance is mandatory – the underlying principle here is called solidarity. And no, Germany does not have socialized medicine, and if you think solidarity sounds socialist, then read its definition here and un-wash your brain! It is basically risk sharing. If only the ones with the risk end up paying for it then healthcare can never be affordable for anyone even with a decent income – unless your are young (i.e. low risk) and healthy, which is not the majority of US citizens. Thank goodness that in the US, most young people will become old people later in life and thus consumers of healthcare (it would probably help if you could take your insurance from job to job). And yes, if you make lots of money and do not buy health insurance, you are probably either extremely shortsighted or fatalistic.

However the mean household income in the US is a somewhat meager $40+ k, and provided you do not have insurance through your employer, according to the Kaiser Family Foundation, an average family plan will run at ~ $11,000 (Oh, and a few thousand on top of that may be your deductible/co-insurance). Does that sound affordable?

That is not to say that healthcare consumers should not share responsibility , i.e. live healthier lives, for which many may need incentives (not punishments).
I think if US citizens – and their leaders – are not able to think out of the box of their Suum Cuique (“to each his own”) mentality, we are heading for healthcare Armageddon. And it won’t matter if we start with 23.7 million uninsured (Betsy, how is that number any better than 43 million?) or more, it’s going to go up, fast.

Crossposted at Stupor Cordis

The Republican Presidential CNN/YouTube debate is just around the corner (November 28th).  As with the Democratic Presidential debate hosted by CNN/YouTube, Americans are submitting videos of questions they have for the candidates. 

Above, the national leaders of the American Medical Student Association, the independent medical student organization with over 50,000 members, from which the National Physicians Alliance was born, framed the healthcare debate with a well-crafted question for the candidates.  Friends, these are the future leaders of American organized medicine, and there are thousands of them, and thankfully, they’re progressive, patient-centered, and dedicated to the public health of America.

Hope comes in many forms, and this is just one of them…

I recently received a letter from a company asking me to participate in a study “examining how new clinical treatments for Diabetes Mellitus (sic) are adopted within a medical community and the resulting implications for the delivery of medical education.” For the ten minutes they expected it would take for me to complete the survey, they would send me a check for $60. Presumably, that comes from “our pharmaceutical industry partners.”
Wow … $360 an hour. That’s definitely a “reasonable” honorarium for an overworked resident physician, right?

After asking me demographic information and what sources of information I trust for diabetes information, I was asked to rank the relative strengths of the various companies that make insulin products. But then I got to the meat of the survey:

Please list the hospitalists in your region and nationally that you feel are recognized as experts in the field.

Please list “up and coming” research physicians in this field.

Wow, $60 to sell out my colleagues so that they can be enticed by this company to give presentations on behalf of drug companies …

I suspect, however, that they will quickly realize that Drs. M. Mouse of Anaheim, H. Potter of the reknowned Hogwarts Institute and S.B. SquarePants of Bikini Bottoms are, perhaps, not world experts in diabetes care.

I will also not be collecting $60, as I declined to consent to that nor did I provide my contact information.

But I probably wasn’t going to get $60 regardless — there’s an asterisk on the letter that noted “the survey will be closed after we receive 125 completed questionnaires….” But since the survey doesn’t tell you if it has closed before you answer all of their questions, I suspect it is a well-spent $7500 to build a database of “respected” physicians.

Emily Yoffe describes in excruciating detail the adventures of serving as a standardized patient to medical students, to evaluate their physical exam skills. I remember the days of medical school when were evaluated in this way. It definitely was awkward, for both the medical students and the “patient”, but it was greatly appreciated. She shares some interesting stories in this piece:

Over the course of three days recently, I had 23 head-to-toe physicals from 23 second-year students at the Georgetown School of Medicine. I was the first person these would-be doctors had ever fully examined on their own. Some were shaking so violently when they approached me with their otoscopes—the pointed device for looking in the ear—that I feared an imminent lobotomy. Some were certain about the location of my organs, but were stymied by the mechanics of my hospital gown and drape. And a few were so polished and confident that they could be dropped midseason into Grey’s Anatomy.

Georgetown allowed me to be a “standardized patient”—that is, a trained person who is paid $15 an hour to be poked and prodded by inexperienced fingers, so that med students can learn communication and examination skills before they are sicced on actual sick people…

The concept of the standardized patient has been around for decades, but only in recent years have medical schools made training with them a regular part of their curriculum. I talked to a 50-ish physician friend about my experiences, and he said when he was in medical school and it was time for the first rectal/genital exam, the students were told to pair off and examine each other. “So, do you pick someone you like, or someone you don’t like?” he recalled. “Either way, it’s lose-lose.”

Now there are standardized patients trained for genital duty (they’re called GUTAs, for genitourinary teaching associates), but I signed up for something less invasive. Mine was the simplest possible assignment. I was to sit on the edge of a padded table in one of those awful, flapping hospital gowns, in a room equipped with recording devices in the ceiling. Each doctor had 30 minutes to conduct a standard head-to-toe physical: from my vital signs, to my nerve function, to my reflexes, etc. Then I was to go to a computer and check off whether they’d done all 45 parts of the exam (“Palpated for fremitus,” “Auscultated carotids”), and write my comments on their bedside manner…

Oh, it gets better. Check out the rest of her piece. Any thoughts on this concept of standardized patients? Any embarassing stories folks have to share?

It is not quite true to Wallace’s words -

For the hand that rocks the cradle
Is the hand that rules the world.

- but drug companies have targeted medical students (in some sense “infant doctors” – no offense implied)  with their marketing and “freebies” for years. As the Baltimore Sun reports,this is the case at the University of Maryland, but it is hardly an isolated case. The rationale is simple: the earlier and more often doctors a ‘primed’ and associate pleasure with a particular drug, the more likely they are to later prescribe that drug when they can make the choice. This holds true for any stage of training. When I was a fellow at the University of Washington, almost every lunch meeting of the residents in Medicine seemed sponsored by a drug rep. This was justified by the Medical Department by stating that they could not afford to pay for these meals and that residents would not show up for conferences if  they were not catered. The latter part may be true (would you skip lunch if you worked 60 to 80 hours a week?). However can we allow the pharamceutical industry and complicit major academic institutions to contaminate the learning enviroment in such a way? The answer is No! The American Medical Student Association (AMSA) and the National Physicans Alliance strongly oppose this practice and I can only urge all medical student, residents and “grown up” physicans to support us in this cause.

During the GOP-controlled 109th Congress, I worked with a number of student groups to reauthorize and improve the student loan programs. In reality, we spent most of our time trying to make the proposed changes less-bad for students.
The past two weeks have heralded a series of investigations into the lending practices – many things we had suspected (like the bribing of school officials by lending companies) and some we had not (Dept of Ed officials with stock in private lenders).

Today, the New York Times is telling the story that we told to many Congressional offices: how private lenders are using the political process to extend their control on the loan industry. It includes a statistic that I didn’t believe the first time that I saw it:

President Bush’s budget reports that in 2006 for every $100 lent by private lenders, the cost to the government of subsidies, defaults and other items was $13.81, while the same amount lent through the direct loan program cost the government $3.85.

It costs the government four times as much to lend money to students through the private industry as opposed to directly doing it. This flies in the face of the sentiment that the government is inefficient and that private industry with competition is always better.

Much of the argument against a single-payer health care system is based on this same fallacy: that the private industry is more efficient than the government. But when examined in an evidence-based manner, we discover that this does not hold true.

Taxpayers should be offended that student loans are being provided through inefficient mechanisms that allow private companies to siphon money from the system. We should also be appalled that we continue to finance our health care system in a way that is based on the same flawed assumptions.

Welcome to NPA Blog. Here you will find a community of physicians who have chosen to look back and look forward. Doctors who long for the return of the values of our profession of service, itegrity and advocacy with the modern spin of an organization that utilizes the tools and ideas of modern times. At the National Physicians Alliance we are striving to create an organization that is nimble,transparent and democratic. To do this we need all of you. There are over 800,000 physicians in this country. Even the largest of our organizations represents a small fraction of those docs. We need a voice. The country needs us to step up as advocates and defenders of what is best, not for doctors, but for the health of our people.

At the NPA we are all here for a dream, a wish, a vision carried over from our days as students.

We need a home.

A place were we can reach across specialties and interests and find each other.

A place we can find support, friendship and the synergy that comes when people of good hearts and altruistic motives come together and make magic.

We need it to fight the cynicism and despair of our times and our world that taints our work.

We need it to nurture young physicians in their ideals and activism.

We need a place to celebrate each other and the miracles large and small you accomplish every day.

We need a place we can go where we can be reminded what an amazing honor and privilege it is to have another put their life in your hands, share their vulnerabilities and nakedness and witness the beginning and end of their time on earth.

Then there is the other reason for the NPA.

Somehow our profession has lost its way.

The obsession with the business of medicine has, like Harry Potters Dementors, sucked the joy out of our jobs.

I believe this is at the core of the void so many of us feel about our work.

For decades now, the focus on financial issues, in particular by the AMA, to the near exclusion of all others, at least in the political and press worlds, has contributed mightily to the loss of trust the public has with our profession.

Our patients question our motives when it comes to decisions about their care and rightly so.

Did we choose that drug because we just had a free lunch or because it is the cheapest and best medicine for that person?

We all swear we are NOT influenced by these things, but there are rafts of research showing it is, in fact, so and ask yourself, if a pharmaceutical company would really spend the equivalent of $12,000 a year per physician on these things if it wasn?t effective.

Today we are no longer this country?s most trusted profession. We now trail nurses and pharmacists.

Now,I’m not so naive as to believe issues of money and financing medical care can be ignored.

Not at least in this country.

Medicine is a business and a big one.

Billions of dollars are being spent and made in this industry annually.

Lest you think I?m a total socialist, I’ll tell you I feel entitled to a piece of that action.

I have sacrificed a good part of my life; probably health and for sure, well being on this alter of medicine.

I want a good life.

I?m grateful we have strong trade associations working on these issues on my behalf, for my compensation and my autonomy to practice without being micromanaged by non-medical entities.

The question I often ask myself however is, how much is enough and at what cost does it come?

The problem is that something is missing. We are missing a different voice in the public discourse.

One that focuses not on issues of physician self interest but one that speaks for physicians as advocates for health.

Many of our professional organizations have become so distracted or politically beholden they have become silent on issues that so clearly scream for a physician voice.

Perhaps no issue illustrated this as clearly as the Terry Schiavo case.

The medical condition of a patient was discussed on the floor of Congress, in the halls of justice and the in court of public opinion, yet organized medicine did nothing to bring medical, scientific sanity to a country craving answers on this issue.

It is time for this voice.

A physician voice that is not so compromised by conflicts of interest that it cannot advocate for the lowest cost medications for seniors.

A voice who will call for the radical overhaul of the malpractice system that fairly compensates all patients injured by poor care, promotes the safest medical practices and stops the waste of frivolous lawsuits.

A voice who advocates for a system of care that first and foremost, ensures that every person in this country can receive affordable, quality healthcare that allows them to reach their full potential.

This after all is supposed to be the promise of a democratic society.

This, then is the mission of the NPA:

“The National Physicians Alliance is founded to restore physicians’ primary emphasis on the core values of our profession: service, integrity, and advocacy. The NPA offers a professional home for physicians seeking creative collaboration and mutual support. As a
diverse physician community, we work to improve health and well being, and to ensure equitable, affordable, high quality health care for all people.”

I encourage you all to join us. Explore this blog, our website, join a committee, make a donation. Help us build a strong community of physicians whose primary mission is to first and foremost to safeguard and improve the health or our people.

Thank you,

Lydia

President and Founder, NPA