We proudly say that medicine is an art and a science; it is a profession and a calling. But as with all professions, there is a treacherous interface with business and profit.

Over at the Happy Hospitalist, he is thrilled that his hospital is marketing “screening” tests for cash-paying patients. What a great business move! Have patients pay cash for tests to ease their fears — except for those patients with possible findings, who will then go on to have more expensive confirmatory testing. It’s a glorious cash-cow.

That erodes the core of our profession.

Yes, perhaps some physicians will quiet their ethical queasiness with the rationalization that cash-paying patients will support the hospital to care for those without means. And others, like Dr. DeQuervains, will see it as an extension of the services that they offer patients.
But it is yet another tarnish in the coat of professionalism that physicians wear. And these are stains that are very hard to remove once they have set.

Modern medicine has a conflict to resolve, one that is actually quite old. Do we provide a service to our patients when we treat, cure and comfort them? Is this a service that should be auctioned off to the highest bidder? Do we merely lay out a menu of tests, procedures and recommendations (along with price tags), and let our “consumers” decided? Should we sell snake oil because our patients will buy it?

(Read more…)

Cross post from: beactive.blogspot.com

Nova Scotia News – TheChronicleHerald.ca

’Every day is the perfect day to stop serving fries and doughnuts. Every day is the perfect day for a health care institution to lead by healthy example.’

If you agree, work with me and the National Physicians Alliance to make Hospital Food Healthy. Have ideas about what is healthy food for a hospital?
Let me know.

Last week, Minnesota became the latest state to have legislation introduced that would ban the practice of prescription datamining. SF 3699 will prevent the sale of prescriber-specific prescription information for commercial purposes.

I had the opportunity represent the NPA at the hearing in favor of the legislation. In addition to my testimony, the Prescription Project and the Minnesota Seniors Federation also spoke in support of the legislation.

The discussion was lively, and quickly moved into the more general topic of gifts and drug detailing. At several intervals, several of the state Senators expressed their personal experiences. I never expected to have many of my arguments presented by a legislator, but one described working in a psychiatry office that has weekly lunches sponsored by drug companies.

The opposition also testified, including PhRMA and a prescription benefits manager (PBM). They argued the same lines: that physicians need detailing to learn about new drugs, that the data is used for research, and that existing legislation is under court review in New Hampshire.

Let’s take those apart:

Physicians need detailing to stay current – Of course not. There are plenty of unbiased, evidenced-based sources of information about new drugs.

Research would be harmed without this information – Very rarely do health policy and public health researchers need data specific to prescribers. But if they did want the data, few researchers would be able to afford it, nor would want to submit their research proposals for approval by the companies, which can be a requirement. Luckily, similar data sets are available from Medicare and other public programs.

Existing law is tied up in court – The New Hampshire law is currently under review in the District court. The drug companies argued that this is a commercial speech issue. (Curious how what physicians prescribe to their patients should be available, but what drug companies pay to physicians is “proprietary information” …) But judges have found that the State has an interest in regulating this area in the public interest. We expect the court to rule in the coming months.

But wait, there’s more! This week, legislation banning gifts to physicians in Minnesota may be introduced. Minnesota already forbids gifts over $50, but the ban is poorly enforced. The NPA will hopefully have an opportunity to testify in support of this legislation as well.

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.

Physicians from around the country have gathered here in Houston this weekend for the 3rd annual National Physicians Alliance meeting, where we’re discussing coalition-building, health disparities, health access issues, and engaging members at the local level.

Keep a look out for a number of new users on this blog and some fresh updates from the conference!

As pediatricians, we are deeply troubled by Senator McCain’s recent and irresponsible comments regarding the etiology of autism (NYT article–”McCain Steps Into Debate Over Cause of Autism” 3/3/08). There is established consensus among scientific bodies including the Institute of Medicine and the Centers for Disease Control that patients need not fear linkage between vaccines and autism. Senator McCain took a grave risk with the public health when he expressed doubt about the safety of immunizations. Immunization can only succeed in protecting the public health when everyone takes part in that protection. Would a President McCain take us forward or backward in preventing deaths from measles, mumps, rubella, diphtheria, polio, tetanus, hepatitis, influenza and more? The National Physicians Alliance calls on all political leaders to use great caution with public statements likely to spur panic and fear.
Josh Rising and Rupin Thakkar
Members of the Board of Directors
The National Physicians Alliance

As the New York Times, the Washington Post, and others report that “researchers found that a $2.50 placebo works better than one that costs 10 cents.” Let me first say, this has the air of a brilliant study – it is small, but concise – I wish I had that idea! It was published in JAMA on March 5th (if you subscribe, here is the full text link).

The placebo effect is nothing new. New is the way it was studed in this paper. In a study reminiscent of the Milgram Experiment, Weber, Carmon and Ariely gave a few young women and men electric shocks and had them rate the associated pain from zero to ‘most excruciating’ (no one got that much it seems – also good to know that mortality appeared to have been 0%). The shocks were repeated after a ‘pain pill’ – which happened to be a placebo – was given. Subjects were told it was a new pain killer like codeine, one group was told it cost $2.50 per pill, the other was quoted 10 cents. Patient in the $2.50 group got 85% pain relief. EIGHTY-FIVE-PER-CENT. The cheaper pill caused 61% to feel less pain. The study lacked a control group that received nothing, leaving open the question if there was any other effect on people, like getting used to being buzzed wit up to 80 V.

How you judge the results depends how you define ‘placebos work’. It is actually the subjects’ brain that do the work (suppressing their pain), unless you think sugar actually is a pain killer (some say that it is an anti-depressant and stress reliever, especially when combined with Cocoa!).

If you want to read about a great placebo effects, or thought that it applied only to medicines, consider the paper on tying off the mammary artery for angina by Cobb et al. in the New England Journal of Medicine in 1959. It is one of the ‘classic randomized controlled trials’ as reviewed by Fuchs, Klag and Whelton in JCE:

After its introduction by Italian surgeons, an operative procedure in which both mammary arteries were ligated was one among several proposed to treat angina. It was enthusiastically accepted by some American surgeons in the 1950s. It was thought that blood from the mammary arteries would be diverted to the coronary circulation through collateral channels proximal to the site of ligation. In a pioneering clinical trial, Cobb and collaborators randomized 17 patients with severe angina pectoris to internal mammary bypass or to a sham surgical procedure. The investigators limited enrollment to patients with severe angina, based exclusively on the presence of angina induced by effort. In each patient, surgery was conducted under local anesthesia, and was identical until both internal mammary arteries were isolated. At this point, the surgeon opened a sealed envelope that contained instructions regarding whether the internal mammary arteries should or should not be ligated. The investigators took special care to maintain blinding of the patients to the choice of their surgery. They were told that they were participating in an evaluation of the new internal mammary artery ligation procedure, which had already been acclaimed as a success in the Reader’s Digest. Likewise, the physicians who evaluated the patient’s postoperative experience were not informed as to the surgery that was actually performed in the operating room. The results showed that the number of nitroglycerin tablets used was reduced by 42% in those whose internal mammary arteries were not ligated and by 34% in their counterparts whose internal mammary arteries were ligated. In each group, five patients re ported a significant improvement after their surgery. One patient, whose arteries were not ligated, claimed complete relief to the extent that he was able to return to work.

The cost perspctive of the drug makes it unique, although similar esults have been found in wine tasting. Which brings me to the following conclusion:

1. It is not surprising that we as a society have bought the tale told by Big Pharma that good pills have to cost a lot.

2. It is not surprising that some people swear brand name drugs are better or generics have more side effects – even less that more often or not accused drugs are psychotropic, while I have seen little about IV antibiotics used to treat serious infections. It can probably be safely assumd that bacteria themselves are not susceptible to the suggestion of a placebo (OK, you guys who will to comment on influence of the mind on the immune system – save it, I am making a point here).

3. Despite its obvious “more expense, more effect” message, this study underlines the fact that what we most need is health care providers to understand and talk to their patients and make them believe in the treatment – not another overpriced “Me too drug”.

read more

Cheers to the U.S. House of Representatives!!

On last evening, the House took a great step toward ending discrimination toward a group of patients with the passage of the “Paul Wellstone Mental Health and Addiction Equity Act of 2007,” named after the late Senator from Minnesota who was a passionate advocate for mental health parity. I salute Reps. Patrick Kennedy, D-R.I. and Jim Radstad, R-Minn. for their bipartisan effort to end stigma and right this severe wrong with regards to healthcare in the United States.

The Senate sponsors, Sen. Edward Kennedy, D-Mass., Sen. Pete Domenici, R-New Mexico and Sen. Mike Enzi, R-Wyoming, will work to help send it to the president for signature. This bill is so important. It pains me to have to tell patients who receive all of their care for primary care and specialty services at our hospital that I can not see them or that they have very high co-pays.

It is embarrassing and shameful that a physician in the house, Rep. Phil Gingrey, R-Ga, would not vote for this bi-partisan bill. When will the medical community remember that the brain is still an organ and is vulnerable to illness and should not be separated from the body when we think about the practice of medicine.

Write your Senators! This bill needs to be passed!

I think we have gone done the road of separate but equal once before. It did not work then and does not work now.

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.