Demystifying Medicine One Month at a Time

Tag: medical ethics

Does Medical Marketing Work?

20140929-dollars-for-docs-300x200_1You bet it does.

In the ‘old days,’ doctors were taken on junkets to sunny destinations and indoctrinated with the latest and greatest in brand name medications. The trips were paid for by the pharmaceutical firms that manufactured these drugs.

Trips like this started to become unseemly, and the public began demanding more transparency in the relationships their doctors had with drug companies. A database was created to keep track of the monies flowing to docs from drug companies.

Docs can still get a meal (as long as it’s ‘educational,’ i.e. there’s a lecture along with it) and the traditional branded pens and pads of paper for the office. Sometimes drug reps (the sales people for the pharma firms, known in the trade as ‘detailers’) bring by bagels or doughnuts to woo the staff and steal a few minutes to tell us about their latest product.

The big money comes to the select few who become ‘thought leaders,’ i.e. spokespeople on behalf of certain drugs. This can range from five to six figures. Per year.

Docs have always been a little defensive about having these relationships explored or highlighted. “No drug company influences the way I prescribe,” is a common sentiment.

“I prescribe the best products that are on the market,” is another retort — not hard to defend, as the brand name drugs create the perception (at least) of being the best.

Conventional wisdom has always held that drug companies wouldn’t spend the billions that they do on marketing if it wasn’t beneficial. Proof of that has been hard to come by, though, as there wasn’t a way to clearly demonstrate a relationship between drug company payments and the rate of prescribing brand name (i.e. heavily marketed, more expensive) drugs.

Now there is.

In a beautifully conceived and executed investigative report, the non-profit news source ProPublica has linked the pharma payment database with the Medicare Part D (which since 2003 has paid for prescription drugs for seniors) database.

You know what?

There’s a perfectly linear correlation: Docs that receive payments (in one database) prescribe more brand name drugs (from the other database).

Nothing about this is illegal. There’s no doubt that some of the doctors receiving payments genuinely believe the brand-name products they prescribe are better. It’s just that no one can claim with a straight face any longer that payments to doctors don’t influence the way we prescribe.

(Mind you, the drug companies have known this all along, but have kept this information private as ‘proprietary’ information. Trade secrets, you know.)

If you like this kind of reporting, you can listen to a story about the investigation here:

#MacLean15

IMG_0536Recently I attended the annual conference of the MacLean Center for Clinical Medical Ethics at the University of Chicago. I was a fellow there a decade ago, spending a year steeped in study of the history and mechanisms of making complicated medical choices and attempting to resolve seemingly irreconcilable choices.

The center began in the 1980s, and has trained nearly three decades worth of fellows. As such, the annual event brings back many alumni but also outside speakers and attendees from across not only the U.S and Canada, but also from Europe and Australia. The conference took place at the University’s Law School, where I snapped the accompanying photo of one of the Law School’s most noted former lecturers outside of Classroom V, which was apparently his favorite place to teach.

There were many interesting topics covered at the conference. Among them:

  • Persons donating kidneys are more likely to eventually need dialysis and transplant themselves, and should be informed of such. (Sounds intuitive, but had not been scientifically proven before.)
  • In spite of massive effort, compliance rates for hand washing in hospitals continues to hover near 30% of available opportunities.
  • Frustration with insurance companies approving expensive drugs for conditions like inflammatory bowel disease led one doctor-researcher to ask, “Do insurance companies have medical ethical standards?” (Apparently not; they only have ‘business’ ethical standards.) He used social media to positive effect for some of his patients to get them ‘restricted’ but indicated medication.
  • A physician with a strong humanist bent shared how his frustrations with the practice of modern medicine (productivity constraints, feeling more like a widget in a system than a professional) were put in context by a trainee of his undergoing excruciating treatment for cancer who maintained a wonderful attitude about his life despite his suffering.
  • Several sessions focused on the struggles of the most vulnerable — and providing care for them — children, elderly, veterans, the mentally ill.

That is only a sample of the presentations. Since the center and the conference are underwritten by benefactors, attendance is free and only requires registration.

Age is Just a Number, Right?

In case you missed them, a couple of lay press articles hammered home the idea of our lifespans being finite.

ezekiel_emanuel_0First there was Zeke Emanuel’s provocatively titled “Why I Hope to Die at 75” in the Atlantic.

The title was unnecessarily inflammatory. A lot of people saw that and thought “Health Care Rationing…” and “what a jerk!

One of the core points of his article is well-taken: when we hit a certain age (75? 80? 85?), it no longer makes sense to “look for disease.”

Health care must continue improving and striving to reflect and honor the wishes of patients, but in addition, we should be more rational about whom we screen for disease and how often. It makes no sense to perform colonscopies in octogenarians to “screen” for colon cancer. Even if they have it, the colonoscopy  is unlikely to extend their life or improve its quality.

I think readers are right to quibble with Emanuel’s contention that at 75 creativity takes a nose dive. He was using that opinion, and the statistical evidence of age-related slowdown, in support of his point about the cutoff age for aggressive medical care. I hope sensible debate is not lost because of his tone and the fact that he’s seen as too political. He did work for the administration during President Obama’s first term, after all.

cohen-01-by_david_boswell

Cohen in younger days.

That same week, the New York Times published an opinion piece by Jason Karlawash of Penn, who wrote about musician Leonard Cohen’s decision to resume smoking (something he’d quit) upon turning 80. Titled “Too Young to Die, Too Old to Worry,” Karlawash examined how the 80+ population has grown from a half of one percent of the population to more than 3.5%. Doesn’t seem like a huge percentage, but it is certainly a significant increase and a huge demographic shift.

As Karlawash writes in the key paragraph of his piece

…Mr. Cohen’s plan presents a provocative question: When should we set aside a life lived for the future and, instead, embrace the pleasures of the present?

Drawing Lines

Where should we draw the line on using medical technology to sustain life?

Envision a scenario:

"Wall Drawing #65" by Sol LeWitt

Milt is 87. Over the years he’s developed diabetes, high blood pressure, arthritis, lumbago (back pain), hearing loss, too many moles to count, and high cholesterol.  He sees his doctor three times a year for checkups on these conditions and to keep his long list of medicines stockpiled. He also sees a specialist or two.

Recently Milt developed “a touch” of pneumonia and was hospitalized for three days. Since being there, his doctor informed him that his kidneys “aren’t filtering as well as they used to.” The doc tells Milt that his kidneys are functioning at about 50% of what they were as a younger man, but not to worry since we know that people do just fine with one kidney.

As often occurs with chronically ill elders, Milt winds up back in the hospital six weeks later with “congestive heart failure.” His heart is not pumping blood effectively, so fluid is backing up in the lungs causing shortness of breath. His legs are swollen. The hospital doctors treat Milt with diuretics to “get the extra fluid off,” but in doing so his kidneys now worsen.

Nephrology is consulted.

Based on Milt’s lab data and urine output over the last 48 hours, the consultant tells the docs that Milt’s effective kidney function is zero. The consultant says the only option is dialysis. Without it, Milt will die due to kidney failure.

Fortunately, since 1972, anyone with End Stage Renal Disease in the U.S is entitled to coverage for such treatment.

When the law passed, it was largely in response to the unfairness perceived in who was selected for dialysis treatment when it first became mainstream. When a resource is scarce, someone is inevitably going to be left out.

Fast forward about forty years, and see this really interesting article from my favorite medical journal, the NY Times.

I vant to suck (and filter) your blood.

Dialysis, the article notes, was originally intended for people in whom substituted kidney function would permit them to return to productive lives. As we continue living longer, more and more patients fall into the category of becoming “eligible” for dialysis treatment. As with many medical decisions, deciding whether to undertake it is not as easy as it seems:

Dialysis is difficult, especially for the old and sick. Most of the nation’s 400,000 dialysis patients spend several hours, three days a week, hooked up to a machine, and additional time traveling back and forth to the clinic.

They have to restrict salt and fluids, and the procedure is so exhausting that some patients rest for the remainder of the day. Although dialysis may alleviate symptoms like fluid accumulation in the legs or lungs, it can lead to dizziness, weakness, leg cramps, nausea and other problems. Complications like bloodstream infections or clogged blood vessels where the dialysis needles are placed are common, often requiring surgery or hospital stays. Ultimately, about one patient in five is unwilling to go on with it.

Having treated patients of advanced age with many co-morbidities, I can say first hand that there are some patients I wish had chosen against dialysis. (Here is the courageous story of one.) Not because I’m stingy or want to be on a “death panel.” But because I want them to live out their days with dignity and in comfort, not tethered to medical appliances and suffering for long stretches.

The thorny ethical question is “when should dialysis not be offered?” In the U.S, we have yet to successfully address this question in most of the workaday world of medicine.

Where would you draw the line?

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