Demystifying Medicine One Month at a Time

Tag: Shots (Page 1 of 2)

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:

The Inflection Point(s) of Aging

A new column of mine has been posted on NPR’s website about “de-prescribing,” the art of pruning medications from older adults that take too many of them, a condition we refer to as polypharmacy.

Katherine Streeter for NPR

Katherine Streeter for NPR

It’s well-known that being on too many medications can lead to more side effects and drug-drug interactions, so anything medical professionals can do to minimize such negative outcomes is welcome. Thus we revert to our Hippocratic doctrine: First, do no harm.

Contrast that with the competing ethical imperative toward beneficence — to do good for patients. Medical science teaches us that many (though far from all) of the medications we prescribe for chronic illnesses (e.g. cardiovascular conditions) lead to fewer ‘events’ (think heart attacks & strokes), which prolong lives.

As a result, doctors wind up prescribing a lot of stuff — and decades of medical practice and now guidelines and quality metrics push us to do this even further.

One area I’d like to see science help us is in identifying “The Inflection Point of Aging,” which I define as the point in a person’s life when we can pare down ‘aggressive’ treatment of chronic conditions because it becomes counterproductive: when taking the “medically proper” action is likely to cause more harm than good.

This whole notion arises out of recent discourse: As I recently blogged, the SPRINT Trial, which was stopped early because it showed that treating blood pressure even more aggressively than we’d previously thought leads to fewer bad ‘events.’ How low, I wonder, is too low?

Also, an article in the Atlantic by medical pundit Ezekiel Emanuel titled “Why I Hope to Die at 75” emphasized this idea.

Emanuel is a known iconoclast, but I appreciate his efforts to stir up dialogue and get us talking about important issues that we are otherwise reluctant to discuss. In this case, I think his editors at the Atlantic did him a disservice, because the provocative headline of the article caused a furor and detracted from his real message, which was simply this: There comes a point where undergoing standard medical practices no longer makes sense. That point is different for everybody and is dependent on a person’s values as much as their physiology. Emanuel never said he wants to die at 75, merely that he plans to stop seeking medical interventions at that age — two very different ideas.

If you click over to the NPR column, you can see that anecdotally, we care for patients for whom physiology does change — and it therefore doesn’t make sense to keep doing the same things over and over. It’s trite to say it (and you’d be amazed at how challenging it can be to fight medical inertia), but we must think about each patient individually and truly weigh the risks and benefits of adhering to population-based norms and recommendations when goals and bodies change.

No, Not Painless

Both the movie and the TV show M*A*S*H share the same theme song. Even if you can recall the music in your head, many people don’t know the song’s strange title: “Suicide is Painless.”

My latest piece for NPR’s Health site, “Shots,” recalls my mother’s death by suicide from my viewpoint as a son and someone entering the medical profession.

In thinking about my Mom’s death, I’ve always remembered the title of the M*A*S*H theme, but had never really thought about its meaning. Here’s the refrain:

That suicide is painless
It brings on many changes
And I can take or leave it if I please.
I try to find a way to make
All our little joys relate
Without that ever-present hate
But now I know that it’s too late, and…

It’s interpreted to mean that compared to the horrors war, suicide is the less painful alternative.

I’m OK with the thought for soldiers and as a literary device, but I’m here to tell you that suicide is most definitely not painless to those it leaves behind.

Tortoises and Hares

slowmedimageI’ve become increasingly aware of a movement, a philosophy, an attitude called Slow Medicine.

The concept is an outgrowth (and homage) of the Slow Food movement.

I’d heard about Slow Medicine from the book “God’s Hotel” by Victoria Sweet, who practiced for two decades at Laguna Honda Hospital outside of San Francisco. Let’s just say that Laguna Honda is not your typical American hospital.

A concept that Sweet shared really stuck with me: viewing the human body as a garden to be tended (a medieval view) instead of the modern attitude of the human body as a machine to be fixed.

Think about that.

More recently, I was fortunate to be included as a recipient of “Updates in Slow Medicine” from two doctors, Pieter Cohen and Michael Hochman, who both trained at the Cambridge Health Alliance, in Massachusetts. That’s where I also trained as a resident.

Their work really resonated, so I was lucky to be able to write about it for NPR:

Post by NPR.

Contagion of Yesteryear

Ebola seems to have taken up a significant portion of the news stream as of late.

sars-2003_custom-1ec2de788947040b25f2065b83f3b0e087fe0768-s40-c85

NPR–>Kevin Frayer/AP

It’s understandable, given the breadth of the epidemic (largest ever), the fact that it’s hit our shores, and that it’s so frightening: hemorrhage! death!

I wrote a first-person account of the time I was asked to evaluate someone for SARS, a 2002-2003 novel disease outbreak that originated in China and spread quickly to the West (in the end, only 27 U.S cases and no deaths; in Canada, 251 cases and 44 deaths).

SARS is a descriptive name: Severe Acute Respiratory Syndrome. We subsequently learned that it’s caused by a corona virus and that it’s spread by contact and respiratory droplets.

The outbreak died down as quickly as it flared up, and it’s nary been heard from since.

Here’s the concluding graf from the story–as true for Ebola as it was for SARS:

Today’s Ebola crisis makes clear what the many of us were slow to accept in 2003. It takes clear thinking, painstaking preparation, flawless execution and clear communication to protect the public health.

We can only hope that Ebola recedes and becomes a distant memory, also.

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