Monday, March 26, 2007

A Visit to the Doctor's Office

What does Healing look like?

A patient asked me this recently, and I wondered.... What does healing look like anyway? If it could look like anything? And where is healing found?

We as doctors believe that we are writing prescriptions for healing left and right. By the end of any given day, we've written countless prescriptions and fulfilled another slew of refill requests. But are we really healing our patients?

What does healing look like?
Is healing a soft little teddy bear cuddled next to your sleeping child providing a comfort of softness and warmth that goes beyond words?

Is it the accentuated smile on a cancer survivor's bald face after the last round of chemotherapy (saying without words, "Here I am. I have survived!"?

Is it an angel wrapped in white garments floating in thin air with a halo of light around their head?

Is it the calm and loving touch of a mother?

Is it the warmth of the sun?

Is it a rainbow after a mid-summer night's thunderstorm?

Is it that moment when your lover apologizes for having caused you untoward pain, when the tears come forth unexpectedly, when you feel like your heart can let go?

Is it when your dog comes running to you all jovial and innocent, just wanting to slap a wet tongue kiss on your face?

Is it that moment when you can finally say I understand what is wrong with me, and now I can let it go, or at least deal with it better?

Is it in the moment of gratitude inside the exam room, when the patient thanks you for never giving up on their case, with tears running down their cheeks?

Healing is found in the hidden corners of the world. In the most unexpected places. It is in nature, as well as in humanity. Healing is everywhere to be found, if we only open our eyes and see it.

Friday, March 23, 2007

The Internet's in the Mix as well.....

Well no stone has been left unturned, as I said. Today I got an email from "InfoSessions at" with the title in the Subject line: "GERD Patient Education Program." Well, sounds all nice and good. We PCP's sometimes don't have enough time to go over every single detail of what GERD is all about. Sure, it would be nice to refer our patients to an impartial online source of information about GERD, its consequences, and how to modify the diet to prevent symptoms. The subtitle is:

Could you use extra help educating your patients about erosive GERD?

Wow! Could I? Yeah! It goes on to say, " Making sure that patients understand their medical condition and comply with therapy can be challenging. Now, an exciting new free patient education program from the makers of PROTONIX® (pantoprazole sodium) is here to help you educate your patients about their condition and PROTONIX 40 mg."

Well, there's the catch. It's sponsored by the makers of Protonix (i.e. Wyeth Pharmaceuticals).

Wednesday, March 21, 2007

The Marriage of Medicine, Mother Pharma and Uncle Sam....

Big Pharma has been closing its gap on medicine in the last two decades. It is hard to find physicians in academia or high level positions of influential medical advisory boards that have not been tapped by the fertile green hands of big pharma. They come dressed as attractive young drug reps, carefully chosen by these companies to have enough look appeal to help them across the doors and thresholds of doctor's offices. Not all welcome them equally, but when they're sporting a potential $750 honorarium for a speaking engagement expounding the virtues of their drug, the poorly paid doctors of our times succomb. Perhaps if the system were different, and doctors didn't have to look for external sources of income to survive (that in itself is ludricous), would the doctors then stay devoid of this corrupting influence. It's no longer pristine. The editors of major medical journals have written that they can no longer guarantee that the studies published in such respected journals as The New England Journal of Medicine and JAMA are free of commercial bias. Sure, any relationships the authors may have with the sponsoring company must be disclosed, but what is not disclosed is how the data may be distorted, how the authors of the papers themselves may not be the real author (instead a ghost writer hired by the drug company), or how the drug company may have only revealed parts of the data from their randomized-controlled trial to the authors that must publish a commentary on the results (obviously to favor their drug). Why would a drug company do otherwise? Their purpose is not to promote the general health and well-being of the population if it does not meet their needs of promoting and selling their highly expensive developed product. Thus knowing that they cannot influence doctors directly without evidence, they have infiltrated the system to make the evidence and guidelines come from seemingly impartial doctors.

But an article in today's NY Times, "Doctor's Ties to Drug Makers are Put on Close View" points out how far these relationships have gone. The amount these doctors that speak on behalf of the sponsoring drug company's products may receive over several years can be as high as the hundreds of thousands. The amount is even higher if the doctor is performing research that could benefit the drug company. The article used the example of Dr. Allan Collins, President of the National Kidney Foundation who had received honorariums from Amgen anywhere between $10 - 20,000. However, the interesting thing is he denies receiving more money in an email, stating that a "contract amount of $1.9 million from Amgen was paid to the Minneapolis Medical Research Foundation (MMRF) for the research contract, on which I am the designated senior researcher." Maybe I'm wrong, but last I checked a senior researcher receives a stipend from his or her research grants. So indirectly, he did receive an unaccounted sum from Amgen. Whoever thinks that may not influence prescribing patterns is deluding themselves. Studies have shown that doctors that have relationships with the drug makers tend to prescribe the newer, pricier drugs they are pushing. Well, don't expect big pharma to be pushing the older, generic and cheaper drugs, of course, because they might be in the best interests of controlling rising healthcare costs. That's not where the money is made. So the interests of the population are mixed with the interests of big pharma under the disguise of a respected physician expert in the field. It's the shrewdest game of deception. Other doctors go to these pharma sponsored dinners to hear an "expert" who is being paid by that very same drug company to give the lecture. Would the drug company pay a physician to get up and speak against its drug? It's the big bad wolf in Grandma's clothes, except the wolf has convinced someone else to dress up like grandma that actually looks like grandma.

An article in the NY Times immediately followed today's article on deceptive pharm influence with the title, "FDA rule limits role of Advisors Tied to Industry." This seems to be an important step in the right direction because for the first time experts that have received money from drug or device makers would not be allowed to vote in the advisory committee hearings that decide on the approval of new products. On the surface this sounds good, but they've allowed a loophole, of course, with any doctor that has received less than $50,000 (a sizeable amount in my books) in the prior year still allowed to participate in these committee hearings. Well, why allow ANY amount at all. In my opinion, if there's money in the game, influence is being exchanged under the table.

Dr. Lutter, FDA acting deputy commissioner, stated, '"The $50,000 threshold is something that we think strikes an appropriate balance between' getting smart advisers and reassuring the public that their advice is not tainted." Well that's a bunch of hogwash! Maybe what he's really saying is that all of the smart advisors have already been infiltrated by the drug industry. Is there no stone unturned? Needlesstosay, I remain skeptical. Why aren't they jumping to make the panels that come up with national treatment guidelines devoid of pharmaceutical influence?

Let's call a spade a spade. If national treatment guidelines are produced by a panel of experts, the majority of which have received money from the drug companies, don't call them "Expert Treatment Guidelines," call them "Grandma's Suggestions on what Drugs to Take to Stay Young and Keep up the Drug Company's Record Profits."

Thursday, March 08, 2007

HPV Vaccine: Why aren't clinics and other docs rushing to offer it?

An article in today's Metro NY talks about the lack of HPV vaccines in New York City's STD clinics and immunization centers. I'm happy to see this article on the front page, because the HPV vaccine needs to be brought to the attention of not only the public, but physicians as well. Gardasil, the quadrivalent version was only released last summer and there is still confusion and misunderstanding amongst physicians as to its use. The article, however, did not make mention of the following very crucial information for the public to be educated about the HPV vaccine:

Gardasil protects against four types of HPV (6, 11, 16, 18). HPV Types 16 and 18 cause 70% of cervical cancer cases, and HPV Types 6 and 11 cause 90% of genital warts cases.

The CDC currently recommends routine vaccination of all girls ages 11-12, although vaccination may start as early as age 9. Catch-up vaccination is recommended for girls and women ages 13 – 26 who did not receive the initial vaccine series. The vaccine cycle involves 3 doses, given at 0 months, 2 months after the first dose, and 6 months after the first dose.

Having a Positive HPV DNA result on a pap smear is NOT a contraindication to getting vaccinated. This is a misconception I have heard OB/GYNs telling their patients. The vaccine still provides some level of protection, even for someone exposed to one subtype of HPV. The HPV DNA test can only test for low-risk or high-risk. It does not distinguish which HPV type(s) were isolated in the pap smear, as this test is very costly to perform.

In addition, the HPV vaccine, which is relatively costly compared to other vaccines, brings to question some ethical issues in medicine. Each vaccine costs the provider approximately $140 to purchase. This was initially a point of hesitation for me as I'm trying to keep my costs down. Often, Merck will give discounts on mass orders, but one does not want unused vaccines sitting in the refrigerator and going to waste. With each vaccine so costly, the recommended cycle of 3 vaccines will cost $420 just for the vaccine; this is without accounting for storage and administration and overhead costs. Factor that in, and each vaccine costs $210 for a small practice, with the total cost running $630. Now you could lower the margin, but it does not help the public to not be able to meet your overhead costs. Fortunately, insurance plans are stepping up and covering the cost of the vaccine, as they rightly should. I have yet to see what they will reimburse for this, as often they pay less than it costs to purchase the vaccine. The initial creative solution for my practice to control up-front costs is to determine our vaccine requirements ahead of time by having qualified patients commit to receiving the cycle, then ordering based on that demand. One can order vaccines at, often with a 24 hr delivery time, which makes demand-ordering possible.

Comparative cost of commonly used vaccines on (other companies offer comparable rates):

Hepatitis A (Adult, single dose) $56.84
Hepatitis B (adult, single dose) $50.54
Gardasil (HPV, single dose) $141.69

Is the high cost justified, or is Merck making a hefty profit before competition hits the market? It seems that MedImmune with GlaxoSmithKline and Norvartis (separately) are racing to bring their own versions of the vaccine to the market. I have mixed feelings about Big Pharma. Even though Merck has helped the public good with its preventive vaccines, it also needs to make money off of them to meet the interests of its shareholders. Its interests are split between helping the public good and helping the pockets of its investors, as we saw with Vioxx. How much profit for Merck is ok when dealing with a matter for the public good? The good news is that competition will eventually lower the price to where it should be.

Finally, while it's true that the US population should be vaccinated for HPV no doubt, cervical cancer rates in this country have markedly dropped since the introduction of the Pap smear more than half a century ago. We should remember that cervical cancer is a more widespread and deadly disease in Africa, where many more women are dying every day from this devastating cancer. In Africa, Pap smears are not routinely done or available. Is there some obligation to make this vaccine available to Africa at a lower cost that these countries could afford to institute a nationwide vaccine program? One day our consciences will hopefully ring in compassion for those more needy.

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