Placebo Journal - Medical Humor With A Purpose

The title “One-sided view tells some truths”, written by Richard Wolf with contributions by Rita Rubin and Julie Appleby, summed up the whole movie. Here was a quote:

Sicko uses omission, exaggeration and cinematic sleight of hand to make its points. In criticizing politicians, insurers and drug makers, it says little about the high quality of U.S. care. In lauding Canada, Great Britain, France and Cuba, it largely avoids mention of the long lines and high taxes that accompany most government-run systems.”

This is very impressive for the biggest paper in the country to pre-empt the launch of the movie and say this. Kudos to them. I will go see Sicko and give my opinion as well. As a physician who rips our system as much as anyone else, I want to see where our opinions differ. I have seen the clips and previews where again he rips Bush for his stupid statements which to me is like shooting fish in a barrel. I am just hoping Mr. Moore is fair and takes a swing at the Edwards-like malpractice attorneys as well.

There hasn’t been much more info on the whole Avandia issue. More studies are needed as physicians, like myself, try to tease out whether we should stop using the drug. GlaxoSmithKline is in for a huge fight and is now coming out swinging. Their opinion now is that they are a pawn in a huge political feud. They believe Democrats are exaggerating safety concerns as another way to take jabs at Bush and the FDA. They may have a point. “You’ve clearly got a major political battle in the middle of this, with Congress trying to paint the Bush administration yet again as having some way failed, and Avandia is kind of the latest club to beat the administration with, “ said Chris Viehbacher, president of Glaxo’s pharmaceutical business in the U.S. Overall scripts for Avandia have dropped 20% and new scripts have dropped 40%. Clearly they are worried. I am not shedding any tears for GSK but I do care about my patients. This case should be an example where Bush hating needs to be set aside so science can take over to figure out the facts.

June’s issue of the Placebo Journal should have gotten to you. If not, please wait another week and get back to us.

The next issue is in the works and we already have some great stuff. If you have any stories, especially from a patient’s perspective, please send them my way.

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4. Gorback’s Thoughts by Michael Gorback MD

I recently read an article from the Bangor Daily News about one of the city's methadone clinics. It paints an appalling picture of addicts dealing drugs in the halls and parking lot, group therapy sessions where they sit around talking about how much they like to use drugs, violent fights inside the clinic among patients waiting for their dose. The shrink who runs the clinic trots out the tired old, "This is part of their pathology" routine. Horse hockey. If you behave like this you
don't really want to get well. You are just scamming the system to get
methadone that you can sell, or maybe you're working off a plea bargain
alternative to a prison sentence.

On the other hand, one woman who was interviewed said she had been clean
for 2-1/2 years, was engaged to be married, had a steady job, and all of her urine screens had been negative, yet they were weaning her so slowly that she still wasn't allowed to be on a home program.

So there are people coming to this clinic that obviously are not interested in recovery, they engage in violent and/or illegal behavior on the premises (there was even one story about people having sex in the back seat of their car while a child sat in the front seat), and they are kept in the program. There are people who have been model patients and have not been weaned out of the program.

What's going on? Well, the clinic receives about $1,000/year for each patient in treatment, and if there are ancillary services required it can run as high as $5,000/year. It looks like the program has a financial incentive to keep its head count as high as possible. That means keeping people in the program who don't belong - either because they are inappropriate candidates who do not really want to get well, or because they are trouble-free patients that are being held prisoner.

A recent Rand study showed that the proportion of adults who are severely obese (over 100 + pounds overweight) jumped by 50% from 2000 to 2005. We are eating ourselves to death. We are so overnourished that we are malnourished. This population has twice as many chronic medical conditions as the rest of the populations and are twice as likely to be in fair to poor health. How will this change in a new universal health system? It won’t. Not unless patients do their fair share to better their health by coming to the table. Or moving away from the table.

New Hampshire tried to ban healthcare information organizations from data mining doctors prescribing habits and selling the information to drug companies. Unfortunately, the law they passed was struck down because it somehow violated their freedom of speech. What? I still see this as an opportunity for doctors to gang together to sell this information ourselves. We can use this money to build up a rather strong political action committee that truly works on our behalf. I can dream, can’t I?

St. Peter walks over to the Pearly Gates and finds three people waiting to get in.

“What did you do during your time on Earth that makes you worthy of entry into the kingdom of heaven?” he asks the first.

“I was a medical researcher,” she replies. “I developed a way to treat childhood leukemia that allowed those children to lead healthy, full and productive lives.”

“You are worthy of the kingdom of heaven; you may enter,” said St. Peter as he turned to the second applicant.

“I was a surgeon, I saved lives and alleviated suffering,” said the man.

“You are worthy of the kingdom of heaven; you may enter,” said St. Peter as he turned to the third applicant.

“I was a health care administrator for a managed care organization,” said the man proudly. “I developed ways of providing services that were more equitable and efficient.”

“You, too, are worthy of the kingdom of heaven; you may enter,” said St. Peter. “You may stay for three days....”

A study in the Archives of Internal Medicine entitled “Physican Self-disclosure in Primary Care Visits” may be the most idiotic waste of money I have ever seen. The USA Today and Rita Rubin examined it recently here:

The study used actors to basically spy on doctors who agreed on having “standardized patients” see them in 2000 and 2001. The actors pretended to have GERD or some other symptoms and the researchers tested whether doctors talked about themselves during the visits. The docs were asked a few days later if they knew the patients were actors which excluded those visits. Of the 113 visits that were left, 38 of them showed physicians talking about themselves in some manner. Who gives a rat’s ass? The study concluded that empathy, understanding and compassion work better than self-disclosure. Rita used a quote from a Brown University family medicine chair who uses the study to teach residents where he said, “People lose sight about where their boundaries are. The focus should always be on the patient”. No kidding.

Now for some truth. First, I question whether this study is statistically significant for anything. Second, their conclusions go against everything written about salesmanship. I highly recommend any book on the subject such as Influence or Blink. The bottom line is that physicians have to connect with their patients to build their trust. We are salesmen whether we like it or not. Admitting your own frailties, speaking about commonalities in where you grew up, bringing up local news just shows your patient that your part of the community and you are just like them. The risk of not doing so would be falling into the trap of being a RoboDoc. We have been accused of being “non-human” so many times in the past that studies like these just make docs feel like they can’t do anything right.

I live in a small town in Maine. Half the people I see in the gym in the morning are my patients. Over the last decade, I know them and I will BS with them. Here is one little diddy you may enjoy. One of my first patients in the morning got wind that I stunk it up on the basketball court playing against his brother. When I walked into the room, he mocked me hard and he was correct on all counts. I am not that good of a player. As we were halfway through his physical, he asked me what that small nodule down by his groin was. I looked and without hesitation stated, “That, my friend, is your penis.” He almost blew his umbilical hernia right in front of me from laughing so hard. Now that, my friends, is empathy.

9. Bacharach’s Beliefs by Ted Bacharach MD, retired

Semantics is a word that can be viewed several different ways. I believe that in the case of the “physician assisted suicide issue” the meaning should be viewed in a conceptual manner. Dr. Kervorkian has been criticized, challenged, and imprisoned for his interpretation of the concept. Physicians have always been opposed to the termination of life by an active act on the part of a physician. (Conceptually they have not been against the “death penalty” but have been against taking an active part in this form of punishment. I suppose it does make a difference if a lethal injection is done by a technician or a physician although the difference is not particularly very great except that the injection may be less skilled and consequently more painful.)

Several years ago Dr. Kervorkian was rather outspoken and active in pursuing the belief that a patient’s desire to terminate his or her life should be honored. The legal profession as well as the medical profession all sided against Dr. Kervorkian’s views and opinions. His persistence resulted in a jail sentence.

The recognition that a patient’s wishes are pertinent was considered by several states who passed legislation concerning physician assisted suicide. Terminating a patient’s painful existence when there is no chance of recovery tugged at many heart strings. The means to accomplish this are complicated. In many patients depression may accompany an illness that is neither fatal nor life threatening. Separating these patients from the ones who are afflicted with a fatal painful illness can be difficult. Clinical situations are rarely black and white but usually fall into shades of gray. Physicians as a group are not against allowing a patient to die but do not want to actively participate in carrying out these wishes. The question then arises as to what can be done. Even in the states that allow physician assisted suicide this is not popular and I suspect is generally avoided.

The problem of pain control is also a difficult one. California, recognizing the fact that there is a problem required all physicians to undergo several hours of instruction on Pain Management. It was not too long ago that many physicians refused to give patients any narcotics for pain control because they were afraid that they might be accused of over-prescribing controlled substances. Identical practices that could be interpreted as over-prescribing in one area could be viewed as under-prescribing in other areas.

The dilemma faced by physicians taking care of terminally ill patients is considerable from the standpoint of medical care as well as medication. The solution that evolved proved to be welcomed by both physicians as well as patients. The solution was “Hospice”. Patients whose outlook for life was six months or less could be placed in the care of Hospice. This eliminated the need for physician participation for most things. Care of the patient would include the amelioration of pain and discomfort. All therapy that might prolong life is precluded. The patient’s comfort is primary even if its achievement requires possible lethal amounts of narcotics.

The difference between “physician assisted suicide” and Hospice is a conceptual one with a similar goal and outcome. I believe that the press and recognition of a problem was furthered by the actions of Dr. Kervorkian. It made people aware of the plight faced by the terminally ill. The actions that have resulted from this awareness are significant. I continue to feel that the Kervorkian approach is wrong but the result of the public awareness of the problems has resulted in a significant advancement in the care of the terminally ill. Dr. Kervorkian although he approached the problem in the wrong way did bring the problem to the public’s attention resulting in great benefit to many patients. He deserves our respect for the good that has resulted for a large number of present and future patients.

Conceptually “Physician Assisted Suicide” and “Hospice” are really closely related.

A company called Avvo Inc in Seattle is running a website which rates and profiles lawyers. I wonder how they like it? Actually, I know the answer. A lawyer representing two other lawyers has filed a lawsuit against the website because they feel the site is deceptive, unfair, and violates state-consumer protection laws. The lawyer who started the suit found out he received a low rating due to a state-bar disciplinary hearing. He lost two clients because of this. Awww. I feel bad for him. Now try having a managed care company direct patients away from you with higher copays and see how you like it. Not so pretty is it?

Also, "Genetic Testing for Women with Breast Cancer." And while I'm away, look for pre-taped packages on "Superfoods" and "Nuts."

Seasonal stories are typically relevant to the masses: hence, allergies, sun, and poison ivy. Furthermore, allergy reports apparently "test well" in Pittsburgh. And in TV, it's all about the ratings.

In my TB piece, with my well-honed reporter's resourcefulness, I believe I effectively showed with a graphic that multi-drug resistant TB has spread on airplanes before. When I was getting an interview at the health department, the public information officer marveled at the piece of information I presented, and said, "I wonder why no one else has brought this up before?" Eat your heart out, CNN.

Despite heavy promotion, the "sun exposure in youth" piece got bumped, because of an unexpected press conference at 5:00 p.m. at police headquarters about a fire that killed five children. And we carried that live, of course. My piece aired the next day as a straight package (meaning it did not include my live intro and tag, which I often use to add more information) in the 4:00, which has a smaller audience. Because it takes a whole day to put together one report, whenever my piece gets bumped, no matter what the reason, it feels like my whole day was for naught. I also felt bad for the family of the cute little girl at the end of the piece who was getting sunscreen put on. They had ordered pizza, and mom even came home from work early just to watch -- and then the piece ended up not airing that day.

It's never said out loud, and it would never, ever officially be acknowledged. But at times, it feels like there's pressure to cover certain things, because it makes our newscast more attractive to advertisers. Despite the sometimes palpable "ick," I go along to get along, because I want to stay employed.

The WSJ highlighted a piece in The Chronicle of Higher Education. It seems there is a growing concern about universities giving doctorates away way too easy. They call it degree inflation. They are creating more and more doctorate programs, especially in the health sciences, that may not require the same rigorous education and training as the traditional ones. In my opinion, this has got to be about money. In what it took to get a degree and maybe a Masters, some students can get doctorates in six or seven years. A lot of faculty members are pissed as some schools are introducing these degrees over their objections. As one chancellor put it, “We are moving in the direction that everyone who sees a patient will be called a ‘doctor’”. Hmmm, now why does that sound familiar?

13. CME

He looks at the whole issue of Big Pharma behind continuing medical education or CME. In the old days these courses were produced and paid for by universities and medical associations. Not anymore. The most recent data shows that drug-industry financing has nearly quadrupled since 1998, from $302 million to $1.12 billion. This begs the questions as to who is setting the agenda and what opinions are given. Well, the answer is obvious. How does a huge conference company like Pri-Med afford charging only $75 for a full conference? I have been there and the amount of pharmaceutical companies in the exhibition area is staggering. Does this spill over into the lectures as well? I don’t have that answer but it needs to be investigated. The problem is in the loop-hole. For-profit companies are allowed to act as middlemen to organize the conferences and they receive the millions from Big Pharma. They in turn create the topics and hire the doctors/researchers to present. Is the content of these individual topics compromised? You bet your sweet ass it is. This is almost like loitering money and we as physicians fall for it hook, line and sinker. As the article states, drug companies should never have been allowed to become the primary educator for America’s doctors. And I agree. That’s why we have a section called CMME or Continuing Meaningless Medical Education in each Placebo Journal. I always get my jabs in.

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