- To Fibro Or Not To Fibro, That Is The Question
- Call For Stories
- Placebo Journal Update
- Gorback’s Thoughts by Michael Gorback MD
- Teacher Comparison
- Too Demanding
- Joke of the Week
- Ridiculous Study of the Month
- Bacharach’s Beliefs by Ted Bacharach MD, retired
- No One Wants To Do The Rectal Anyway
- All Clear
- Word Play
- New Studio?
- Feedback About The Placebo Gazette
1. To Fibro Or Not to Fibro,That Is The Question
Oh, it is on now. A New York Times piece recently questioned the very existence of fibromyalgia (http://www.nytimes.com/2008/01/14/health/14pain.html). The debate has come up because Pfizer has been off and running with “evidence” that their medication helps this designer disease. Pfizer reps, by the way, can be very touchy as they live and breathe their company. I remember seeing them at a conference, before it started, and they were gathered in groups doing some Amway like cheers to get motivated. Scary. Anyway, I recently had one of their reps, whom I have known for many years, get real testy as I started to question the facts behind the Fibro Phenomenon. Oh no, he says. It certainly does exist and he ripped off all the Pet Scan evidence he could think of. Now the Times article brings the whole issue to light because there is going to be big money for Pfizer when docs start prescribing Lyrica for fibro. The question on most physicians’ minds will always be whether fibro really exists. The article points out that the researcher and physician who wrote the 1990 paper that defined fibromyalgia has since changed his mind saying that the disease does not exist and that Lyrica and the other drugs will be taken by millions of people who do not need them. Wow. That has set off the fibro advocacy groups because they feel the drug will actually legitimize this disease. I highly recommend you read this link and tell me your thoughts. On one hand you have the fibro followers linking up with Pfizer and on the other you have doctors; many of which still aren’t fully committed to believing that fibro is nothing more than a label.
Here are some quotes from the doctors in the NY Time piece:
“The diagnosis of fibromyalgia itself worsens the condition by encouraging people to think of themselves as sick and catalog their pain. These people live under a cloud and the more they seem to be around the medical establishment, the sicker they get, “said Dr. Nortin Hadler, a rheumatologist and professor of medicine at the University of North Carolina who has written extensively about fibromyalgia.
“Some of us in those days thought that we had actually identified a disease, which this clearly is not. To make people ill, to give them an illness, was the wrong thing” , said Dr. Frederick Wolfe, the director of the National Databank for Rheumatic Diseases and the lead author of the 1990 paper that first defined the diagnostic guidelines for fibromyalgia.
Wolfe thinks the condition a physical response to stress, depression, and economic and social anxiety. I tend to agree but it doesn’t matter what I think because the commercials from Pfizer are on their way. Will it succeed in the long run? Since Lyrica causes weight gain (sometimes over 7%), I have some suspicions. The one thing that will beat the pain of fibromyalgia is the possibility of gaining weight. Patients will realize that maybe the symptoms of fibro weren’t so bad after all.
2. Call For Stories
Did you ever want a free subscription to the print edition of our Placebo Journal? Well, there is a way. We are in need of more true stories of medicine. If you send something in and we publish it, then we will either send you a free subscription or extend the one that you have. It’s that simple. Almost. You see, the stories have to follow some rules:
- They must be true
- There must be no compromise of care (malpractice)
- They must be anonymous
- They must have happened to you (no urban legends)
- They must be funny, outrageous, weird or at least interesting
- They must be well written with some description and detail
If you are holding on to a story that you always wanted to share, no matter how long ago it happened, please go to the link below. You HAVE to fill in all the boxes for legal purposes and then just paste or write in your story.
The stories we are looking for could be funny things that patients or doctors have done, stupid things you have done, weird nursing tales, outlandish things that happen to pharmacists and so on. Hope to read your stuff soon. We cannot use them all so don’t be discouraged if you don’t get published. We also save some of them for later issues. We will contact you if we use your material.
http://www.placebojournal.com/submitstory3.asp
3. Placebo Journal Update
The February issue of the Placebo Journal has been wrapped up and is off to the printers. You have until Jan 30th to get in on this issue. If you haven’t seen the print edition of our journal lately, then you have missed some updates. The quality of the cover is much better and the issue is now all full-color. This next issue has some great stories, parodies called Administra-doh and E-Z Can Prescription Service, and so much more. Hurry up and subscribe as you only have ONE WEEK LEFT!
http://www.placebojournal.com/shopdisplayproducts.asp?id=12&cat=Subscriptions
4. Gorback’s Thoughts by Michael Gorback MD
The people in charge of managing Part D plans have made it next to impossible to practice medicine. Here is a letter I have written to explain to a patient why I can’t use the appropriate drug for him. A little education doesn't hurt. We have to fight back with every weapon we have, including letting these schmucks know that we are advising our patients to change plans.
Carpe jugulum!
Dear Mr. xxxxx,
As you know, I recently prescribed you Cymbalta for your neuropathic pain. Your Medicare Part D insurer denied the prescription, suggesting a different anti-depressant. The medications they suggested would be fine if you had depression but that is not what I prescribed this for. I sent them a note explaining that the prescription clearly said “nerve pain” but I received another denial because it was not diabetic nerve pain.
I tried to speak with someone at Caremark and ran up against a wall of bureaucracy. I tried to explain that most drugs for nerve pain are used “off-label” (in other words, for purposes other than what the FDA approved it for) and that you had failed to respond to other, less expensive, medications. They said they would not override policy but I could try to speak with a medical director and convince him to override the policy. This is a typical game played by insurance companies.
Unfortunately I do not have time to go a fourth round with your insurance company, which I suspect is what they counted on. I therefore suggest you try one of the following:
- Try to develop diabetes so we can try Cymbalta.
- Pay for the prescription yourself. Your prescription will cost about $225.
- Find a Part D carrier with more reasonable policies.
I am very sorry that you have had to go through this. We can discuss other options at your next appointment.
Sincerely,
Michael S. Gorback, M.D.
Diplomate, American Board of Anesthesiology with
Subspecialty Certification in Pain Management
Diplomate, American Board of Pain Medicine
5. Teacher Comparison
New York City is going to rate about 2500 of their teachers on how well their students perform on annual standardized tests under a new pilot program. The data could be used to determine teacher tenures, evaluations and bonuses. There are a lot of people unhappy about this. The teacher’s union president said that “there is no way that any of this current data could actually, fairly, honestly or with any integrity be used to isolate contributions of an individual teacher”.
There is an obvious comparison to the P4P mess that physicians have gotten into. My hunch is that the teachers will eventually block the rating system because they have representation by their unions. Physicians, on the other hand, are fragmented and have been sold out by the leaders of their individual organizations who have spun this as a way to make more money.
Since doctors are divided they will be conquered. I am sure this is written in some managed care office somewhere.
6. Too Demanding
Priests and rabbis, beware. Your health is now on the line. New demands being placed on the clergy have created a healthcare crisis for these religious leaders. According to the Chronicle of Philanthropy, the job pressures for these folks are taking a toll on them as the “consumer-oriented congregants” raise their expectations of these religious leaders. My favorite quote from the piece goes like this:
“They demand more programs for their families…and expect the pastor to operate as efficiently as the chief executives they see at their own jobs”.
This is so interesting as I see the same thing happening to doctors. Patients are also called “consumers” and they are putting the same pressures and demands on us. Instead of saying enough is enough, we capitulate and try to change everything we do so that some pencil pusher likes the way the medical records or statistics look. And we are getting sick in the process. And now we have no one to complain to as all the clergy are dying off. God damn it. Oops. Sorry.
7. Joke of the Week
Question: How many Vietnam Vets does it take to change a light bulb?
Answer: “You don’t man. You weren’t there!”
8. Ridiculous Study of the Month
In the Journal of Family Practice, there actually was a published study entitled, Sigh syndrome: Is it a sign of trouble?” This syndrome, which consists of irrepressible, persistent sighing, seemed to bother these researchers enough to set out on a journey to seek out whether there is something deeper. They felt this symptom is stressful to the patient and thought maybe there was some association between sighing and an organic disease. Turns out, no.
This is not a joke. The physicians spent 3 years finding 40 patients with “sigh syndrome” which, by the way, the patient has to have 10 sigh syndrome criteria in order to claim this diagnosis. In the paper, they admit that 25% of those patients had anxiety and somatoform-related disorders. Their conclusions were tremendously astute; the recommend support and understanding from the treating physicians. Good call.
So what’s next on their agenda? Studying the effects of boredom? Or farting?
9. Bacharach’s Beliefs by Ted Bacharach MD, retired
My Doctor
When you ask anyone about their doctor you get a surprising array of answers. You do not get the now obsolete reply: “My doctor is Dr. Abernathy.”, or “Our family physician has always been Dr. Smith.”
In today’s environment the responses are much more likely to be: “My Doctor is “Health Corporation Xylast” or, our doctor is the Smithfield Medical Clinic. Common also is the response: “My Doctor is Kaiser or Mayo’s or some other Medical Clinic, Medical Foundation or Group”. While some of these entities are “Not for Profit” almost all of them pay their executives far more than their employed physicians whose identity has been lost.
Physicians like most tools are considered replaceable. The decision to employ a physician is no longer in the hands of colleagues but is left to the corporate executive types who hire physicians who will work for less. A surgeon is qualified if he has the proper certification on paper, his performance is expected to be exactly the same as the last surgeon regardless of experience or performance. It may take a year of bad results before it is noticed that his or her performance has produced statistical results that are below expected performance standards.
Patients sent to the hospital by their primary care physician are treated by the “hospitalist” who really needs no name since he or she will only take care of the patient on a rotation basis. Jones on Monday, Smith on Tuesday and so forth.
Physician Identity in today’s environment is gone and forgotten by most people except for a few of us septo- and octogenarians who remember the “Old Days” when we had real names and identity, and were considered to be vital and valuable community members.
Has the price of regular hours and regular pay been worth what we have had to give up?
10. No Wants To Do The Rectal Anyway
Here is a little secret: no doctor really wants to do the rectal exam. It is not the most glamorous part of the job. We do it because, well, we have to. As more and more evidence shows that it really isn’t needed, physicians will be more than happy enough to stop poking their patients. A case in NYC is bringing the whole concept out in the open. It seems a patient came to the ER with a head injury. The ER doc wanted to do a rectal because of a possible spinal injury; I am assuming to assess rectal tone and determine if more testing (MRI) would be needed. More details on this are still sketchy. The patient objected to the rectal but the doctor performed it anyway even to the point of having the patient held down. That is when the patient punched him. At that point the patient was sedated and intubated. When he regained consciousness, he was arrested for assault. Now the patient is suing because of PTSD from the incident. Though that diagnosis is obviously a load of crap (no pun intended) and was artificially created to say that damages occurred, it still begs the question of when doctors can force care upon a patient.
Informed consent is the big term being tossed around here but the bottom line is that the dude had a head injury. If the doctor is questioning the patient’s competence due to that injury then the physician has the obligation to make sure he is medically cleared before sending him on his merry way.
Once again, no doc wants to do a rectal exam. He felt he had to due it or else he would be negligent in his care. As no good deed goes unpunished, that physician got sucker punched in the ER and is getting sued in the courts to boot. Now that’s justice. The real question is whether the ER doc, if he wins the case, can turn around and sue the patient for PTSD?
11. All Clear
Good news. The makers of Cialis recently received approval from the FDA to use the drug as a daily dose. Kind of like an erection vitamin. The company says it takes the pressure off users who can’t predict when they will have sex. Something tells me that this new “approval” just may be based on the company’s goal to make more money. I see many a woman in the future replacing their spouse’s morning Cialis with something else as the increased blood level of this drug keeps their man at attention way too often for her liking.
This is why PJ Pharmaceuticals created Shealis.
12. Word Play
As tears well up in my eyes from reading the AAFP News Now, which is the newsletter for the American Academy of Family Physicians, I have trouble distinguishing whether those tears are from joy or from sadness. In a tribute to the moronic skill of word spinning, the newsletter is a hodge-podge of in vogue words or phrases which really have no meaning. Let me list some of them: patient-centered, transforMed, gateway to care, demonstration project, meaningful outcome analysis, systems in place, bold steps toward change, advocacy, honing efforts to communicate, bold champion, assertive actions, new brand identity, and so on. And this was taken out of only two small articles. In a time where family docs are becoming replaceable by NPs in retail clinics, where less and less medical students are going into the specialty, and where more and more of us are burning out (the most recent Family Doctor of the Year died a week after the announcement at age 58), our representatives use Administralian talk instead of any real and measured action in order to make positive change. Whoops. I’m sorry. I take that back. They spent tons of time and money to create a new AAFP logo which they hope will show the world that we mean business. That took a full page in the newsletter.
I guess those tears were from sadness.
13. New Studio?
Placebo Television #9 came out about a week ago. Check out my new studio. No, I do not have Niacin poisoning, just having some technical difficulties. Anyway, I think you may enjoy some of the topics including: testosterone supplementation, free samples, and the use of placebos by doctors. Check it out here:
14. Feedback About The Placebo Gazette
I WANT TO KNOW WHAT YOU THINK. Please go below and post your thoughts under the WRITE A REVIEW section. You can also see some one of these articles on our blog:
Until next time, keep smiling, keep laughing and keep out of the sample closet.
Doug
King of Medicine
