Dangerous Information

June 25, 2008

(1 votes, average: 1 out of 5)

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A patient left me a message earlier this week: “I was reading the information on the drug that Dr. Rob prescribed, and I am really worried about it.” He went on to say he was faxing me the prescribing information, just in case I didn’t realize the risk of the medication.

I hate it when people do this. Do they realize that I studied for eight years and have practiced another thirteen? Why would I prescribe something for them that I don’t know about? Why would I put my name behind a “dangerous” prescription? Why would they bother coming to me if they thought I did not know these things?

I don’t really take it as a personal insult, and I do feel that it is fine to question the doctor. I am sure it has happened that I have given prescriptions with interactions and/or side effects that I did not think of, but there are some levels of questioning that cross the line. I am an internal medicine doctor, so medications are my tool. Would you ask a surgeon, “Are you sure you should make a midline incision? Do you think that a lateral approach may be better?” Do you tell a cardiologist, “I read on the Internet that the non drug-eluting stents are better than the drug-eluting ones”? Do you ask the radiologist, “Don’t you think that density could represent pleural plaque rather than an infiltrate?” Probably not.

But somehow, the Internet has made second-guessing medications very easy. Websites have made experts out of everyone who can type. So let me make the following points very clear:

1. I only prescribe drugs that I feel comfortable prescribing.
2. I only feel comfortable prescribing drugs that I know the side effects, interactions, and contra-indications of. While there may be very rare side effects I do not consider, this is the exception, not the rule.
3. My EMR allows me to check interactions, so I do this on every prescription I give.
4. I do realize the potential danger of drugs, and weigh that out against the potential benefit in each circumstance. The benefit must significantly outweigh the risk for me to prescribe it.
5. Drugs always have risk. That is why it takes an advanced degree and a license to be able to prescribe them. If they were not risky, then they would be put on the shelf next to peanut butter in the supermarket.

I hate to sound like I don’t want to be questioned. I do my best to give each patient enough information that when they walk out of my office, they know why I have ordered each test and prescribed each drug. In that light, perhaps I failed this patient. Maybe I did not give enough information as to the risk/benefits of the drugs.

But then again, I don’t get paid for taking more time with my patients. Plus, sometimes more information just increases the worry.

And there are some people who should probably stay away from the Internet.

Posted in Being a Doctor, Rants 17 Comments »

Nine

June 24, 2008

(4 votes, average: 4.5 out of 5)

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There once was a wonderful daughter
Who was sweeter than anyone oughter
She’s always been fine
But now she is nine
And craving the presents we boughter

Hey, little Pikmin
Walking down the lane
Just how I’m feelin’
Should be pretty plain
Just bat those lashes
And my heart is slain
Though you’re still little
You’re my biggest gain
Hey, little Pikmin
I’m so glad you came.

Happy Birthday, Little C (and co-founder of Zippy, by the way)

Posted in Personal Musings 3 Comments »

Excuses, Excuses

June 23, 2008

(2 votes, average: 4.5 out of 5)

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I got a message last week: Patient’s mother requests a note so she can bring his lunch to daycare.  They say it is federal law that he eat a healthy diet.

OK.  So I have to write a note saying, “Please allow Jonnie to bring his lunch to school?”  It takes MD after your name to have the authority to say that lunches should be brought?  Apparently so.

It seems the daycare was up in arms because the child’s mother packs Cokes and sweets, which makes the other kids want the same.  They begged me to rescind the note.  I told them that, while this was bad parenting, it was not my place to be in the middle of this discussion.  They have the right to kick the child out of daycare if they choose.

It makes me wonder, how do I get in the middle of this kind of thing?  This is not the first time that I have had to write a note like this; I get requests regularly for notes for all sorts of things.

• My child needs to get up and go to the bathroom during class.  Could you give me a note saying that if he needs to go, it is OK?  I wrote it, but wonder how my medical education was used in making this judgment.  Why wouldn’t the teacher just let the kid get up to go?
• My daughter gets thirsty a lot during class.  Can she get a note saying its OK to get a drink?  I did not write that one.  The child would somehow have license to get up multiple times per class.  Dehydration does not take 45 minutes.  Besides, would my asking for this obligate the teacher to follow it?  Thirst is not a medical condition that I treat
• Can I get out of PE?  I have kids who hate PE, who want any possible excuse to get out of it.  Personally, I got out of PE for the first two years in high school due to a knee condition I had (this proved to me once and for all that there is a God).  Not liking PE, however, is not a good enough excuse.
• Jury Duty - Everyone wants to get out of jury duty.  Panic attacks, chronic back pain, migraines, everything seems to be an excuse to get out of it.  I don’t usually give exemptions because I think they should do it.  I did (and missed three days of work).  I guess jury duty is the adult equivalent of PE.
• Airline tickets - There are special occasions where patients require an excuse from a booked flight (surgery, serious illness, etc).
• Health Club Membership - This is generally more difficult to get out of than anything I have ever seen.  Health clubs are very reluctant to let a contract go, even sometimes with a note from the doctor.  The practice has made me have very negative feelings toward the industry.
• I was sick last week and missed a couple of days of work, can you give me a note?  No.  I don’t write a note for someone I did not see.  When I write a note for someone, I usually just state the fact that I saw them in my office, so please excuse the absence.

No Child Left Behind

The NCLB law has been an incredible boon to both pediatricians and the fake excuse industry.  Why?  Here’s what happens:

1. The schools are not only judged by test scores, but by attendance of students.  Schools can get on the “bad” list if their students miss too many days.  Each student is allowed only five unexcused absences from school.  Notes from parents don’t count.
2. If a child gets sick enough to stay home, the parent is often forced to bring the child to the doctor, even though it is a sickness that they know needs no treatment.  Why?  Doctors are clearly more skilled at saying a child has diarrhea than a parent.  We are experts at it, so we must make the clinical judgment that the child does, in fact, have diarrhea.
3. Some parents resort to forging notes for multiple absences.  In the past year I have had to discharge families from our practice because of multiple forged excuses.  Do I blame them for wanting to save money?  Not at all.  But forging a doctor’s excuse undermines the relationship.

My kids are healthy, so I haven’t faced it yet, but I suspect that my note saying they were absent for diarrhea would not be accepted.  I think this is because my judgement of diarrhea is blurred by my close relationship with my child.

Overall, excuses are both a power trip (I can get people out of nearly anything) and a pain in the rear.  I wonder what would happen if physicians started wielding this power as a weapon.  What would happen if, after Medicare cuts, we started writing excuses at such a rate that there would be a major economic down-turn causing staggering inflation and rising interest rates.

That’d show them, wouldn’t it?  Then when they asked us to testify in court as to why we did this, we could get one of our colleagues to write us an excuse for that.

Then if they wanted the records showing that the person was in fact sick, we can say that our dog ate it.

It sounds foolproof to me.

Posted in Being a Doctor 5 Comments »

A Joke

June 19, 2008

(2 votes, average: 3 out of 5)

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An elderly man told me this joke yesterday.  These things help get you through the day.

There was a man whose father gave him some advice: “Just put gunpowder in your oatmeal and eat it every day and you will live to be a ripe old age.”

So the man did what his father said, eating oatmeal and gunpowder, and he did in fact live very long.  He finally died at the age of 102, leaving behind him 6 children, 22 grand children, and 50 great-grand children.

And a crater where the crematorium used to be.

Posted in Humor 6 Comments »

Obvious XP

June 19, 2008

(2 votes, average: 2.5 out of 5)

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They’ve been doing it since I was a medical student. Drug companies’ patents run out, so they make a new formulation of it and extend the patent.

It is a shell game, and the FDA has played along up to now. I call it the XP version of the drug - for eXtend Patent. These XP drugs are sometimes better, but usually not much. Here are some ways they have done this:

Use an isomer

Many molecules come in Left and Right hand shapes called stereoisomers (trust me on this one), and usually one of the hands does most of the work. The drug companies have been re-marketing the active component as a new drug - and have gotten away with it.

Examples:

• Nexium - Nexium is the Left-handed isomer of the drug Prilosec. Prilosec was the greatest thing in the world until it went off patent, so then came Nexium. Mysteriously (through drug reps wearing short skirts and direct to consumer marketing), the drug became a blockbuster, even as Prilosec went both generic and OTC at the same time.
• Lexapro - Related to Celexa (for depression) - very successful as well.
• Xopenex - The active component of albuterol (for asthma). Supposedly less side effects, but this is possibly due to just using a lower dose.

Use a Metabolite

Some drugs are not effective until they are broken down by the body. There are often several active metabolites from a single drug.

Examples:

• Clarinex - This is the anti-Nexium. Unlike Nexium, Clarinex is another molecule altogether. It is a metabolite of Claritin, the blockbuster allergy drug. Just like Nexium, Clarinex came on the market just as Claritin went generic and OTC. Clarinex flopped. What is the difference? Marketing.
• Allegra - Metabolite of Seldane, the allergy drug that caused heart problems.

Change the dosage schedule

A twice a day drug becomes once a day, and the patent is extended.

Examples:

• Cardizem - used for blood pressure, it went from 4 to 2 to 1 time per day, each time extending the patent. Overall was a big winner for them.
• Coreg - Newest boy on the block. Coreg CR is being pushed heavily as the twice-daily Coreg went generic.
• Effexor - Again, went from twice to once a day and became a much better seller at the new dose. There is a new version of Effexor called Pristiq that is a metabolite. Would it surprise you if I told you the patent for Effexor is running out?
• Ambien - I thought Ambien was a great drug…until the reps told me it didn’t last long enough and my patients needed Ambien CR. This drug went from once a day to once a day (extended), and kept the patent alive. Cool trick!
• LOTS of others.

Mix with other drugs

If patent expires, the drug can be mixed with other drugs whose patents have not expired, extending the life of the generic. This is more convenient for the patient and could be less expensive than giving the two drugs separately, but that may not be the case if the generics are cheap enough.

Examples:

• Glucovance - Diabetic drug that was mix of two meds. More potent together, but both meds available separately.
• Vytorin - The famous combination of Zocor (generic now) and Zetia (not generic). Works well for lowering LDL a bunch, although the jury is still out as to whether this means people actually live longer.

I am sure there are other examples of this game, but you understand my point. The best marketers are able to get doctors to prescribe and consumers to buy the “NEW AND IMPROVED” version of a drug, even if they liked the “OLD AND WAY WORSE” version. It is the same ploy used by paper towel, laundry detergent, and shampoo manufacturers (My Pantene shampoo has “Amino Proteins” in it - kind of like having “letter words” as amino acids make up proteins).

The tactic is blatantly obvious, but has been winked at by the FDA…up to now. Recently the FDA has rebuffed some XP attempts. From the WSJ:

Rolling out an extended-release version of a drug a year or two before it goes generic is one of the oldest pages in the pharma brand-extension playbook. But, at least in the case of GlaxoSmithKline, the FDA doesn’t seem to be playing by the book.

Over the weekend, the agency approved Requip XL, an extended-release version of Glaxo’s drug for Parkinson’s. But the approval came only a long delay, and a generic version of regular Requip, or ropinirole, hit the market last month, the WSJ reports.

My Favorite quote is at the end of the article:

“Requip CR did not make it to market. Why? Not because it’s not safe. Not because it’s not efficacious. The FDA said, ‘Yeah, you’ve got all that. But tell me why you’re better than [Requip].’ Well, that was an unprecedented question from the FDA,” Christopher Viehbacher, president of North American pharmaceuticals, said at an investor conference last month, according to a transcript.

Why is it better? It is Requip XP! It’s new and improved! It’s Requip 2.0!

Anything for the shareholders.

I can’t believe I am saying it, but Thank you, FDA.

Posted in American Medicine, Rants 6 Comments »