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As a family physician, one of the more fun conditions for me to care for is pregnancy, childbirth, and the well child checkups that follow.
I meet women at the start of their pregnancies and learn a little about their lives beyond their pregnant “condition.” I see them every month for a long stretch, meeting mothers, mothers-in-law, friends, and husbands along the way. As things progress I see them every two weeks, and then weekly.
By the time the weekly visits occur I find out what my patients are made of – and they get to know me, as well. Mama is very pregnant, and my job is to convince her that every day inside, even past the mythical due date, is good for the baby. I then get to witness the miracle of childbirth (and occasionally play a larger role).
In my practice, mother and baby come back to visit weekly, monthly, and then annually as the children reach toddlerhood. We continue to have conversations around the new family and the transitions up until the age of three. After that, if the child is well, we are limited to an annual “Hi, how are you doing?” For the most part, they are moving on with their lives as a young family and fortunately do not need my help. In the words of the Lone Ranger,”My work here is done.”
However, it isn’t quite as easy as that. Doctoring is a funny gig when it comes to personal relationships. I’m sure there are others just as funny, dentistry probably being one. I see these folks back for a visit after a couple of years, or at a community activity, or elsewhere in Mobile and surrounds, and the mothers will proudly say to their (very embarrassed) twelve-year-old, “There’s the first person who ever saw you.” We’ll make some small talk — what do you say to a twelve year old after nine years? — and typically the mother will ask about my family and my kids.
Because, as it turns out, while they were sharing a part of their story with me, I was sharing a little of my story with them. I used my children as examples for feeding and discipline problem-solving, as both good and bad examples. I discussed my wife’s meal-time solutions for feeding grown-ups and kids at the same table. In other words, I shared with them as they were sharing with me. A little piece of my version of how we put our kids to bed has entered into the bedtime strategy of many of the families that I have cared for. If “Good Night Moon” did become a successful part of their ritual, I hope they think of Dr. Perkins in a really good way (after the toddler is actually asleep, of course).
I don’t get to care for a lot of young families any more, given my other duties, but I do still see folks that I have cared for over the last twenty years, people with whom I have shared family anecdotes in this manner in the hope of leading them to better health.
It has been six months since my wife’s death. Many of my patients, coming in for a variety of reasons, or running into me around Mobile, have wanted me to know that they are here for me just as I, and our family, and some of my
wife’s child-rearing strategies, were there for them. It has meant a great deal to me.
Through pestilence, hurricanes, and conflagrations the people continued to sing. They sang through the long oppressive years of conquering the swampland and fortifying the town against the ever threatening Mississippi. They are singing today. An irrepressible joie de vivre maintains the unbroken thread of music through the air. Yet, on occasion, if you ask an overburdened citizen why he is singing so gaily, he will give the time-honored reason, “Why to keep from crying, of course!
It is a month today since Danielle’s death. I had already planned to go to New Orleans for my 30th medical school reunion by myself prior to her death, as she was to be playing Amanda this weekend in a local production of Glass Menagerie. The play is set in St Louis. Tennessee Williams, the writer of the play, once said “America has only three cities: New York, San Francisco, and New Orleans. Everywhere else is Cleveland.” Clearly, he set it in St Louis for a reason. Danielle was a New Orleans native, and she understood those reasons.
I lived in the Faubourg Marigny (a neighborhood just outside of the French Quarter) while I was in medical school. After we married, Danielle and I moved to the Irish Channel, a neighborhood that is quite gentrified now but was much less so 34 years ago. For those of you who know New Orleans, we were one block off Magazine and spent many afternoons there walking and window shopping.
After moving to Mobile we found ourselves in New Orleans many times a year. We would go to Danielle’s mother’s house and, after a suitable time, we would make an excuse and go to Magazine Street. The children had valuable grandparent bonding time, and we had New Orleans time. This became less frequent as the children grew older. After Katrina, both of our immediate families left south Louisiana and so our visits were limited to special occasions. We still made it about three or four times a year, however, enjoying many delicious meals with our friends and extended family, and spending time window shopping on Magazine.
This weekend, I played hooky for much of my 30th reunion. Staying with friends of ours in their uptown home, we drank wine and remembered the old times. New Orleans being New Orleans, we went to the Boogaloo Festival and heard the Lost Bayou Ramblers. We spent time among the thirty-somethings, watching them frolic in the old (not very clean looking) Bayou St. John canal. It was hot. All in all, a very New Orleans experience.
At the reunion events I did attend, word quickly spread about my wife’s death. Many came up to me and offered condolences. Most of them only knew Danielle peripherally, so I didn’t have many in-depth conversations. “So sorry for your loss,” they would say. “Thank you for your kind words,” I would mumble back. Since many of these old acquaintances are no longer married to the spouse they boasted in medical school, discussions of marriage and relationships are typically avoided at these reunions altogether. One of the more awkward moments, in fact, was when we toasted to those who helped us get where we are and the person next to me said: “Wait, am I toasting my EX-wives?”
I guess my loss really hit me when I was driving down Magazine Street on my way out of town. I saw all the familiar buildings that were built before we were born and will likely be there after our deaths, and I realized that my loss is not just the Danielle of today. My loss is the life we built together and the life we expected to continue to share. That loss includes our shared experiences and memories. Our stories. Our jokes. I realized that I had lost not only Danielle but our shared New Orleans.
“So sorry for your loss.” For those who knew us, it is a shared loss and I am sorry for your loss as well. For others, I really do appreciate the sentiment, even though I may respond less than enthusiastically at times.
“Unless there is a public outcry, I don’t see any changes.”
Alabama Senate President Pro Tem Del Marsh on passing a Medicaid budget that reduced payments to physicians, hospitals, and would end all “optional services” including home health programs, hospice, outpatient dialysis, adult eyeglasses and PACE, a program to help some elderly people avoid having to be admitted to nursing homes
How do you create a public outcry? That is the question for the 500 dialysis patients who rely on dialysis to continue living.
Dialysis is a funny thing. When Medicare and Medicaid were established in 1965, renal replacement therapy (known by lay folks as dialysis) was known to save lives. People who had lost kidney function from diabetes, polycystic disease, or some other malady, unless they were fortunate enough to be a part of an experimental protocol, would die from a build-up of toxins in their body. If they were enrolled in a protocol or had the good fortune of living near a place that was experimenting with renal replacement therapy, they would live.
In the late 1960’s, a report came out that identified renal replacement therapy as established as opposed to experimental. In addition, because of the “experiments” funded through Medicare, the number of people on dialysis increased by a factor of 10 (from 1,000 to 10,000) and the number of physicians performing dialysis increased dramatically. This set the stage for the hearings in the 1970 where this testimony was heard:
I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a non-competitive line, was found out,and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up? (U.S. Congress, House, Committee on Ways and Means, 1971b)
Following this, the house and the senate passed and President Nixon signed a bill creating a dialysis benefit for those eligible for Medicare.
Fast forward to today. In America we have 400,000 people on dialysis. They have to have their blood cleansed 3 times a week. If they do, they can live a relatively normal life. If they don’t, they can develop shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia) and when it gets bad enough that they’re deemed to be near death, they are given dialysis via the emergency room.
Most people on routine dialysis have it paid for by Medicare. Who gets it on the federal nickel? To quote CMS, these folks are eligible:
- You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.
- You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
- You’re the spouse or dependent child of a person who meets either of the requirements listed above.
If you don’t meet these criteria, and require renal replacement therapy, you pay cash (between $52,000 and $73,000 per year), obtain coverage from Medicaid, wait in a state of anticipation until you need emergent dialysis (costing about $300,000 a year as a strategy), or die.
Alabama would be the first state to take it away from ALL Medicaid recipients. Texas does not pay through Medicaid but instead pays through a separate fund. They were able to take away dialysis from undocumented folks. Because of the pesky EMTALA laws passed by President Reagan, hospitals are required to provide EMERGENCY treatment. The consequence? A bunch of folks who hang out at the hospital every day getting their blood drawn to see if they win the emergency dialysis lottery.
So, back to my original question. You see, Alabama is $100 million short on their Medicaid budget. On a budget of about $6 billion, that would seem like a small number. Alabama legislators, though, are ready to make a stand. The 500 Alabama citizens on dialysis will either die or spend the rest of their days hanging out next to the emergency room so that we can prove the value of “low taxes” unless there is a “public outcry.” How do you stop folks entrusted with the health and welfare of the citizens of Alabama if they are able to murder 500 people to prove a point? I can’t figure it out.
Student overheard on interview tour: Boy, I really put one over on Perkins. I told him I wanted to be a Primary Care doctor…and he bought it. I’m sure to get in now.
What do we look for in medical students? No matter what, we want our physicians to be smart. The selection process is designed to weed out “not-smart” people. Unfortunately, we can only measure smart in a couple of different ways (grades and MCAT scores), ways that tend to benefit the wealthy (60% of medical students are from the upper quintile of income) and non-minority folks (14% of medical students are from underrepresented minorities compared to almost 25% of the population).
Is there another criteria we should use for selecting medical students? Altruism in medicine is best described in the words of this medical student:
So, for me, I see it as always putting yourself behind the person that you’re with. So the patient comes first, no matter what. If it means spending extra time past normal office hours to stay, if it means going out of your way for somebody, if it means sacrificing something for yourself, I think that’s what it is. First and foremost, you’re taking care of the patient.
Can we assess this in a medical school application? Unfortunately, not very well and not in a reproducible manner. We tend to put value on things we can quantify, so an MCAT equivalent of 37 (99th percentile) would attract the attention of the admissions committee much quicker than a prolonged experience at a soup kitchen. As one of my fellow admissions committee members said, “You can’t assay for the Give A Crap gene,” but you sure want your doctors to have it. The MCAT predicts how well the student will perform on tests but has no bearing on how good of a physician they will be. The soup kitchen experience may take away some grade and MCAT points, but give me that doctor-to-be every time.
Another marker is not the number of experiences but the intensity and commitment shown. The best people I have interviewed have been folks who have decided on medicine after several years of Teach For America or similar life experience. These folks tend to be better able to communicate with patients and, not coincidentally, tend to seek careers in primary care.
The best way to assess this, so they say, is through the interview process. As an interviewer, I will look at the student’s activities and query them regarding each of the things listed. Although not focused on primary care, I try to focus on whether or not the person has the GAC gene. To be honest, if in my opinion they don’t, I am not certain enough on my ability to assess to sabotage the application. If they do, I try to recruit them into our school. If not, I try to sell them on the other allopathic medical school in the state.
Discussion in medical school admissions committee:
Colleague: So I asked him “just why do you think you want to be a doctor” and he said, “Oh, you know, I like science, want to help people , like to problem solve.”
Me: I just learned about a new term called “the consent agenda.” In a meeting, if there is stuff everyone agrees on, you put it on the agenda as “consent items.” Then, with no discussion it can pass and you can move on to discussing something germane. I propose we notify all students that love of science, helping people, and problem solving are consent items. Then, we need to find out, how does this person know they REALLY want to be a doctor?
I just learned about this web site called DOC. DOC stands for “Drop Out Club” and it exists to help people transition from clinical medicine into a non-clinical arena such as management or sales. On their web site they say that the “name reflects the sentiment at our original gathering that no clear support systems existed for the paths we were pursuing.”
The site has about 10,000 members, although some may be lurkers like me. The forum at the site is full of folks who feel like they have made a terrible mistake with their lives and are looking for a way out. Many are in residency with statements like “I look around and can’t see myself doing this for the rest of my life” predominating.
Physician career dissatisfaction is a real problem. About 400 physicians commit suicide each year. Suicide is the number 2 cause of death in medical students (following accidents, some of which are also likely suicide). This is thought to be a consequence of underdiagnosed depression, almost certainly made worse by a rapid and monumental debt accumulation. In addition, I will concede that a love of science, a desire to help people, and a joy of problem solving are all good attributes. Unfortunately, they are not sufficient to combat an inchoate fear that you are 5 years and $300,000 into a terrible, terrible mistake. And it starts early, also:
A study of all medical students in the United States found that about 49.6% of medical students met the criteria for burn out and 51.3% for depression. Trust me—it’s not all from studying, but from being treated like crap, feeling like we can never make a mistake or ask for help and wondering if anything we do will help to change the status quo or are we just cogs in a wheel trying to crush us.
Approximately 15 years ago, Don Berwick outlined the triple aim for improving healthcare in this country – enhancing patient experience, improving population health, and reducing costs. Tom Bodenheimer recently outlined a fourth aim – improving the work life of health care providers, including clinicians and staff. He identifies the following as some of six things we can do in primary care to keep our colleagues engaged and off the DOC website:
Reduce the burden on the physician through team documentation: An encouraging trend I have seen among pre-med students is their being engaged as scribes. This way they get to learn what it is really like to be a physician by being a part of the team and the physician gets to go home without having to do two hours worth of charting after dinner.
Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders. Things that are automated should happen automatically with the physician not being a barrier to good preventive care. We need to model this for students
Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day. We have gotten rid of the office in our practice. The physician work space is a shared space where interaction can occur. It is really important to level the field.
To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice. This holds true for student members of the team as well. They need to understand their role in care delivery as part of the stress of being a student is constantly being thrown into a new environment.
In short, what we as educators need to do is make sure students understand what they are getting themselves into and make sure they have the tools necessary to do the tasks they are assigned. What students need to do is look away from the books and understand that this is not about science or helping people but is about acquiring the skills to enter into a very difficult profession. While interviewing a residency candidate for our residency it came out that she had been to cosmetology school and had cut hair at Walmart for 2 years. I asked her what the best thing she had learned from that experience was, and she said “When people sit down in that chair and say ‘do whatever you want,’ they don’t mean it.” I suspect she won’t burn out.
“If the entire materia medica at our disposal were limited to the choice and use of only one drug, I am sure that a great many, if not the majority, of us would choose opium; and I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.”
Disabled, chronically abandoned
(Sign held by a young woman protesting in front of a pain clinic shuttered by the DEA last week)
Often in nature, a substance is found (or some believe God has placed a substance) that has serendipitous properties in humans. One of the first instance of humans discovering this was with the milky substance found in a flower now known as the poppy. Thousands of years ago, someone (we think an Arab adventurer) for whatever reason ingested that the milky substance in the “proto” poppy plant and found it relieved his pain. For the next thousand years, through cultivation and trial and error the opium poppy was born in China. Papaver somniferum.
Pain is a funny thing in people. It is a mechanism almost all of God’s creatures have to tell them that if they stay in their current situation bad stuff might happen to them. One of the things we are taught in medical school is how to get people to describe their pain. We tell students to get people to use a 1-10 scale with “1 being a paper cut and 10 being an elephant sitting on your chest.” Did you know there are a lot of people whose paper cuts are a 10? Once the situation has resolved, we have chemicals in our body that connect with the pain receptors (there are 4 such receptors, with mu being one) to relieve the pain and give pleasure. The opium poppy, which likely could only move back and forth and doesn’t need a lot of pleasure materials, has been bred to have 12% of its latex made up of these pleasure drugs (morphine, codeine, and to a lesser extent thebaine which was used to make hydromorphine).
Having a drug that reduces pain is lucrative. Having a drug that causes pleasure is more lucrative. In the 1800s, German scientists were able to extract pure opium from the poppies. Although available for pain relief, the larger market was in euphoria production in shops (mostly in China) using water pipe technology. Ironically, it was declared illegal in China (where the poppies were grown) but was smuggled by the British into China and sold to the opium dens to offset the imbalance of trade they found themselves in from importing tea. Only fair, I suppose.
We don’t need flowers today. Thanks to the God-given ability of humans to reverse engineer, the world produces about 700 tons of narcotics. Most of this medication makes its way to the US. We have 5% of the population and account for 99% of the hydrocodone use in the world (active ingredient in Vicodan), 83% of the hydrocodone use (active ingredient of Oxycontin), and 37% of the world supply of Fentanyl. We consume twice as much per capita as the next highest nation. Within our country, even, there is much variation with Alabamians consuming 2 1/2 times (1 1/2 prescriptions per person) as much as Hawaiians. The misuse of these drugs contributes to 17,000 deaths annually, as many as ovarian cancer but without a ribbon to raise awareness. Deaths aside, there is the problem of diversion. Many people get a prescription for 90 Vicodan, take 60, and sell 30. There are willing markets of buyers and many physicians are unaware that their sweet little elderly lady patient (who has the medicine in her urine) has a side business.
It turns out opioids have a downside. They are addictive, meaning that they cause aberrant behaviors on people unable to get access to the drugs by buying pills from the guy down the street. They cause a physical dependence. People who are suddenly denied access will suffer from physical symptoms such as nausea, vomiting, and profuse sweating. Chronic use results in tolerance, meaning that it takes an increasing dose to get the same effect. If you are going to create a market, what better product to sell?
As detailed in this New Yorker article, this problem has been a long time coming, and we in the healthcare field are complicit. Beginning in the 1980s, scholarly articles encouraging the addition of narcotics to our inadequate pain treatment regimes have been published. Some very smart people believed that treatment of chronic, non-cancer pain with opioids could work “with relatively little risk of producing the maladaptive behaviors which define opioid abuse.” In the 1990s makers of legal narcotics (Purdue in particular) began marketing their products to physicians and patients as safe for everyday ailments such as neck and back pain. With a team of 5000 sales people, a bonus system that encouraged “market growth,” and the assistance of the Joint Commission which began requiring hospitals to evaluate and treat pain, over $1 billion worth of Purdue’s Oxycontin was sold in the US in 2000.
So, God placed this wondrous drug in the proto-poppy for what reason? If used correctly, say for the pain associated with metastatic cancer, it is truly a miracle. If used by people to mask the psychic pain of living in America and written by physicians who are just too busy to talk to their patients, it is probably not what God intended. If given by physicians to folks in exchange for sexual favors thus feeding their addiction it is almost certainly not what God intended.
Perhaps God put the proto-poppy on earth to test physicians. We can make a lot of money selling these poppy derivatives but we can also get in big trouble. The test for us is to use it correctly.
Dr Perkins, can you come see this baby? Something about it just makes me feel uncomfortable.
I walk into the exam room to evaluate the week-and-a-half-old baby that was being seen by our new nurse practitioner. The child had a late morning appointment, the mother having called at 8 because the baby “wasn’t feeding.” No fevers, nothing else out of the ordinary per mom (although the baby did up having a fast heart rate). But as soon as I walked into the room, I quickly agreed with the nurse practitioner. The child was sent to the hospital for a “septic work-up” and was indeed septic.
Dr Perkins, I just don’t feel good. I have this chest pain when I go to sleep at night. Not during the day, mind you, only at night. That’s right, it hurts right there when you mash down.Why, yes, I have been getting a little short winded when I walk the golf course but isn’t that just weight gain?
Despite the reassurance that reproducible chest wall pain brings, based on reduced exercise tolerance we went ahead and obtained an EKG. To make a long story short, 3 vessel disease.
It was quite the Monday.
Despite running a busy department, I do a lot of clinical medicine. Trained in the underserved environment where I continue to practice today, I care for all ages, do some minor procedures, deliver babies (and now the babies of the babies I delivered). As my practice has aged with me, I see a lot more older than younger folks and find myself diagnosing more dementia and less strep throat the older I and my patients get.
Being comprehensive defines my specialty along with continuity, coordination, and first contact care. We preach to our learners the importance of these attributes, we test our graduates on the comprehensiveness of their knowledge, and we criticize ourselves for allowing our scope of practice to shrink. Now there is one more piece of evidence that should make us think twice about that cushy outpatient job ($50,000 signing bonus, no call, no hospital, 15 minutes to the beach). The Graham Center has authored a very elegant study that links scope of practice with actual practice. They found that doctors who were able to do more (were more comprehensive in their approach) had Medicare patients who were less likely to be hospitalized and who had better care-seeking behavior. By better, I mean that they cost the system about 15% less.
Not measured in this study were quality and patient satisfaction. This is important. As one of the commenters points out, sometimes comprehensiveness can be misused.
[F]or some populations with higher disease burden, high comprehensiveness (or scope, as we say) may be counterproductive. PCPs that maintain “too much” comprehensiveness for patients who need more contributions by other providers may be doing so because of lack of coordination with specialists, inadequate supply of alternative providers, an inability to recognize limitations, or resistance to “letting go”. Whatever the reason, the decreasing value of expanded scope in high risk individuals is a phenomena we have seen in numerous populations.
Despite these limitations, this is important. In the words of Kevin Grumbach (one of the smartest people I know) on NPR (one of the best sources for information I know)
the new study confirms a belief that had long been suspected, but has rarely been proven: Coordinated care, led by a family doctor who is judicious about referring patients to specialists, leads to cost savings.
“It goes from a matter of philosophical preference to actually showing that this saves money,” Grumbach says.
Me: Ms G, you have atrial fibrilliation and a lot of other medical problems. That means that your heart can form blood clots that go to your brain It is REALLY important that you take the blood thinner the cardiologist put you on.
Ms G: I know but he gave me this Elliquis and I just can’t afford it. My Blue Cross charges me $140 a month for the medication and that’s just too much
Me: There are much cheaper alternatives. Warfarin, for example, can be used very safely and keep you from getting a stroke.
Ms G: He never even mentioned that to me. Can you talk to him?
When this happened this past week, I was a little irritated. Ms G is not the easiest patient to care for and now I was having to deal with a problem not of my making. After making several phone calls we switched the Elliquis ($275 a month, $140 out of pocket to my patient) to warfarin ($6.50 a month plus $24 in monitoring costs, less than $10 a month to my patient) and everybody left happy (and late). Eliquis and other expensive blood thinners offer only a marginal improvement over warfarin and they do it in a very expensive manner. They reduce of the risk of stroke over 3 years from 16 stokes per 1000 people treated with warfarin to 12 stokes for people taking the newer medications. Of those 1000 patients, an extra one (2 vs 3) on warfarin will have a major bleeding problem. While an advantage, my patient chose not to trade $1200 in food money to do this and instead made the decision on her own to triple her risk of stroke (10 strokes per 1000 annually in those untreated with atrial fibrillation and her other conditions) by not taking anything. My patient is now on warfarin and presumably much better protected from having a stroke. Why was my patient not offered the opportunity to make a choice between the new improved method OR the tried and true method?
May have had something to do with marketing. As was pointed out last night, Americans have an expensive ($330 billion) prescription drug habit. The habit not only pays for the pills (a very small part of the cost) but also the payments to doctors who do the “education” of their colleagues. In 2013 this education cost Americans $24 billion, with marketing accounting for more than research in 9 of 10 companies. In the words of John Oliver “Drug companies are like high school boyfriends: they are more interested in getting inside you than in being effective once they are there.” Bristol Meyer Squibb spent an estimated $20 million in 2013 to “educate” physicians regarding the advantages of Elliquis over warfarin in stroke prevention, with about $15 million going to physicians to extol its virtues to other physicians. I don’t know if that was the reason for the oversight. To be honest I suspect in my patient’s case it was mostly ignorance of my patient’s social situation by the cardiologist that caused my long day.
At least my patient didn’t die from an overzealous sales force. Every day, 46 people die of prescription narcotic overdoses in the US. In Alabama in 2012 there were 140 narcotic prescriptions written for every 100 people. We really don’t need folks selling doctors on selling more narcotics. However, in 2012 a potent narcotic (Fentanyl) was introduced in a sublingual spray to compete with others similar preparations (Fentora and Actiq). These medications typically have, as their very specific indication (the reason to give to a patient), cancer pain not responding to around the clock narcotics. Insys, the company that makes Subsys, spent an estimated $6 million to educate physicians about this drug in 2013. I have to admit, until I read the Propublica article, I had not heard of it. As I don’t treat many patients with intractable cancer pain, that did not particularly surprise me. They only spent $44 a meal to educate 5,000 physicians. They did pay for 775 educational events (paying a physician $2,500 to talk about the drug every time) and hired 189 consultant physicians at $2,370 each. I guess they had to get the word out. Problem is they were and are getting the word out to the wrong people. Less than 1% of the prescriptions were written by oncologists. The product was a high potency narcotic of which there were already others on the market (a “me too” drug):
The former sales employees said that while the company targeted some oncologists, it placed more focus on high prescribers of competing products like Actiq and Fentora, regardless of whether those doctors treated cancer patients. They also said they were trained to mention the restriction to cancer pain at the beginning of the sales pitch and then to move on to a more general discussion of “breakthrough pain” in the doctors’ other patients.
Not only did Insys not worry about its drug getting into the wrong hands, it kind of counted on it:
Comments from a Wall Street analyst underscore that view. “As Subsys grows more mature, we expect the number of experienced patients to grow,” Michael E. Faerm, an analyst for Wells Fargo, wrote last year in a note to investors. “As the experienced patients titrate higher, the average dose per prescription should increase.”
The company used physicians who had problems with the DEA as their speakers and unorthodox methods to motivate its sales force. A cursory review of the Opiophiile forum reveals that their product is a success, with many addicted individuals enjoying the convenience and simplicity of the medication, with some even ingeniously discovering they can use it intravenously…just like heroin. Also the boards attest to the effectiveness of the marketing strategy.
Shelley, my doctor recommended it to me pretty much as soon as it came out. He said that the company that makes them wanted him to be a representative for them or something like that.
No wonder sales have increased 400% in the most recent quarter over last year and people are bullish on Insys’s prospects. in fact, investors only got skittish when a physician in Michigan who accounted for 20% of the drug sales lost his license. Fortunately for investors, their “medical marijuana” product is about to come to market to broaden the Insys portfolio and the market cap is back up.
Don’t get me wrong, I am by no means anti-medication. In fact, only 30% of people who would benefit from warfarin or related blood thinners receive them in the correct dosage and we need to work to use this inexpensive drug more effectively. I would personally prefer to find a different way to get the Opiophile readers their fix (with entries such as “Fentenyl patch, shootable” I am concerned their might be a lot of misuse in that community). Most importantly, as a profession, let’s stop shilling for Wall Street. I’m sure they’ll do fine without us.
In 1987, during my internship, there was a cautionary tale making the rounds about violating patient privacy and the consequences. I was in Norfolk but a friend swore he had heard it from a friend who was working in an emergency room in Philadelphia. It seems that a local newscaster showed up after a night of fun with friends with a little problem…a gerbil had “wormed” its way up the newscasters exit hole and had to be extracted. Oh, it was very true, I was assured, the newscaster even had to go to surgery (gerbils are unable to survive the passage through the large bowel no matter how entered). What’s worse, the health care workers who provided the public service of notifying the inquiring public were not only left unrewarded but FIRED. Can you believe??
These were the days before internet and to be honest, since I didn’t know anyone in Philly the story meant very little to me. I will say I had a friend who happened to be gay that I did tell the story to and he proclaimed it BS. He, as it turns out, was correct. No one, not even Richard Gere, has ever been x-rayed with gerbil remains “up there.”
Doctors see a lot of stuff. For those of us who collect stories, it is a really neat job. People pay money, sit down, look me in the eye, and after I say “How are you today” they say “Fine, except for this gerbil…” Okay, there are no gerbils, but they do tell me a lot of stuff. One of the key classes in medical school is the one where the student is reminded to keep a straight face and show no emotion no matter what comes out of the patient’s mouth. As a physician, your job is to problem-solve, educate, and instruct, but not to judge.
Doctors have the bond of “guess what silly thing my patient did” in common. The number of people who come in with a Coke bottle where it shouldn’t be and a lame story such as “I slipped in the shower while drinking a Coke” is actually quite high. Doctors’ lounges used to be places away from the average citizen where these stories could be recounted in a private, safe, environment. Now much health care occurs outside of the hospital, many doctors have little time to lounge, and (at least in the lounges around here) docs hollering, “Say it, Brother Sean” at the TV blaring Fox tend to drown out other conversation. So who can blame doctors for moving this conversation to social media?
Dr Milton Wolf is one such doctor. A Kansan and distant relative of Barack Obama, he graduated about 10 years ago and is a practicing radiologist in Kansas. He is one of 20 some-odd physicians running this year. The odd part, for some, is Dr Wolf’s use of Facebook to “educate.” Turns out that prior to deciding that a career in politics was in order, Dr Wolf found humor in radiographic images of people who suffered tragically, mostly from trauma. He collected these images and posted them, with comment, on a blog and to a Facebook account. One such exchange:
Wolf launched a Facebook chat about the 3D image by explaining it was taken from a postmortem examination. A Facebook friend, Melissa Ring-Pessen, responded that she performed the scan on Jan. 22, 2010, and was admonished for improperly positioning the man’s head.
“Seriously?” she wrote.
“Sheesh Melissa,” Wolf replied, “it’s not like the patient was going to complain.”
There is a video of the reporter confronting Dr Wolf about this post and it is worth watching. Apparently this particular image and discussion was posted before the patient’s funeral.
The Federation of Boards of Medical Examiners has suggested some guidelines for physicians when using social media that include using candor regarding possible personal gain, respecting the privacy of patients, and maintaining professional integrity. For anyone who is in the medical profession and uses social media, this is a must read.
The Doctors’ lounge had a couple of things. It had a door that separated “us” from “them.” The conversations were evanescent; if something untrue or hurtful was said, it didn’t sit on the Internet for years. If someone was too much of a jerk, they wouldn’t get patients sent their way. Lastly, when someone was a persistent problem, the medical staff president was always there to threaten a loss of privileges. Unfortunately no one seems to police the virtual Facebook lounge. Notice that the cautionary tale about the misplaced gerbil ends in a firing. The real story about the real patient (Google search “homicide victim” “Johnson County” Kansas on that date and I bet you can find the decedent’s name) ended in the guy getting on Fox and Friends and running for Senate. Go figure.
From Michigan via the Detroit Free Press:
Patients who didn’t have cancer were diagnosed as such. Sick patients were given too-high doses of powerful drugs. Some in remission were sent for unneeded chemotherapy. End-of-life patients were pumped full of drugs that couldn’t help them anymore.
These millions of dollars of medical treatments and tests were billed to Medicare in a pricey health care scheme run by metro Detroit hematologist oncologist Farid Fata, according to a federal criminal complaint filed Tuesday. The complaint says Fata intentionally misdiagnosed patients “as having cancer to justify unnecessary cancer treatment.”
So is this an example of government over reach? The invasion of ObamaCare into the doctor-patient relationship?
In one case, the federal complaint outlines, Fata prescribed 56 doses of rituximab to a non-Hodgkin’s lymphoma patient over two years, when the norm would be a dozen in two years. In another instance cited in the complaint, Fata allegedly forced a sick man who’d fallen down and hit his head when he came to the center to get his chemo before he could be taken to the emergency room — and the man later died as a result of the head injury.
OK, maybe not.
However, it is an example of our patients’ difficulty in judging quality. He was highly qualified based on the measures doctors use:
According to the Michigan Hematology Oncology Centers’ website, Fata did his his hematology oncology fellowship at the world-renown Memorial Sloan-Kettering Cancer Center in New York. He was voted one of the “Top Docs” in hematology or oncology in 2008, 2009, 2011 and 2012 by Hour Detroit Magazine.
as well as based no society’s measures
Fata founded the Swan for Life Cancer Foundation, which offers support to cancer patients and their loved ones in southeast Michigan, according to the oncology centers’ website.
From a follow-up article, he was qualified based on patient criteria as well:
“I always liked Dr. Fata. He had kind eyes,” she said Wednesday, a day after Fata’s arrest.
The real problem I have with the whole, sordid, alleged affair is that we are being told perhaps we should not expect any better:
“The trust that a professional is acting as a professional becomes a matter of survival,” said Ann Mongoven, assistant professor at Michigan State University’s Center for Ethics and Humanities in the Life Sciences. “ That’s why some might argue physicians have a special kind of obligation.”
And I guess some might argue otherwise??