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Should a Medical College Dean Take Money from Pharma?

One of the first posts I wrote here, was a about how pharmaceutical reps provide lunch for physicians while presenting information about a medication that they are promoting.  The post, and others like it, have generated visceral reactions on the part of the public. A similar article to the one that I wrote (also on kevinmd) prompted comments like “Get over yourself and buy your own lunch” and “I’m certainly glad that you are not my doctor”.

The opinions were so strong I was invited to speak on CNN about the topic. In particular, I was asked to speak about all the other extravagant things that physicians get from drug companies. I ultimately did not do the interview on account of me not having any experience with receiving any of the extravagant things they were talking about. It seemed to me that individual physicians receiving lunch was (excuse the pun) small potatoes compared to what happens behind closed doors in the halls of power. While upcoming rules will soon provide the public with a window into the value of goods provided to physicians by drug companies, they will provide little insight about where pharma has its greatest and most effective influence: behind the closed doors of those halls with thought leaders, opinion makers and legislators.

To that point, a story came to my attention recently that reminded me about that fact. The Dean of Weill Cornell Medical College, a prestigious and highly regarded medical school, has apparently kept close financial ties with industry, as reported in the the college’s newspaper.  The college’s Dean, a highly accomplished and awarded physician researcher, has retained positions with a major pharmaceutical company and a laboratory equipment company. In these roles last year she reportedly received about $260,000 from one of the companies and about $277,000 from the other last year. The Cornell Daily Sun also reports that she has apparently received millions of dollars in compensation from both companies over the years as well as more than a million dollars worth of shares and stock options in the companies. Continue reading “Should a Medical College Dean Take Money from Pharma?”

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Hospital Names New Executive Vice President in Charge of Lobby Christmas Tree.

An Announcement from The Holy Profit Medical Center.

“Holy Profit Medical Center” is a series of fake satirical press releases and news articles from an imaginary hospital. . . 

The Holy Profit Medical Center today named Bess E. Morass to the new post of Executive Vice President in Charge of Lobby Christmas Tree.

“We are very excited to have Bess here”, said HPMC CEO Haywood Jabuzov. “Ms. Morass received her MBA from Northwestern Michigan University, which is nationally recognized as being slightly better than Southwestern Michigan University.”

“We are very excited about this years lobby Christmas tree project” said Ms. Morass. “We have a very imposing task ahead of us, and it all begins with the Strategic Christmas Vision Project, which has already formed a committee. In those meetings we have given several power point presentations on how we might go about forming subcommittees to tackle the number of challenges that we are likely to face. We have already identified a number of areas where we may acheive strategic synergy, particularly in collaboration with the Task Force on The Formation of The Christmas Tree Decoration Committee.

Also at issue this year, is the very expensive lighting and extremely bright star on the top of the tree. Last year many patients complained that the light was so bright that it was keeping them up at night. Many employees are also questioning the cost of the tree in light of the many recent cut backs at the hospital. “This is an important point. It is the very reason we are proceeding with the Strategic Christmas Vision Project, after all, when people are laid off or are sick in the hospital, it’s more improtant that ever to have Christmas spirit!” She added, “however, the decision on the star is not under my purview, and will need to go through the ESCCTS (Executive Sub-Committee on Christmas Tree Star). We expect to have a decision on that by July of next year.”

“The first issue on our agenda was the color of the tree,” said Mr. Morass ”and I am pleased to report that we have decided to go with a yellow tree this year to promote gall bladder sludge awareness.” The Lobby Christmas Tree will be on display until mid-January, after which the Committee on Lobby Christmas Tree Disassembly will be tasked with its removal.

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Offer Hospice Patients a Smile.

Hospitals are busy places to work. The work is fast paced, and never seems to stop. For most physicians, the work ends when the work is done, or until you fall over, whichever comes first. So as a consultant, when I am seeing a patient wherein there is no longer anything that I am contributing to a patient’s care it’s routine that a physician would “sign off” the case, meaning I would not continue to see the patient on a daily basis but would be available if I were needed. Sure, I might have a good repoire with a patient, and some even tell me that I have a nice smile, but it hardly seems like a reason to continue to bill their insurance company without actually contributing any expertise. Despite how nice I think my smile is, I have yet to find an insurance company  willing to pay to see it.

It’s no surprise then, that in such a busy workplace the physicians-in-training that I regularly work with would want to sign off a case as soon as possible. Unlike most of their bosses, they get paid the same no matter how many patients they see. There’s no incentive for them to see more, and if they see too many, it becomes difficult to learn anything.

So for many specialists who round on patients in a hospital, and for physicians in training in particular, the typical approach to a patient who has enrolled in hospice or decided to otherwise stop all treatments other than comfort measures, is to sign off the case.

For those patients, the thought is, most of them are waiting to be discharged home or to another facility, and have accepted that the end of life is coming. In such situations families are typically grieving, making end of life arrangements or simply trying to spend as much time with their loved one as possible before the end comes. Why would it be necessary then for a specialist or a team of physicians to enter the room of such a person, ask a plethora of unnecessary questions, perform an exam and offer meaningless platitudes like “hang in there! you’re doing great!”?.  All this to a person whose one certainty is that they’re not doing great, and they’re most definitely not going to be able to “hang in there”!

Thus my approach has been to sign off such patients, and based on what I’ve seen, it’s the approach of most other physicians as well. I had always thought that ridding people of my pestering presence at the end of their lives was the most reasonable and humane thing I could do.

But things changed for me recently, when my own father entered hospice. He was in the hospital for a few weeks, and being a physician himself, he knew the end was coming. My mother, of course found it difficult to let go. After 50 years together, who could blame her? She agreed grudgingly to hospice, but needed constant reassurance that it was the right thing to do. I remember the constant look of consternation and worry etched on her face in the days after he was enrolled in hospice (but was still in the hospital). One by one, the physicians who had convinced her that there was nothing more to be done, disappeared. The physicians who reassured her that he would be well taken care of no longer visited, at just the time that she needed their reassurance more than ever. Her face wore a look that said, “Are we doing the right thing? Are they just trying to get rid of us?” Despite having a pulmonary, critical care physician for a son, there are some things you just need to hear from your doctors, the people who have been taking care of you, the professionals who know you.

Ultimately she came to accept the inevitable, she’s a strong person, and she knew she had no choice. He passed away peacefully.

But that experience taught me to change something in my own practice. I still round with my physicians-in-training, as I always have, we still sign off those patients who are going into hospice as we always have, so  the team does not needlessly pester a person at the end of their life. Instead, I walk into the room by myself, I perform no exam, I ask no medical questions. I offer them nothing but my smile. And it’s for free.

Related Articles: An “Untouchable” Who Touched the Lives of Many.   Code Status and Living Wills, and Why They Might Not Matter.

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Bridging Anti-coagulation is Dead! Long Live Bridging Anti-coagulation!

I am interrupting my current obsession with Top 5 lists  to bring you this important announcement: Peri-operative anti-coagulation, (also known as bridging anti-coagulation) is done! Is it time to stick a fork in it?

Right now you’re probably wondering, what the heck I’m talking about, and why you should consider it important. Currently hundreds of thousands of people throughout the country are on the oral blood thinner coumadin (also known as warfarin) to prevent a blood clot. For those who are on it long term, having a procedure can be problematic, as stopping the drug can increase the risk of blood clots, while continuation of the drug increases the risk of bleeding with surgery. Thus many patients undergo a process known as “bridging” wherein the coumadin is stopped  several days before the surgery, and a short acting injectable blood thinner is substituted so that the blood thinning effect of coumadin has time to wane before the surgery. This practice has been perpetuated without very clear evidence that it decreases the risk of blood clots or bleeding, and without much certainty about which people on coumadin need to be “bridged”. Recently, researchers sought to shed some light on this question by pooling together data from several smaller studies looking at patients who underwent bridging  to determine what the various risks and benefits of bridging might be.  The study  “Periprocedural Heparin Bridging in Patients Receiving Vitamin K Antagonists” was published  in the Journal Circulation and has received much attention, as it should have as it was co-authored by my former mentor (shout out Dr. Kaatz!) but also since it is the first large scale study of its kind. Continue reading “Bridging Anti-coagulation is Dead! Long Live Bridging Anti-coagulation!”

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Top 10 Advances in Medicine (1-5)

As promised, here’s the conclusion of my list of the Top 10 advances in medicine.  As stated before, here are the ground rules: I’m not ranking surgical advances,  I’m sticking to American medical problems, and we’re not including public health initiatives like clean drinking water. No, what we have here is a rare tribute to our  much maligned pharmaceutical industry in all its capitalistic chemical glory.
So once again, without further delay or  pre-authorization, here’s the cream of the crop of the top 10 medical advances.

5. Antihypertensives. Hypertension, like diabetes is a common contributor to vascular disease which lead to, among other things, stroke and coronary artery disease. The greater control of blood pressure by these medications has undoubtedly contributed to a reduction in morbidity. In addition, medications like angiotensin converting enzyme inhibitors and beta-blockers have other beneficial effects that go beyond their blood pressure lowering effects.

4. Birth control. In olden times in this country, and in many parts of the world today, it has been financially advantageous to have children. In an agrarian world, children contribute to labor, and tend to their parents as they age. Marriage of children could also mean merging of families and greater wealth. Nowadays, it costs close to $300,000 to raise a child. In addition, fewer children has meant more women in the job force and reduced strain on people, and marriages, which make for healthier people. Fewer children also means more resources for each child, which make for healthier children.

3. Insulin and other hypoglycemic agents: Diabetes is a major contributor to disease in the world. While it only ranks as the number 7 cause of death in the U.S. it is being increasingly understood that even minor amounts of hyperglycemia can contribute to vascular disease, particularly heart disease and stroke (which rank as the first and fourth most common causes of death). Undoubtedly without these treatments the incidence of vascular disease and infection would be astronomically higher.

2. Anesthetics and Pain medication. Imagine a world in which only the most basic surgical  procedures could be performed. A world where even lancing a boil would be considered barbaric and avoided at all costs. That’s what the world was like in the dark age before anesthesia and pain medicines. So many things that we take for granted in today’s medical world, like medicines for a minor procedure or obstetrical deliveries would not be possible without anesthetic agents. And that’s before we even consider things like hip repairs, open heart surgeries, and appendectomies. No, I think I would rather not try to imagine that world.

1. Antibiotics. Ok, this was an easy one, even most kids know about the invention of the first antibiotic. I shudder to think of where we would be today without the father of modern medicine, Dr. Penicillin, whose incredible legacy is today carried on by his grandson, Dr. Vancomycin. I kid. Check out this fascinating  first-hand account of the first use of penicillin in the U.S.; a 33 year old woman at Yale, New Haven hospital. A single vial of the “black magic” was shipped from England, the physicians actually collected the patients urine to reclaim the drug and re-administer it. She lived to the age of 90. Awesome stuff.

Check out the CDC’s list of the top 10 public health achievements of the previous decade. I found the statistics on the benefits of vaccines of particular interest; “A recent economic analysis indicated that vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease, with net savings of nearly $14 billion in direct costs and $69 billion in total societal costs.”

Related Articles: Top 10 Medical Advances (6-10);   Top 5 Things No One Taught Me in Training;   Top 5 Things You Don’t Know About Your Doctor;  Top 5 OTC Meds That Would Require  Prescription if Released Today.

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Coming Soon: Get Your Implantable Defibrillator on Craigslist?

Yes, I know I’m supposed to bring you the stunning conclusion to my top ten list of medical advances. But I was so excited to talk about this article I read recently that I’m bringing you this post instead. The top ten medical advances (1-5) will be up in 2 weeks. Unless I decide to bump it again.

We live in a golden age of technology and manufacturing. An age in which we’ve been spoiled by machines, personal devices and electronics have been created to ever increasing standards. Just a few decades ago, you couldn’t buy a Chevy Nova whose bumper didn’t fall off a week after you drove it off the lot. But today’s cars are engineered so well that they easily go hundred thousand miles and beyond.  Consumers expectations are now so high, that to ensure that electronics last the expected amount of time, they‘re engineered to last much longer than that. The cell phone(s) in your closet that you forgot about when you renewed your contract probably makes calls just as well as the one you’re using now.
The same goes for medical devices, particularly crucially important medical devices like implantable cardiac defibrillators (ICD). To ensure that they last the expected amount of time and deliver their life sustaining jolts, they have to be built to last. (For the amount of money they charge for them, they had better be). Unfortunately, building something like an implantable cardiac defibrillator to such exacting standards makes them extraordinarily expensive. Think your average Mercedes Benz expensive. And that significantly raises the bar for entry, particularly for the poor both in this country and abroad. In third world countries, access to such devices is limited to the super wealthy, as private insurance plans are limited and government resources are typically directed towards more elemental aspects of health that affect the larger population. In other words, in countries like India, if you’re fortunate enough to have lived long enough to have a cardiac problem which warrants the placement of a defibrillator, you had better be rich enough to afford one. If not, you’re on your own. Continue reading “Coming Soon: Get Your Implantable Defibrillator on Craigslist?”

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Top 10 Advances in Medicine (6-10)

I’ve been thinking lately about all the great advances in medicine over the years. There have been lots of them. And despite everything you’ve heard about looming cuts in healthcare, I have no doubt that the hits will keep on coming. Since I seem to be on this Top 5 thing lately, I figured I would continue this ride and rank my top 10 medical advances over the years. There had to be a few ground rules before putting together a list like this. I’m a medical doctor ranking medical therapies, and so surgical advances can take up space on someone else’s server. And just to be clear,  since it’s been awhile since I’ve treated malaria and cholera, I’m going to stick to western world problems and western world drugs.  I’m also not the young idealist I once was, so public policy initiatives, like seat belts, clean drinking water, and vaccinated babies are being tossed out with the bathwater. No, we’re talking about good old fashioned chemicals with long complicated names produced in soot belching factories and administered in our nations pharmacies and hospitals with epic markups to ensure future stock gains research funding.
So without further delay, and with no pre-authorization required, here is the latter half of the top 10 medical advances.

10. Psychiatric Meds. One has only to look at the CDC’s list of the top causes of mortality in America to see the logic behind this choice, as suicide rounds out the top 10 causes of death. But psychiatric problems also have a much greater impact beyond suicide. Problems like depression and anxiety often exacerbate other medical conditions, increasing the risk of complications.  They put strain on family members and cause lost productivity and income. They are one of the most common reasons for enrollment in disability. Continue reading “Top 10 Advances in Medicine (6-10)”

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I’m Tired Of. . .

It’s been a long few months. What with the recent death of a family member, the usual barrage at work, and trying to raise a family, I think I may be in the early stages of physician burnout. So I’m going to give myself liberty to do something I rarely do. . . I’m gonna complain. Oh yeah, I’m gonna gripe and whine, and cry like a little baby. Just this once. But don’t worry about me.  Because as you read this I’m sitting in a meditative cleansing trance, taking in beautiful scenery, and trust me,  it feels oh so good. So I’ll be back soon, batteries recharged, taking all the things I’m griping about here with a swing in my step and a smile on my face. Continue reading “I’m Tired Of. . .”