the Natural Condition

The Public Library of Science seems, to my nerdy eye, to be the ‘open source’ repository of the publishing community. Last week, PLoS Medicine hosted an article that provided a fascinating, and chilling, look into the mind of a ‘drug rep.’ Drug reps are the suave pawns of the pharmaceutical companies who market the newest therapeutic agents. They meet with physicians, prepared with a convincing heap of data supporting their products, and most importantly, armed with a smile and a checkbook. Drug reps often treat physicians to fine dinners that create a convenient forum to discuss family life and, should it come up, cycloxyprxanimibidodizole, or whatever the drug of the week is.

In the article, the authors discuss some of the thought processes of the reps. The main ‘informant’ is a former drug representative for the pharmaceutical company Eli Lilly. If you read anything from the original piece, make sure to peruse Table 1, “Tactics for Manipulating Physicians.” The table describes various ways to market a product based on the type of physician, from the “high-prescribers” to the “acquiescent docs” to the “aloof and skeptical.” The article covers many common practices in the field, such as clever script tracking schemes and the value of giving out samples. While the article is professional and rigorous in its evaluation, it also offers several personal quotes from the front lines of the business:

While it’s the doctors’ job to treat patients and not to justify their actions, it’s my job to constantly sway the doctors. It’s a job I’m paid and trained to do. Doctors are neither trained nor paid to negotiate. Most of the time they don’t even realize that’s what they’re doing…

and

During training, I was told, when you’re out to dinner with a doctor, ‘The physician is eating with a friend. You are eating with a client.’

Even I, a lowly research assistant (but future physician!), was once chatted up by a smooth-talking, curiously-pretty-for-her-age drug rep. I happen to work in a cubicle next to a fellowship program director, who in turn organizes the lives of the actual doctors in the fellowship program, who, finally, are the young, clinical minds who wield the malleable prescription pads. She was, naturally, of an exceptionally amiable nature, but I found the true aim of her banter to be quite obvious: get in good with the right people and, indirectly, the favors and face-time will come. A wry smile came across my face as I thought to myself, “I don’t even know the names of the fellows … you’re wasting your time, miss.”

Despite my obvious skepticism, from an economical perspective, I believe these salespeople are probably integral parts to the progress of modern medicine. When all is said and done, the main thing that drives innovation — and I speak in generalities — is the bottom line. Pharmaceutical companies are firms that sell a product, who are accountable to shareholders. The only way they can attract the brightest minds to develop the breakthrough drugs is by competitive compensation, which stems from a great market share. This is not to say that pharmaceutical companies are purely money-making machines; they probably rely on high volume products (Viagra) to subsidize research efforts for meds that are cost sinks because of either low disease prevalence, or an inability to pay among the afflicted population (poverty). In any case, foolish beneficence on the part of the drug company would be bad for everyone. Drug companies need to sell their products or else no one gets better, and physicians happen to be the retailers — or, at least, the gatekeepers.

So long as the drug reps are not presenting falsified or incomplete information, then schmoozing a doc to prescribe your pill seems just business as usual. I, however, will remain “aloof and skeptical” as long as I can.

References:
(1) Following the Script: How Drug Reps Make Friends and Influence Doctors. Fugh-Berman A, Ahari S. PLoS Medicine Vol. 4, No. 4, e150 doi:10.1371/journal.pmed.0040150

Health Affairs released a report yesterday (March 10th) that outlined trends in American Emergency Department wait-times between 1997 and 2004. They considered three overlapping cases: all patients (18 and older), patients with ‘emergent’ conditions as indicated by triage staff (should be seen within 15 minutes), and patients with an eventual diagnosis of acute myocardial infarction — heart attack. On the whole, the median wait time to see an ED physician increased 36%. While wait times for ‘all patients’ and ‘emergent patients’ increased by about 40% per year (22 to 30 minutes, and 10 to 14 minutes, respectively), the change in the ‘AMI patient’ wait time dwarfed them both:

During the 7 years examined, the median wait time for patients eventually diagnosed with AMI increased by 150%, from 12 minutes in 1997 to 20 minutes in 2004. That is truly shocking news. Cardiogenic-shocking news, to be precise (pardon the pun).

In the decade from 1994 to 2004, total ED visits increased by about 18% (from 93 million to 110 million, annually). Emergency Department closures — as many as 12% during the decade — compounded the boom in visits. “Other likely contributors include inpatient bed shortages leading to bottlenecks in the ED; increasing uninsurance; population aging; shortages of staffing, space, and interpreters; and difficulties assuring non-ED follow-up care.” The sum of which totaled to a crucial deferral of care in the neediest patients. The authors of the paper raise the important point that staggering wait times, or even the misgiving of staggering wait times, will cause many prospective patients to avoid the ED altogether.¹

Wide-angle reports like this one demonstrate that all the ingenious, expensive, life-saving interventions are worthless if we do not first step back and survey the simple obstructions to keeping people healthy. We might do well to count something on this scale more often.

Reference:
(1) Waits To See An Emergency Department Physician: U.S. Trends And Predictors, 1997–2004. Health Affairs. 2008. [full text - restricted access] The full article contains many more interesting statistics about wait-time changes in sub-populations (race, gender, region, etc.).

“Count something.”

This keen piece of advice comes from Dr. Atul Gawande, as espoused in his most recent book, Better: A Surgeon’s Notes on Performance. Gawande is a general and endocrine surgeon at the Brigham and Women’s Hospital in Boston, MA. Although he is a surgical fledgling, completing his residency in 2003, Dr. Gawande’s insights blossom from his experience in public health issues, at one point serving as a senior health policy adviser for the Clinton administration.¹

The thesis of Better is that, while advances in medical technology, new drugs, and the like can lead to an overall healthier humanity, the most effective — and commonly overlooked — way to improve well-being is to make better use of what we already have. When he proposes that everyone in the healthcare community ‘count something,’ he means that evaluation and reevaluation of current methodology and practice are the true keys to success. We must measure ourselves, and then use those measurements to understand where shortcomings occur. He also makes it gravely clear that all doctors are not created equal in their ability to treat patients.
… (Read the rest of this article »)

Health Affairs, a journal dedicated to health policy, published an article today that reports on the forecast for healthcare spending in the US. In 2007, America spent about 16% of its Gross Domestic Product on healthcare. By 2017, that number is expected to rise to about 20% of GDP (a total of about $4.3 trillion). A 4% increase may not seem like much, but it represents a proportional growth that outpaces the adjusted growth for the 2017 GDP. By my calculations, the dollar amount of a 4% increase in healthcare-spending-as-proportion-of-GDP would cost more than current budgets for the Department of Defense, Homeland Security, Education, and Energy, combined.¹ The following chart shows the forecast for this increase:

^{Image courtesy of Health Affairs.}

This growth is equivalent to about a 6.7% increase in … (Read the rest of this article »)

The Washington Post published a blunt, acrimonious, and utterly superb article by Susan Jacoby this past weekend, which took aim — and hit the mark — at the demise of true intellectualism in the nation. A National Science Foundation poll observed that as many as one in five Americans believes that the sun revolves around the earth. Shocking¹. Jacoby writes that the dumbing-down of America is the inevitable byproduct of a culture who will not tolerate any source of information besides fast-paced, sound-bite-ridden visual media². People have become wholly uninformed, and even graduates of higher education are complicit, reading less frequently and watching obsessively. What is worse, she notes that the citizenry does not seem to care. The blend of ignorance and indifference is of greatest, and gravest, concern.

An exemplary excerpt:

Not knowing a foreign language or the location of an important country is … (Read the rest of this article »)

The New England Journal of Medicine recently conducted a panel discussion on the issue of Physicians and Execution. The panel members consisted of a general surgeon as the moderator (Dr. Atul Gawande from the Brigham and Women’s Hospital in Boston, a notable author)¹, a law professor (Deborah W. Denno, Ph.D., J.D.), and two anesthesiologists (Dr. Robert Truog and Dr. David Waisel). As individuals who know the science and have researched the ethics behind the topic of execution, one should duly consider their opinions.

Dr. Waisel outlined that the typical lethal concoction consists of 3 drugs. The first drug, sodium thiopental, is a barbituate whose aim is “to put you to sleep, create amnesia and anesthesia.” The second drug, pancuronium bromide, causes muscle paralysis. While anesthesiologists often use both of these drugs to sedate patients in the operating room, the lethal injection doses are necessarily much larger. The third and final drug, however, is not part of a doctor’s toolbox. Potassium chloride … (Read the rest of this article »)

Today I attended a forum on genetic testing for the Massachusetts General Hospital’s weekly Breast Rounds (I do research in breast oncology at the MGH). This week’s lecture, presented by Joseph D. McInerney, the Director of the National Coalition for Health Professional Education in Genetics, considered various aspects of the new wave of direct-to-consumer genetic testing. Genetic testing for specific gene markers¹ has been available for many years, and the results are primarily used by doctors and genetic counselors to determine the relative risks of disease onset and/or recurrence. This information allows the healthcare team to plan a course of treatment or preventative measures for a patient under supervised, knowledgeable care.

However, unlike “traditional” genetic testing, the professional health world does not filter this new era of direct-to-consumer genetic testing before it reaches the “consumers” (read: patients). Sites such as 23andMe.com and Navigenics.com advertise that anyone can obtain a complete genetic profile for as little as $999, which will outline propensity for certain diseases, among other recreational identifiers, like food preference. A most important note about these sorts of health-related tests: the FDA … (Read the rest of this article »)