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Nothing New Under The Opiate Sun

The “War against prescription drug abuse” (don’t you really hate that phrase ‘war against’?) is alive and well, focusing as always on the wrong issues.  The latest salvo comes from a California company called Zogenix.  It has come out with a “new” drug called Zohydro, a long-acting version of hydrocodone  (Zogenix plus Hydrocodone.  Get it?  Drug companies are super clever!).  Here’s what the Zogenix website says their company’s goal is:

“We are developing and commercializing products for the treatment of central nervous system disorders and pain by leveraging technology to provide innovative solutions for unmet medical needs.”

OK, so first of all, a long-acting opioid is not an unmet medical need.  There are plenty of long-acting opioids out there that come in pill form, patch form, IV form, epidural form, and any other form you can think of.  Second, a new formulation of an old drug is not really “leveraging technology”.  It’s more like leveraging shareholder value. Why is this one better?  Since it does not contain acetaminophen, the new drug will provide steady relief without the risk of liver damage, according to officials at Zogenix.  Once again, we have other pills that don’t contain Tylenol.  Like, oh, say, morphine.  Oral morphine, in it’s various forms, costs $12.99 retail.  Zohydro costs $375.

But, the FDA has approved Zohydro.  So you can buy it, if you want.  It’s great for snorting.  Those awesome little capsules are full of pure hydrocodone powder.  The FDA advisory committee, which is supposed to be a panel of experts, strongly discouraged the FDA from approving it.  The NYT article has the following two paragraphs that say it all in response to this advice:

“F.D.A. officials say they have an obligation to approve new treatment options for the more than 100 million americans who live with chronic pain, which can be debilitating and can prevent them from working and living productive lives, though that figure has been questioned.”

“To say to people with chronic pain who are taking opiates around the clock that we shouldn’t offer them an extended-release option is unnecessarily penalizing the patient,” Dr. Janet Woodcock, director of the agency’s Center for Drug Evaluation and Research, said in an interview. “We need to balance the medical needs of people in severe pain with the risks of these medications, including the risk of abuse and addiction.”

But since Zohydro is not a new treatment option and since there are extended-release options that cost far less, the above statements are ludicrous at worst, disingenuous at best.  The FDA has tried to curb prescription drug abuse by targeting all but the actual person putting the pills in their mouth.  It has required stronger language on labeling, restrictions on refills, and lots of post-marketing studies.  It has made doctors take special classes and register with various governmental agencies.  The Times article says the FDA has also approved a drug that can be injected to reverse the effects of narcotics.  You mean Naloxone, which has been available since the 1960′s?

Please don’t prescribe or take this drug.  Stop the madness.

Zen And The Art of Car Maintenance

Click and Clack, the Magliozzi brothers of “Car Talk”, often get asked questions about life embedded in questions about cars.  I was listening to one of their archived shows yesterday (alas, they are not making any new ones).  It made me think of health care, naturally.  Here’s how:

Every 5,000 miles I take my car in for an oil change.  Every time I go the technician pulls up a bunch of maintenance requirements based on mileage.  I can choose to follow “manufacturers suggested maintenance” or I can just choose to get the oil changed and go on with my day.  My choice is based on a number of variables on any given day:  how much time do I have?  How much will it cost?  How much money do I have, now and in the future?  How much faith do I put in those suggested maintenance charts put together by Toyota?  How much do I care about my car?  How old is my car?  Do I really believe in the consequences of disregarding the recommendations?  How much do I trust this particular garage to competently perform said maintenance?

If you look at this list you notice a few themes.  Hang on, this relates to health care, eventually.

1. Notice how three of those variables involve how much I believe what I’m being told.  How much do I trust Toyota, and Valvoline, and the particular set of Valvoline employees that are working that day?  I recently went to a delightful lunch with a bunch of very smart people sponsored by Trust Across America.  People, I can tell you for a fact that people trust their bankers and their mechanics more than they trust their doctors these days.  For example,  how much faith do I put in the suggested maintenance of my colon, as delineated by the American Society of Gastroenterologists, who get paid for every colonoscopy?  How much do I believe I’ll die an early and grisly death of colon cancer if I don’t follow those rules?  And if I do follow the rules, how much do I trust this particular doctor to do my procedure?  Trust is so important, and needs to be earned.  How do I know to trust Toyota and Valvoline?  Well, I don’t trust Toyota completely, because there scheduled maintenance recommendations could be set up to maximize profits for their dealerships.  So I use my own judgement based on my own beliefs to decide whether to do what Toyota says.  Remember that regardless of their motives, they still know a hell of a lot more about cars than I do.  As for Valvoline, I trust this particular Valvoline store because they always tell me the truth and they do good work.  I don’t think I need to extend the analogy any further, you get the idea.

2. Some of these variables have to do with money.  How much do I want to spend?  Would I have more money later, if I wait?  If I wait, will a small problem become a more expensive problem?  Is this Valvoline charging me more than another one would?  Should I shop around for the best price on air filters?  And the biggie:  Will my insurance cover it?  Here is where car maintenance deviates from body maintenance.  Health insurance takes away most of these questions, except for instances of co-pays and deductibles.  The Affordable Care Act has insured 8 million more people.  That’s 8 million bodies that need servicing, requiring 8 million more units of money, whatever the conversion factors are.  It is no surprise that health care spending is projected to go up.  http://www.nytimes.com/2014/04/19/business/economy/health-care-spendings-recent-surge-stirs-unease.html?ref=health.  The ACA doesn’t decrease costs.  It just hides them from more people.

3. There are variables that have to do with my personal values.  How much do I care about this car?  How much longer do I expect it to last?  How old is my car?  How many dings and scratches does it have on it?  Do I really like this model anyway?  How much time do I have to devote to maintenance of this car?  Do I want to sit here in my car while some guys do a bunch of work on it or would I rather go out and enjoy this sunny day?  Personal priorities are so important.  My oncologist tells me I should get chemo and radiation.  Well, maybe I’m old and have had a good life.  Maybe I’m a little dinged up and it’s not so easy to get around anymore.  Maybe I’d rather see my grandkids than sit in the chemo treatment room.  How much longer do I expect to live, and at what cost to me and the people around me?

Trust, money, and personal values.  Basic, and often conflicting, decision-making components.  That’s why health care reform is so hard.

Let The Witch Hunt Begin

Well, the cat is out of the bag now.  All this time we’ve been told that Internal Medicine is a dying art, you can’t make a living at it, payments to physicians are too low, etc.  Now the New York Times is telling me that Internal Medicine is fifth on the list of best-paid doctors!  How can this be?

Here’s what has happened: Medicare has released the names and specialties of all the doctors it has paid in 2012.   That’s a lot of data.  It’s, well, Big Data.  It’s data on two things: 1) doctors; 2) money.  The healthcare reform debate in a nutshell.  So this will likely get a lot of press.  I haven’t seen the actual numbers yet, and I’m told it will take many weeks to go through all of it.  Since nobody pays me to write, I’ll have to keep my day job, and thus will have to leave the number crunching to others.

Thankfully, the New York Times has come to my rescue. (http://www.nytimes.com/2014/04/09/business/sliver-of-medicare-doctors-get-big-share-of-payouts.html?hp&_r=0).  According to the NYT, 880,000 practitioners and 77 billion dollars are covered in the report.  Twenty-five percent of that 77 billion seems to have gone to two percent of doctors: those in opthalmology, oncology, and cardiology.  Internal medicine is right behind, wouldn’t you know.  The article actually has a chart that they named “The best-paid 2 percent of doctors”.  Yep.  Those family doctors are really raking it in.

The paper singles out a specific opthalmology procedure as a prominent, and, it implies, therefore suspect, reason for big payouts.  In fact, the paper had to be asked (nicely) not to release the names of the actual doctors with the highest billing records, or to contact them, until all the data is released to the public.  I suspect a couple of eye-doctors are going to have a really bad day today.  The opthalmology data is a good illustration of how Big Data can be Limited Data.  And how it can be interpreted a number of ways.  The NYT is implying that because eye doctors’ billing is so high, and so much higher than other specialties, there must be some something criminal going on.  Either eye doctors are committing fraud, or they are doing unnecessary procedures, or they are using drugs that are too expensive.  The doctors must be wrong.

But the data doesn’t say that at all.  All it says it that Medicare, which sets it’s reimbursement rates at levels mandated by Congress, not doctors, pays more money to treat people with eye diseases than it does other diseases.  That’s it.  It says nothing about a doctor’s practice at all.  Nothing.

Let’s take a couple of examples.  Opthalmology is a sub-specialized field.  A doctor who does cataracts doesn’t do Lasik, or he does Lasik but he doesn’t handle macular degeneration, etc.  A lot of specialties are getting like this.  Now, say a few doctors have specialized in this one procedure the NYT is all upset about.  Other doctors send their patients to these guys.  All of their practices becomes doing this procedure.  Because it’s their specialty.  So they bill Medicare for the procedure.  Medicare pays out what it decided to pay for this procedure.  How is this the doctor’s fault?  (By the way, funny story.  There’s a Lasik advertisement on the internet page with this article.)

Another example.  Say you are an oncologist.  You treat a lot of blood cancers, leukemia and such.  Other doctors send you their patients if they have leukemia.  There are a lot of types of leukemia, many of which are very expensive to treat and some which actually become chronic.  You bill Medicare for your treatments.  Medicare pays back what it decided to pay for these treatments.  It costs a lot to treat leukemia.  That’s what the data says.  That’s all it says.  It says nothing about quality of care, patient population, number of patients, or disease complexity.  It says nothing about variability in office visit time or the level of co-existing disease in a specific doctor’s patient population.

I am all for transparency.  I think having this data out there is fine, as long as we understand what we are getting.  And I’m not sure we do.  Specific doctors are going to be targeted for a lot of scrutiny because of this report.  Maybe they deserve to, maybe they don’t.  Fraud and over-treatment do exist.  But this data is far from able to tell the whole story.

Check Her Out!

I was super surprised and honored today when I saw that Dr. Karen Sibert had mentioned me in a tweet.  She is an anesthesiologist and blogger, and all her posts are fantastic.  She wrote a piece on pain management and opioid addiction and drug regulation that is so good, so complete, I wouldn’t dare try to re-invent her wheel.  Check it out!

http://apennedpoint.com/the-problem-of-pain-when-best-medical-advice-doesnt-equal-patient-satisfaction/

How Do I Know If I Really Love It?

Very interesting question from a med student reader the other day:  How do I choose what specialty to go into?  Her particular decision was worded  differently, but the general idea of the query is the same:  how can I possibly know what it’s going to be like to be this or that kind of doctor?  It’s a great question.  After all, you have to choose during the third year of medical school because of the lengthy match process.  (For those of you who don’t know what the match is, I’ll rant on that another day.)  Plus, once you pick you’re going to spend the next 3-10 years training in that specialty.  It really sucks when after all that you realize you chose wrong.

Some people just know.  “I’ve wanted to be a pediatrician since I was 5, my mom is a pediatrician, my grandfather is a pediatrician, I was Doc McStuffins as a child, I loooooove kids…”  Great.  Awesome.  Those people are lucky, and usually right.  Others have it narrowed down to, at least, adults vs. kids, medicine vs. surgery, out-patient vs. in-patient, etc.  Those people are less lucky, and sometimes right.  For the rest of us, all we have to go on is what we see in the third year of medical school, when real clinical rotations get going.  Remember, I was a nurse before I went to med school.  I was a cardiac nurse.  I wanted to become a cardiologist.  I thought I knew exactly what I was getting into.  I was so wrong.  So, as someone who has chosen wrong more than once in her life, I herewith give you a list of things to consider so you don’t do what I did.

1. DO NOT LET A BAD ROTATION INFLUENCE YOU.  I can’t emphasize this enough.  For a medical student, the experience she has during clinical rotations has more to do with the residents and their treatment of her than anything else.  For example, I had a horrible surgical rotation.  The residents were stressed and thus either mean or dismissive of students, who are generally not useful and can be a significant added burden.  No responsibility or accountability was given to the students, so I could disappear all day and show up for rounds in the evening and nobody would notice or care.  I felt hesitant to ask to scrub in and nobody insisted that I do so.  Med students in that rotation were not valued.  And I could feel that.  On the other hand, in medicine everyone was super nice and let me do stuff and ate lunch with me and generally tolerated my presence.  So I went into medicine, which was a terrible decision.  Please don’t take any of it personally or dismiss a specialty out of hand because some miserable resident was a jerk to you.

2. FIND THE BORING PART.  What is it that the attending in each specialty does repeatedly?  Because I guarantee you there is at least one thing that each doctor in every specialty does over and over every day.  Happiness in a specialty is going to depend in part on how well you tolerate this repetition.  Examples:  Don’t become a pediatrician if you are bored to death treating ear infections.  Even if you love kids.  Don’t become a general surgeon if, after doing three appendectomies you’re ready to shoot yourself if you have to do another.  Even if you love appendices.  There’s a boring part, I guarantee it.  Find it.

3. DON’T MAKE LIFESTYLE YOUR MAIN CRITERIA.  This one is sort of counter to what people are aiming for these days, but I’ll tell you why I say it.  It relates to #2.  If you love the lifestyle of dermatology but can’t stand rashes, even the 9-5 office hours and lack of call will not redeem days filled with rashes.  If you like that anesthesiologists get a lot of vacation time (we do) but can’t stand sitting in the OR all day, no amount of fabulous days at Disney World is going to make up for what you have to do when you’re not on vacation.

4. FORGET #1.  PAY ATTENTION TO HOW YOU FEEL.  By this I mean observe yourself in each rotation.  Are you cold, hungry, and sleepy all the time?  Not a good specialty for you, even if you think you would like it.  You’re bored, don’t waste your time.  Are you on call every other night and can’t wait to get back to it every day?  Better choice.  Does the work induce “flow”?  That is, do you look up at the end of a day and go “That was fast!”?  Good choice.  Don’t find excuses for how you feel if you have your heart set on a specialty.  Just because you thought you would like it doesn’t mean your body and mind aren’t telling you “no way”.

5. BEWARE OF THE NOVELTY FACTOR.  You might think OB is awesome because you’ve never seen a baby born before.  You might find cardiac surgery totally cool because you’ve never seen someone stick a hose in a ventricle.  These things are awesome, but they better be awesome 15 years from now.  Even if you love a specialty, residency will make you practice that specialty so much it won’t be fun anymore.  You have to be able to sustain your passion through that.

Good luck!

 

Patient Safety = Nurses

File this one under the “duh” heading.  A study out of Europe has found that patients do better with more educated nurses and lower nurse-patient ratios.  Here’s the link: http://www.nytimes.com/2014/03/31/world/europe/nurse-education-level-affects-death-rates-study-says.html.

This is what the researchers did: they reviewed charts and nursing employment files at 300 hospitals across 9 countries.  All patients 50 years and older who had surgery for general, orthopedic, or vascular problems were included.  So, retrospective, but very large sample size – 422,730 patients.  There were two main findings:

1. For every 10% increase in the proportion of nurses with bachelor’s degrees, there was a 7% drop in post-surgical mortality.

2. For every 1 patient increase in the nurse-patient ratio, mortality rose 7%.

The NYT article suggests that the reasons for these findings are matters up for debate.  No, they’re not.  As I’ve said many times, you don’t go to a hospital for a doctor.  You go because you need a nurse.  The better educated your nurse is, and the few patients he/she has, the better care you will get.  Period.  The quality of the doctors, physical plant, janitorial staff, candy-stripers, or CEO doesn’t matter.

Here are some reasons for the findings in the Lancet study.  Say you are an 80-year-old woman and you come in for an hip fracture.  I’ve used this little old lady before, and she will be me someday.  You are old but you have all your wits about you, and then some.  In order for you to make it out of the hospital alive, and to still be alive 6 months later, you need some specific things from your nurse: adequate pain management, good food, plenty of fluids and rest, someone to look at your wound and dress it carefully, someone to force you to get out of bed, good physical therapy, adequate referrals for rehabilitation, an advocate and liaison with the surgical staff, and someone who knows what to do if something goes wrong.  The more your nurse understands your condition and the underlying physiology, the more these tasks will be correctly accomplished.  I am not impugning nurses who are not bachelor’s trained; many of them make up in experience what they lack in education.  But for new nurses, a bachelor’s is going to provide an head-start.

How can your nurse do all of these things for you and for 7 others?  She can’t, of course.  In my opinion, nurse-patient ratios are one of the most important determinants of patient outcomes.  Lower ratios are more expensive, it’s true.  But remember, you go to the hospital because you need a nurse.  You want patient safety and high quality?  Provide an adequate number of well-educated nurses.  It really is as simple as that.

Who Do You Think You Are, A Doctor?

Remember the scene in the movie Knocked Up, where the obstetrician is telling Allison she can’t have an epidural?  Greatest scene ever.  I know for a fact that at least three of my most loyal and beloved readers won’t get this cultural reference, so I’ll quote it for you:

Setting:  Labor room, Allison (Katherine Heigle) about to have a baby, Seth Rogen’s character, the father, is there, along with the nurse, Deb, and the obstetrician, played by Ken Jeong, who is actually a real doctor.

Allison:”Oh this really hurts.”

Jeong: “I see we’re well on our way.”

Allison: “I want the… I want the epidural.  Okay?”

Rogen: “Give it to her now.”

Jeong: “Ok Allison.  We’re past the point of an epidural.  Okay?  The cervix is fully dilated.”

Allison: “No seriously, I want an epidural…”

Jeong: “We can’t give you the epidural.”

Allsion: “I’ll make sure it doesn’t come out!  I’ll stop pushing!’

Jeong: “We’re gonna just have to do this the all-natural way, okay?  The way you wanted to do it.”

Allison: “This is messed up.  Something’s wrong in there.”

Jeong.  “Oh, no, no.  I mean, granted, gynecology’s only a hobby of mine, but it sounds to me like she’s crowning.  Is that right, Deb?”

Actually, there a few scenes in the movie in which Ken Jeong’s character hilariously says things that doctors would love to say on occasion but never do. They are variations on the theme of “Who’s the doctor here?”  This post is not a yearning for the old, paternalistic way medicine used to be practiced, but every time I see these scenes I remember similar discussions with patients who are trying to play doctor.

This rant started because a colleague pointed out  a piece by Tom Nichols at The Federalist entitled “The Death of Expertise”. (Thanks Jess Geerling!)  http://thefederalist.com/2014/01/17/the-death-of-expertise/.  Here’s how he introduces the topic:

“I fear we are witnessing the “death of expertise”: a Google-fueled, Wikipedia-based, blog-sodden collapse of any division between professionals and laymen, students and teachers, knowers and wonderers – in other words, between those of any achievement in an area and those with none at all. By this, I do not mean the death of actual expertise, the knowledge of specific things that sets some people apart from others in various areas. There will always be doctors, lawyers, engineers, and other specialists in various fields. Rather, what I fear has died is any acknowledgement of expertise as anything that should alter our thoughts or change the way we live.”

I’ll ignore the blog-sodden comment.  Here’s the thing.  Information is readily available.  Access to the greatest minds in every field is more accessible than it’s ever been.  Information, however, even from thought leaders, is useless unless it is processed appropriately in the right context.  For example, imagine that I, arguably an “expert” in the field of anesthesia, decide to go consult a lawyer on a possible real estate purchase.  This lawyer would presumably be an “expert” in the field of real estate law.  I could play my visit two ways:  I could go to her (it’s a her.  It’s my blog.) and say “Here’s this building I was thinking of investing in, but it has several zoning regulations, what do you think…” and then do what she says.  Which is what I would do, since I know zilch about real estate.  Or, I could go to her and say “I’ve spent all day on the internet and I’ve discovered that in zone 3 in this state the statute of limitations on blah blah…”  If she then patiently explains zoning laws to me, I could come back with “Are you sure, because realestaterus.com says that according to article 33 of amendment 501 of the zoning regulation…”.  But I’m not going to do that, right?  Because she is the expert, and I am not.  It doesn’t mean I’m inferior to her, or somehow in her debt, or that I should feel bad about myself because I don’t know anything about zoning.  Nor should I feel attacked or threatened by her superior education and skill in law.  I subjugate myself to her in this particular area.

Patients are in a difficult spot.  They feel vulnerable, threatened, fearful of pain and unfamiliar circumstances.  Especially in anesthesia, which is a black box to most folks.  In medicine, patients must subjugate themselves, within reason, to an expert.  So many people feel threatened by this. The source of this feeling is distrust.  I’ll admit to feeling the same way about my mechanic. But I know less about cars than I know about real estate law.  I can, and should, look at the information that’s available that I can understand, but ultimately I must trust.  May we doctors be forever worthy of yours.

 

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