NPR does a good job reporting on health care issues. Recently there was a story about a case headed for the US Supreme Court, in which drug companies are claiming First Amendment protection of their right to maximize the efficiency of their efforts to market prescription drugs to doctors.
When your doctor writes a prescription and you get it filled, the fact that you were prescribed that medicine is considered Protected Health Information under federal law. But the fact that your doctor wrote that prescription is not similarly regarded as a confidential matter. There are "data mining" companies that pay pharmacies for information about the prescriptions doctors write. In turn, these companies sell the information to drug companies. The pharmaceutical manufacturers can then use the information to target their efforts in marketing their products to doctors.
Many doctors have been unaware of this. I recently made a presentation on relations between the pharmaceutical industry and medical organizations to a group of emergency physicians at the University of Iowa. I mentioned this issue, and few (if any) in the audience knew about it.
But the Vermont Medical Society knew about it, and they didn't like it. They asked the state legislature to do something about it. Vermont lawmakers decided the doctors' group was right, and they enacted a ban on this data mining.
Now the data mining companies and the drug companies have filed suit, claiming the ban interferes with their marketing efforts in a way that violates First Amendment guarantees of free expression.
A federal district court in Vermont upheld the ban. Similar bans in Maine and New Hampshire have also been upheld. But the US Court of Appeals for the Second Circuit overturned the ban on constitutional grounds. Such disparate rulings by lower federal courts commonly result in appeals to the Supreme Court for ultimate resolution. The high court has now been hearing oral arguments in the case.
I am an avid student of constitutional law, although I have had no formal training, and I find it fascinating to try to analyze the issues involved in such a case. Clearly, the ban on the mining of data and on the sale of the data to drug companies in no way interferes with their freedom of expression in promoting the merits of their products to physicians. Rather, it hampers their efforts to target that marketing most efficiently.
Say Company A makes Drug X and markets it for treatment of Disease Z. If the company can buy information that tells it I almost never prescribe Drug X, even though my specialty is one that would indicate I see many patients with Disease Z, the company can target me with a special effort to convince me that their product is the best choice for these patients. Without this information, Company A is left to treat all doctors in my specialty equally as targets for their promotional activities.
It so happens that I don't meet with sales representatives, and I tend to ignore marketing brochures, so for me personally this is mostly of academic or intellectual concern. But I am always intrigued when the profit motive causes people to try to make a case in constitutional law that a provision in the Bill of Rights protects their economic interests.
Patients prefer that their doctors make decisions about prescribing drugs based on the best scientific evidence available - not on the most efficient and effective marketing efforts that the pharmaceutical manufacturers can muster. I am hopeful that the Supreme Court will decide, in this case, that what is best for patient care and what is constitutionally sound are in accord.
Friday, April 29, 2011
Thursday, April 28, 2011
24 - without Jack Bauer
For the last fourteen months I have practiced the specialty of emergency medicine at a hospital where the doctors in the emergency department (ED) work 24-hour shifts. When I signed on there last spring, I wasn't sure if I would like that kind of scheduling. I had never worked 24-hour shifts before.
Such shifts are typically scheduled 7 AM to 7 AM. Obviously that is a long time to work at a mentally demanding job with no sleep. Its feasibility depends on two things. First, how busy is the ED between 7 AM and midnight? Second, how many patients typically come in between midnight and 7 AM? If the workload between 7 AM and midnight is moderate, and few patients come in after midnight, it may be reasonable. So, in a community in which no one goes to the hospital in the middle of the night for things that are not true emergencies, it can work.
Increasingly, however, we live in a 24-7 world. People go to Wal-Marts and supermarkets that are open round the clock. So, when the sore throat for three days or the back pain for two weeks is just too annoying in the middle of the night, they go to the ED at the local hospital. They expect that the staff on duty are there to take care of them at 3 AM the same as 3 PM.
You might think the problem with 24-hour shifts is that the doctor won't be at his or her best at 5 AM when there is a patient who is critically ill or injured, or who requires clear thinking about a diagnostic puzzle or a meticulous repair of a wound in a cosmetically important area of the body. But I've been doing this for more than 25 years, so my diagnostic and procedural skills are not easily challenged, even when I would much prefer to be napping. And for the critical patients, the adrenaline rush can sharpen my edge in a flash.
No, for me the true challenge is that sore throat for three days or back pain for two weeks - the "reason for visit," as the phrase on the patient's chart reads, that makes me wonder, "Why now?" Why not 8 hours ago, when I wasn't hoping for a nap, or any time in the primary care doctor's office? I have to draw upon my dwindling inner reserve of niceness, because I know patients expect the same cheerful, eager-to-serve attitude and demeanor whether it's 4 AM or 4 PM.
The published scientific literature says 24-hour shifts for emergency physicians are not a good idea, except in hospitals that don't get many patients in 24 hours - and very few (meaning only true emergencies) after midnight. I've decided they're probably not best for me. I'll be doing them for only another month and then moving to a different hospital, although primarily for other reasons, having to do with what I really love in the practice of my specialty. I will surely write more about that in times to come.
Such shifts are typically scheduled 7 AM to 7 AM. Obviously that is a long time to work at a mentally demanding job with no sleep. Its feasibility depends on two things. First, how busy is the ED between 7 AM and midnight? Second, how many patients typically come in between midnight and 7 AM? If the workload between 7 AM and midnight is moderate, and few patients come in after midnight, it may be reasonable. So, in a community in which no one goes to the hospital in the middle of the night for things that are not true emergencies, it can work.
Increasingly, however, we live in a 24-7 world. People go to Wal-Marts and supermarkets that are open round the clock. So, when the sore throat for three days or the back pain for two weeks is just too annoying in the middle of the night, they go to the ED at the local hospital. They expect that the staff on duty are there to take care of them at 3 AM the same as 3 PM.
You might think the problem with 24-hour shifts is that the doctor won't be at his or her best at 5 AM when there is a patient who is critically ill or injured, or who requires clear thinking about a diagnostic puzzle or a meticulous repair of a wound in a cosmetically important area of the body. But I've been doing this for more than 25 years, so my diagnostic and procedural skills are not easily challenged, even when I would much prefer to be napping. And for the critical patients, the adrenaline rush can sharpen my edge in a flash.
No, for me the true challenge is that sore throat for three days or back pain for two weeks - the "reason for visit," as the phrase on the patient's chart reads, that makes me wonder, "Why now?" Why not 8 hours ago, when I wasn't hoping for a nap, or any time in the primary care doctor's office? I have to draw upon my dwindling inner reserve of niceness, because I know patients expect the same cheerful, eager-to-serve attitude and demeanor whether it's 4 AM or 4 PM.
The published scientific literature says 24-hour shifts for emergency physicians are not a good idea, except in hospitals that don't get many patients in 24 hours - and very few (meaning only true emergencies) after midnight. I've decided they're probably not best for me. I'll be doing them for only another month and then moving to a different hospital, although primarily for other reasons, having to do with what I really love in the practice of my specialty. I will surely write more about that in times to come.
The Libertarian and Restrictive Covenants
It used to be that restrictive covenants were mostly intended to control a neighborhood's ethnic, religious, or racial composition. "Your kind are not welcome around here." A property's deed prohibited any owner, current or future, from selling to someone in an undesirable class.
Nowadays, however, restrictive covenants are used by "planned communities" governed by homeowners' associations as a way of enforcing a set of rules. Accepting the deed to a property obligates you to abide by the association's bylaws and a set of rules, which may be quite lengthy and detailed.
The idea is to protect property values and avoid offending neighbors. It might, for example, not only be hard on your eyes but also make it more difficult to sell your house if your neighbor across the street were to have the paint on his house changed from its current traditional white or subdued earth tones to purple with orange polka dots. The same might be true if he routinely allowed the grass in his front yard to grow to 15 inches tall and accumulate a diverse crop of weeds, or if he used his front driveway as a place to rehabilitate junkers.
Three years ago my family moved to a new community. Like our old neighborhood, the new one has restrictive covenants and a homeowners' association. Now they are looking for folks to serve on a committee to make rules for the new clubhouse and swimming pool. Count me out.
When I became aware that our old neighborhood had lots of rules, I was concerned. You see, I am a libertarian, and I am innately suspicious of rules. So I decided I should get involved. If I was going to live in a place with lots of rules, I wanted to have a role in reviewing and amending them, adopting new ones, and making decisions about how they should be enforced. I was especially interested in assuring that all rules were simple, clear, truly beneficial to the community, not burdensome to the individual homeowner, and - perhaps as important as anything else - readily enforceable.
So I sought election to the association's board of directors. I ultimately served on that board for fifteen years, the latter thirteen as president. I strove to assure that the rules were fair and fairly enforced and focused much attention on improving the community through careful expenditures of residents' dues dollars. I wrote a monthly column in our newsletter to let everyone know what the board of directors was doing and why.
Serving on that association's board of directors had its rewards. I got to see the improvements we were able to make in the community, spending dues dollars mostly on recreational facilities that were much used and appreciated by large subsets of the residents. (No matter what you build, there will be people who ask, "Why did you waste money on that?") And I made friends with others who were community leaders. It was all volunteer work, and I contributed many, many hours each year to something I perceived as a very worthwhile endeavor.
So why do I say "count me out" when it comes to serving on a committee in my new neighborhood? Partly it's just that I feel as though I've already done enough of that for one lifetime. (Fifteen years is a long time!) And part of it is that I have so many more rewarding things to do with my time that I am disinclined to take on what I know will be a thankless task. While I believe a job well done is its own reward, it is nice to be appreciated, and in the fifteen years I devoted myself to governance of my old neighborhood, I did not receive as many as fifteen words of gratitude.
So if you live in a planned community with a homeowners' association, keep an eye on what the association is doing and make your opinions known. Participate in governance if that is work that appeals to you. But remember that the people doing that work are volunteers who got involved because they want to make the community a better place to live. Once in a while, say thanks.
Nowadays, however, restrictive covenants are used by "planned communities" governed by homeowners' associations as a way of enforcing a set of rules. Accepting the deed to a property obligates you to abide by the association's bylaws and a set of rules, which may be quite lengthy and detailed.
The idea is to protect property values and avoid offending neighbors. It might, for example, not only be hard on your eyes but also make it more difficult to sell your house if your neighbor across the street were to have the paint on his house changed from its current traditional white or subdued earth tones to purple with orange polka dots. The same might be true if he routinely allowed the grass in his front yard to grow to 15 inches tall and accumulate a diverse crop of weeds, or if he used his front driveway as a place to rehabilitate junkers.
Three years ago my family moved to a new community. Like our old neighborhood, the new one has restrictive covenants and a homeowners' association. Now they are looking for folks to serve on a committee to make rules for the new clubhouse and swimming pool. Count me out.
When I became aware that our old neighborhood had lots of rules, I was concerned. You see, I am a libertarian, and I am innately suspicious of rules. So I decided I should get involved. If I was going to live in a place with lots of rules, I wanted to have a role in reviewing and amending them, adopting new ones, and making decisions about how they should be enforced. I was especially interested in assuring that all rules were simple, clear, truly beneficial to the community, not burdensome to the individual homeowner, and - perhaps as important as anything else - readily enforceable.
So I sought election to the association's board of directors. I ultimately served on that board for fifteen years, the latter thirteen as president. I strove to assure that the rules were fair and fairly enforced and focused much attention on improving the community through careful expenditures of residents' dues dollars. I wrote a monthly column in our newsletter to let everyone know what the board of directors was doing and why.
Serving on that association's board of directors had its rewards. I got to see the improvements we were able to make in the community, spending dues dollars mostly on recreational facilities that were much used and appreciated by large subsets of the residents. (No matter what you build, there will be people who ask, "Why did you waste money on that?") And I made friends with others who were community leaders. It was all volunteer work, and I contributed many, many hours each year to something I perceived as a very worthwhile endeavor.
So why do I say "count me out" when it comes to serving on a committee in my new neighborhood? Partly it's just that I feel as though I've already done enough of that for one lifetime. (Fifteen years is a long time!) And part of it is that I have so many more rewarding things to do with my time that I am disinclined to take on what I know will be a thankless task. While I believe a job well done is its own reward, it is nice to be appreciated, and in the fifteen years I devoted myself to governance of my old neighborhood, I did not receive as many as fifteen words of gratitude.
So if you live in a planned community with a homeowners' association, keep an eye on what the association is doing and make your opinions known. Participate in governance if that is work that appeals to you. But remember that the people doing that work are volunteers who got involved because they want to make the community a better place to live. Once in a while, say thanks.
Monday, April 25, 2011
I Have a Cold
My specialty is emergency medicine.
If you've ever visited the emergency department (ED) at a hospital, you may have noticed that not everyone there has a life-threatening problem. Some people are there because they think they need to see a doctor and don't have a routine source of medical care or cannot get an appointment in the time frame they prefer.
Perhaps you have a fever and a bad cough, and it hurts ("right here," pointing to an area of your chest) when you take a deep breath, and you are concerned that you might have pneumonia. You tell me about your symptoms, I ask some questions to elicit additional information, and I examine you, with particular attention to your heart and lungs, listening for sounds that might suggest you do have pneumonia. I may recommend a chest x-ray.
You could see your doctor in the office for this - if you could get an appointment today, or even this week, and then you might be sent from the office to the hospital radiology department (right next to the ED) for an x-ray. Not quite as convenient as just visiting the ED.
Your medical problem is not an immediate threat to life or limb, but you need to see a doctor, and the ED is your best bet for timely and effective evaluation and treatment.
On the other hand, if you come in saying, "I have a cold," I will wonder why. Not why you have a cold. (I know plenty about that.) Not why you have chosen to visit the ED for that. No, I will wonder why you want to see a doctor about a cold.
You see, that falls into the realm of what a doctor calls "an acute, self-limited illness." That means an illness that is going to go away by itself without any sort of intervention. You may have heard the old saying that a cold will last seven days, or if you see a doctor (or implement any other sort of intervention), it will last a week. That doesn't mean there is nothing you can do about the symptoms. There are many cold remedies you can buy in a drugstore, and some of them actually make you feel a bit better while your immune system is fighting off the cold virus. But there is nothing a doctor can prescribe that is superior. (OK, maybe there is one exception: if you have a terribly distressing cough, prescription cough medicines, which are narcotic, are more effective than the OTC stuff at making you feel better.)
The point of this blog entry is not that you shouldn't see a doctor for a cold - although if you didn't already know that, it is a point worth noting. Rather, the point is that people go to see doctors (and not just in the ED, but in primary care offices, urgent care facilities, and "retail clinics," where you can see a nurse practitioner) for lots of problems that are very unlikely to benefit from medical attention.
This has become part of our culture: health care seeking behavior that is unproductive or ineffective. It happens for many reasons, and an exposition on that subject would make a very long essay in itself. I have not seen any good scientific studies examining the question of how much money we, as a society, waste seeking health care for conditions unlikely to benefit from it. But I think it's a lot.
If you've ever visited the emergency department (ED) at a hospital, you may have noticed that not everyone there has a life-threatening problem. Some people are there because they think they need to see a doctor and don't have a routine source of medical care or cannot get an appointment in the time frame they prefer.
Perhaps you have a fever and a bad cough, and it hurts ("right here," pointing to an area of your chest) when you take a deep breath, and you are concerned that you might have pneumonia. You tell me about your symptoms, I ask some questions to elicit additional information, and I examine you, with particular attention to your heart and lungs, listening for sounds that might suggest you do have pneumonia. I may recommend a chest x-ray.
You could see your doctor in the office for this - if you could get an appointment today, or even this week, and then you might be sent from the office to the hospital radiology department (right next to the ED) for an x-ray. Not quite as convenient as just visiting the ED.
Your medical problem is not an immediate threat to life or limb, but you need to see a doctor, and the ED is your best bet for timely and effective evaluation and treatment.
On the other hand, if you come in saying, "I have a cold," I will wonder why. Not why you have a cold. (I know plenty about that.) Not why you have chosen to visit the ED for that. No, I will wonder why you want to see a doctor about a cold.
You see, that falls into the realm of what a doctor calls "an acute, self-limited illness." That means an illness that is going to go away by itself without any sort of intervention. You may have heard the old saying that a cold will last seven days, or if you see a doctor (or implement any other sort of intervention), it will last a week. That doesn't mean there is nothing you can do about the symptoms. There are many cold remedies you can buy in a drugstore, and some of them actually make you feel a bit better while your immune system is fighting off the cold virus. But there is nothing a doctor can prescribe that is superior. (OK, maybe there is one exception: if you have a terribly distressing cough, prescription cough medicines, which are narcotic, are more effective than the OTC stuff at making you feel better.)
The point of this blog entry is not that you shouldn't see a doctor for a cold - although if you didn't already know that, it is a point worth noting. Rather, the point is that people go to see doctors (and not just in the ED, but in primary care offices, urgent care facilities, and "retail clinics," where you can see a nurse practitioner) for lots of problems that are very unlikely to benefit from medical attention.
This has become part of our culture: health care seeking behavior that is unproductive or ineffective. It happens for many reasons, and an exposition on that subject would make a very long essay in itself. I have not seen any good scientific studies examining the question of how much money we, as a society, waste seeking health care for conditions unlikely to benefit from it. But I think it's a lot.
Sunday, April 24, 2011
The Humanities
Having just returned from a wonderful conference at the University of Iowa, I am full of thoughts about the humanities and our need to place greater emphasis upon them in higher education.
The conference was titled "The Examined Life: Writing and the Art of Medicine." It was thoroughly enjoyable, and it gave me a renewed sense of hope that there really are doctors who care about branches of knowledge outside of the sciences.
So many of my colleagues seem to have a fund of knowledge in the humanities that approaches absolute zero. (Yes, I know, Lord Kelvin would object to this characterization.) But so often remarks upon famous literary figures and their works, nineteenth century US politics, Baroque music, or even the history or philosophy of medicine itself have drawn blank looks.
At this conference no one doubted the importance of the humanities to the medical profession, but there was significant discussion of the views of others on that subject. Do members of the general public care whether their doctors know anything outside of medicine and science? Do they think a broader educational foundation, and the continued pursuit of knowledge in other disciplines throughout life, help physicians to connect with their patients as human beings?
I hope they do. When I ponder these matters, I try not to think about the responses elicited by Jay Leno when he talks to people on the street, on camera ("Jay-Walking"). "Who wrote Handel's Messiah?" I laughed at the question, as it reminded me of junior high school humor (Who is buried in Grant's tomb?). But the answer? "I don't read books." That revealed ignorance (as my teenage and young adult daughters would say) on so many levels.
Did you know that Nathaniel Hawthorne and Franklin Pierce were good friends?
If you did, I'd be delighted to make your acquaintance at a cocktail party some day - or to have you as a patient. If you didn't, you could look it up.
The conference was titled "The Examined Life: Writing and the Art of Medicine." It was thoroughly enjoyable, and it gave me a renewed sense of hope that there really are doctors who care about branches of knowledge outside of the sciences.
So many of my colleagues seem to have a fund of knowledge in the humanities that approaches absolute zero. (Yes, I know, Lord Kelvin would object to this characterization.) But so often remarks upon famous literary figures and their works, nineteenth century US politics, Baroque music, or even the history or philosophy of medicine itself have drawn blank looks.
At this conference no one doubted the importance of the humanities to the medical profession, but there was significant discussion of the views of others on that subject. Do members of the general public care whether their doctors know anything outside of medicine and science? Do they think a broader educational foundation, and the continued pursuit of knowledge in other disciplines throughout life, help physicians to connect with their patients as human beings?
I hope they do. When I ponder these matters, I try not to think about the responses elicited by Jay Leno when he talks to people on the street, on camera ("Jay-Walking"). "Who wrote Handel's Messiah?" I laughed at the question, as it reminded me of junior high school humor (Who is buried in Grant's tomb?). But the answer? "I don't read books." That revealed ignorance (as my teenage and young adult daughters would say) on so many levels.
Did you know that Nathaniel Hawthorne and Franklin Pierce were good friends?
If you did, I'd be delighted to make your acquaintance at a cocktail party some day - or to have you as a patient. If you didn't, you could look it up.
The Information Age
We live in The Information Age, and yet we seem to be so ill-informed. How can this be?
Soon after the election of 2008, CNN/Opinion Research Corp. polling reported that 23% of respondents said VP Dick Cheney is the "worst ever" vice president of the US. Out of a sample of 1,013 respondents, this comes to 233 people who said that.
Hmmm.... I have a hypothesis. We've had 46 vice presidents. Let's take a 10% sample of those who said Cheney was the worst ever - 23 people - and ask them to name ten of our nation's vice presidents. I'm betting no more than one or two of them could do that. But they all said Cheney was the worst ever. It's amazing what people will say without actually having any idea what they're talking about.
The Internet is full of "information" posted by folks whose knowledge of the subjects on which they write is woefully inadequate, and it is then read by many others who are insufficiently skeptical.
But skepticism is appropriate irrespective of the source of the information. Whether it is a blog (including this one), a major news outlet such as The New York Times or The Wall Street Journal, or programming on television or radio, your responsibility as a member of the audience is, first and foremost, to be a skeptic, a critic. Do not suspend disbelief readily.
And so this very first posting on this blog is intended as a word to the wise, because "The Wisdom of Solomon" may be wise or foolish, and you must be the judge.
I am a physician, a social critic, a political pundit, and a grouchy grammarian (with apologies to Thomas Parrish). I am especially fond of finding fault with the work of professional journalists, who are too often sloppy, lazy, or both. That should give you some sense of the range of subjects on which I might write.
I will welcome and encourage comments, criticism, diatribes, invective, vituperation, and even the occasional "attaboy" if you think I got something right.
Most of all I encourage readers (if there ever should happen to be any) to suggest topics on which you might (for some inscrutable reason) like to know my opinion.
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