Surprise! A New Post

Surprising myself by getting this post out there so soon after the last one. Amazingly, I'm on call, have finished all my e-work, and have time to sit here and wax poetical. Or wax something.

This past weekend I went to a conference on medical matters called PriMed Updates. PriMed conferences are rather interesting. They started in Boston with a large, 3 day primary medicine conference that was sponsored by some of the insurance plans, local hospitals and by the pharmacy industry. The speakers tend to be excellent and well known in their fields. The speakers are still quite good in the Updates, but I finally noticed some interesting things about the whole concept.

First, I want to say that it was refreshing to go to a fairly large conference of this sort that didn't have an entire huge room filled with drug company displays. Mind you, the displays are always interesting, in a carnival sort of way. They haul in thick and lush carpets and huge displays. They bring in interesting little food thingies, capuccino, ice cream and do things like check your cholesterol for you. All very interesting and entertaining. Probably just a drop in the bucket compared to what they spend on television DTC marketing. Yet you can't help but wonder how it is they have so much money to spend in this lunatic way, and yet have to charge such immense fees for their products.

Updates, as I said, didn't have this sort of thing going on. There were very modest pharmaceutical displays that were very easy to ignore. The most I did while I was there was snatch a pen. That part wasn't bad.

The cracks in the smooth presentation became visible, or at least audible, when one of the presenters started his talk with a diatribe about how upset he was that he wasn't allowed to use his own slides. The slides pertained to an article he had just had published in the NEJM about Eisenhower's heart attack and how it tanked the stock exchange. Apparently, the whole show was written ahead of time, and not necessarily by the presenters. That really makes me think. Who was it who wrote the show and made the Powerpoint presentation?

After that, I listened far more closely. You see, I have some real objections to the matters presented at these conferences. No one ever seems to pay any attention to cost-effectiveness in treatment, to outcomes, or to inexpensive medications that patients can afford. Well, a few people paid attention, but most of them don't. They don't pay attention to compliance issues with patients either, and deal with side effects by saying they don't exist (often). I can understand their frustration with the amount of meaningless bullshit out there on the internet and its effect on patients, because I share it, but not everything a patient tells you is wrong, just because it doesn't fit in with your preconceived notions of what should be happening.

The cholesterol talk was really illuminating. The current state of the art focuses almost solely on the LDL cholesterol levels. Interestingly enough, this is a calculated number. You can measure it directly, but it always seems a bit weird when you get the result (i.e. not what you'd expect), and all the tests were done on the basis of the calculated number anyway, so I tend to not bother ordering it unless the triglycerides are really really high (they throw this result off). We do know that HDL levels are very important also, and should be as high as possible. Now, there are a few patients that have a high total cholesterol and a high HDL. I see enough of them to know the condition isn't rare. Yet, for some reason, no one has ever done an outcome study on them to know exactly what their risk is for vascular disease. Every conference I've been to in at least the past 5 years I have asked what to do with them, and every presenter has said I should treat the LDL and ignore the HDL. It's maddening.

However, I have now, finally, figured out what the deal is here. The drug companies have no medication that will raise the HDL on patent. Let me repeat that: The drug companies have no medicaiton that will raise the HDL on patent. You see, the bulk of outcome studies, the ones that look for outcomes related to cholesterol and to changes in outcomes with treatment, are all funded by the drug companies as they test their new medications. They have no interest in testing for anything that won't earn them money. In fact, they have a disincentive to look for benefits from anything that will compete against their drugs. Sadly, the government, supposedly by the people and for the people, has no interest in pursuing those things either. For instance, Niacin, a B vitamin, can raise HDL cholesterol. It has more side effects than statin drugs in effective doses, but it's pretty cheap. I asked if it would help for patients and the response I got was, "It's never been shown to help. Statins have been shown to help."

You have to listen closely to catch it, but it's there. The comment isn't, "niacin has been shown not to help," it was "it's not been shown to help." What this means is that no one has actually tested it to see if it improves outcomes. Who knows? Do the pharmaceuticals care? Hell, no! They wouldn't profit from checking anyway.

I find myself wondering if there isn't a place somewhere in this world for a foundation that sponsors studies looking at orphan types of treatments. These are treatments that will never have a high profit margin, but might be really, truly effective; treatments that no one ever uses because we don't know if they'll work or not. I don't mean just alternative medicine treatments. I have great problems with these products. I don't think there is anything particularly saint-like about the people who run alternative medication companies, or anything any different from the profiteering that goes on at pharmaceuticals. As concerned as we are that the FDA doesn't provide enough oversight over pharmaceuticals, they provide far less over the alternative medications. Product purity and contents are a real issue with these people. Yet there are treatments we have forgotten and that have never been pursued because no one's going to earn a lot of money on them.

I promise to do better

Wow, this has got to be one of the most boring blogs ever. I checked and saw that I haven't added to it since APRIL! Ouch. Well, I have been very busy, but then I doubt there will ever be a time when I can't say that.

I'm going to expand my blogging a bit, too. I'll be putting up a more personal blog and link it one-way to this one. Something to connect people to what I'm personally up to.

I've been doing some interesting reading lately. A few months ago, I finished a book called Authentic Happiness, which was very interesting. It's from Seligman, a psychologist who is promoting positive psychology. It's and interesting book, and unlike so many of the self-help books out there, is based on some actual research, not just philosophizing or mining past literature. Well, there's some mining of past literature there as well. I am struck by how he differentiates between Pleasures and Gratifications. Pleasures are those things that feel really good at the time. Stuff like sex, drugs, and (for me) eating good foods. These things trigger a pleasure response that feels really good, but is ephemeral. What's worse, is that you're immediately driven to repeat the experience, but it takes more of a hit to get the same surge of pleasure, because you accomodate to it right away. You develop tolerance, in other words. This is supported by recent research into addictions, and addictive personalities. It has to do with receptors in areas of the brain, and the neurochemical dopamine. Dopamine appears to be related to a feeling of well-being and is triggered by a lot of behaviors and drugs, including alcohol, cocaine, speed, nicotine, etc. I think you also get a surge of dopamine and serotonin when you eat certain foods, if you happen to be susceptible.

This is supported by a recent article in Science News (http://www.sciencenews.org/articles/20050903/bob10.asp). The article describes the neurochemistry of eating and supports the theory that yes, there are indeed carb addicts, or just food addicts in general. As a card carrying carb addict, I can attest to the problem with not being able to stop, and to the gradual need for a more intense hit if you overdo.

Gratifications, on the other hand, aren't noticeably pleasurable, but are absorbing. The sense of well being you get from them isn't as intense, but is more satisfying and lasts for a longer time. It appears to be tied in with a sense of accomplishment. For instance, I can get a gratification from customizing a chief complaint in the EMR, something that keeps me going into the wee hours of the night when I really should be sleeping. It's what keeps me going back to karate and advancing up the belt ranks. It was the deep gratification I got when I was working on my MBA, and accounts for how much I enjoy listening to my Great Courses CD's that I'm currently running in the car while I drive to work.

The book also helps me make sense of how it is that people (and I include myself here) can have a great life, with no real wants, pursuing rewarding careers and with great families and still be depressed. It seems to have to do with the feeling that you are missing some great, unknown "Happiness" somewhere that some people have and which hasn't come your way as of yet. It comes from mistakenly thinking pleasure will lead to happiness. What you really need to do, I think, is to find a way to work your gratifications into your life in such a way that is most fulfilling to you. I'm still pondering that one.

Other good books? Well, I went through the entire Stephen Covey set on CD (took FOREVER, too). Lots of good stuff there, but a lot of presentation to get through. When you listen to Covey, after a while you realize that he could probably easily fit it all onto one CD without missing a drop of wisdom. It's interesting to listen to the set and get an idea how the inside of his mind works, as well. Occasionally, he will make some historical gaffes, and he has an interesting tendency to quote popular films about historical figures (like Gandhi, for instance), as if they were all historical fact. This probably flies really well with a lot of Americans, since they share this tendency, but makes me look at him somewhat askance. Metaphorically speaking of course, since he's not really here for me to look at anyway. All that aside, he has some excellent points to make about time management and getting things done. His latest, the Eighth Habit, primarily focuses on a paradigm shift in management brought about by the rise of the information worker. Good stuff, but there's a long way to go before this concept takes hold of most of coporate America. Interestingly, lots of what he's talking about is stuff covered by the Gallup poll everyone is so fired up about at work. At this point, we're like some giant hybrid organization--all set to roll on Gallup, but no one really wants to commit to changing the management paradigm to fit.

Some of the best stuff I've read is Malcolm Gladwell's two books, The Tipping Point and Blink. These books are terrific. The Tipping Point ranks right up there with Influence: The Psychology of Persuasion. It's important stuff for people who want to influence others, and to help protect those who would like to avoid being unduly influenced, if at all possible. In face, I think the entire Democratic Party should read The Tipping Point, if they want to have any chance of regaining some power in the next decade or two.

Blink is great on a more personal level. It explains the basis of expertise (a really well-trained sub-conscious) and shows how you can learn things so well, they go below the level of consciousness. It explains why you sometimes muff up a kata when you start consciously thinking too much about it, and why mentally practicing a sport while sitting down can train you as well as practicing physically. Since reading it, I have decided to go back to playing with my ACLS video game to try to get some training in. Knowing right away what to do is much faster than having to think your way through a decision tree and could make the difference between life and death. Given I have no actual opportunity to practice this in real-time (thank God), training via computer game is kind of like logging simulator hours for a pilot. In fact, it's probably something that should be required, but isn't.

Well, must go now. Going to go set up that other blog and do something on there as well. I hope to long on and write another post of two here, though I'm not sure this blog sees much traffic. At least it will be entertaining to go back and read what I was thinking about at some time in the future...