Canadian pharmacies--revisted

I've generally been a big fan of Canadian pharmacies and any other method consumers can use to get lower cost medications, but I've recently had to rethink the Canadian pharmacy issue. I still think Canadian drugs are fine. The problem is, if you order from an online pharmacy, there's no guarantee your medications are going to come from Canada. In fact, they're likely to come from somewhere else.

I myself ordered Zyrtec from my usual place, and ended up getting a shipment that seems to have come from England. Since I have nothing against English drugs, I'm taking it and doing fine. Still, there is probably a temptation to get the medications from wherever they can find them. Plus, the websites don't tell you where the drugs might come from up front. India makes a lot of inexpensive generics, and there are other places that I wouldn't trust for quality control. So on the whole, I'd suggest avoiding internet foreign purchase of medications.

Road trips to Canada, though, would be just fine.

Future of Healthcare

I went to Boskone today and sat in on a panel on the future of healthcare in this country. Seems sort of a boring and banal subject for a science ficiton convention, but then speculative fiction covers a lot of areas. It probably helps that most SF fans that go to these cons are of the baby boomer generation and are all getting a lot older, grayer, and, dare I say it? fatter. So health care is becoming increasingly important to us.

The speaker was a physician who wrote SF and mystery stories, in his copious free time away from his day job as an anesthesiologist in New York. He spent most of the half hour allocated to the talk describing where healthcare was today in this country, as well as devoting a little time to where it is in Canada. He didn't have a lot to say, really, on the topic of where healthcare was going. I think he summed it up by saying he thought we would eventually go to legislated universal coverage where the states would move to force all employers to pay for some health insurance, and where the very poor and unemployed would receive some form of government insurance. I expect he was possibly right on this topic.

The problem is, there are a lot of special interest groups with a lot of money that would have a lot to lose if the situation changed significantly. Certainly doctors would be affected. That's why the AMA is often one of the more vocal special interest groups. The economic situation is that there are a bunch of things doctors do in their work lives that they would cease to be willing to do if compensation were to drop significantly. They would likely leave the profession. If this were to happen, then the market for mid-levels would heat up and nurse practitioners and physicians assistants would be in high demand. After all, they make significantly less money that doctors. Of course, in our practice the mid-levels see fewer patients per hour and don't take any call.

Where would all those mid-levels come from? As it is, one of the reasons it's hard to find RN's these days is that so many of them are becoming nurse practitioners. If we suck even more RN's out of regular nursing, where are we going to find our nurses? Interesting thought. As it stands, I've seen more nursing programs close than open in recent years.

Another special interest group is the nation's major pharma. Here's a group that develops new drugs, then charges a huge premium for them for as many years as they can. They claim that the reason they need to charge so much is because of the costs of research, but if you look at their annual income statements, you can see that as much is spent on marketing as on research. Despite their much ballyhooed costs, they generally manage to piece together double-digit income GROWTH. This is also despite the losses they claim to take in other countries due to price ceilings set by the government. With so much excess profit at stake, they have a lot to lose if the government starts passing legislation to reign them in.

Let me clarify one thing--the people who run these companies aren't in some giant conspiracy to do evil and hurt people. They're no more selfish and venal than anyone else in any other line of work. The current philosopy in business states that the highest duty of a company manager is to maximize shareholder value. That's maximize, not get as much as is reasonable.

So here's a prediction: the government is painting itself in a corner. Within a few years, it will find itself eating away at the special privileges enjoyed by Big Pharma. One of the first to go might be the little loopholes they squeeze extensions of their patents through. That won't seem so bad, will it? The government will suddenly find it's saving money with the loopholes closed. But then the baby boomers will get even older, costs will soar. Eventually, the government will either need to raise taxes or put in price controls. Politicians get money from Pharma, but if the tide turns and the large part of the population demands taxes be kept low by putting in price controls, price controls will be put in place. After all, you won't be given any money at all if you get voted out of office.

More on big Pharma later...

Bird Flu Blues

I've been doing some reading and a lot of thinking about the bird flu these last couple of weeks. Here's the list of points that I find particularly pertinent:

• The current bird flu strain, which started in domestic fowl, has retained its virulence in domestic birds, but has evolved into a survivable infection in wild, migratory birds.
• Bird flu has not yet mutated to a form that will spread to humans and through humans, but the flu virus mutates easily and is currently present and being transmitted in a large number of birds, leading to increased replication and increased risk for mutation with each replication.
• Presence in migratory birds means bird flu will extend across Asia and head to Europe, safely nestled inside birds.
• Newly reconstituted Spanish flu virus was clearly a bird flu. And it's still really, really virulent.
• We suck at administering flu shots.

The last one is really distressing. Think about it--there's not really much we can do to change whether or not the bird flu mutates into something that will spread to humans. Sure, people are trying to prevent it by slaughtering entire flocks of chickens and ducks, but it's slipped that leash. Trying not to live with our chickens is probably a good step in the right direction, but there are parts of the world where people don't really have that choice. If it happens, it happens, and we'll just have to deal.

It's the dealing I take issue with. Last year was the start of the salutary lesson we have received in just how good our ability to deliver vaccine is. There were 2 manufacturers of vaccine for 2004/2005. One of them repeatedly failed quality inspections and none of their vaccine was usable. Pasteur Aventis came through, but distribution was a nightmare. In our clinic, we didn't have enough vaccine during the recommended vaccine season of October through November, but by January, we were drowning in it. We ended up having to throw a lot of it out.

This year, we ordered our vaccine from a different source, and ordered a different variety. So, you'd think, in a year when the CDC is claiming no problem with supply, we'd be busily vaccinating away, making sure everyone in our practice is fully protected. But then you'd be wrong. No, we just got the first 25 of the 160 vials that we ordered today, when we originally ordered them for early October. The local hospitals had so little supply, they have already run out. We have no idea when more will be available. The state of NH has insufficient supply to support local flu clinics and tells us that California and points west of us get the first supply, since flu usually starts there. That was news for us, since we've already documented a case in our clinic this past week, not that it's been posted at the CDC yet.

We've been given to understand that the bulk of our supply has been diverted to the Katrina vicitms by the same CDC that is now announcing no supply problems. I have no real issues with distributing vaccine to refugees, though I personally feel any refugee camps are likely to be cleared out by the time flu season hits. What really frosts my cookies is having the CDC announce that there's no shortage, when they single-handedly created one!

And here's the real concern: if we can screw up so much in a regular flu shot season with no underlying supply problem, what the hell is going to happen if a bird flu hits? It may be very difficult to get vaccine made and distributed in time, and the panic that will without a doubt accompany it will make it all worse. So what do we do to prevent the spread or limit the effect?

One thing I've noticed we do a pretty poor job at in this country is make any kind of accomodation for prevention of illness. We seem to feel that we have a prerogative to do exactly as we wish, whether or not it increases our risk of disease. We make no attempts to isolate the ill. In fact, we expect them to soldier on as much as possible, especially if we're their managers or family members. I have an elderly patient with asthma who shares a room with her teenaged granddaughter. I have another patient with dreadful lung disease who goes from well to near-dead in less than 24 hours, and who still welcomes her young, snotty nosed grandchildren and cuddles them on her lap. It's miserable to separate yourself from loved ones when they're sick, but that's the likeliest source of your next respiratory illness.

Last year, despite the inadequate immunizations, the flu season was mild. The year before wasn't bad, either, at least in New Hampshire. That year was distinguished by a snowstorm on Christmas day and a lot less visiting over the holidays. Ever wonder why the flu gets so severe in January? Last year, people were very jumpy because of the SARS scare. For the first time ever, we instituted the wearing of masks in our clinic, for those people with respiratory infections, including staff. We weren't alone in this. I think this may have had an impact. The CDC apparently doesn't feel that masks are all that effective, but I think it limits the amount of respiratory droplets that get dispersed through coughing, keep people's hands away from their mouths and noses, and just decreases the volume of stuff that's out there in the environment.

I can personally attest to the importance of individual attempts to avoid infection. For many years I have practiced near-religious hand washing, both before and after seeing patients For most of that time, I have had relatively few colds. Then suddenly, several years ago, I started having cold after cold after cold. It seemed one no sooner cleared, than another one started. I couldn't figure out what was going on. My family seemed to be getting the illnesses from me, not the other way around. Eventually, it dawned on me. I had recently started looking up noses as a routine part of examining people. It was impossible to keep track of how many times people breathed in my mouth or coughed on me when I did this. I could look at throats from a distance, and ears and eyes were off to the side, but for noses I had to get right in there.

I immediately turned over a new leaf. First, I vowed to stop looking up noses unless it was really, really necessary. Second, when I had to look up a nose, I ALWAYS wore a mask. Presto change-o! No more colds.

I've also changed from wearing clothes that need dry-cleaning (including suit jackets that would get worn multiple times before being cleaned) to wash and wear clothing so that my personal germ load is reduced. After all, I see patients with some really nasty germs. I don't need to wear them in to see other patients. I don't look as elegant as before, but I suspect I'm a lot healthier to be around. A study actually showed that male doctors' ties in hospitals were covered with nasty bacteria. It strikes me that polo shirts left casually open would actually be a better choice for them.

So here's some community based advice for people wanting to avoid colds and flu:

• Avoid sick people. This sounds easy, but it includes family members. Don't get too huggy or kissy-faced with friends and loved ones who aren't sick. Content yourself with patting their hand and then washing afterwards.
• Wash your hands a lot.
• Don't touch your mouth or nose except after washing your hands to prevent transmission of germs here.
• Stay home if you're sick. Don't take those germs to work. If you must go out, wear a mask that you change frequently, or use kleenexes that you dispose of in a sanitary fashion and wash your hands a lot.
• Refrain from coughing on people.
• Try to avoid going to the doctor's office for unnecessary visits in the winter. That's were sick people go. If you're really paranoid about it, see if your doctor provides masks for people with symptoms and snag one on the way in.
• At home, don't share glasses and wipe off the phone if someone else has to use it.
• A recent study suggested that people who drink tea every day have a reduced risk of getting the flu. Not sure how that works, but it's probably the most pleasant preventive I can think of!
  

If you do get sick with a high fever and something that feels like a cold otherwise, call your doctor right away. There are some medications that can shorten the flu for you, and may reduce your risk of complications, but you have to start them within 72 hours to get any benefit. Otherwise, pamper yourself with plenty of rest, and take in some chicken soup with chicken in it. Tylenol helps with the fever. The arthritis strength version lasts a whole 8 hours and provides smoother relief of fever. For those in the United States, a cool product called Mucinex DM is now over the counter and has high levels of dextromethorphan (a cough suppressant) and an expectorant in it, to keep your cough loose, and less frequent. My husband and I swear by Tessalon perles for those nasty dry coughs, but that's available by prescription only.

Try to avoid nasal decongestants. They only get you in trouble.

Finally, I heard a recent report on the health benefits of sinus irrigation, especially in prevention of colds. I'm not sure if I can support that, but I did buy a Sinu-cleanse neti pot from Walgreens and am using it to see if it provides any benefit for chronic stuffy nose. If it goes well, I'll give it the husband test, and then see if it's ready for prime time. To be honest, after using it for 3 days I'm fairly certain that you have to have a lot of determination and a strong constitution to want to pour water up your nose every day.

Bush goes crony again

Bush nominated his next Supreme Court justice today, and revealed to the world his complete and utter commitment to the concept of cronyism. The news said, prior to the announcement, that there were stories Laura Bush was pushing for a woman to replace Sandra Day O’Connor. Surely there are other women somewhere out there in the judiciary that have even a drop more experience that Miers? Even a week on the bench would give them an edge. This is slightly more legitimate than making Brown the head of FEMA, since at least this woman is a lawyer and presumably understands law, but you think there’d be a little more care taken after the recent Hurricane Katrina debacle. After all, even the Economist has run an op-ed piece about the obvious and dangerous Bush tendency to elevate incompetent people to high posts, just because he knows them.

I suspect there were two forces at work that led to this woman’s nomination. The first was that Bush knows her. He is presumably aware to a great degree of where she stands on issues that are near and dear to his heart, though if I were him, I wouldn’t rely on her views being precisely his, even if she has appeared to support him wholeheartedly. My experience with lawyers has suggested that they are a somewhat flexible lot, fitting themselves into the proper mode to give their clients exactly what they need. Like hired gunfighters in all those Old West movies, they defend their clients the best they know how and generally don’t let absolute truth and a rigid set of morals confine them in their activities. There is legal truth, after all, and a truth of the greater world. Legal truth is what has been decided in a court of law and depends on previous judgements and only what is presented in the court at the time of the trial. If an attorney can get something barred from testimony, no matter how true it is, then it doesn’t exist.

No, I’m not saying all lawyers are like this. In fact, I have a fairly balanced view of lawyers for your average doctor. I have found in my dealings with them, that they tend to have supple minds, and are often found of argumentation. Trial lawyers in particular are far more tolerant of confrontation than ordinary people. They seem to relish it, and even get a charge from a good battle in court. It’s not clear they need to be crusading for any particular cause to get that adrenaline hit. Yes, some lawyers will go on a crusade, and there are plenty of people with a law degree who never appear in court. There are other things in law they enjoy. I think Perry Mason has done the general population a disservice, though, by making us expect such principled behavior from all trial lawyers.

To the point, Mier’s compliance and agreement with all things GW may not run quite as deep as he would like to think. I’m sure she’s not a flaming liberal, because such a person wouldn’t have been able to survive being so closely associated with him for so long. She may, however, harbor a somewhat more moderate soul. Of course, she could be the Genghis Khan of frothing-at-the-mouth conservatives, too. We can’t be sure. What we can be sure of, is that if she’s nominated, we will find out. Once she’s on the Supreme Court, she will have to answer to no one except her own conscience, whichever deity she follows, and her own understanding of the law.

This leads directly to the second force at work. Bush managed to neatly nominate someone who had such good credentials and was so unshakeable, he slid through Congress sleeker than a greased pig in shit. There aren’t really that many candidates like Roberts out there. What better way to go than to nominate someone who has almost no public record for anyone to object to? I’m sure Bush has learned the lesson taught by his conservative buddies when running against Kerry—if you have many years of public service, which includes some of the compromises you need to make to get things done, you’re vulnerable to anyone who wants to reinterpret what happened and spin it in the direction they want it to go. Pretty soon they’ll be wanted to nominate someone just out of law school, and eventually, why not get them when they’re pre-law? Or wait—that may not work. What if they’re like me and publish a blog that is available to the public, even if no one bothers to read it?

I expect Bush will get this nomination confirmed. At this point, he owns the Congress, more or less. Perhaps some of the more ideologically driven Congressmen on the far right will be as uncomfortable as the Democrats are bound to be, but I suspect they won’t oppose their president on this. And the Democrats may decide they just can’t stand it and commence a filibuster, but they’re too far in the minority for that to be ultimately effective.

In the best of all possible worlds, Mier would be nominated and prove herself to be a capable, moderate and thoughtful justice. Too bad things don’t usually happen like that.

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...

Darn! Lost that post!

Darn it all, lost a whole post! Urg. Let me tell you, it was the most in depth and insightful post ever put on the web. It would have changed the world, brought about universal peace and brotherly love and brought about the end of the national deficit. Bu we'll never get a chance to see it...

Guess I'll have to work on it later. Again.