Sunday, August 28, 2016

Mylan Defends EpiPen Price Hike

Why do smart people often do dumb things?  Would you plagiarize a speech that you know is going to be carefully scrutinized?   Would you respond to a robocall that congratulates you on winning a free cruise?  Would you keep eating sushi that didn’t smell right? 

I’m certainly not judging anyone here.  I’ve had plenty of my own misadventures and I periodically add to the list. 

Our presidential candidates fall prey to human error and misjudgments surprisingly often.  Aren’t these folks supposed to be pros or at least managed by honed handlers?  Why would Donald Trump have insulted nearly every constituency and rival during the primary election process knowing that this might render him unelectable in the general election?  Why would Hillary Clinton demand unconscionable speaking fees from special interest groups when she knew that she would pursue the presidency and her payoffs would be publicized?

I’ll leave it to readers to ponder their own responses to the above inquiries.



If the sushi doesn't pass the sniff test, head to Burger King.

Last year, I posted on a drug company that raised the price of a pill from $13.50 to $750.00.  Even if such a practice is legal, or is justified by market forces, it is very, very dumb.  It is guaranteed to provoke outrage and will surely result in scrutiny that will go much wider and deeper than the initial offense.  It did.  For more details, just click here.

One would think that rival pharmaceutical companies would be more cautious before enacting similar price gouging.   Guess again.  Mylan, who makes EpiPen, raised the price of this product about 500% over the past years, bringing the price to $608 for a two pack.   The company stands by the new pricing.  Sure, they have offered a few discount coupons, but they are leading from way behind. They are not likely to prevail, even if they have a potent economic argument.  

This stuff is ripe grist for politicians, who can rail against the pharmaceutical barons, in order to distract the public from their own abysmal performance.  And, angry parents will use social media and other methods to publicize their outrage.  The fact that many patients who rely upon EpiPens are young children doesn’t make the company’s case any easier.  

If Mylan’s CEO Heather Bresch is called to testify, how will the optics be when she states that her compensation last year was about $19 million?

Why are so many pharmaceutical folks so allergic to good judgment?  Perhaps, they should carry around an EpiPen, if they can afford it.

Sunday, August 21, 2016

Who is Responsible for Prescription Drug Abuse?

I have written about pain medicine previously on this blog, and it generated some spirited responses.  Let me be clear that I am completely against all forms of pain, whether foreign or domestic, physical, spiritual, psychic or even phantom.  The medical profession has superb tools to combat and relieve pain, and physicians should utilize them, within the boundaries of appropriate use.  We now have an actual specialty – pain management – who are physicians with special training on the science and treatment of all varieties of pain.  I utilize these specialists when necessary and I am grateful for the help they provide to my patients. 

There are two forms of drug abuse in our society – legal and illegal.  The latter has become a health scourge that is shattering families across the country.  A few days before I wrote this, I read the stats of overdose deaths in my state of Ohio.  I was shocked to learn that in our state alone, we lose thousands of individuals every year to drug overdoses, most of which are not intentional.  The street drugs are often impure, or laced with potent additives or substitutes that become a fatal concoction.   Extrapolating Ohio’s stats across the country would create a stunning number of drug deaths.  The causes and the potential solutions to this plague are vexing, but must be pursued.

An Opium Poppy - Cure or Disease?

There is also a legal avenue for drug abuse, medicines prescribed by doctors.  This sphere of abuse will be easier to control than the illegal counterpart, as the process is initiated by a doctor’s prescription and subsequently involves a pharmacist.  No doctor or pharmacist wants to be a pawn in this game.  I believe that these professionals have adapted to a looser culture of prescribing pain medicines and changing expectations on pain relief of the public.

Consider this staggering statistic:  According to the National Institute on Drug Abuse, Americans consume more than 80% of the planet’s opioid medicines, yet are less than 5% of the world’s population.  Does this make any sense?   Would advocates of the status quo argue that America has nearly 20 times more pain than other nations have?

I can state plainly that I have never seen so many patients in the hospital who are on intravenous and powerful narcotics for stomach pain.  These same patients a few decades ago were treated differently, and I recall that we kept most of them reasonably comfortable.  The risks of narcoticomania are self-evident.   Many patients and their families are suffering heartache and misery whose origin can be traced back to a narcotic prescription.  This is a great tragedy.

Narcotics have an important role in our patients’ care, and I support their appropriate use.  There are patients who need opiod use to manage chronic conditions.  But, opiods and narcotics are overused and we need to admit this so we can begin to remedy this reality.  Physicians and the public need to reach an understanding on what each expects from the other.  Both doctors and our patients need more training on this issue.  Doctors should do all we can to make our patients comfortable.  Indeed, relieving pain and suffering is fundamental to the healing mission.  Patients should recognize that physicians may not be able to guarantee 100% pain relief for every situation that you may face.   We have an obligation to minimize your pain and discomfort, but also a responsibility to protect you from wandering down a dark and destructive path that may lead you ensnared in a den of demons.

Sunday, August 14, 2016

Are Doctors Paid Too Much?

Years ago on Cape Cod, my kids and I stumbled across a man who had spent the day creating a sand sculpture of a mermaid.  It was an impressive piece of art.  “How long did it take you to make it? ” we asked.   While I can’t recall his precise words, the response was something like “25 years and 7 hours”.  I’m sure my astute readers will get his point.

We are transfixed now watching Olympic athletes performing in Rio.  So much depends upon their brief routines which can last seconds to a few minutes.  While a diver’s acrobatic plunge may take 2 seconds, it would not be fair to leave aside the years of work and training that prepared the athlete for this moment.

The same point can be made for anyone who has worked and trained hard to reach a point where the action performed seems easy to a spectator or a customer.   If an attorney prepares estate documents, we can assume that the fee for this reflects the prior training and research that the lawyer has done on this issue, as it should.  If an appliance repairman, by virtue of his expertise, fixed our ailing washing machine in 5 minutes and charged us $100, should we balk at this price gouging?  If a less skilled competitor spent 2 hours before finding and correcting the glitch, would we feel better about handing over $100?  Is this fair?  A musician doesn’t just wake up one morning and hop onto a stage to give a concert.  When we pay to listen to an artist perform for 2 hours, we are likely listening to the product of years of grinding work, disappointment, innovation and discovery.

What's a fair price for an hour of Aretha?

I believe that this same principle applies to my own profession.  Over the years I have heard patients complain about various medical charges and fees. While we all know that there have been excesses, many of their gripes are misplaced, in my view.   It’s not fair to equate the medical fee with the time that the physician expended on providing your care.  A cardiac bypass operation takes just a few hours.  A colonoscopy takes 10 minutes.   Treating a patient in an emergency room with a drug overdose may take just a few hours.  A psychiatrist might guide a suicidal patient to choose another path in half an hour.  A spine injection to relieve chronic pain takes only a few minutes.  A dermatologist recognizes a suspicious lesion in a few seconds.  A seasoned surgeon tells an anxious patient after a 20 minute consultation that surgery is not necessary.

Often, folks who make is all look easy are fooling us.  If we think it’s as easy as it looks, then we’re the fools. 


Sunday, August 7, 2016

Overtreatment and Unnecessary Medical Testing? You Make the Call!


Ok, readers.  I know how many of you fantasize about being part of the high drama and glamor of the medical profession.  Believe me, it’s even more exciting than the medical TV shows that have been part of pop culture for generations.  Remember Ben Casey?  Marcus Welby?  Dr. Kildare?  Dr. Seuss?   Rescuing folks hovering over the Grim Reaper was just another day at work for these guys.


The Grim Reaper

Here’s your chance to play doctor for the duration of this post.

A patient wants a colonoscopy, but it is not medically necessary.  Assuming he cannot be convinced to withdraw the request, should you perform it?

A physician wants you to perform colonoscopy on his patient, but it is not medically necessary.  Assuming the physician cannot be convinced to withdraw the request, should you perform it?

An elderly patient’s son wants a colonoscopy performed on his father, but it is not medically necessary.  The patient is ambivalent and delegates the decision to his son. Assuming the son cannot be convinced to withdraw the request, should you perform it?

A nursing home requests that a feeding tube be placed on an elderly resident.  While the tube would be much more convenient for the staff with regard to administering food and medication, the tube could be avoided if a staff member had sufficient time to assist the patient with meals and medicines.   Should you place the feeding tube? 

An anxious mom (please forgive the sexism here) demands an antibiotic for her child’s sore throat, which is not medically necessary.  Assuming she cannot be dissuaded from her request, reinforced by prior physicians who prescribed antibiotics under similar circumstances, should you acquiesce?

A man is critically ill in the intensive care unit and is nearing the afterlife.  The consensus among the treating physicians is that additional care would be medically futile.  There is no advanced directive or medical power of attorney.  The next of kin insists that the patient be placed on life support.  He is not persuaded to withdraw his demand and suggests that there would be consequences if his relative is simply allowed to die.   What would you do here?

So, ‘doctors’, any thoughts?


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