The practice of medicine, like everything, involves balancing many things, monitoring how one might be pulled into one extreme or the other. One area of particular concern to me has to do with pharmaceuticals. I try hard to resist the ubiquitous and at times overwhelming influence of the pharmaceutical industry's marketing machine on my practice of medicine. This affects so many areas of practice that if I had the time and discipline a daily blog just on this would be worthwhile, if not always interesting.
Prescribing generics has been something I've emphasized for a number of reasons, not the least of which is to offset the high cost of everything medical. Bioequivalence is a concept that indicates the degree to which a generic medication acts like the brand name in the body. Generics have the same active chemical at the same dose as brand names, but may very in how they are made, the inactive ingredients, the ingredients that "carry" or "bind" the active ingredient. A recent article in the Wall Street Journal describes the case of Wellbutrin, and points to yet another aspect in which the FDA may be suffering from the inability to live up to it's mandate.
It concerns me that patient reports of their experiences with medicines are minimized. This occurs frequently with reports of adverse effects with medicines whether brand name or generic.
I wouldn't want this article to feed the coffers of the pharmaceutical industry by making absolute that "brand is better". Brand may be different from generic A, and generic A may be different from generic B. Different does not mean better or worse. You might be doing great on generic A, and if you were switched to brand, it could be work less well. Bottom line: if you're on a brand and are switched to generic, or you're on a generic and you're switched to another generic, pay attention, and discuss it with me when you see me. Let your pharmacy know that you want the same brand or generic every time and that you want to know if it has changed. If you're pill looks different, it is.
And finally, what if we shifted some of the defense budget to the FDA? Hmmmmm.
Saturday, April 26, 2008
Sunday, March 09, 2008
No to cookie cutter care for the elderly (or anyone, for that matter)
Today the NYT reviewed a book about altering our approach to care for the elderly. This issues doesn’t end with the “Living Will”, and each one of us will need to accept the burden of determining for ourselves and our loved ones what constitutes health care and quality of life. Our profit and cure driven system has many strengths but clarifying the nuances of quality of life isn’t one of them.
Colon cancer screening in the news
Always a topic in a preventive health examination is cancer screening. Typically at age 50, colon cancer screening is recommended. This involves the direct visualization of the colon - that part of the intestinal tract that starts at about the level of the appendix in the lower right part of the abdomen, and ends at the anus. There are a number of means of screening for colon cancer, the most common being the insertion of a flexible tube with a camera on the tip into the anus, which is then snaked up over and down to see the entire length of the colon. Trouble is that, like many cancers, colon cancer usually causes no symptoms until it has spread to a fairly advanced state. Recently the American Cancer Society added to other tests to those recommended for screening. Here is a review of these recommendations, as well as other information about colon cancer screening. There was also this recent article about some precancerous lesions in the colon which are more common, and more difficult to detect, than previously thought.
BUGS!
One of the (many) difficult areas of medicine is the identification of rashes and bites. Recently there’s been a resurgence of bed bugs, and now this is not an uncommon concern of people after traveling. Here’s some information from the Harvard School of Public Health that covers the topic fairly well.
Friday, February 15, 2008
Depression III: Heart Disease
Besides the fact that depression just sucks and makes you miserable, here’s a discussion about another reason that helping people to get better matters.
Depression II: Music therapy
There’s this review in Cochrane about the use of music therapy for depression. While it is inconclusive, it’s worth a look, I think.
Depression I: Overmedicated?
I’ve read several articles lately about depression, which is an area of particular personal and professional interest. For several years I have been under the influence of "Against Depression" by Peter Kramer, MD, which makes an impassioned and persuasive case for the treatment of depression, and particularly the legitimacy of pharmacologic treatment of depression. It is a perspective and explanatory model that I am still informed by in my treatment of depression.
The question of excessive medication is something I also ponder frequently both in the context of mental health treatment, and generally. I therefore was interested to read this this article in the NYT by Judith Warner. One of my core values is moderation, and avoidance of polarization, so I like the basic thrust of this article. Like Kramer, Warner recommends, and I agree, that we look a little closer at our beliefs about “designer drugs” for depression and other mental health disorders. I followed the links to the articles in SLATE by Peter Kramer, which I recommend if you’re interested in walking the line between the poles in the treatment of depression and the place of pharmacotherapy in the treatment of it and various other diseases.
Warner’s article alone is a bit too dismissive of those who allege overmedication. While I agree that patients very rarely accept the use of chronic daily medicine blithely, an example of overuse is found in the marketing and use of sleep aids (Ambien, Sonata, Lunesta, anyone?), and there are others. I have also seen innumerable patients for whom anti-depressants have been recommended, though often not accepted, in scenarios accompanied by lines such as “well, there’s nothing really wrong with you but you don’t feel well, so you must be depressed.”
The question of excessive medication is something I also ponder frequently both in the context of mental health treatment, and generally. I therefore was interested to read this this article in the NYT by Judith Warner. One of my core values is moderation, and avoidance of polarization, so I like the basic thrust of this article. Like Kramer, Warner recommends, and I agree, that we look a little closer at our beliefs about “designer drugs” for depression and other mental health disorders. I followed the links to the articles in SLATE by Peter Kramer, which I recommend if you’re interested in walking the line between the poles in the treatment of depression and the place of pharmacotherapy in the treatment of it and various other diseases.
Warner’s article alone is a bit too dismissive of those who allege overmedication. While I agree that patients very rarely accept the use of chronic daily medicine blithely, an example of overuse is found in the marketing and use of sleep aids (Ambien, Sonata, Lunesta, anyone?), and there are others. I have also seen innumerable patients for whom anti-depressants have been recommended, though often not accepted, in scenarios accompanied by lines such as “well, there’s nothing really wrong with you but you don’t feel well, so you must be depressed.”
Saturday, February 09, 2008
Progressive Muscle Relaxation (PMR)
I was talking with my brother and sister this morning, and the topic of progressive muscle relaxation came up. It is based on early work by Edmund Jacobson, who first wrote about it in Progressive Relaxation in 1929, and the premise is that one can't simultaneously experience warm well-being and psychological stress. There are innumerable ways of accomplishing the relaxation response, and there are times when it helps to use the body and/or breath - when the mind is so uneasy that it can't be used to calm itself. Duh!
Anyway, you can find the instructions, including an audio-file here. I also recommend the book The Relaxation and Stress Reduction Workbook by Martha Davis, PhD, et. al. which includes information about PMR and a number of other related topics.
Anyway, you can find the instructions, including an audio-file here. I also recommend the book The Relaxation and Stress Reduction Workbook by Martha Davis, PhD, et. al. which includes information about PMR and a number of other related topics.
(A Spoonful of) Sugar
Kids are on my mind this week, I think because of some very special infants I saw in my practice. Two of them were in for 6 month shots. The issue of pain and infancy is one I remember well from residency, when during obstretrics rotation we were required to perform circumcisions. The question then was whether anesthetizing injections decreased pain associated with the procedure. I always anesthetized, and had also heard that some sucrose (table sugar) also helped, so I would let the infant suck a little sugar off of my little finger before the procedure. A familiar sound to any pediatric or family practice office is that of children getting, or preparing to get, immunized. A recent article in pediatrics affirms the helpfulness of sucrose in decreasing pain associated with this procedure.
Tuesday, February 05, 2008
Innerweave update
After a very positive initial program in our "Positive Psychology" series, our second and third programs were postponed. "Mind your Heart" will take place on March 8, and "Healing with your Stories" will take place on March 15. Please call 518.456.5951 or e-mail us at info@InnerweaveMindBody.com for more information and to register. We're also currently working on launching the 12-week program, including arranging for insurance coverage if possible.
On-line house calls
I'm very interested in the use of internet technology in primary care and also have some misgivings about it. Approaching this topic, one can quickly get mired in the sometimes dreary state of primary care and family medicine in general. I'll save that for another time. Suffice it to say that medicine continues to value technology over intellect, testing over talking, doing over discussing.
My greatest satisfaction in my work comes from well-paced, thoughtful, personal dialogues face-to-face with my patients. As a result of the energy I dedicate to these many encounters daily and my own personality style (or limitations, you might say), phone-calling is a dreaded task of mine. All of us know the satisfaction that it gives our patients to get the personal attention of a doctor phone call. The demands of the "modern" primary care doctor are overwhelming, however. There simply will need to be some means of compensating us for the time required to continue to give you, the patient, that personal touch, that both of us deserve and crave.
Here's an article about on-line house calls which describes a trend in frequent trendsetter (for better and for worse) Kaiser Permanente in California.
My greatest satisfaction in my work comes from well-paced, thoughtful, personal dialogues face-to-face with my patients. As a result of the energy I dedicate to these many encounters daily and my own personality style (or limitations, you might say), phone-calling is a dreaded task of mine. All of us know the satisfaction that it gives our patients to get the personal attention of a doctor phone call. The demands of the "modern" primary care doctor are overwhelming, however. There simply will need to be some means of compensating us for the time required to continue to give you, the patient, that personal touch, that both of us deserve and crave.
Here's an article about on-line house calls which describes a trend in frequent trendsetter (for better and for worse) Kaiser Permanente in California.
Monday, January 28, 2008
How would you treat me?
Chief complaint: The patient, who is a physician, awakened today with persistent sore throat, and now with a feeling of slight dizziness, weakness and muscle aches. Sore throat started on the return from Arizona 2 days ago. Patient had been exposed to several others with upper respiratory tract / viral syndrome symptoms while at a conference. Not prone to frequent infections, however has noticed some association between air travel and such syndromes. Echinacea (Nature Made) was immediately started, at a dose of about 1500 mg daily (250 mg every 3-4 hours), along with 1000 mg of vitamin C in the form of "Emergen-C", as well as chicken soup (lovingly home-made).
The dilemma: Your patient isn't too worried about the infection itself, as he's healthy and isn't prone to nor does he have a history of worrisome infections. His main concern is . . . should he go to work?
The process: This is a tough one for Doctor J. He knows what his mother would say - "honey, you need to take care of yourself!" He imagines his other colleagues toughing it out. He hems, he haws, he takes his temperature - that's helpful, it is 100 - still not quite enough. Finally, the answer comes in the form of a question: "If this were someone else - one of your colleagues - what would you advise them?" Easy - stay home, take care of yourself, you take care of people all the time.
The resolution: After calling and having patients cancelled for the day, and writing a contrite e-mail to colleagues (likely unnecessary but I couldn't help myself), I felt worse and worse for several hours. Temperature went up a wee bit, and down to normal since mid-afternoon with only ibuprofen in the mid-morning. Have continued the echinacea, which I'll do for the next several days. Usually I advise that patients not return to usual activities until they have a full day of improvement. In this regard, alas, I will not heed my own advise, and I will return in the morning. Hope that's OK with you.
The dilemma: Your patient isn't too worried about the infection itself, as he's healthy and isn't prone to nor does he have a history of worrisome infections. His main concern is . . . should he go to work?
The process: This is a tough one for Doctor J. He knows what his mother would say - "honey, you need to take care of yourself!" He imagines his other colleagues toughing it out. He hems, he haws, he takes his temperature - that's helpful, it is 100 - still not quite enough. Finally, the answer comes in the form of a question: "If this were someone else - one of your colleagues - what would you advise them?" Easy - stay home, take care of yourself, you take care of people all the time.
The resolution: After calling and having patients cancelled for the day, and writing a contrite e-mail to colleagues (likely unnecessary but I couldn't help myself), I felt worse and worse for several hours. Temperature went up a wee bit, and down to normal since mid-afternoon with only ibuprofen in the mid-morning. Have continued the echinacea, which I'll do for the next several days. Usually I advise that patients not return to usual activities until they have a full day of improvement. In this regard, alas, I will not heed my own advise, and I will return in the morning. Hope that's OK with you.
Sunday, January 27, 2008
NYT Health Section Review
One of my sources for keeping up with what is happening in the larger culture with respect to medicine, and occasionally for being directed to what is in the medical literature itself, is through the NYT online. I go to the "Health" tab and browse through articles that have appeared there lately. Since this blog is new, its eventual form isn't quite clear, but it occurs to me to periodically add comments and links to this section, since there is such a wide variety of information available there.
Today:
1. Positive Psychology course at Harvard is discussed. Of course it's interesting to me given my work with Innerweave, and it is also reassuring in some way to see happiness getting entrenched in one of the power centers of our culture. Even questioning my/our cynicism about this trend is interesting.
2. There's a post about probiotics, which I followed to find an older article about the same topic, which I think better represents a variety of opinions and sources, while admittedly not exhausting the topic by any means. I'd also recommend a page on culturelle.com which has a list of links which appears interesting. Culturelle is a product recommended by many integrative physicians.
3. I liked an article I saw about losing weight - "Bringing home the bacon ...". I saw a little bit of myself in each story.
4. And this article about the DASH diet, or "Dietary Approaches to Stop Hypertension". I have rediscovered this diet after it was presented in the integrative fellowship. You won't find it on the best-seller list, but it is tried and true.
4. Jerome Groopman, MD, writes a review of "The Cure Within: A History of Mind-Body Medicine". It is a well-written review and traces some important moments in the science of Mind-Body Medicine to the current time. I loved Groopman's book "How Doctors Think".
5. Last but not least, there's been a plethora of articles lately in the wake of the Vytorin and Zetia news. The most recent one I've read is the Op-Ed today by Gary Taubes. I liked the article in Businessweek - "Do Cholesterol Drugs Do Any Good?" - which presents some very important concepts in deconstructing medical stories such as number needed to treat and relative risk. There will no doubt be a swing away from some of the group think about high cholesterol, just as there seems to be with SSRIs, and many other drug classes. It would be wonderful to see the dots get connected between direct-to-consumer advertising and overblown pharmaceutical claims. However, as one who regrets the hype about our pharma-culture, I wouldn't suggest that the same illogic exaggerate the dangers of using pharmaceuticals. The promises and cautions of most pharmaceutical and medical interventions can both be excessive. The burden, however, in keeping with the principle of "first, do no harm" must ultimately rest with the proponents of pill-popping.
Today:
1. Positive Psychology course at Harvard is discussed. Of course it's interesting to me given my work with Innerweave, and it is also reassuring in some way to see happiness getting entrenched in one of the power centers of our culture. Even questioning my/our cynicism about this trend is interesting.
2. There's a post about probiotics, which I followed to find an older article about the same topic, which I think better represents a variety of opinions and sources, while admittedly not exhausting the topic by any means. I'd also recommend a page on culturelle.com which has a list of links which appears interesting. Culturelle is a product recommended by many integrative physicians.
3. I liked an article I saw about losing weight - "Bringing home the bacon ...". I saw a little bit of myself in each story.
4. And this article about the DASH diet, or "Dietary Approaches to Stop Hypertension". I have rediscovered this diet after it was presented in the integrative fellowship. You won't find it on the best-seller list, but it is tried and true.
4. Jerome Groopman, MD, writes a review of "The Cure Within: A History of Mind-Body Medicine". It is a well-written review and traces some important moments in the science of Mind-Body Medicine to the current time. I loved Groopman's book "How Doctors Think".
5. Last but not least, there's been a plethora of articles lately in the wake of the Vytorin and Zetia news. The most recent one I've read is the Op-Ed today by Gary Taubes. I liked the article in Businessweek - "Do Cholesterol Drugs Do Any Good?" - which presents some very important concepts in deconstructing medical stories such as number needed to treat and relative risk. There will no doubt be a swing away from some of the group think about high cholesterol, just as there seems to be with SSRIs, and many other drug classes. It would be wonderful to see the dots get connected between direct-to-consumer advertising and overblown pharmaceutical claims. However, as one who regrets the hype about our pharma-culture, I wouldn't suggest that the same illogic exaggerate the dangers of using pharmaceuticals. The promises and cautions of most pharmaceutical and medical interventions can both be excessive. The burden, however, in keeping with the principle of "first, do no harm" must ultimately rest with the proponents of pill-popping.
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