ACP Internist Blog


Monday, August 20, 2018

How can attending physicians promote wellness?

As a ward attending physician, I have some influence over learners' lives. During my time with them, I can impact their daily activities, but I can also serve as a role model of wellness.

Step #1 – Run efficient rounds. The time we spend on rounds can have a negative impact on a resident's ability to leave on time. Develop time constraints for rounds. Recognize when a consult or order has a high priority and give the intern or resident time during rounds to get that work done.

Step #2 – Maximize their control. Total lack of control negatively impacts wellness. Do not micromanage, rather manage. Do not tell the interns and resident everything that they must do, rather ask them what they want to do. If you disagree strongly, use that disagreement as a teaching opportunity.

Step #3 – Celebrate off days. Ask your learners what they did for fun. The simple ask endorses that they are human beings who deserve fun.

Step #4 – Share your activities. Tell the team about a good movie you saw, or discuss good restaurants. Let them see that you are well rounded.

Of course if the attending physician suffers burnout, then everyone is in trouble.

This blog post from Stay Out of my Wellness is insightful and worthwhile: “Wellness is not a one-size-fits-all concept. What resident physicians need is the unstructured time to define for themselves what wellness is, to seek it out, and to feel guilt-free in doing so.”

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Friday, August 17, 2018

God, GOOP, and the EPA

Scott Pruitt, the disgraced and departed head of the EPA, sullied that office not only with his scandalous abuses of taxpayer money, but with his obvious disdain for science. Good riddance to him. Alas, both deficiencies he epitomized will survive him. Personal enrichment and indulgence as perks of power and post are a sordid tale as old as civilization. Disdain for science is newer, because science is newer, but it likely emanates from a similar source. Science is a threat to the exercise of absolute authority predicated on false pretenses. Every manner of despot finds it highly inconvenient.

The transformative power of scientific advance, from the relative simplicity of smart thermometers that aggregate population-wide indications of fever, and thus the spread of flu, to the mind-boggling potential of quantum computing, is all around, suffusing our very modern existence. I am using such science now to project my reflections to you in this orderly march of cooperative electrons.

Yet also suffusing this same modern existence is that repudiation of science, its subordination to pseudoscience, celebrity, profiteering, propaganda, folklore, and faith. That the collision of the two trends, the co-evolution of scientific prowess, and disdain for science, finds ever readier expression through the products of science, such as the Internet, is an exercise in irony.

Some months ago, I shared a New York Times commentary repudiating the threat of pseudoscience. I share the concern, too, although not the conjoined summary judgment about naturopathic medicine. I personally know naturopathic physicians in the vanguard of devotion to evidence-based medicine, just as I know conventionally trained physicians routinely at odds with it. Fatuousness is an enemy to our better destinies, wherever it takes root.

That piece, and others like it, encouraged me to reflect on an experience just a bit further back. A little over a year ago, I was privileged to speak at the Foodfluence conference in Vienna, Austria. My friend Tim Caulfield, an inveterate defender of science over pseudoscience, did the same, and Gwyneth Paltrow was the star of Prof. Caulfield's show. This was not unexpected, given the literary attention Prof. Caulfield has directed to the actress before. Ms. Paltrow is the founder of the merchandising platform, GOOP, which specializes in glitzy pseudoscience for the platinum-cards-ever-at-the-ready crowd.

I posed a question, or perhaps more correctly a provocation, after Prof. Caulfield's talk. I proposed that Ms. Paltrow and any others peddling celebrity pixie dust were penny ante players. We have a much bigger problem.

God.

To be clear, this is not a concern about any actual god; I am not inviting debate about the existence of a power and intelligence greater than our own. In my view, frankly, that would not take much. Let's hope so.

Rather, this is a concern about flagrantly human varieties of silliness (at best), or contemptibility that we casually blame on whatever gods may be. In so doing, we invite ourselves and one another to embrace a calamitous standard of decision-making.

We can devise wildly improbable stories, attach them to god, and thus deny one another the right to question them. See the room for hucksters and propagandists in that wide wake?

If our biblical heroes are justified in slaughtering innocents for the higher aims of higher authorities, how do the suicidal soldiers of ISIS differ? One religion's terrorist is another's hero, or martyr.

The menace in this subjugation of science and sense alike to the tyrannies of unchallenged assertion is ever clearer, and ever more omnipresent. Despite redundant hope in happy seasonal songs about peace and solidarity, we are engaged in killing and defaming one another as ever. We are destroying this planet and everything on it, and the corruption of the modern mind by fatuous nonsense is a primary reason for climate change denial. And while Gwyneth Paltrow may figure in it, she is hardly on the marquee.

Much of what we tell one another about god doesn't pass the least test of the meanest sense. But we not only tell it to one another, we tell one another we must believe it, and that questioning it is taboo. God, then, as characterized by, to, and for us, is the gateway drug for GOOP, for denying climate change, for prevarication and procrastination.

Routinely, all of this is swept under the celestial rug with claims that there is a plan we can't understand. But that's a very troubling notion in its own right. Why would an almighty creator create both a plan for his favorite creatures, and make them incapable of understanding the plan? Obviously he/she/it had the power to endow us with understanding. Why not understanding commensurate with the plan? Is there something about the plan he/she/it prefers we not know? Thinking about those times the underlings are engaged in a plan they are not privileged to understand because it is above their paygrade does not provide much comfort. Cosmic cannon fodder comes to mind, along with the ”The Charge of the Light Brigade.”

My intent here is not to encourage or even pose questions about religion, or god. Others have that specific intent, but for me, such matters are simply encountered along the road to my goal. My goal is for us to be able to question nonsense at odds with testable, verifiable, falsifiable evidence of science.

If we can't, because an acceptance of flagrant nonsense has been inculcated in us among the sacred staples of our culture, then we can't and won't question nonsense about climate change, or vaccines, or diet, or guns; immigrants, Muslims, or Jews; celebrities and psychics.

We will be dupes, rubes, suckers when it is calamitous to be so. We will be putty in the hands of GOOP, the play things of fools and fanatics. We will melt away in the heat of our own oblivious, delusional devising.

Prof. Caulfield would like the world to perceive its native gullibility, to renounce GOOP for the gobbledygook it is, to recognize that the celebrity empresses and emperors of pop-culture pseudoscience, and politics, own neither clothes, nor truth. I would additionally welcome the repudiation of the preposterous hubris of every “I can see the one great diet truth no one else can see or will dare to reveal” nutrition-messiah-wannabe in the same dose of disinfecting daylight. But I fear the paths traveled by these misguiding icons of New Age nonsense may have been paved well above their pay grade.

Some champions of science, including in certain cases my personal heroes, oppose the concept of god, religion, and faith with an almost religious zeal. I am not inclined to go so far, for I see distinct value in faith, and not only the religious faith that confers solace when it is most needed. I have in mind faith in ourselves, faith that humanity will prevail, faith in compassion, faith in a better future. Fundamentally, I believe in the value of faith in hope, even when, and perhaps especially when, hope must triumph over experience. When the value proposition of hope is not empirically validated, faith is all we have. The best way to predict the future, famously, is to create it. Perhaps the best way to create a future worth having is to believe in the possibility of it, in the absence of evidence. That's faith.

Religion, per se, is a double-edged sword, only one edge of which works well as a plowshare for tilling the fields of our common dreams. We all see the pernicious potential for divisiveness, the belief-based Balkanization of the human family into rival clans of competing convictions. But, alternatively, religion is a common home to higher ideals, a place to gather with the better angels of our own nature and engage in their good works.

The one problem truly immanent to faith, then, is the subordination of science. Leading theologians have long recognized the need, and found the artful ways, for religious faith and science to co-exist. In a time when science until recently unimaginable resides in the phones we carry in our pockets, denial of science is as ludicrous as it is dangerous and dysfunctional. Projecting ideas as organized electrons through the canals of cyberspace excavated by scientists to repudiate science at large, or those conclusions of it one deems inconvenient, is an act of preposterous and flagrant hypocrisy.

Yes, we are mired in GOOP. Yes, pseudo-science is a threat. But celebrities like Gwyneth Paltrow are the small fish in this sea of troubles. Where competing and incompatible depictions of a deity beyond question are invoked as a license to renounce the empirical realities of science, there is a larger fish to fry. The likely alternative seems to be our cooked goose.

We are educated, in principle, to question authority. In practice, the temple of our culture reverberates to its rafters with the relentless murmur: don't do it.

May god, or GOOP, help us all?

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his Linked In page.
Thursday, August 16, 2018

Dang. Just have to rant about some really expensive drugs: Lucemyra, Trelegy Ellipta, Andexxa

The price of new drugs just seems to go up. I've stopped being excited about innovative pharmaceuticals that target various hard to treat diseases and conditions, simply because they cost so horribly much. Each of these new developments looks like a classic philosophical dilemma. Do I pull the lever that makes the trolley kill one person instead of five or do I save the one and allow the trolley to kill five? Do I prescribe the new drug that potentially helps my patient but may destine a whole population to lousy health care by making the overall budget unsupportable?

When I was in residency in the 1980s medication that cost a dollar a pill was crazy expensive. Inflation doubles that plus a little more, so think $2.25 a pill in 2018 money. But today's expensive medication costs $10-$20 dollars a pill. Or $1,000 a pill for the drug to cure hepatitis C. Or, in the case of a now pretty commonly used drug for advanced cancer, $150,000 a year. This is real money. On the lower end, it costs as much as all of one's food. At the higher end, it is enough to live like a rich person. If we insist that everyone have access to some of these new drugs we admit that we will never be able to offer universal health care. It would eat up all of the money we have.

Here are the new, latest and greatest drugs announced in The Medical Letter of Drugs and Therapeutics, a publication published by a non-profit not aligned with any pharmaceutical companies.
1. Lofexidine (Lucemyra) for opioid withdrawal. This is a central alpha receptor agonist, similar to the drug clonidine, which has been available and successfully used for the physical symptoms associated with ceasing to take opioid drugs when one is addicted. It reduces the anxiety, sweating, irritability and diarrhea that characterize withdrawal. It costs $1,738 for a week supply. It is no more effective than clonidine, which costs $1 for a week, though it does cause less reduction in blood pressure. The drug of choice for this situation is buprenorphine, which costs $23 for a week.
2. Trelegy Ellipta. Inhalers for asthma have been prohibitively expensive for years. People with airway obstruction, classic asthma with wheezing, shortness of breath and cough, usually require inhaled medication to open up the small airways in the lungs and to reduce mucus and inflammation. Originally the only drug for this was epinephrine, which eased breathing when injected, taken orally or inhaled, but also sped up the heart and caused the shakiness associated with adrenaline release. Newer drugs worked on the inflammatory response, reduced the cardiac side effects and were longer acting. Inhalers cost less than $20 for a month supply when I graduated from medical school. Now some of the common brand name inhalers, combinations of long acting bronchodilator and a corticosteroid for inflammation, cost $300-$400. Now Trelegy Ellipta has been introduced which costs $530 for a month's supply. It includes three drugs rather than two, and if one were to buy those three types of drugs as individual inhalers they would cost more than that. People mostly use a drug like this every day forever, at a cost of $6,360 per year. Many of these drugs are not available as a generic, but even generics can be costly. Some of the generic combination inhalers cost less than $100 a month, but different patients respond differently and some have no luck at all with certain drugs or combinations and will end up on branded products.
3. Andexxa (andexanet alpha) will rapidly reverse certain anticoagulants. A few years ago the most commonly used anticoagulant, warfarin (coumadin), got some competition. A new drug was approved that reduced clotting by a slightly different mechanism and did not require regular blood tests to monitor it. Now there are at least three such drugs commonly used for patients who have a high risk of blood clots. They are considerably more expensive but also a bit safer and quite a bit more convenient. Unlike warfarin, however, which can be reversed by vitamin K or fresh frozen plasma, the new anticoagulants did not have an effective reversal agent. So if a patient on one of these new blood thinners came in having injured themselves, with uncontrolled bleeding, it was very difficult to stop the bleeding. We did discover that prothrombin complex (Kcentra is the brand name) worked pretty well. The hitch was that it cost about $5,000 for the usual injection. We still used it, but it definitely put a dent in pharmacy budgets in hospitals. Andexxa was specifically developed to reverse two of these newer anticoagulants, apixaban and rivaroxaban. It can be dosed low or high, depending on the dose of the anticoagulant. One high dose treatment costs …. wait for it … think high … YES. $49,500.

Costs of this magnitude are hard to put in context. I have read that there are about 750,000 people on the newer anticoagulants. If one in a hundred of them had a bleeding episode in a year which was treated with Andexxa, that would be nearly $400 million, enough money to buy a year's supply of a nice cheap generic blood pressure pill for 10 million people to help prevent the atrial fibrillation which eventually leads to prescription of the anticoagulant. Or enough money to pay for a week's vacation to Hawaii for 10,000 people, which is mostly irrelevant.

What makes me sad here is that these new drugs are being pushed out of the pharmaceutical pipeline and, although they have the potential to reduce misery if used for the conditions they can treat, they will bankrupt either real people or health care budgets or both. The folks who could benefit from them will perhaps achieve better health only to be crushed by debt or unable to afford health insurance.

Something could be done to fix this.

Pharmaceutical companies are motivated to create drugs whose high prices and popularity will result in profits. We can, however, fund drug development in a different way. If academic labs developed drugs through grants from the National Institutes of Health or other government agencies, their costs would not need to be made up by sky high drug prices. In fact, since the government pays the vast majority of health care costs in one way or another, the payoff for these grants for drug development would be through lower pharmacy costs and also improved health and productivity. This kind of payment would favor affordability and efficacy, not just expensive drugs that add very little incremental benefit for patients.

For now, new drugs come from pharmaceutical companies and are priced beyond what a conscientious health care system can pay. Still, these drugs will be advertised and prescribed and health care costs will go up and medical debt will destroy lives. It's really hard to get excited about this most recent batch of wonder drugs.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Doctors and the opioid epidemic

I am against all forms of bodily pain, both foreign and domestic. I wish the world were pain free. When I am suffering from even a routine headache, I want immediate relief just like everyone else. The medical approach to pain control has changed dramatically even during my own career. When I started practicing a few decades ago, the strategy was pain reduction. We gave narcotics for very few indications such as kidney stones, heart attacks, and severe abdominal pain after a surgeon evaluated the patient. (The reason for this was so the surgeon could obtain an accurate assessment of the patient's belly before pain medicine masked the findings.)

The new goal is pain elimination, which I believe is one factor that has fueled the overconsumption of opioids, although there are other factors present. I admit that I am opining on this as an individual who is blessed to be pain free. I do not pretend or suggest that if I were afflicted with a painful condition, that I would not want whatever it might take to bring me relief. In medicine and in life, the world looks very different when you are a victim. Your view on health care reform, for example, might ‘evolve’ if you or a loved one is suddenly uninsured.

But patients' rising expectation of eliminating pain and the medical professions willingness to join in this mission has exacted a great societal cost. I am not blaming anyone here. Of course, patients want pain to go away. Of course, physicians want to relieve suffering. Isn't a doctor's mission to make his patient feel better?

The consequences of this approach have exploded. Narcotics and opioids are addictive agents. Any individual who takes these medicines over time risks addiction, which is a new disease. In fact, the addiction may very well be a more severe illness than the original medical condition. When OxyContin (oxycodone) came on the scene in 1995 the drug company recommended it as first line treatment for chronic pain as well as for musculoskeletal pain, two conditions that today would not be initially treated with opioids. Over a decade later, the pharmaceutical company accepted a guilty plea in federal court and admitted that it trivialized the drug's addictive properties, along with other deceptive practices.

Consider this sobering statistic. The United States is about 5% of the world's population yet consumes about 80% of the world's oxycodone supply.

When a doctor is prescribing opioids to a patient, which may be entirely appropriate, the physician and the patient must be mindful of how carefully this must be monitored and the addictive risks of prolonged use. We must guard against creating a new disease that may be fatal and that may result from unrestricted or inadequately monitored pain medication use.

Ohio announced new rules recently that would limit opioid prescription for only seven days for acute pain. While I generally resist politicians interfering with medical practice, with thousands of overdose deaths in our state every year, I understand their need to intervene.

Many heroin addicts today can trace their affliction back to a doctor's prescription, which was given for the right reasons.

The medical profession and the scientific community needs to triple down on research to develop new drugs and techniques that attack pain but leave patients protected from the ravages and misery of drug addiction.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.