Sunday, November 28, 2010

Drug Companies...The True Motivation?

Imagine this: you walk into your local pharmacy to pick up a bottle of aspirin. You usually grab the store brand--it's cheaper! Now imagine your surprise when you can't find the store fact, there's only one brand of aspirin on the shelf! You pick it up, look at the price, and discover that the bottle that usually costs you about $9 now costs you $485! If you typically use aspirin for things like headaches, you might just turn to another painkiller. But what if you had heart problems and needed to use aspirin every day for that reason?

If that sounds far-fetched, think again. Take the example of colchicine, a drug that has literally been used for centuries, for the treatment of gouty arthritis, among other maladies. Given this drug's age, it was on the market long before the advent of the FDA, and thus had never been officially approved by the same. Ah, but the drug company URL Pharma has come along to dot the i's and cross the t's for the FDA! They went through the motions of running colchicine through the official drug-approving process, and in return, the FDA gave them a 3 year patent on their brand-name "Colcrys".

I found this out during my Family Medicine rotation this month. We had just finished seeing a patient who had an acute attack of gout. After seeing the patient, removing a bunch of the painful uric acid crystals in his knee and adjusting his prescriptions, I talked with my preceptor. He told me about how URL Pharma had been awarded the patent. He told me about how they immediately turned around and sued to have all competitor brands of colchicine removed from the market, a fight which they just won in September. And he told me about how the price for colchicine had basically increased by 50 times now.

Needless to say, I was floored. I came home and did the research myself to confirm. Mostly, insurance companies will bear the up-front cost. But it all comes around to bite all of us in the end. I read it's expected to cost Medicare an extra $50 million, altogether, as if it wasn't strained enough. I understand rewarding a company for finally doing the grunt work to get the data for safety, efficacy, pharmacokinetics, etc. But this is absolutely ridiculous.

And real people are going to suffer.

Friday, November 19, 2010

"So You Know What Hell is Like"

It was the last patient of the day. I grabbed the chart, glancing at the reason for visit. "Med Check" is what was written. I flipped through her last few visits, noting that she had begun an antidepressant 6 months earlier. I make a mental note that her blood pressure was significantly elevated today...a problem she had not had before. Then I knocked on the door and entered with my canned speech, "Hi, I'm a medical student working with Dr. __ today..."

Observation is a huge part of being a doctor, and the first few seconds can be very telling. This woman was standing in front of the examining table, hands held in front, head down. As I walked in, her head raised and her expression went from one of fatigue mixed with grief, to one of clear alarm. "Oh, I'm sorry", she said. "I don't deal well with men. That's the whole reason I see Dr. __." I retreated a little so as not to appear as a threat, and apologized. I said something to the effect that I certainly didn't want her to be uncomfortable, but Dr. __ was with another patient at the moment, and would she mind terribly if we just talked for a little while? She gave me a dubious look but agreed.

I sat down and began inquiring into the purpose of the visit. She had been taking such-and-such medication for 6 months now, correct? How did she feel about that drug? Did she feel it was helping her? Her answers were vague at first, and she said the drug had been helping her "cope" but that she had a lot going on in her life. Not wanting to pry, I inquired if these were things she'd already discussed with my preceptor or not. She said that well, all these things had happened since her last visit. I said, "Would you be comfortable talking with me about what's going on?"

And I guess at that point I won her trust. Her eyes misted and she told me about her son who had been addicted to narcotics and other medications, but had moved in with her while he "quit cold turkey". She told me about her daughter, 9 months pregnant and going through a divorce. She told me about her fiance who was undergoing an ugly court battle with his ex-wife. And there was she, caught in the middle, the one that everyone turns to with no one to turn to herself.

I put the chart down, and rolled my stool closer to her, validating her as a human being and not as "just a patient". I briefly shared with her some of my struggles from a few years ago, when I felt like my own life was falling apart. She summed it all up pretty well when she said, "So you know what hell is like." I said that my hell had certainly not been like what she was going through, but she said, "Everyone has their own hell."

We really touched each other, and definitely came back stronger from sharing our experiences. We talked about how all these things had happened at one time in her life, but that many aspects of them were temporary, and she had a lot to look forward to: her son being clean, her new grandbaby, her soon-to-be husband. We talked about making sure SHE had someone to vent to. We talked about her blood pressure, and the possibility of adding some anti-anxiety medication to help her handle everything. And, as I left the room, we talked about prayer.

That's why I do what I do.

Thursday, November 11, 2010

Is Family Medicine for me?

I'm writing this on my lunch break during my Family Medicine rotation. That's right...I get a lunch break. That's just one of the nice things about FM! The "little things" really do add up sometimes.

I've never really considered FM before, for a lot of reasons. But, in the last few weeks, it's gone from not even being on the radar, to what I'm actually probably going to go into. Why?

One thing I really love is the continuity of care. I really like Emergency Medicine, and many of the other specialties are intriguing. The problem I've had with them, though, is that you treat the patient, and then send them to someone else. I always find myself wondering how they ended up. In FM, you see people over months, years, and even decades. You get to see generations of the same the 2 weeks I've worked at this office, I've seen 4 generations of a single family!

That gives you CONTEXT as well. If I have someone who's feeling anxious, but know that the husband is possibly about to lose his job, I can put two and two together. If the parents are stressed and suddnely a child is coming in with abdominal pain...that's something to think about. Etc! I've always been a fan of knowing the "big picture."

You DO get to do some cool stuff in FM. It's not "just" seeing patients in the office. In the last 2 weeks, I've removed moles and skin tags, done Pap smears, used the microscope for various things, injected joints, aspirated joints, given shots...all in the office! You never know what a day is going to bring you. In one day, I saw a 6 day old newborn, and an 88 year old man.

There's lot of little things. Having time for lunch is nice. Not being exhausted when I come home, and being able to play with my son and talk with my wife instead of going straight to bed, is huge. And I'm really enjoying talking with people about managing their diabetes, their blood pressures, the benefits of smoking cessation, and how to really do it, having safe sex, how to manage a cold, how to handle depression and anxiety...I love it!

Which has brought me to the question: can I afford to do primary care? This is part of why I've never considered it. I'm going to graduate with $275,000 of debt, which will explode to over half a million in interest within 10 years. How can I afford to pay that off on the salary of a PCP? To top it off, it looks like the Medicare cuts will be allowed to go into effect in January, cutting (I think I remember correctly) 29% of reimbursement for Medicare patients. We talk about that almost every day in the office here...about where we can add more slots to see more patients in a day, taking on more private insurance patients, etc. We already don't accept new Medicare patients. It's unreal.

I found a REALLY cool program that's JUST for people like me...that are seriously considering primary care, but are worried about paying off the debt. I'll spare you the details, but the gist is that I'd pay between $1000-2000 a month for 10 years of my debt, after which the rest of my debt (approximately $450,000 at that point) would be forgiven by the government. I'd have to work for a government or non-profit agency during that time. But it's sounding like the way I'm going to go.

As to how I'm going to handle the Medicare/Medicaid/health insurance Gordian knot...well, I don't know yet. But I'm excited about figuring it out.

Monday, November 8, 2010

Teen Sex & other news

This morning, there were a lot of interesting articles with respect to teenage sexuality (much of my morning reading comes from "Today's Briefing List" of Albert Mohler). I thought I'd share some of them, and my thoughts about them.

Oh, I also wanted to share this article with you. It's a well-written and fair article about the current state of the Republican party. Key quote: "The Democratic Party may have the wrong answers to these problems. But the Republican Party as an institution often seems to have no answers whatsoever."

OK! I actually found this article from the NY times rather fascinating. It highlights a recent slideshow from about the significant differences between how Europeans handle sex education, and how we handle it in the USA. Overall, it seems as if the American approach is denial and fear, whereas Europeans recognize that teens will eventually have sex, and so they talk about it with their teens and try to help them make informed, "safe" choices as much as possible. The results? Their teens have sex on average the same age as we do (17), but with significantly fewer regrets (girls regret their first time 69% of the time in the US, vs. 12% in Holland), pregnancy and STDs including HIV. I think the results speak for themselves: parents need to TALK with their kids openly and honestly about sex, from an early age. I will definitely encourage my children to hold off on sex, but I'm definitely not going to leave the conversation at that. Your thoughts?

This article from USA Today kind of fits with that theme. Teen girls have a LOT of misinformation about their changing-pubescent bodies, and about sex. Remember that article from last week? Teens actually PREFER to get their education about sex from their parents, and especially missing is input from Dad. They're not going to ask for it, though. Parents, we have to step up to the plate!

Finally, an article about "shacking up", and how it's becoming much more prevalent these days. Your thoughts? I moved in with my fiancee a month before our wedding. My advice would definitely be against it, in case you were wondering. Still, what are your thoughts?

Discuss! :D