I've been bad about updating this blog. To my vast audience out there (of probably one or two people), I sincerely apologize. It's not that I don't want to write, it's just that when I get home I eat dinner then flip open my weekly copy The Economist, get pissed off at the world for a bit and pass out shortly after at around 10 -ish. Today, I broke the vicious cycle and I am writing to update you on my life adventures.
Last week we had our first real case study in our IQ group (small-group session). The case centered around the behavioral and psychosocial factors involved with diabetes care in a Mexican-American women with presumably no health insurance, among other obstacles. Overall I learned a lot about diabetes and I was able to refresh my memory on some public health and epidemiology principles I learned about last year.
Something came up during our last session on Friday that I have wanted to bring up in this blog, and that is the notion of ethics regarding pharmaceutical companies and physicians. In this particular case we were reviewing, the doctor treating the Mexican-American diabetic at the clinic gave her free samples of Avandia (rosiglitazone) to help her manage her diabetes. One of our group objectives, which we came up with, was to study and learn more about the ethics regarding free samples as well as other gifts given to physicians by pharmaceutical drug-reps (including free dinners/lunches to pens sporting the nifty trade names of all the drugs on the market).
Our group concluded that accepting free samples could affect a physician's prescribing practices. For instance, say you're a physician and you get a bunch of free samples of drug A. Say that there is another drug B, which is the exact same as drug B, but a generic version which is much cheaper for the patient. By giving free samples of A, you might be more tempted in the future to keep giving A even though it would be easier for the patient if you would just prescribe B. Get the idea?
It's hard to believe these types of arguments. You would think the physician should exercise discretion. Apparently the general argument regarding gift-giving is that any gift, no matter how big or small, can affect you subconsciously. Yes Dr., that Viagra pen you are holding can influence your prescribing practices. Maybe it does, maybe it doesn't. Honestly, I don't know. I guess a bunch of psychologists and economists did some studies and showed that it does.
Well my group pretty much agreed that these gifts are probably not good. That's fair for them to think that way and I have no problem with that. The crazy thing is, I have a feeling most of my class thinks negatively about pharmaceutical gift giving, even with regards to small things like pens or staplers.
This is kind of a problem for me. See, all of a sudden I feel like I turned from a nice friendly, resourceful guy into a dirty little whore. As my group members were reaching a consensus, I was slowly hiding that Olanzapine pen into my cargo pant pocket...
My family has a history with pharmaceutical companies. As I mentioned before, my dad is a self-employed child and adolescent psychiatrist and he knows all about drug reps. They visit him in his 3 offices all the time. They call the house all the time. They've even hooked me up with other docs they know so I could shadow them. Hell, one of them even helped get me a summer job.
But it's more than that. You see, back in the day (as in about 7 or 8 years ago) there were very little restrictions drug reps could do with regards to gift giving. I've sat in club seats before for the Indians, Browns and Cavs. I've been to fancy 5-course dinners where I get confused about the silverware sequence. I've experienced a couple free rounds of golf at country clubs (which is kind of funny since my dad doesn't golf). I even got a free trip to Hilton Head with my dad to "attend a conference." In reality, he drove the cart and gave me counseling to help me on my way to breaking bogey golf in paradise. This was just part of life growing up, that is once my dad got hist medical license in 1994 after training for a bazillion years. Hard, I know.
You might have read that last paragraph and lost what little respect you already had for me. Am I adding insult to injury by telling you that about the only pens I carry around are pens my dad gets for free?
Gone are the days of free trips and tickets to pro sports games (yes, I actually paid $200 to see Lebron beat the Pistons last year). This is a good thing, and my dad thinks so too. However, the free meals and pens are still around. I don't know if this is necessarily a bad thing, though.
First, I'm not sure if the standard arguments regarding pharma gift giving applies to my dad's line of work. In C&A psychiatry, there are no generic medications. All the drugs on the market are patented and will remain that way for some time. Furthermore, all treatments are made off-label. Drug companies are prohibited from marketing their medications for off-label purposes, and from my experience in pharmaceutical research and from my dad's anecdotes, I believe that this is actually reflected in daily practice with drug reps.
Furthermore, I think people need to realize that drug companies and physicians act like business/businessmen. Yes, not every physician is working a salaried academic position in a hospital. Most physicians operate practices or work in small-practice/business settings. This is even true for surgery where there has been a great shift towards outpatient care. Whether or not you agree with this is another matter. We may hate pharm companies, but in the end of the day, if they're not making those drugs and coming up with discoveries, we're screwed.
This is a touchy subject and I'm still trying to feel my way through. Are pharm companies evil? Maybe. It all comes back to business, money and politics. We live in America. Home of individualism and capitalism. Is it fair for patients? Probably not. Is it good for their health? Probably not.
In the end, I really don't care that my new pen screams "Olanzapine" on the side in fancy handwriting. In fact, Olanzapine is a shitty drug. Just ask all those poor schizophrenic or bipolar patients who develped hyperlipidemia, metabolic syndrome and type 2 diabetes. Screw olanzapine. I do have to admit though, the Olanzapine pen is amazing. I just hope I can make it four years without having to give up all those cool pens in my desk at home. Believe me, they really are cool. They write well and sure beat the hell out of the crap you get in the store.
Seriously, what do you all think? Do you think physicians should accept minor gifts? And no, this is not a rhetorical question...tell me what you think.
Moving on...in other news we had our first gross anatomy lab yesterday. We got to hold prosected hearts and lungs. I held a human heart and stuck my fingers in it to get a feel for the flow of blood through the chambers and valves...sweet. The lungs were soft and kind of mushy. Lab made me hungry. For edible food, not body parts.
We're a little more than half-way through our first block. I think a common complaint many students have is that they are getting tired of the non-medical concerns for patients. These concerns include public health and psychosocial considerations of disease and illness. When are we going to learn REAL science? That's a common question.
Now I know I've always been interested in psychiatry. It's kind of in my blood and it's been validated by the research and clinical experiences I've had before (though I admit this might change after third year, who knows), but I think it's been further validated by the fact that I really don't mind the "touchy-feely" stuff we do during this block. In fact, I kind of like it. Not to mention, when I'm collecting medical history from standard patients, I kind of tend to venture off and ask questions regarding how they feel about certain things. This isn't to say I don't like hard science. In fact, anyone who knows me knows that I am quite into chemistry, especially organic. It's just that I think psychosocial considerations are an important fascet of medicine which are often ignored by physicians. It doesn't mean we have to be all goo-goo with our patients and go Dr. Phil on them, but we need to acknowledge external considerations such as personal, interpersonal and societal circumstances. Our fancy pants procedures and magic pills will not cure our patients alone.
I do understand the frustration my classmates might be having. The social sciences are difficult to appreciate without actual real-world experience. Science is important in medicine, but you can't reduce your patient to a certain pathophysiological state. It's not like biochem where I can draw a pathway or show a mechanism. I always thought of myself as a researcher and I think (even to this day) I'll probably end up in academics, but I have to admit, I'm really dying to get away from the basic science books and to get more clinical exposure. You should check out my blog two years from now when I get out on the wards and ask me how I feel then.
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