The argument for drug samples

Over the last few years, the pharmaceutical industry has gone through significant changes.  The days of free trips and rounds of golf are long gone (I'd be lying if I said I didn't miss the occasional round of golf on the drug rep's tab).  There has been significant consolidation, with larger companies purchasing smaller ones, leaving the landscape with just a few mega-companies who call on physicians,  detailing us on their products - the medicines we prescribe.

There have been many arguments against physicians giving out free "samples" of pharmaceuticals.  I understand what the experts say.  They argue that in the end, the free medicine costs patients more because we have a tendency to hand out the free, more expensive branded product before we consider cheaper alternatives.  They argue that visiting with cute (or handsome) drug reps will change the way we prescribe, specifically, that we will prescribe more of that sales reps product.  They argue that Big Pharma has built in so much profit into their branded medicines that the free samples are a drop in the bucket, and that even one new script will bring in profit enough to support the "hard sell" we doctors get from the reps.

I completely understand these arguments.  There is some validity to them.  However, I feel the need to offer some retort.

With so many excellent generic medicines available, a physician would have to be really disconnected from their patient to not reach for a generic first.  We may not like this, but with deductibles continuing to rise, we are stewards of our patients health care dollars.  It is in our best interests, outside of being incentivized to do so, to be as cost-effective as we can.  This is true for all aspects of our job, whether it's medicines, test ordering, frequency of medical visits, et cetera.

My biggest concern about turning off the samples is that there are some excellent new medicines that have come on the market that physicians will be less likely to try if they don't take samples or see reps.  It's not easy for us to learn about new classes of medicines.  If I didn't visit with reps, I suppose I could go to a symposium, corner a colleague at the hospital, or ask a local pharmacist.  Don't you think it is a little easier to have a brief conversation with a sales rep who can give you a 2 minute spiel, and leave some science behind?

Having samples allows me to test-drive some of these new therapies.  I can give 2, 3, or 4 weeks of samples to a patient to see how they respond to the therapy.  During this time, they can call their insurance to check on their out of pocket costs.  I always let the patient decide if the medicine is worth their cost.  In particular, with certain diabetes medicines like the new DPP-4 inhibitors, I will make a hard sell, because I truly believe that the cost is worth it.  These new therapies don't have the dangerous side effects some of their older generic counterparts have.

I have a well organized sample closet in my practice.  Honestly, we dispose of expired samples in at least a 6:1 ratio of samples we give to patients.   If a patient fails generic therapy, or, if your professional opinion is that a branded medicine is a better choice, let the patient take the new medicine for a spin, before they drop $35 on a branded co-pay.

We just need to put our patients first.  Period.  Be the smartest guy on the block.  Use your training and expertise to decide if you think a new therapy has merit, not the gleaming smile across the front desk or the Moo Goo Gai Pan they bring for lunch.  Explain your decisions about the medicine you are prescribing to the patient.  They'll understand.   Remember, we are supposed to be our patients advocates.  Let's behave like it.

Add it up

R. came in for a physical last week.  I've cared for him and his family for years.  They are the the type of family FPs love - nice, funny, engaging, cute kids.  R is in his early 30s and drives a truck.  Pretty healthy guy for the most part, except for one problem.  He weighs 325 pounds.

After a few minutes of chit chat, I asked him if there was anything on his list he wanted to address.  He said he was tired of being overweight, and he was looking for some guidance on how to begin losing weight.  You could sense that his weight has begun to bother him, not physically, but emotionally.  He seemed genuinely ready to lose weight, so we began our discussion in the usual place,  talking  about his diet.

I usually begin these kind of discussions asking about the typical "empty calories" that people take in, so I asked R about his soda intake.  R admitted that he drinks 2 Cokes per day.  "2 Cokes per day" can mean anything, so I questioned him further, and  it turns out he drinks 2 large Cokes per day, bought from one of the major  fast food chains, the one that has $1 sodas, any size.   He said he does this every day.  Even weekends.

I went online to try to find out how many ounces were in a large Coke from the above chain.  It turns out that a large Coke is about 24 ounces (2 cans), if one adds ice.   So, he was drinking the equivalent of 4 cans of Coke daily.

A can of Coke has 140 calories.  So, R takes in 550 (rounded) empty calories every day.  When I told him this, he didn't look at all concerned.  We then talked about the number of calories men should consume per day.  Usually, men should consume 2000-2200 calories per day.  He still didn't seem to get it.  That is, until I did the math.

550 empty calories, every day, is 16,500 extra calories per month.  He is taking in 8 extra days of calories each month just in Coke.  Let's just say that this got his attention.  His jaw literally fell open.

I guaranteed him that if he could transition from regular Coke to something like Coke Zero, he would lose 10-15 pounds, without making one other change to his diet or exercise regimen (which was non-existent).   In 3 weeks, I'm going to go through starch reductions, increasing his protein intake, and how to eat healthy (speed of eating, water intake, snacking, etc.).  We should be able to get him under 300 pounds by Halloween.

Small changes seem just that, small.  But if you add up those changes over time, they will make a big impact.  So, if you are looking to make changes in your diet (or any behavior for that matter), start with something small and be consistent.  It will definitely make a difference.

Free advice to Big Box practices

We see about 40 new patients a month in our practice.  We've done this for years, without advertising.  We rely on the word of mouth of our patients and referring specialists to build our practice.  It's been a successful approach so far.

When I first meet a new patient, I ask them about how they heard about our practice.  The majority are referred by either friends or family.  Once I've established some repoire, I'll explain my practice philosophy, some of the history of the practice, and how the hierarchy of my practice is designed.  I make a point to tell patients that I am their physician, and that by coming to a small group, they will always either see me or my physician assistant Karla.

It never gets old to see how new patients respond to this.  They almost seem relieved.  I had one patient say to me, "Finally! I'm sick and tired of seeing every other doctor or assistant than the one that's supposed to be my doctor".  You hear this enough times from enough patients, and sooner or later, you come to the conclusion that the paying public is looking for something more than what they are getting.

The majority of our new patients are former customers of the Big Box Practice (BBP going forward) which has locations throughout the western suburbs of Chicago.  I have some fairly strong opinions about the way BBP does business, but in this post, I want to focus on the patient, specifically the patients who have left BBP as unhappy customers.

The number one complaint I hear from our new patients is that they "felt like a number" at the Big Box.  This criticism is a reflection on the business model that large medical practices have adopted.  Physicians simply want to dilute their duties among as many "partners" as possible, even if it means alienating the most important piece of the equation, the patient.

Primary care medicine should always be built on the long-term relationship of a physician and patient.  If you notice, the word "physician" in the last sentence is singular.  There is no feasible way to provide insightful care without getting to know your patient, and the only way to get to know your patient is for the physician to see and care for them, not their seven partners.  Patients shouldn't tell their friends and family, "I'm a patient of Big Box Practice".  They should say, "I'm Dr. (insert name here)'s patient".

So, as a small practice physician, I'm going to give BBP a free consultation.

First of all, it's OK to have a large group of physicians.  What you need to do is make that large group feel intimate, and that starts by having your physicians take ownership of their patients.  As important as it is for patients to identify with a specific physician, it's equally important for the physician to identify with their patient.  To do this, you need to break the large group into smaller parts.

It's not that hard.  If you have 8 physicians, split into four 2-physician groups.  When one physician is on vacation, the other physician can cover, and vice-a-versa.   When you shrink your practice down into manageable parcels like this, call becomes easy.  Trust me - I've done it for years.  We take care of 6000+ patients, and I'm lucky to get one call a night during the week.  On the weekends, divvy up the hospital call amongst the 8 of you.   Patients completely understand your need for some down time.

What this will do will be amazing.  Your patient attrition will slow down, patient satisfaction will soar, and  you will start to like medicine again.  I'm not say all physicians are unhappy working for BBP, but I can tell you that how they practice medicine isn't what they imagined when they went to medical school.  I take great pride that my patients are my patients.  I am protective of them.  I work harder for them.  I am accountable.

BBP docs, don't hide inside the big groups you have built.  Re-design the way you deliver care.  I understand if you do this, I may see less new patients coming my way.  That is completely fine with me.  It will mean that your patients are happier, and getting the care they deserve.  It will mean that your patients no longer feel like they are just a number.

Like I said, this consult is a freebie.  I'd be happy to talk about my going rate if you need any other advice.

The value of a good sports physical

Our office has been busy the last few weeks pounding through our annual rush of school and sports physicals.  I really enjoy this time of year, because it gives me a chance to catch up with kids who've been healthy over the past 12 months and haven't been in to see me.  It also gives me an opportunity to really dig through any issues they may have had over the past year, especially any red flags for sudden cardiac death.

About 1 in 100,000 students will die from sudden cardiac death every year.  Every time I hear or read about a student athlete who died suddenly, I think to myself "Somebody cleared that kid to play sports".   There is no way we can prevent every case of sudden cardiac death in youths, but we can definitely prevent a few of them by doing a comprehensive annual exam.

These exams focus particularly on obtaining a thorough history from the student and their parent(s).  We ask questions about chest pain, lightheadedness, and shortness of breath, either at rest or with exertion.  Other important parts of the history include fainting, almost fainting, decrease in exercise tolerance and updating the patient's family history regarding any family members who have died suddenly.  The encounter also give us a chance to talk about concussions, physical and emotional development, academic successes and family life.  On physical examination, all patients require a thorough cardiac exam and evaluation for conditions such as Marfan's syndrome, which can lead to sudden cardiac death.

There is no possible way to do this type of clearance exam on a child/adolescent  in 5 minutes.  Unfortunately, there are parents who utilize this type of sports physical to clear their child to participate in sports.   There are walk-in clinics just up the street from my office who offer these "convenient" exams for $30.  I implore all of you to avoid this.

Take your child to his or her physician for a full well-child exam.  It only takes about 15 minutes.  The exam will  reinforce your child's relationship with their physician, and it will give you peace of mind that a trained professional has determined your child is safe to participate.

One child dying from a preventable condition is one too many.

The burden of dying

I discharged a 20 year old patient of mine from the hospital a few weeks ago.  He's the second college aged kid I've cared for with a malignant brain tumor.  T passed away in March after a 4 year fight.  T's tumor was operable, thank goodness, so we were able to buy him some good time.  K's unfortunately isn't.  His recent stay was for a complication of his cancer, and he required 2 major surgeries. It was really awful.

At one point during K's recovery, he looked like a beaten kid.  He was exhausted.  I asked him how he was doing, and he curtly said "Fine".  I said "No you're not.  I wouldn't be either".  After I checked him over, his mom followed me out of the room.   She asked me a few questions, and went back in to be with her son.  She was smiling, engaging, uncomfortably upbeat.  Throughout his stay, she didn't show a single crack in her emotional foundation.  Her matter of fact approach to her son's illness has made me realize that she hadn't had the opportunity to wrap her emotions around what her son was going through.  She needed to be strong for him, even when he wasn't.

T was the first young person I had ever diagnosed with cancer.  I remember the night I diagnosed him like it was yesterday.  Each experience he and his family went through was a new experience for me as well.  It was a privilege to watch him battle.  He was beyond inspirational. Out of all those experiences, the most surprising was how T's mom responded to her son's illness.  Even when he was done fighting, she kept him going.  It was an amazing thing to watch.   The last time I saw him, he said, "I'll see you again, don't worry".  His eyes said something different.

You could see the burden on him.   He knew his days were numbered.  As much as he wanted to wave the white flag, he couldn't, because his mom wouldn't let him.  Her ability to fight for her child was the most instinctual thing I've ever witnessed.  It came from the depths of her DNA.  This ability, to fight till the end for her child, had to be unbelievably difficult on her.  I can't imagine either of their burdens.

K hasn't stopped fighting.  But when he does, I don't think he's going to have the heart to ask him mom to stop fighting.  T couldn't.  T's love for his mom allowed him to carry her burden as well as his own.  Who knows how many other people's burdens he put on his broad shoulders?  Maybe his ability to carry the extra weight was also buried somewhere deep in his code.  Then again, maybe it came from above.  Either way, he carried the weight with incredible dignity.

Being part of these kids lives has given me such an appreciation for the strength of our bonds to one another.  Keep both of these families in your prayers.

Let's get together, and feel all right

Happy 4th of July everybody.  It's a beautiful morning here in Chicago.  I got up early to see my patients in the hospital, and now I'm home.  Kids are up, and the house is getting busy.  Life is grand.

Looking through my expansive iTunes library, I decided to stream Bob Marley "Legend" to my stereo while I worked around the house.  This album is beyond reproach.  There are few artists who's songs can elicit emotion in people from all walks of life.  The human race is better because he blessed us with his gift.

Not many people know how Bob Marley died.  Most assume it was drug related.  He actually died of melanoma at the age of 36.  He injured his toe playing soccer, and when it didn't heal, he had it biopsied.  Once he was diagnosed, the toe was amputated, but by that point, the melanoma had spread.  Within 6 months, he was gone.

All those years in the Jamaican sun, shoeless, with the tops of his feet pointing skyward took its toll. So this sunny 4th of July weekend, wear your sunscreen.  Everyone.  I don't care how dark your skin is.  Protect yourself.  It will allow you to enjoy life to it's fullest.

God Bless!

A good use of health care dollars

According to recent statistics from the American Diabetic Association, 25.8 million Americans have diabetes mellitus, a condition where the body does not process glucose, or sugar, efficiently.  Instead of glucose making it's way into cells, it stays in the blood stream, causing a slew of medical problems over time, including but not limited to blindness, kidney failure, heart disease and vascular disease, which increases risk of amputation.

The cost of diabetes in America is staggering.  In 2007, the cost of providing care for this disease was $218 billion dollars.  That is not a typo.  To put this in perspective, heart disease in 2009 cost us $316 billion (and is a complication of diabetes), and cancer care in the U.S. is expected to reach ~$160 billion by 2020.

The incidence of diabetes in America is increasing, so the above statistic is just the beginning.  Americans are more and more sedentary (both at home and at work), and our diets are high in starchy foods, such as pizza, pasta, rice, potatoes and breads.  We have trended away from preparing our own meals, instead opting for fast food.  Our intake of fruits and vegetables isn't enough, and when we do eat them, it's usually with a caramel dipping sauce or ranch dressing.  It's not good.

Once someone becomes diabetic, I aggressively educate them on behavior modification.  Exercise more, even if it's going for a long brisk walk.  Cut back on those starchy food, and replace them with more proteins or veggies.  Drink more water.  Really count your calories for a few days, just to see how much you are eating (people are usually amazed they are eating as much as they are).  Information is power, and once you show the patient the data, it really can change their behaviors.

Part of that data is blood glucose testing.  Each physician is different, but I tell my patients to check their fasting morning sugars, before breakfast, and the to check 2 hours after meals, to see how high their numbers go.  If their sugars are really high, they can correlate that high number with what and how much they ate.  It's pretty easy.

Data is king in this disease, and it brings me to the crux of this post.  The cost of testing.

I am simply amazed at how much diabetic testing supplies cost.  For some of my patients, the cost of testing is significantly more than the cost of their medicines.  I have patients tell me regularly that they don't test their sugars as much as they would like because of the cost.  This simply is unacceptable.

Data is a funny thing.  It's just information.  It lacks emotion.   That changes when the data comes from a drop of someone's blood.  It's a snapshot of how someone "is".  When patients see their how abnormal their blood sugars are, they respond emotionally.  They feel bad about it, ashamed, angry.  They take it personally.  This emotional reaction becomes a powerful tool for change, specifically, behavioral change.   Once patients improve their behaviors, their blood sugars also improve, and it feels good to see that objective change in their data.  It's positive emotional reinforcement.

I challenge the system to provide testing supplies to all diabetics.  For free.  No strings attached.  If you remove the financial disincentive to testing, patients will be more apt to do it.  In order to make a dent in the end cost of this disease, we need to improve the access of diabetics to their own blood sugar data.  I would expect the cost savings to be significant.  Improved glycemic control means fewer heart attacks, amputations, dialysis and blindness.  It's not rocket science.

There isn't a reason why this simple plan couldn't be put into place immediately.  Big Medicine - are you listening?