The Angry Doctor

AT YOUR OWN RISK

2009-04-12T22:12:00.003-04:00

By a lucky accident, I stumbled upon one of the greatest books I have ever read. The book is “At Your Own Risk: The Case Against Chiropractic” by Ralph Lee Smith, who is some kind of genius. You can read it here.

I’m only halfway through it, and its forty years old, but the things you read in it are unbelievable. It is one astounding revelation after another about the origins of chiropractic, the drive to create a money making bonanza for its founders and “students”, the complete disregard for human life and morals, the love of pseudoscience and “gadgets” that do nothing, and the inability of the government to stop them.

Out of curiosity, I visited the American Chiropractic Association’s website, to see if 50 plus years and a lot of scientific discovery had changed their mission, or at least whittled away some of the more ridiculous ideas they purport. I love these quotes from their website

Doctors of Chiropractic are physicians who consider man as an integrated being

"Chiropractic is a drug-free, non-surgical science and, as such, does
not include pharmaceuticals* or incisive surgery.

With regard to the core chiropractic principle, which holds that
the relationship between structure and function in the human body is
a significant health factor and that such relationships between
the spinal column and the nervous system are highly significant
because the normal transmission and expression of nerve energy are
essential to the restoration and maintenance of health.

For those who don’t know, these guys used to state that they could cure every disease by manipulating out the “subluxations” of the spine. Of course there is no reason scientifically why this should be the case, but whatever.

I dispute that they are physicians of ANYTHING! And of course it’s drug free. Drugs would WORK and their treatments DON’T! And of course the nervous system is “highly significant”. It just isn’t the reason you had a coronary event or pneumonia or meningitis or gallstones or leukemia. And what is an “integrated being”? Is that like Dr. Manhattan from Watchmen?

Chiropractors are, at best, glorified massage therapists, and at worst, greedy fortune hunters with a license. My dream is that one day, all their “schools” will be closed and they’ll all have to get real jobs.

NO POSTS

2009-04-09T10:00:00.002-04:00

I haven't posted in a year??? That's just because I've been trying to make enough money so I can pay my taxes, so Barack Obama can just give it away to the poor banks. God, I feel so sorry for those bankers, having to beg for change, not knowing where their next meal is coming from, working long hard days trying to manipulate the economy. THEY'RE ENTITLED TO THOSE BONUSES DAMMIT!!! WE HAVE A CONTRACT!!!

I know this has little to do with medicine, but I work my ass off to make a living, and I make too much money to get any rebates/stimulus/etc, so I choose to vent.

Medicare gave a slight raise this year, I detect about 2 bucks for my visits. Medicine is in the toilet.

THE APOCALYPSE (SIGN NUMBER 1)

2008-04-13T23:44:00.002-04:00

The Sunday Times Week In Review section contained this nifty letter:

To the Editor:

Thank you for bringing attention to the growing problem of access to primary care in Massachusetts. The problem has been worsened by our universal health care initiative, which was missing a strategy to increase the number of providers to serve the increase in patient load.

Your article, however, focused on increasing the number of doctors to solve the primary care shortage. Nurse practitioners have been filling this role for more than three decades by providing the best in health care.

We are the future of primary care. Make an appointment. We’re open.

Robb Stenson West Falmouth, Mass., April 7, 2008

What universe am I living in? The buffoon can’t be serious! It’s just not possible. Nurse Practitioners are the future of primary care? They are providing the BEST in health care? No one, and I mean NO one in their right mind could believe such a thing. Not even Robb Stenson (and by the way, why the two ‘b’s? Does that stand for BIG BUFFOON??) asks to see an NP OVER a doctor! That’s right! I don’t see any NP hospitals and people clamoring to see NP’s INSTEAD of doctors! They are ANCILLARIES!!! Did they forget that?

It truly makes me just want to give up. Can Internal Medicine be devalued any further? Why do I teach it to med students, when apparently NP’s are the future anyway? And they wonder why students don’t want to pursue a career in IM. Jackasses like Robb Stenson apparently feel they are better than IM doctors and they have a tenth of the training.

I give up. The Apocalypse of Medicine is surely upon us.

ECONOMIC MALPRACTICE

2008-03-16T11:46:00.002-04:00

The New York Times published a story on the front page of Sunday’s paper about a drug used to treat Gaucher’s disease. The drug is a enzyme replacement for the inherited deficiency in glucocerebrocidase. I was not even aware that the disease can present initially in adulthood. I’ve never seen a patient with it. Not surprising, since only about 20,000 individuals in the United States have ti (according to UpToDate).

The drug in question, Cerezyme, is made by the Genzyme company. As the Times’ Andrew Pollack reports:

“Sales of Cerezyme totaled $1.1 billion last year, making it a blockbuster by industry standards.”

Yeah, I’d say that’s a blockbuster by industry standards. Or ANY freaking standards. Of course, any drug rep whoring for Pfizer will tell you, it’s the R AND D costs that make these drugs so expensive. The article goes on to say:

“But critics say the company’s development costs were minimal, because the early work on the treatment was done by the National Institutes of Health, which gave Genzyme a contract to manufacture it. And analysts estimate the current cost of manufacturing the drug to be only about 10 percent of its price.”

When the government hands out these “contracts” to private companies, they don’t seem to care too much about the general public, do they.

Now, I’m all for businesses making a profit. I’m no socialist. However, just as the public (and the government) have decided that doctors should not be aloowed to make too much money, so they (and the government) should not allow ANY healthcare providing entity to make any amount of money they want. This goes for Big Pharma, for medical equipment companies, for medical insurance companies, etc. etc. Since physicians are supposed to be putting patients first, why the HELL aren’t these other companies forced to do the same? It’s not as if they have different customers than doctors do. It’s not as if they are getting the money from a different place than doctors are.

And another thing, if this drug is costing insurers 1.1 billion dollars a year (and I’m assuming none of that is being paid for out of pocket by patients), then how can doctors be primarily to blame for rising healthcare costs? I don’t cost anywhere NEAR that much. Think how much money could have been saved if the United States had just set up the drug manufacturing for Cerezyme by itself. No profit would have been sought. The drug would probably be like 100 bucks a shot.

BUT NO!!! Let’s cut reimbursement to all Primary Care doctors, so we can heap billions of dollars for a drug that treats a few thousand people. Makes perfect sense. In CRAZYLAND!!!

HEALTHCARE AND TACOS

2008-03-03T19:01:00.002-05:00

I was just watching the travesty that is the CBS Evening News with Katie Couric. They reported that in Texas (and even Iowa) many people fly to Mexico for healthcare and prescriptions to reap the delicioso savings available in a town called Metmoros or something like that. Apparently a doctor’s office visit is as low as THREE BUCKS! (He says a visit to a US doctor is 125 bucks. Where the hell did he get that number?)

And then they plant some truck driver making next to nothing who says “The American Healthcare system is a TRAVESTY!”

Byron Pitts is, I am sure, a nice guy. But does he make any mention of the fixed costs that doctors have that they probably do NOT have in Mexico. Rent, for instance, for the Primary Care doctor in my office is FOUR Thousand DOLLARS A MONTH! That’s probably, like, a million bazillion pesos. But I’m guessing the rents are not so exorbitant south of the border. Also no mention of electricity costs, malpractice costs, billing and overhead costs.

If I charged each patient 3 bucks (which the CBS Evening News seems to be exhorting me to do) then I see my practice lasting about 4 weeks, until the rent is due.

I mean, three into 4000 is 1333, so I only have to see 66 patients day to pay the rent. What’s left for my bartender?

I’m guessing neither presidential candidate is going to advise people to go to Mexico for healthcare, a la Mike Bloomberg telling NYC residents to go to Starbucks if they need a bathroom. And doctors are scapgoated, once again, for the rising costs of healthcare. And one of their brilliant proposals is to lower the poverty rate so more people will qualify for Medicaid. I can't wait to get 30 bucks instead of three for an office visit. (and 7 bucks for a follow up in the hospital. Woo hoo!)

THE CROCK OF CHRONIC LYME DISEASE

2007-10-13T12:59:00.000-04:00

My apologies for not writing in so long. There are many things I read that I want to blog about, but then I watch television.

I want to get right back on the train with a round of applause for one of the best articles I have ever read in the New England Journal of Medicine. Their critical appraisal of “Chronic Lyme Disease” (and I LOVE the quote marks) was short and sweet, and there are so many takeaway messages.

The first, of course, is that there is NO good evidence of any such entity in the medical lexicon. What I mean to say is, it is NOT A RECOGNIZED INFECTIOUS DISEASE! Here’s a quote from the Infectious Disease Society of America website:

an extensive review of scientifically rigorous studies and papers available to date, has determined that there is no convincing biologic evidence to support a diagnosis of chronic Lyme disease after completion of the recommended treatment

But don’t tell the chowderheads at so-called “support groups” like this one. They are all over the country (even in places where Lyme is NOT endemic), composed of rich people, and have NOTHING BETTER TO DO but use the internet to obsess over their pathetic lives.

Apparently, for the believers, you do not even need to have a positive antibody test against Borrelia burgdorferi to make the diagnosis., because it might not be valid unless done by a “specialty laboratory”, which is, of course, a scam, since they are performing tests that are not even validated or supported by the FDA, and are using criteria that are based only on their own fantasy values.

This is the second takeaway message: that there’s a sucker born every minute. In this case, the sucker is the poor sap (or self-important “expert” patient) who seeks out the “Chronic Lyme specialist” (laugh heartily, men-of-science) for weeks, months, even YEARS of chronic antibiotic therapy which is proven to do NOTHING except cause complications of side effects and catheter infections (one resulting in DEATH, according to the article).

The article goes on to discount every theory that the “Chronic Lyme” fraudsters purport. But the most disturbing part of the article comes near the end. Here’s a quote:

The attorney general of Connecticut has begun an unprecedented antitrust investigation of the Infectious Diseases Society of America, which issued treatment guidelines for Lyme disease that do not support open-ended antibiotic treatment regimens

An attorney general is actually pursuing legal action against an academic society because they disagree with his unscientific view of a bogus clinical entity that is disproved by science. Saying I am shocked and nauseated does not begin to describe my true feelings. How is this possible in 2007? Why are lawyers pretending to be scientists??? Does this guy own a bunch of these “specialty” clinics or something?

That’s the final takeaway message: science is now being dictated to by people who have absolutely no idea what they’re talking about, and aren’t interested in real research.

Thank you Henry M. Feder, Jr., MD er al, and the Ad Hoc International Lyme Disease Group for the article of the year!!

NP STANDS FOR "NO PLEASE"

2007-09-25T22:33:00.000-04:00

My wife recently took my 18 month old to a pediatric neurologist that was recommended by our pediatrician. I like our pediatrician. She’s very direct and “old school” and is highly competent. So I trust a recommendation from her.

She may be right, and this pediatric neurologist may be great. However, I would never know because my wife told me that she NEVER EVEN GOT TO SEE HIM!!! No, she saw the Nurse Practitioner (cue scary music). And then when my wife protested, the staff told her “Oh, don’t worry. The doctor will come in to see your child afterward”.

Well, that turned out to be a gigantic load of bird-plop! He wasn’t EVEN IN THE OFFICE!!!

I called the doctor himself to protest this shoddy treatment. He reassured me that his NP was his “partner” for six years, that the NP had published more papers than the doctor had, that the NP’s capabilities were superb.

I told him that, while all of this may be true, there was one indisputable fact: I know what kind of training (for the most part) a pediatric neurologist has received. I have NO FREAKING IDEA what kind of training a pediatric neurology NP has received. And what’s more, I really don’t care! I don’t care if the NP has written 100 papers, published in every major journal in the nation (well, actually that would be pretty cool).

Also, I object to his use of the word “partner”, as if his credentials were somehow equivalent with the NP’s. What is he thinking?

Look, I understand why NP’s exist. It’s an economic reality of office based practice. It increases the number of patients that can be seen. However, when it comes to a very specialized group of patients, especially nervous parents who obsess about their little one, for whom they’ve lost so much sleep (SO MUCH) in the last 18 months, I think an NP is not good enough. And shame on his staff for lying about his availability. (He states he was stuck at another hospital, which I understand. But the staff completely misled my wife).

I will never employ an NP to see my patients for me. End of story. Ditto for PA’s. They can draw blood, they can do post visit counseling, they can hold a patient’s hand.

But they aren’t doctors.

WHOSE FAULT IS IT, ANYWAY?

2007-09-16T12:15:00.000-04:00

There is a certain kind of blog poster that has been angering me. It’s the nuts on KevinMD that make the claim over and over that somehow I, and all doctors like me, are responsible for creating this system where insurance companies bilk doctors and patients, and that, after years of “doctor abuse” and “doctor fraud”, I am just now getting what I deserve.

What a complete load of garbage.

Just to clue all of these brilliant thinkers in, I completed residency training FIVE YEARS AGO!!! So the idea that somehow I am responsible for the current system is total crap. Does anyone think doctors made any substantial monetary gains in the last FIVE years? Or even the last FIFTEEN???

When I entered medical school, I had ideas about being a respected professional who could offer opinions and diagnoses to ease suffering, cure disease, and as my father told me “You won’t get rich, but you’ll never go hungry”. Well, truer words were never spoken my friends. I am not rich, and for the most part, I haven’t missed a meal (except on call of course). But I did manage to amass over ONE HUNDRED AND FIFTY THOUSAND DOLLARS IN DEBT!!!

So when I was slogging through Gross Anatomy and Physiology, according to the “just desserts” crowd, I should have KNOWN that HMO’s and insurances were perpetrating dwindling reimbursement on doctors and that Medicare was dropping their payments. I should have KNOWN that doctors in the 70’s and 80’s were doing unscrupulous things like putting pacemakers in dead people and charging for them (a fact told to me by an esteemed medical director who saw these things happen and did nothing to prevent it). I should have KNOWN to study these things just as hard as the Biochemistry and Microbiology and Pathology I thought I would need to be a good doctor.

After four years of school and three years of mind-numbing residency, I was, of course, desperate to find a job that would help me pay down this debt I had acquired. So I took the first job offered that paid well (I felt). According to the “just desserts” crowd I should have rejected all insurances, Medicare, etc, and just took cash only or raised my fees.

Well then, I just have one question… WHERE THE HELL AM I GOING TO FIND PATIENTS???

The people who make these statements are just clueless. And they blame doctors like myself for the way the system is. Just as you would blame me for slavery during the Civil War or I would blame Germans today for the Holocaust. It’s such a tired argument and serves no purpose, except to make the “just desserts” crowd feel better about blaming doctors for high health costs. They forgot that doctors become competent only through studying and hard work. The best doctors aren’t the most business savvy ones. They should ask themselves which doctor they want to see: the one who’s practice is booming because they’re making money hand-over-fist, or the one who paid attention in Path.

CNN HEADLINE NEWS IS A BIG TURD

2007-09-04T22:28:00.000-04:00

Anytime I watch the television news I get severe dyspepsia, but recently I had the misfortune of watching CNN headline news.

You see, CNN often has long boring stories about John Edwards’ haircuts, so sometimes I just want to hear the top stories before work. They’ve employed some Asian doofus named Richard Lui, who insists on peppering the headlines with “funny” comments. Hey, more power to ‘em.

But this is not why I exploded with rage.

After an obnoxious commercial for Aricept, Richard Lui returns with a shocking headline. His quote: “Lettuce could help wipe diabetes off the face of the map!”.

At this point, I’m pondering losing many of my patients to the “miracle” cure. I am awed at the possibility of curing an epidemic that plagues America and causes so much morbidity and mortality. I await Richard’s next words with razor-like attention.

He goes on to say that a study from the University of Central Florida is working with genetically modified lettuce AND… researchers are going to test it on humans to see if it affects insulin levels.” THE END!

Well, the weight of the headline is belied by the fact that the "report" is lacking in any substance. I’m not sure why I expected anything more from “CNN Headline News”, but the story was so misleading, that CNN and Ted Turner really ought to say a million Hail Marys and Our Fathers before they can even THINK about forgiveness. Mr. Lui doesn’t even make an effort to explain how this mutant lettuce has one damn thing to do WITH diabetes. It’s all left to the imagination, as if some aliens had left the recipe buried in Hanger 51.

Well, every obese diabetic who has a Devil Dog in one hand, and their insulin in the other just caaaaaaalm down. First of all, it’s only a potential cure for Type ONE diabetics, not Type TWO (the ones we see in the office). Apparently, Professor Henry Daniell at UCF has created a way to deliver insulin-producing genes that he is infusing into lettuce. He previously used tobacco plants and fed them to diabetic rats. (He’s going to give them a heart attack, I tell you…) You can read more about it here.

So good job Richard and your CNN brethren. Way to pump up the hopes of 20 million diabetics in America with your “psudo” news article. You really are true human excrement.

SIN OF ADMISSION

2007-08-23T21:51:00.000-04:00

The New York Times published a story today involving the growing MinuteClinics at various Duane Reade pharmacies throughout the Northeast. They differ from the typical MinuteClincs which staff NP’s and PA’s and instead have actual doctors. This is an improvement, though it encourages the one-time visit, and leaves little chance for follow up, as the patient likely couldn’t make an appointment with anyone.

I love this quote:

“And doctors’ groups, whose members stand to lose business from the clinics, are citing concerns about standards of care, safety and hygiene, and they have urged the federal and state governments to step in to more rigorously regulate the new businesses”

Now why did they have to go and add that little gem? Couldn’t the statement stand on its own without it. It just undercuts the VALID concerns placed after it.

But anyway, this is not what made me angry about the article. That part is buried near the end. Apparently, Continuum Health, my former employer, is joining into an unholy alliance with Duane Reade to supply the very doctors I mentioned above. Here’s the quote:

“Under the partnership agreement, the doctors at Duane Reade will have admitting privileges at the Continuum hospitals and the drugstore clinics can streamline a patient’s journey to a specialist or through the emergency room, when that is necessary, because of the relationship, company officials said.”

So did everybody catch that? These doctors from Duane Reade will have ADMITTING PRIVELEGES!

Now, these Continuum hospitals hire numerous faculty attendings, and presumably by having these OTHER doctors staff these new clinics, they are undercutting their own faculty by siphoning away the business to these Duane Reade clinics. So at first this didn’t make sense to me.

But then a colleague explained it to me. They will be able to increase admissions to the hospitals, since these pharmacy docs have admitting privileges. So if they lose it on one end, they’ll get it back on the other. Good for them. It’s this kind of entrepreneurial thinking that makes me proud to be an American.

Of course, it will simply increase the amount of TOTAL CRAP that gets admitted to the unsuspecting medical teams. But hey, doctors can even learn from crap, can’t they?

"LAW & ORDER: SPECIAL ETHICS UNIT"

2007-07-10T20:48:00.000-04:00

An editorial in the NEJM this week concerns medical futility in Texas. Dr. Robert Truog MD writes about the case of Emilio Gonzalez.

Emilio had been diagnosed with Leigh’s disease, a pediatric illness which is fatal. Sometime before he was 2, he ended up on life support at Children’s Hospital of Austin for five months! Dr. Truog describes some of the painful events, especially how the mother refused to let the hospital move the child. She took the hospital to court, but before the judge could issue a ruling, the child died.

(Does this outcome vindicate the judgment of the doctors? Hmmmm….)

Anyway, it’s a sad ending to a sad case. But this is not what made me angry.

It’s Dr. Truog’s take on ethics committees themselves. Here’s what he says:

“ ...most members are physicians, nurses, and other clinicians from the hospital staff... they are unavoidably “insiders,” completely acculturated to the clinical world and its attendant values. This is hardly a “jury of peers” for a low-income woman of color and her infant son.”

He feels that the ethics committees agree too often with providers. (He states later that ethics committee at Baylor agreed with the clinicians 43 out of 47 times. Gee, I wonder why.)

I will tell you why: Because they know what they are doing.

First, I hate the seamy implication that because the woman is of “color” and is “low income”, that the doctors involved (pediatricians, I suppose) were more willing to treat them unfairly. They kept him on life support for FIVE MONTHS!!! And he died of his TERMINAL ILLNESS!!! (It’s like Terri Schiavo all over again).

Additionally, I do not understand AT ALL his beef that the committee is made up of mostly doctors, nurses and people who are “insiders”. WHO SHOULD IT BE??? Lawyers and people who have never cared for a sick person a day in their life!!???

I’m sure we’d all like someone with no clinical judgment or experience except what they’ve seen on TV to offer an ethical opinion. That makes as much sense as letting a postal worker manage your finances!

Ethics committees are correctly loaded with people who understand a life is at stake, and that family members are the best advocates of the patient. The fact that they agree with practitioners is a testament to the practitioners’ clinical judgment, NOT evidence of a “conspiracy”. I mean, did anyone ever meet someone on an ethics committee who wasn't a "touchy feely" do-gooder? I sure haven't.

Also, what is with his obsession with the whole “jury of peers” and “due process” systema? This isn’t a court of law. It’s an ethics committee. There is no need for a “jury of peers”. No one is on trial. Doctors, nurses, social workers and clinical minds are trying to come to a solution, much the same way a “tumor board” works. I don’t think anyone would call for a “jury of peers” at Tumor Board, if a patient’s cancer treatment was to be decided. That’s because it isn’t appropriate.

Dr. Truog has got it wrong.

SPECIALISTS: THE DELICATE GENIUS

2007-07-09T21:59:00.000-04:00

A recent thread of posts about the relationship between PCP’s and specialists, spawned by Dr. Rob’s sardonic “open letter” has inspired me to comment on one particular beef I have with consults.

Specifically, in-hospital consults.

I won’t comment on the anger that bubbles inside me when a consult fellow will just outright “refuse” to see someone because they don’t think it’s an “appropriate” consult. That’s a whole different blog entry.

No, I want to comment on the annoying tendency of specialists to say absolutely NOTHING!

Here’s an example. An older patient comes with some bright red blood per rectum. They may have a history in the family of colon cancer, or maybe they were anemic. Whatever. The consult note usually reads thusly. First they mention the chief complaint, then they have a brief history, then there is the ubiquitous rectal exam.

And then at the end it says “Assesment/Plan: Colonscopy Monday.”

Ummmm, excuse me? That’s an assessment?

No, that’s a test.

So rarely is any thought offered in the note. Now, I’m sure the differential diagnosis is well scripted in their minds. But unfortunately, it doesn’t get put to page, and there is no communication until after the test, when you may get a courtesy call from the gastroenterologist who says “Yeah, colon looked clean. A few hemorrhoids.”

Well that’s just super. But of course, you never get an inkling of what they thought was MOST LIKELY! And it’s not just GI consults. Heme consults have irritated me with the annoying “So what do you want me to do? It’s medical management.” In other words, if they can’t do a bone marrow biopsy, and it’s a boring anemia case, then good luck to you.

(Oops, there I go, talking about fellows. Must … re…sist)

But I digress. Whether it’s a fellow or an attending consult, the note should be helpful and the PCP should not be left in the dark. Please just remember we didn’t call you only to do a test. Thought MUST occur!

LACK OF POSTS

2007-07-08T20:55:00.001-04:00

Sorry for the lack of posts. I've just started my private practice and have been a bit busy.

I have some posts brewing, including my continuing series on "Blank MD".

Stay tuned.

A LITTLE HYPOCRITICAL?

2007-07-04T21:08:00.000-04:00

I'm probably beating a dead hrose with the whole ER thread I wrote last week, but I just want to quote PandaBear. He writes a post about drug addicts, and says that one tried to fake his way through a chief complaint of rectal bleeding. He syas:

"It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit."

So even before he checks the guy's labs, he is saying he doesn't believe he's having a significant bleed. Probably what any sane internist/primary care doc would surmise.

But Panda also says this:

"And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry"

So he drew a stat hemoglobin and hematocrit, EVEN THOUGH he figured the guy was full of garbage. Why didn't he just kick the guy out of the ER if he was so sure? Why did he send the stat labs???

Because, my friends, even the Panda knows that liability is key, and just in case the guy is NOT full of it, he has protected himself. And he's in the ER, so he has access to those stat labs when he needs them.

So for those ER-heads out there who would laugh if an internist sent such a patient to the ER (or any other patient who could use a stat lab to rule out a life threatening condition), please reflect if you would have acted any differently had you recieved the call or lab result or whatever at your office or home. Clearly, the PandaBear is making the same mistakes the primary care guys are making.

I promise this is my last post on the topic. Until I get angry again, that is.

SHOULD THESE PEOPLE GO TO THE ER?

2007-07-01T21:25:00.000-04:00

Here are four scenarios:

1)A patient has their PCP paged at 6:30 PM, after hours, when the PCP is on the way home. They complain of diarrhea and abdominal pain that seems mild, but has not stopped.

2)An older patient comes in without an appointment and complains she saw blood in her toilet. She has felt dizzy and wanted to run in to see her PCP. But the office is swamped and she’d have to wait. There is no nurse to draw blood.

3)The lab calls with an emergency value. The potassium is 3.3.

4)It’s the weekend. The lab calls: INR is 5.

So what should a PCP do? Should he:

a)Tell these patients to wait until they can be seen
or
b)Tell them to go to the Emergency Room?

I don’t feel there is any other answer to the question than ‘B’. And I’ll tell you why. Because momma raised me to NEVER DIAGNOSE OVER THE PHONE! That is just something a doctor should not do under any circumstances. And unless the office has a nurse and a lab, as well as NG tubes, central line kits, and blood, you’d have to accept the fact that most PCP’s offices are not equipped to deal with these situations anyway.

Case one is based on an actual gastroenterologist in Florida who was told by a man’s wife he was having these symptoms. He advised Maalox and see him the following day. He ended up having IBD and dying that night. Oops. Malpractice ensued of course.

Case two is common enough. And I don’t want to personally wait on a CBC for a whole day, even with negative orthostatics, as that physical exam finding is notoriously unreliable (I can cite an ER doc who made this statement at a conference if anyone takes umbrage with that.)

Cases three and four speak for themselves. Even if I called the patient with low potassium at home and asked him to check his pulse, I’d STILL not take a chance. Same goes for the INR patient.

911doc made the following statement:

Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me. What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.

I say “Yeah, so what?" Is there something different an internist or FP could do in the office for these patients? I fail to understand the point and what should be different. What is an emergency room for? If the chest pain is even remotely possibly cardiac, that’s an emergency. At least for me it would be.

Whether the PCP shows up at the ER, whether the PCP sends a note, whether the PCP’s midlevel made the call are all complaints that have NOTHING TO DO with the point 911doc is making, which I find is false and hollow.

The fact is, is that hospital care doesn’t pay enough for the time spent. So if a PCP hasn’t placed a central line since residency, so what? An ER doctor probably doesn’t remember a lot of other things they once learned in medical school. Because they don’t need to know them anymore. And even if I placed a central line in my office, then what? I don’t have a 24 hour center in my office. Even if I ran a code, they still have to go to the hospital.

I had an ER attending tell me he wouldn’t do a paracentesis because he wasn’t covered for that under his liability insurance. The resident under him couldn’t believe it any more than I could. He probably just hadn’t done one in years. And you know what? Big deal. So I did it. And now it’s been years, and I probably would have to remember how.

Big deal.

Hey 911doc, here is your generalist. And nothing has happened to me! Your head just got a little too big.

IM VERSUS ER PART II

2007-06-30T12:14:00.000-04:00

In my last post I responded to 911doc's post about the decline of primary care by posting a vignette I experienced which crystallized one hallmark of ER medicine nowadays: DISPO!

Clearly the ER mentality is that the workup and stabilization are NICE, but the mindset has become that of an over-educated administrator: ADMIT EM OR STREET EM! Once the decision is made, the job is done, more or less. ER residents are inundated with this advice from the moment they start residency.

I want to address specifically the complaint about these lazy internists/hospitalists upstairs and their desire for "completeness".

What does "completeness" mean? Does it mean we want EVERYTHING done? Does it mean we expect a diagnosis if admitted?

No, of course not. What it means is basically not STICKING YOUR COLLEAGUES WITH SCUT!!

I will illustrate with one of my favorite personal examples.

When I was a third year resident, a famous incident occured between the ER and our department. It was a particularly busy winter evening, and during the night, there were so mnay patients in the emergency room, you could hardly walk without stepping over someone. There was a tremendous pressure to get people upstairs (naturally) and of course there were NO ICU beds.

One younger, sick patient had symptoms typical of meningitis. However, the ER was so desparate to get people out, they had assigned a bed on the regular medical floor, DESPITE that no LP had been done.

The famous part of this story, is that the third year IM resident, who was the liason between the ER and the IM department, LEAPED ON THE GURNEY and refused to let them move the patient. The ER was aghast, and they would NOT do the LP or anything else for the patient. So this IM guy gowns up (even though he's busy as hell), does the LP, and guess what... PUS comes out of her spine. So of course she has to go to the ICU, and he REFUSES to let them send the patient anywhere else.

Can you imagine?

So that's a good example of where "completeness" might mean one thing to the ER doctor, and something else to an internist/generalist.

The point is NOT to criticize ER docs. Its to point out that the system isn't perfect. So STOP lamenting how primary care docs are responsible for all your ills. It's not so.

Part III in my next post, where I'll address the idea about what kind of patient gets referred to the ER from the office.

IM VERSUS ER

2007-06-28T20:49:00.000-04:00

Happyman referred me to 911doc's column about the downfall of Internal Medicine and Generalists... but then proceeds to rip Primary Care doctors a new one, including hospitalists (which I was for the last 5 years) because they demand "completeness". He faults IM and FP's for punting to the ER for many different complaints, unwilling to take on the "liability". He laments how we don't want to run codes anymore.

So much is wrong and/or asinine about the column, I hardly know what to say. Being the Angry Doctor, I've decided to say the following: you are full of garbage, 911doc!

Let me tell you my personal favorite story concerning the ER:

One evening, I was admitting an 80 year old female who had multiple medical problems including heart failure, asthma, cancer, etc... yet despite this, she was a sweet old lady and still functioning well. I'm called to see her up on the floor at around 6 PM. I walk in and the woman is gasping practically. I check the ER "workup" sheet. This woman had gotten an X ray, the ubiquitus troponin, and Tylenol. Yes folks, they gave her only Tylenol for her shortness of breath.

OK, so I slap oxygen on her, I go review the X ray, and then I whip down to the ER to confront the physician who sent her upstairs. The attending physician listened to my diatribe, and then called over his resident and said "Dr. Angry wants to talk with you."

Fine, I said, if you want to sacrifice your resident to me, be that way.

I begin my tirade: "Ms. so-and-so is gasping upstairs. You didn't do anything down here for her, so obviously you couldn't have been that concerned. Why did you admit her?"

"Shortness of breath.", the resident replied.

"Well, she had a history of asthma. Did you give her any nebulizers?"
"No." he repsonds.
"Why not?"
"Because she wasn't wheezing."
"So then why did you admit her?"

"Shortness of breath" he replies.

"Her X ray was reported to have an infiltrate on it. Did you think about giving antibiotics?" I mused.
"Yeah, my attending and I looked at it, and we just didn't think she had pneumonia. She had no fever or cough."
"So why did you admit her?"

"Shortness of breath" he replies.

"She has a history of cancer. Did you consider a pulmonary embolus?" I ask.
"Yeah, she just didn't seem like she had a P.E."
"So why did you admit her?"

"Shortness of breath" he replied.

"She has a history of heart failure. Did you give any lasix?"
"No. There was no congestion on the X ray."
"So what did you admit her for?"

Do I even need to type his reply?

I was shocked. Usually my complaint about the ER is that they perform and administer many unnecessary things, making it harder for those lazy internists upstairs to make a diagnosis. Here was the exact opposite: they had done NOTHING! (Oh, except they gave Tylenol. I forgot.)

So I turn up her oxygen, I give her nebulizers, I give her antibiotics. I gave her lasix.

It doesn't occur to them that maybe she doesn't have a fever because she's immunocompromised from cancer. It doesn't occur to them to check for a blood clot, even with her unexplained dyspnea and history of cancer. That maybe she's not wheezing because she's having what they used to call stage IV asthma.

I get called two hours later and the nurses are like "she's still very short of breath." I say "OK, give her lovenox and get a stat CT angiogram" And guess what... she had THREE PULMONARY EMBOLI in her lungs. (Gee, good thing its not an emergency, right ER docs?)

So it's just as easy for me to make disparaging remarks about the ER's complete lack of motivation to diagnose (DISPO DISPO DISPO... the mantra goes, right?) as it is for these ER heads to lament how lazy primary care docs have become. Why all the intellectual dishonesty? We all know the truth: the REAL reason ER docs didn't do primary care is because they don't want to deal with chronically ill patients and their paperwork! If they had to look at a patient for more than twelve hours, they would start yelling "Why isn't this patient upstairs???" The worst time to BE a patient is that lull between ER admission and going upstairs because everybody knows the ER doc has lost interest in you.

My best friend is an ER doctor. And I did rotations through ER as a medical student and a resident. (I actually did more shifts than the ER residents themselves.. their way of dumping on the IM residents I imagine). It's a tough job and it requires real skill. But don't pretend that primary care doctors aren't doing exactly what they're supposed to be doing.

Part II of this rant tomorrow.

THE TRUTH ABOUT ESA'S

2007-06-21T13:58:00.000-04:00

The New England Journal of Medicine published an interesting series of editorials this week about ESA’s. (erythropoesis stimulating agents, click here and here). For the non medically inclined, these are injectable agents which stimulate the bone marrow to produce red blood cells. I want to point out some fascinating things I learned from these articles.

One is that it is NOT indicated for anemia from cancer. It is only recommended for anemia secondary to chemotherapy, or at least it was only evaluated on that basis, an attempt to reduce the number of transfusions required.

Secondly, it is NOT approved by the FDA for alleviating fatigue or weakness or to improve a patient’s quality of life. In fact, the FDA has stated that there is “no evidence that [the agents] improve quality of life or cancer outcomes”.

I didn’t realize that, and from the commercials released by Amgen, you’d suspect otherwise. You remember those, right? An older woman is power walking and she describes how her fatigue was due to anemia and the Procrit had given her back her energy. Well, since there was no evidence to back up that little bit if play acting, why was it allowed to air?

Well, the FDA’s own Oncologic Drigs Advisory Committee recently criticized these very ads and director Richard Padzur made this helpful quote, saying the FDA should give “the American public…the reason why these ads were allowed to go on”.

I don’t think we need to look too far for the reason. My guess is, it’s green, made of paper, and can buy a lot of nice things.

Finally, I did not know that it INCREASED your risk of dying of your cancer. And I’m not just talking about hematologic cancers. Apparently HEAD AND NECK cancers! And METASTATIC BREAST CANCER! How in the world does this happen? No one has a clue right now, because there just isn’t any good test to detect if there are receptors on these tumors for the drug, or if its due to more angiogenesis and, thus, more tumor proliferation.

Talk about your poorly publicized facts.

I have given ESA’s to many anemic patients suffering from end stage renal disease and if they have chronic disease anemia without underlying bleeding, or if they required a lot of transfusions, but were refusing surgery or colonoscopy. I never tried to get the hematocrit about 30% and I don’t think these papers apply as much to my practice as an oncologist’s. But I still think its more evidence of chicanery between the FDA and Big Pharma, and 180 degrees removed from the best interests of patients.

Ok, off for a few days with the family. See you next week.

And STAY ANGRY!!!!!!!

A SUPPLEMENT THAT WORKS??? (MELATONIN)

2007-06-20T14:22:00.000-04:00

I am fascinated by my recent revelation that melatonin somehow has effects on cancer. It originally came to my attention during my research on “Sleep MD”; specifically during a passage in a review article on melatonin in the NEJM in 1997. The mechanisms by which melatonin exerts this effect are not known. The following mechanisms are proposed:

1) inducing apoptosis in tumors with the melatonin receptor
2) stimulating production of IL2 (antitumor response)
3) modulation of oncogene regulation (???you got me)

Melatonin is an antioxidant, apparently it is a more potent free radical scavenger than vitamin E or the other antioxidants usually bandied about on TV.

Most of the studies have been done by a group of Radiation Oncologists in Milan, Italy. In 1995, one small study was carried out with patients who had metastatic breast cancer and it appeared to slow their disease. In 1996, they published a study in the journal Oncology which showed increased survival in a small number of patients with glioblastoma who got melatonin.

In 1991, a study by a different group of malignant melanoma patients showed a transient reduction in tumor size. Considering the miserable prognosis for such patients, it’s worth noting.

The most recent study from this group in Milan fascinates me. I went to my local medical library and had them print me out a copy. It was published just a few months ago and involved 370 patients, all of whom had either advanced non-small cell lung cancer, or advanced gastrointestinal tumors (colon and stomach). They received standard chemotherapy with or without melatonin (doses of 20 mg per day, which is higher than the typical sleep doses).

Turns out, there was statistically significant differences in overall tumor regression AND 2 year survival. (At the end of two years, there was 25% survival in the melatonin group, vs. 13% for the non melatonin group, p<0.05).

I am not a fan of nutritional and holistic supplements. But these studies illustrate the exact reason why: we need well performed, repeated studies with real results. THAT could make many physicians and science-minded people converts! So based on this data, I believe I would recommend melatonin to some cancer patients. It’s not a cure, but there is no cure for metastatic disease, is there?

And let the message go out to other supplements: if you want to be taken seriously, get your pathetic butts in the lab! Maybe someday, we can drive these herbalists/naturopaths out of business! (I can dream, can’t I?)

THE "REAL" MEDICARE FRAUD

2007-06-18T21:00:00.000-04:00

The New York Times offered an editorial by David Leonhardt, one of their economic writers, concerning the reason healthcare in this country is so expensive. Here’s his take:

The main reason so many people lack health insurance is because of its cost. And a big reason for that cost is the explosion of expensive, medically questionable care, be it knee replacement, preventive angioplasty or lumbar fusion

The example he cites is of lumbar fusion. Apparently, a tiny town in Idaho accounts for a disproportionate number of spinal fusion surgeries, and that the data on its efficacy is mixed. He also says that it cost Medicare 600 million dollars to provide these surgeries in 2003.

A large number, to be sure. I would note that after this introduction, Mr. Leonhardt abandons the topic of disparate medical procedures and manages to focus on Democratic presidential candidates’ plans for universal health care. I’m not sure why Republican candidates’ policies aren’t mentioned. Must be that ol’ “liberal bias” that seems to land George Bush in the White House every four years like clockwork.

But I digress. I have no idea if lumbar spinal fusion is medically questionable. I have not looked at the data. My personal feeling is that back surgery, in general, has disappointing outcomes. The newest one is “kyphoplasty”, but the data I was shown looked promising, as long as an orthopedist didn’t get greedy and try to do multiple vertebrae.

The point I want to make is that, while there may be too many lumbar fusions, that isn’t the biggest expenditure we should be focusing on. It’s EXPENSIVE ELECTRIC WHEELCAHIRS and other frauds! Consider this quote from a CNN article:

Medicare's 80 percent share for power wheelchairs grew from $22.3 million in 1995 to $663.1 million in 2002. That total already has been surpassed in the first nine months of 2003.

Some of these wheelchairs cost as much as used cars! Should a wheelchair cost so much? Of course not. I mean, a baby stroller is maybe a few hundred dollars. How does a wheelchair cost 5000 dollars? Isn't that what a Segway costs?

And I can’t count how many patients in my resident clinic asked me for a letter so they could get disability. One said to me that she couldn’t do her job because her “feet hurt”. I said “Why don’t you get a job on the phone.” She looked at me like I was crazy and said “Oh, I got schizophrenia, I don’t think so good.”

With so many “hard working” Americans sucking at the teat of Medicare and collecting disability and SSI, no wonder the system is going broke. If some of these deadbeats went to work and stopped defrauding their own government, maybe Mr. Leonhardt wouldn’t have to write this article. Why is so little attention devoted to this topic? I guess because it’s more fashionable to solely blame doctors and hospitals for exploding costs.

SLEEP MD

2007-06-15T22:01:00.000-04:00

I will continue my investigation of the “BLANK MD” product line. Check here for the beginning of my series. The ingredients in SLEEP MD can be found here.

The first ingredient listed, white willow bark, is also known as Salix alba. “Salix” is Latin for “willow” so that’s logical. They isolated salicin in 1828 from the bark. It is a derivative of salicylic acid, hence it does have ability to treat fever. Sometimes I hear NSAIDS make patients sleepy, so I suppose this may have utility, or if your insomnia is due to pain, in which case I might see a doctor (shudder).

There is a delicious helping of “Valerian extract”. (it says “deodorized grade”, so the stinky version must not be so helpful). A journal called “Sleep Medicine” (gee, I wonder what that’s about) published a systematic review of the literature on this tasty herb and guess what? I’ll quote them:

“The evidence for valerian as a treatment for insomnia is inconclusive.”

So far, we have a weak pain reliever and an inconclusive stinky herb. What else is in this crud?

There’s some lemon balm and hops extract. Maybe a Mike’s Hard Lemonade is in order.

OK, what about our old friend melatonin? In the 1950’s, the hormone melatonin was isolated, and over the years it was discovered that the pineal gland releases more melatonin when it’s dark, and inhibits its production when it’s light out. A study in the Lancet from 1995 seemed to find melatonin helped in elderly patients, but there were only TWELVE people in the study!

Studies done in the journal Sleep indicated young adults had faster time to sleep and a deeper hypnotic state (wheeeee…) There’s also inconsistent results in allieviating jet lag. Most of the studies are summarized in a nice review in the NEJM here. The most fascinating (to me) is that melatonin may slow METASTATIC BREAST CANCER! That’s right! You heard it here first folks (well, not first, but anyway.) Check out the citation here.

A review of chronic insomnia in the NEJM in 2005 notes the following:

Studies of melatonin, which have involved small numbers of subjects treated for short periods with various doses and formulations, have demonstrated conflicting results.

So melatonin may (or may not) help sleep onset, jet lag, and sleep potency.

Passionflower extract is also an old time medicine used for insomnia and anxiety. The problem is that no good scientific data exists to intelligently evaluate this compound. If you don’t believe me, just read these learned people here. Ditto for the Scutellaria lateriflora.

Coenzyme Q10 rounds out the slop, but I couldn’t find treatment of insomnia as even one of the common uses of this supplement. You can find a nice list here

So this is how Marvin Heuer, MD and this band of quacks make the big bucks. They package melatonin and valerian root together with some other garbage that has no science to back it up, and call it “SLEEP MD”!

All in a days’ work for these chowderheads.

By the way, melatonin from drugstore.com – 5.99 for 120 tablets
SLEEP MD from drugstore.com - 15.99 for 30 tablets..

WHY IS IT ALWAYS THE GOOD ONES

2007-06-13T13:57:00.000-04:00

Two colleagues who are Cardiologists have decided within a few months of each other to abandon private practice. They both cited the same reason: dwindling reimbursement. One had just moved his office to a new site and after a month had had enough! He said that insurers just wouldn’t pay and office costs had gotten out of control. He said the whole thing was a mess.

The other was the first attending I ever had as an intern in residency (about eight years ago). As far as I am concerned, he is synonymous with my hospital. He’s an older doc who is very honest and smart. As such, he refuses to perform what Happyman calls the “trifecta” of ECHO, stress test and holter on every person that walks through the door. This left him the option of seeing, as he puts it “100 patients a day”. He is now joining a practice at a hospital across town.

So the message appears to be that if you are a smart clinical cardiologist, and you decide that a patient doesn’t need a bunch of expensive tests, you will actually LOSE money. If you are not clinically skilled, or if you just need to make more money, then doing a bunch of unnecessary tests becomes NECESSARY to stay afloat.

Obviously, if you put in an extra three years of fellowship in Cardiology, I think you are entitled to more money. I think you deserve it, primarily because of the liability factor. As an internist, if I’m not sure about something, I can just defer to you and then in court I can plead “Hey, I accepted that I wasn’t sure what was going on, so I appropriately called a Cardiologist.” So the buck stops with the specialist.

But I don’t think the extra money should ONLY come from unnecessary tests. That just encourages fraud and waste. And drives intelligent specialists to merge with hospitals to reduce costs and overhead. So then the HOSPITAL can foist unnecessary tests on the public.

I am doing the “reverse commute” soon, leaving the hospital for private practice. I’ll let all of you know whether I fall on my face or not.

Soon, I will return to the “BLANK MD” product line which so angers me.

THE MILKEN CODE

2007-06-11T14:01:00.002-04:00

“The business of America is business!” Calvin Coolidge once said. (Well, he actually said “the chief business of the American people is business”, but hey, close enough). Nothing wrong with that, right? Profiting from any new technology is as American as apple pies and facelifts.

So when I read in the New York Times’ Week in Review section that a startup company called 23andme is going to be selling transcripts of what it deems to be the important parts of your DNA genome, I thought to myself “Gee, what a great idea.”

And if you believe that was my first thought, then you haven’t been reading my blog. Companies such as Illumina, Applied Biosystems and 454 Life Sciences can supply your entire genome for the low, low price of $100,000! The Times tells us that some of the people who have already signed up include Paul Allen, co-founder of Microsoft, Stephen Hawking, and Larry “Loan me 50 dollars” King. Oh, and Michael Milken. Gee, what a treasure trove of information his genome will be.

So many problems exist with the idea of having your genome on a disk that I hardly know where to begin. One is the theft issue. If you think thieves can benefit from your social security number, just think what they can do with your genetic blueprint. I think your insurance company would looooove to get their hands on it, which brings up another thorny ethical problem. There are some laws that protect us against genetic discrimination, but that field is still being sorted out.

I also do not look forward to having a patient show up and say “It looks like I’m positive for a DR2 mutation. I want to get tested for vasculitis.” What do I say to such a patient? Do I have to spend a half hour explaining to them that they have no signs or symptoms of vasculitis? That the blood tests are not definitive? That insurance would likely not cover the tests? That there’s no preventive measure to take anyway? Will there be any time left to actually check their blood pressure?

On top of all of this, an interesting article appeared in the April 11, 2007 issue of JAMA. Researchers tested 85 variants of 70 genes previously reported to be associated with coronary artery disease. And guess what… they found that NONE… that’s right, NONE of the variants were more common in the patients with CAD.

What does that mean? That means WE DON’T KNOW S%&$ about genomics! So for those of you who are plopping down 100 GRAND to get your genetic code, GOOD LUCK doing anything with the information!

Jackassess! (That means YOU Larry King!)

MARVIN HEUER, MD: REDUX

2007-06-07T16:38:00.000-04:00

Just to recap my series on Dr. Marvin Heuer, MD. Be sure to read each thrilling installment.
MARVIN HEUER, MD PART I
MARVIN HEUER, MD PART II
THE PHYSICIANS RECOGNITION AWARD
SUPPLEMENTS INVADE IRAQ

Dr. Heuer received a medical degree in the 70’s and actually saw real patients (I believe) for six years. Then he joined Smithkline in the 1980’s and started a journey where he sold his soul, and broke it into so many pieces, that all that is left is a powdery substance that, when added to water, produces a power drink that builds muscle mass.

Seriously, look back at Part II to get a sense of how many "medical" businesses he was a part of. From hawking pharmaceuticals, to infertility clinics, to “novel vaccines”, to bogus nutritional supplements, to an ANIMAL HYDRATING BEVERAGE (gee, I thought it was called “water”). How low can a doctor sink when he is spending time creating drinks for non humans???

Here’s a list of diseases his CV suggests he did research on:
Rheumatoid arthritis
Osteoarthritis
Osteoporosis
Hypertension
Antidepressants
Seizures
Hormone replacement therapy
Overactive bladder
Candidiasis
Acute exacerbation of chronic bronchitis
Community acquired pneumonia
Endometriosis
Diabetes
Lipid lowering
Sinusitis
Migraine

Most researchers spend their whole life on one topic. Not Dr. Heuer. If a drug company comes calling, he ANSWERS the call with aplomb!

Here is a picture I find particularly amusing and apropos. Here’s Dr. Marvin posing with a fellow "researcher" marveling at a fabulous new product meant to better mankind:

Makes him proud, I bet. Shown with Jay Cutler (who the heck is Jay Cutler), Dr. Heuer has finally become a punch line. A very sad one.

This is the man behind the “science” of the “BLANK MD” product line.

Weep for him.

SUPPLEMENTS INVADE IRAQ

2007-06-06T17:08:00.000-04:00

An overseas military newspaper called “Stars and Stripes” published an interesting article recently. Apparently, two soldiers currently serving in Iraq felt compelled to try the weight loss supplement Hydroxycut (I can’t imagine losing weight would be my first priority if I were in Iraq, but anyway…)

Both men ended up in the emergency room. One of them, 20 years old, had a change of mental status and collapsed. The other, a 19 year old, had a potentially fatal arrhythmia. Colonel Frederick C. Good, the treating ER physician wrote a letter stating:

“Hydroxycut … should not be used in a combat zone with the inherent problems encountered in regard to hydrating adequately and eating regularly,” according to the letter. “… The use of this product or any similar products is strongly discouraged, and any remaining product should be discarded. This product and any similar products are not a shortcut to fitness, and no substitute for a regular Physical Training program.””.

Seems like straightforward advice that’s pretty sound.

Starightforward that is, unless you’re Dr. Marvin Heuer, MD!!!

You see, Dr. Marvin is the head of Iovate, and they make Hydroxycut. Here’s his take:

“My gut feeling as a physician who has worked in the emergency room is that there were tons of other factors there that may have had an influence,” said Heuer in a telephone interview…

So he’s telling our soldiers “It’s perfectly safe!” and it sounds like he’s encouraging its use, EVEN THOUGH a military doctor is advising our soldiers to avoid it. Now, I’m not sure what effect these supplements played in these soldiers’ medical problems. However, since they are fighting for our country, and since there’s potential for harm, and very little benefit, maybe Dr. Heuer could do the responsible thing and just shut the f%$# up.

THE PHYSICIANS RECOGNITION AWARD

2007-06-05T17:39:00.000-04:00

On Dr. Marvin Heuer’s CV, there is a list of awards he has received. According to the GAKIC website:

“He has been honored with the American Medical Association's Physicians Recognition Award 13 times”

An impressive accomplishment! Thirteen times! How could he have been so recognized 13 times?? Did he discover plutonium? Save a busload of nuns?

Well, I checked the AMA’s website to see how one qualifies for this prestigious achievement. This is what they say:

The American Medical Association (AMA) Physician’s Recognition
Award (PRA) has recognized physician participation in continuing
medical education (CME) for more than 35 years. Established in 1968, the AMA PRA certificate and the related AMA PRA credit system recognize physicians who, by participating in CME activities, have demonstrated their commitment to staying current with advances in medicine.

So kudos to Dr. Heuer for keeping up with his CME THIRTEEN TIMES!!! Just imagine what would happen if you actually DID save a busload of nuns.

Seriously, they give an AWARD for keeping up with continuing medical education? Isn’t that like giving your kid a candy bar for cleaning his room? I've gone to a lot of the Grand Rounds given at my hospital this year. So I guess I'm entitled to one of those babies. Oh, or at least I would, IF I were a member of the AMA.

I guess even a pharmaceutical com0pany whore can pad his resume.

MARVIN HEUER, MD PART II

2007-06-04T17:29:00.000-04:00

In a previous post, I introduced the chief science officer of the bogus “BLANK MD” product line, Dr. Marvin Heuer. I just want to hit some of the highlights of his career, or at least the stuff I was able to learn through the internet.

Most of this information is obtained from his CV, which you can look at here.

Dr. Heuer spent the years 1974 to 1980 actually being a doctor. I’m guessing at some point he realized that there was more money to be made in pharmaceutical research… a LOT more.

So he spent much of the eightes and nineties working for SmithKline, Ayerst Labs, Wallace Labs, Smithkline AGAIN (this time with Beecham) then worked for a biotech trade company called Medical Alley for six years, and ended up at the Womens Health Clinic at the University of Florida in 1997. In 1998 he joined Integramed, a small cap company with a national network of fertility clinics. He left a year later.

In 2002, it looks like he took a job as Vice President of Scientific Affairs at a company called Novavax. You can see the contract he was offered here. Looks like they offered 50,000 bucks just to sign the contract. Niiiiiiice. He also got some stock options. The company creates “novel vaccines” according to their website. I’m not sure if his hire was the reason the stock plunged that month about 12 bucks per share (from 14 to 2). The only product I see available is Estrasorb, an estrogen cream treatment for hot flashes and such. He no longer appears connected to the company.

Currently, he is the head of a startup from UF called BIOGALAXY. They specialize in “hydration” products. Ugh. They also make oral hydration and multivitamin formulas… FOR YOUR DOG!!! (I AM NOT MAKING THIS UP... click here).

His CV indicates he authored or coauthored 22 abstracts, Eight of them concerned a gold salt used for rheumatoid arthritis called auranofin, whose brand name is Ridaura. And guess which company makes Ridaura??? You guessed it… Smithkline, Dr. Heuer’s bread and butter for 20 years. IS this true scholarship? Methinks not.

Here is a list of many of the companies Dr. Heuer has done research for:

Smithkline Beecham
Ayerst labs
Wallace labs
Scherring labs
Upjohn labs
Nautilis Inc.
Ciba – Geigy
Wyeth labs
Lederle labs
Abbott labs
3M
Zeneca Pharmaceuticals
Novo Nordisk Pharmaceuticals
Eli Lilly
Proctor and Gamble
Ortho McNeil
Pfizer

The list goes on and on. If there’s a company not on there, please contact Dr. Marvin Heuer. I’m sure he’ll be in touch with them soon.

I’ll close tomorrow on Dr. Heuer with a few last comments. But much more to come on the “BLANK MD” product line.

MARVIN HEUER, MD PART I

2007-06-01T20:53:00.000-04:00

I have been blogging about the “BLANK MD” product line. Somewhat randomly, I’m trying to examine them piece by piece to better understand just why this product exists and which people are behind it.

A look at their website indicates that the head of the product line’s “MD Advisory Board” is a kindly-looking older physician named Marvin Heuer, MD.

Who is Marvin Heuer, MD?

Well, according to this website, he is the Chief Science Officer for “Team Muscletech”, which makes “Anator p70” (a “muscle gene activator”, whatever unnatural compound that might be). He is also the Chief Science Officer for GAKIC (catchy name. It stands for ‘glycine-l-arginine-alpha-ketoisocaproic acid’), AND the chief science officer for Iomedix (which makes the MD product line). Busy guy.

But it isn’t a coincidence. He’s chief science officer for Iovate, and they make all this stuff. He seems to be an expert on all sorts of supplements. How did he develop this talent? Does he have a background in the fields necessary to tackle building muscle mass AND to help heartburn, sleep disorders, cholesterol problems, AND arthritis and rheumatologic disease???

I don’t know about all that. But upon researching about this gentleman, I discovered two things:

1)He has taken part in a LOT of research, and

2) You can find a LOT of stuff on the internet.

He is a medical doctor. It appears he graduated from Minnesota Medical School and then did an internship and became a Family Practitioner in the 70’s. At some point, he decided that seeing patients probably wasn’t where it’s at, and became a researcher, where he took part in studies conercerning FOURTEEN DIFFERENT DISEASES!!!

Impressive. Some doctors struggle to just master research in one or two areas. This man has dipped his beak in topics as widely different as migraine, Urinary tract infection, and osteoporosis.

Oh, did I mention that the research was funded by almost ANY DRUG COMPANY YOU CAN NAME???

I do not know Dr. Marvin Heuer personally. He may be a great guy, the salt of the earth. He certainly doesn’t seem like a monster. But based on my cursory look at him, he appears to be a bit of a mercenary. And I think his “MD” product line is garbage.

Much more to follow (with documentation of course).

GNC

2007-05-31T16:57:00.000-04:00

I am researching my next post, so I’ll just write a blurb about a visit to GNC. It seems like this blog has become all about supplements lately, and Happyman said he thinks supplements often do make wild claims, which seems to go against the DSHEA rule I cited in my post “BLANK MD II”, which basically forbid saying they can treat or mitigate a disease, unless the FDA has stated they can.

So I went to GNC to take a look for myself at some of the labels.

Turns out this was a waste of time.

For anyone who hasn’t been to a GNC lately, here’s what I learned:

1) They have a smoothie/energy drink bar, similar to what you find in the lobby of gyms and health clubs, or a typical jamba juice. You can get all kinds of additives, and the calories are listed.

2) The owners were all Indian or Pakistani. I’m not sure if this is just in New York or everywhere, but I got the feeling they were laughing at the customers.

3) Their supplements are all GNC labeled, so there isn’t a good representative sample for supplement labels. As far as their own products go, however, their labels were very vague, and always carried the disclaimer at the bottom about how the stuff isn’t regulated, etc etc.

4) Abut 90% or more of what they sell is geared toward gigantic muscle bound gym rats. The back of the store (and front) is FILLED with huge canisters of powdered muscle “milk” with labels that have lightning bolts and lettering that looks EXTREME!!! There is also a large shelf of power bars and the like.

I think I’ll have to visit the Vitamin Store or InVite to get a better sampling. The GNC labels were very fair.

HEARTBURN MD

2007-05-30T13:01:00.000-04:00

My last post introduced what I consider an obnoxious set of products sold by a company called Iovate (whose website appears to be just their address and logo… seems like a waste) that have the names “Blank MD”, and substitute “Heartburn” or “Cholesterol” for “blank”. I described my feelings about calling the products “conditions”, rather than the supplements they contain, and using the phrase “MD” in the names, as if OTC supplements were the same as prescription medication.

So what’s in these witches’ brews? I’ll start with “Heartburn MD”. As I said in my last post, the main ingredient is Calcium Carbonate, which is fine. That’s no different than what you’ll get in Rolaids, Tums, Mylanta, Maalox, or just about any other over the counter instant relief antacid. But for you supplement-types, there’s also some “orange peel extract”.

What does “orange peel extract” do? Does it really treat reflux? Well, a Pubmed search turns up about 10 to 20 small studies on possible cancer protective effects of orange peel extract, mostly in mice and rat journals (i.e. research done on little furry mammals). However, many places on the internet claim it is good for heartburn. One page in particular caught my attention, something called “Ask the Doctor”., which is an interview with a guy named Dr. Decker Weiss who, ironically enough, is NOT a doctor. (not a medical doctor anyway, though it goes on to say he did a Cardiology residency, so, go figure). He is a “naturopath”. I’ll write about those another time.

He helpfully tells us that orange peel extract is PROVEN to reduce symptoms of acid reflux. That’s great “Doctor” Weiss. The problem is, he only cites one study, OVER AND OVER AGAIN as the “proof”. And guess what? That study is PROPRIETARY!!! So you can’t look it up anywhere. Apparently it was based on a questionnaire with NO control group. Oy vay!

On the advertisement for “Heartburn MD”, a footnote at the bottom tells us that:

“In a two phase clinical trial, subjects taking just one of the key compounds (???) of Heartburn MD reported significant relief of occasional heartburn”

Gee, want to bet that the “key ingredient” they were referring to was the CALCIUM CARBONATE??? We’ll never know, because there is no citation.

Heartburn MD also contains a delicious helping of Garcinia mangostana extract which has many reported medicinal uses. On the Asian continent, it appears to be used for dysentery, colitis, eczema, cystitis, gonorrhea… yeah, okay. I’ll take penicillin thanks. There’s some other things, extract of Ginger, caraway seeds, and pomegranate. Funny. In medical school, I don’t remember discussing the healing powers of pomegranate for reflux. Must be a conspiracy by the medical community to keep us from these powerful natural medicines.

Bottom line: buy Tums à cost on drugstore.com… 4.99.
Heartburn MD à cost on drugstore.com… 17.99

Don’t be a sucker, please. Much more to follow on this subject.

BLANK MD II

2007-05-28T11:43:00.000-04:00

In my last post, I opined about a print ad I saw for a line of products I call “BLANK MD”, and how I objected to the use of “MD” in the product names. But upon further reflection I realized the MAIN REASON why I find the “BLANK MD” ad campaign so objectionable.. It is not just the use of MD in the name that is obnoxious. It is the name of the products themselves that is obnoxious!

What do I mean? Well, most health food supplements are named what they are. For instance, if one went to GNC and bought a box of Gingko biloba on the recommendation of a friend or a radio show host, presumably to help memory or ward off a cold, or whatever the particular interest in the supplement, then you would simply look for a product called “Gingko biloba”. That is all well and good. And the product may make such claims.

Incidentally, supplement companies do not get a pass under DSHEA regarding labeling of their products. To quote Dr. Stephen Holt, MD, who wrote an article in 1996 on this topic in a journal I don’t read called “Alternative and Complementary Therapies”:

It is of utmost importance to note that labeling statements made under the DSHEA cannot make a claim to diagnose, mitigate, treat, cure, or prevent diseases. Only those specific claims linking a supplement to a disease state that have been preapproved by the FDA under the NLEA, such as soluble fiber and heart disease, may be made.

So the manufacturer of Gingko biloba cannot write on the label “Can cure Alzheimer’s disease”. Instead they write something like “May support mental sharpness”. In this way, we can separate medicine from supplement.

But, o-HO, Iovate, being the clever company it is, figured out a way around this problem. By calling the product a DISEASE, rather than the supplement it contains, and slapping a respectable “MD” after it, they create the appearance of a legitimate medicine, while making absolutely NO wild claims! Instead of selling a product called “Oramge peel extract” and making the claim “Believed to relieve symptoms of acid reflux”, one can just call it “Heartburn MD” and then technically need not say anything! The phrase “Joint MD” is even more vague and open to flights of imagination. They could sell Gingko biloba mixed with some other garbage and call it “Memory MD” or “Alzheimers MD”.

I find this abhorrent. They should not be allowed to sell this garbage under these names. It should be called what it is.

My next few posts will examine the supplements in question and the doctors behind them.

"BLANK MD"

2007-05-25T12:05:00.000-04:00

For my first post since my long hiatus, I’d like to discuss an anger-inducing advertisement I saw in my newspaper the other day. It was the Enquirer (yes, I read the Enquirer, so sue me) magazine and it was a full page spread pushing a product line by Iovate named “blank MD”. For instance, they sell “Heartburn MD” or “Cholesterol MD”.

Many things about this ad and product line got me ANGRY!!! I’ll detail in the next few posts more details about why, but I’ll just begin with the first and most obvious… the use of the letters “MD” in the product line.

“What is so wrong with that?” you ask. Well, the ad shows a group of very friendly doctors with knowing smiles and crossed arms at the bottom of the page, and their website describes their qualifications and they do appear to be physicians (one is a DO). So they aren’t really misleading anyone, right?

I suppose not, technically. However, one must acknowledge the trend nowadays to have scientific-sounding outlets for nutty positions. For instance, the global warming “debate” has been invaded by all kinds of “journal” articles and “research” conducted by people who are no more scientists than your average “American Idol” watcher. Ditto with abortion studies that purport to show an increased risk of breast cancer or sucide risk among women who’ve had an abortion.

So my feeling here is that by invading the marketplace with “supplements” (because that’s what these products are, which I’ll detail in my next post) and putting “MD” in the name, and having a team of doctors who are actually board certified behind them, they can convince a gullible public that they are somehow equivalent to prescription medicine, which has been TESTED (most of the time).

To be fair, the “Heartburn MD” product appears to be mostly calcium carbonate, so its no different than your average pack of Rolaids. But of course its also laced with bat wings and eye of newt (an exaggeration obviously) so they have a “proprietary” product.

Whatever they need to do to make a living. In my next few posts, I’ll take a closer look at these doctors and these products.

DSHEA II

2007-05-17T08:41:00.000-04:00

Yesterday I wrote a blog entry about the WSJ Health Blog survey which stated that a third of young doctors didn’t know about the DSHEA and the complete non-regulation of dietary supplements.

Fair enough. A patient looking for information on these supplements might be told otherwise by a well-meaning, but ill informed doctor. In fact, data regarding dietary supplements from placebo controlled trials has been lacking until recently. In other countries (like Germany, which published “The complete German Commission E monographs— therapeutic guide to herbal medicines.” In 1998) there is more data regarding these products. They take these products more seriously. The UK’s “Medicine Control Agency” in 2002 published a list of supplements it was calling “medicinal” and therefore illegal to be sold without regulation. I personally think that’s overkill.

In the U.S., the attitude taken is that these supplements are often not worth testing because:
1)The quality of the products is so variable, since there is no standardization
2)They appeal to a crowd who wouldn’t believe a negative study anyway
But, I have to say I’m seeing a lot more supplement related studies, and guess what? No surprise that all of them appear to be NEGATIVE!

Anyway, none of this has anything to do with what got me so angry. It’s this comment from Christian Goodman:

“Makes one wonder what else doctors are misleading their clients about. That’s one reason why I always say; get a second opinion.”
- Christian

I see. So because a doctor wasn’t aware of federal regulations regarding products which are essentially placebos, you deduce that doctors are “misleading” patients about other things which are more important. That makes about as much sense as saying an English teacher not knowing about what’s inside a number 2 pencil.

I also object to the word “client”, as if we were lawyers trying to sue a 7-11 for a slippery floor. We see “patients” Christain, NOT “clients”.

Why is there an incessant drumbeat of negativity about doctors and what they don’t know and won’t say? The public has no idea how much new medical information occurs EVERYDAY! Fifty years ago there were like fifty drugs. Now there are HUNDREDS, but Pharmacology is still taught in the same amount of time. Medical school is still only four years.

So forgive us doctors if we weren’t cognizant of the oversight on BOGUS NUTRITIONAL SUPPLEMENTS THAT DON’T DO ANYTHING!! I’ll just stick to learning about medicine that is actually proven to work, thank you.

Anyway, I'm off with the family on vacation for a few days. See you next week. And STAY ANGRY!!!!

DSHEA

2007-05-16T16:27:00.001-04:00

The Wall Street Journal Online Health Blog reported that a third of young doctors (residents and their supervisory attendings) didn’t know that herbal and dietary supplements were NOT regulated by the FDA. I am unsurprised by this. While in medical school and during residency, I don’t think anyone brought up this topic even once. In fact the only reason I know anything on the subject is because of my own curiosity. While presenting at a morning conference, I prepared a slide show about herbals, mainly so I could learn me a little something.

And do you know what I learned? Pretty much what every doctor and supplement manufacturer already knows… they DON’T WORK!!

A little background: The U.S Congress in 1994 enacted the Dietary Supplement Health and Education Act (DSHEA) of 1994, which did the following:
• Removed the FDA’s authority to regulate “dietary supplements”
• Not required to provide research or testing
• Not mandatory to provide proof of effectiveness
• Proof of safety is also not required… the FDA must prove the product is unsafe
• No standards on the accuracy and amount of information that has to be supplied on the label

Why did the Congress do this? Because if the companies who made these products had to undergo the stringent requirements that pharmaceuticals do, including safety trials, then they would have to charge a lot more for their product. Since they are now treated as “food”, they can be sold at much lower prices to a public that wants them. And I one hundred percent agree with this thinking. Because as I said above, these products DON’T DO ANYTHING!!!

How do I know they don’t do anything? Because if they DID do anything, then doctors would be using them. But every hack likes to concoct conspiracy theories, like Kevin Trudeau, a former jailbird who published “Natural Cures They Don’t Want you To Know About”. Who is THEY??? I would love to know about them.

I’ll post part II of this rant tomorrow, including the reason why this blog entry made me so ANGRY!!!.

DIE WITHOUT DIGNITY

2007-05-15T16:25:00.000-04:00

An interesting editorial appeared in this Sunday’s New York Times concerning end-of life decisions in New York (where I practice). I think I’ll let Eliot Spitzer sum up the current law on the subject:

…under current New York law, no one, not even a family member, has the right to decide about your medical treatment if you are unable to do so, unless you have given them the legal authority to make decisions for you or leave clear and convincing evidence of your treatment wishes. (full text and citations here)

You got that? So if you told everybody you know that you would NEVER want to be hooked up to machines, and then you are hit by a car and become comatose, you WILL BE hooked up to machines! Period! And nobody CARES that everyone overheard you say this over and over.

“Oh, but you should have signed a health care proxy.” Yeah, well, that isn’t reality. I’m 35 and I have never thought about doing that. AND I’M A DOCTOR!

This situation in New York is different than many other states. So why would a forward-thinking state like New York, home to a great metropolis, be so backward on their thinking here? (Here’s a clue… most of the New York State Senate are Republicans.)

A bill floating in the Senate right now, the Family Healthcare Decisions Act, championed by Eliot Spitzer, could put decisions back into the hands of family members, but as the New York Times tells us “Semate Republicans are worried about same sex partners being named surrogates. Abortion rights activists are worried about pregnant comatose patients.” Preganant comatose patients? Are you kidding me??? How many of those could there be??? Is that a good reason to block the ENTIRE legislation?

Being a physician who has attended to so many situations where patients’ wishes are not fully known, and all kinds of ethical dilemmas occur (including conflicts of interest among family members), it would be nice to eliminate ONE of the obstacles. I hope the Senate can finally put aside stone-age thinking and face the reality of end-of-life decision-making… it ain’t pretty.

FAIT ACCOMPLIA

2007-05-14T14:27:00.001-04:00

On the Wall Street Journal Health Blog, a March 27th entry talked about some of the problems for Sanofi Aventis’ hotly-awaited blockbuster obesity drug Accomplia…oh, I’m sorry, now its being called “Zimulti” (apparently, “accomplia’ was too suggestive???) Unfortunately, it also makes you a little too aggressive. I guess the FDA isn’t so quick to pull the trigger after recent developments.
So while overweight people everywhere salivate over the promise of “exercise in a pill”, comments like this appear:

“I am so disappointed. I have struggled with weight problems all of my adult life, and I have been waiting for this drug to become available in the USA for two years. I wish all the people at the FDA would gain 100 pounds apiece overnight. Then, maybe they could have some sympathy for those of us who need help in shedding pounds. If a doctor prescribes it, he/she should follow up with the patient to see if they have unpleasant side effects. Why keep it from all the others who need it? “
Comment by Mary - March 29, 2007 at 2:43 pm

Yes, your doctor will surely follow up. And if anything goes wrong… then he can go DOWN!!! After all, your safety watchdog shouldn’t keep honest, hard-working Americans from the drugs that are RIGHTFULLY THEIRS!!! It’s everyone’s right to have all the drugs they want, right?

Someone tell that to the guys who convicted Dr. William Hurwitz who was convicted of drug trafficking in an Alexandria, VA court.

Please! Doctors are on the hook for everything. We are supposed to be able to predict which side effect you get. We are supposed to recognize every side effect. We are supposed to predict who will have an allergic response to a drug, even if they have no history of allergies. We are supposed to predict who will take a drug, and who will sell it on the street. Since when did doctors become DEA agents??? Now this moronic woman wants doctors to run their own individual safety studies.

I’m sure she’d be willing to sign something that says “If I die or have some other horrible side effect, I and my family agree not to sue my doctor” And guess what? If she did sign it…they’d STILL sue! Because their douchebag lawyers would argue that it was signed “under duress”. It’s a no-win situation, and the brilliant (and obviously overweight) scribe quoted above just doesn’t get that.

BOGUS BONIVA

2007-05-11T17:20:00.000-04:00

I was at a shocking dinner for Boniva the other night. Obviously the dinner was meant to coincide with the study in NEJM about Zometa (don’t forgot about your old friend Boniva). The talk was given by a reproductive endocrinologist who sounded very smart. I was accidentally learning all kinds of things that night. She forgot that we went there to eat a free steak, NOT listen to a lecture.

But I guess the biggest eye opener came near the end of the talk when she talked about the non-inferiority study (I want to write about those soon) that gave Roche and GSK the bonanza they so desperately wanted. Apparently she was one of the principle investigators for the study (gee, what a surprise) and she was describing a funny thing that happened during enrollment.

But first I should probably remind everyone (in case you forgot, and how could you with news being on EVERY FREAKIN RADIO AND TV SHOW) that bisphosphonates might cause osteonecrosis of the jaw, and that part of the reason stopping it before dental procedures does no good is that it hangs out in your bones for freakin TEN YEARS!!!

OK, so back to the story. The lecturer states that the women being enrolled were excluded if they had previously taken other bisphosphonates (for the reason cited above). So one patient is enrolled, she swears up and down she has never taken a bisphosphonate. And so everything seems hunky dory. Now part of the process involves routine review of any prior lab tests, for instance bloodwork, bone mineral density tests, etc. etc.

So our hero is flipping through these old results and finds an old BMD result. Everything looks cool, except… WAIT! As she scans the result, she sees the clinical history that was given “Elderly female, rule out osteoporosis, on Fosamax…” HUH?

Did she just read that right? “ON FOSAMAX”!!!

OK. So even though this enrollee swore up and down she never took a bisphosphoante before, and even though she’s already passed the screening process, we discover she should have been excluded… and COMPLETELY BY ACCIDENT! And obviously, the next question is… how many MORE of these forgetful women made it into the study???

Well, I asked the lecturer this very question, with what most likely was a very shocked look on my face. She just nodded and accepted that “yeah, it’s a problem.” Audible laughter went up from those assembled.

I’m speechless.

So, to summarize, you can’t believe any studies from drug companies. I know, it goes without saying. Just more evidence. And this Boniva study is more tainted than the scallions at Taco Bell.

DUNCAN HUNTER

2007-05-10T13:45:00.000-04:00

I don’t want to discuss politics on this page because I don’t feel that has a lot to do with why I am blogging.

But may I just identify a disturbing item relating to last weeks’ Republican Presidential Debate. I specifically want to mention a quote made by Duncan Hunter. Who is Duncan Hunter you ask? He’s the congressional representative from San Diego, CA. He is a Vietnam veteran who served his country in the 173rd airborne. He also, apparently, is a douchebag.

Why do I say this? Well, it has nothing to do with his great initiatives, including his idea that somehow a big “fence” can keep out Mexican immigrants, or that abortion is a no-no against human life. No, I don’t want to discuss these things.

I do want to discuss his response to Chris Matthews’ question about having a Clinton in the White House again. Here’s his response:

HUNTER: You know, Bill Clinton cut the U.S. army by almost 50 percent. In this war against terror, he's the wrong guy to have in there. And incidentally, on the Schiavo case, you know, Ronald Reagan said, on the question of life, "When there's a question, err on the side of life." I think Congress did the right thing.

This is an unambiguous statement. He is basically saying “Despite what doctors think about brain death, and even though we were clearly wrong when we intervened on the Schiavo case, (which we know after autopsy which proved her brain was a soupy mess) Congress should make decisions regarding end of life issues, because as we all know, Congress is all-wise and all-knowing about everything”

Is this what doctors have to choose between? Either Democrats who want universal health care, or Republicans who want to control doctors’ decision making? Talk about a rock and a hard place.

DAN-ACTIVE REDUX

2007-05-09T17:39:00.000-04:00

I just want to make a few last comments regarding the DAn-Active commercial I've been discussing over the last few days, which, by the way, you can watch here.

One aspect is the initial statement about "stress". There is NO evidence that Dan Active decreases stress effects on the immune system. And they never visit this topic on their website. So I'm not sure why they even mention this fact at the beginning of the commercial.

Secondly, they say that "70% of your immune system is in your GI tract". Even if this is true, that doesn't mean that your GI tract is primarily responsible for the health of your immune system. The GI tract is HUGE, so naturally you would have a lot of immune cells there. Their implication is that this is where our immune system mostly "hangs out".

Finally, they claim it can give your immune system a "boost". I don't know if its just me, but the takeaway message appears to be that you can down some of this stuff, and then just inhale all the virions you want, and this will somehow reduce the chance of infection, which is bogus.

Also, they don't mention the sugar content, which is probably rotting their kids' teeth. Its flavored with some sweet strawberry crud.

I think the FCC needs to regulate these commercials better, especially if they're going to hawk this stuff as medicinal.

DAN-ACTIVE III

2007-05-08T20:46:00.000-04:00

In my first post, I described a sickening commercial airing on your evening news promoting the “immune boost” you can get from Danactive.

Next, I quoted their studies, to give a sense of how meager their effects really are (though not strictly ‘lying).

Here I offer some interesting studies about probiotics that I think are real benefits. A great number of studies on L. reuteri are grouped on a nice page here.

In Mexico City, a place where diarrhea is just expected, they performed a randomized, placebo-controlled trial for 4 months of 250 infants and found that the ones drinking milk spiked with L. reuteri had significantly less episodes of community acquired diarrhea. (76% vs 64%).

Another tasty experiment involved giving women intravaginal and perineal L. casei strain GR 1 who had frequent UTI. Apparently, they had increased infection free periods, and they didn’t have to take antibiotics. Unfortunately, they couldn’t just drink it (if you know what I mean), but they didn’t suffer any yeast infections, which is a known side effect of antibiotics.

One of the more intriguing studies of probiotics is the possibility of reducing the incidence of atopic disease by exposing young children to the Lactobacillus rhamnosus GG strain. They fed it to mothers prenatally and to the infants 6 months postnatally, and there was a significant risk reduction (almost 50%) in the incidence of atopic eczema.

So why doesn’t Dannon mention these studies? Because their strain (L. casei DN 114001) isn’t proven to do any of these things. And you can buy any of the known products at a health food store.

The take home message is that the immune boost advertised on their commercial is extremely misleading (so what else is new) and even more disturbing is their lack of supporting data on their website. Before you decide to start pouring this down your kids’ throats for YEARS to shorten their diarrheal episodes by one or two days, check out this page. Their list of strains is more reliable. It's only 2.29 for a four pack, but check out this page for a quote you wont believe, that just proves my point:

The drink contains the active culture L. Casei, which is supposed to provide balance in your digestive tract and strengthen your immune system. That caught my attention, because my younger son had been battling a mild flu-like virus for several days and I felt his symptoms starting. I drank DanActive for four successive days. After the second day all my viral symptoms went away. My poor son had suffered for a week. I’m not sure if DanActive was responsible for my quick recovery, but it sure didn’t hurt.

Unreal!

DANACTIVE II

2007-05-04T18:52:00.000-04:00

Happyman asked for the link to Dannon’s cited studies. I’ll discuss each one below in turn. They also link to a page called the scientific summary where you can read about cellular permeability and other esoteric effects that don’t seem to be clinical.

The first study cited is a British study looking at about 1,000 babies aged 6 to 24 months and the incidence of self limited diarrheal illness (you know it’s a British study, because they spell it “diarrhoea”) in babies randomized to either standard yogurt and the Lactobacillus casei yogurt. The study lasted four months. Well, it didn’t decrease the number of diarrheal episodes, but it did decrease the duration by about 4 days.

The next study is from Spain. 136 university students randomized to receive either a glass of skim milk a day or milk spiked with this Lactobacillus frappe. They wanted to see if they could attenuate the known decline in lymphocytes from stress prior to exams, and thereby reduce anxiety. (I wish they had looked at exam performance). Well, there was no difference in anxiety, but there was a difference in lymphocyte count, as well as the amount of CD56, which the DAnnon website tells us is “one of the most important cells for the defense system of our body” (???). Not too impressive methinks.

Next they cite a British study looking at 360 elderly people to see if yogurt spiked milk could reduce diarrheal illness in the elderly. Oops, it didn’t reduce the number of diarrheal illnesses. But it did cut the duration from about 9 days to about 7. (Are any of these studies done in the U.S.? I guess because the DAnnon center is in Italy, Europe gets all the free spiked milk).

I’m not going to even bother looking at their last quoted study because the claim is only that the decrease in NK cells during exercise is less in those drinking their spiked cultures. What an accomplishment! Nowhere do any of these citations point to any improved outcomes.

Does that mean there is nothing to the claims about the benefits of this “probiotic”? I’ll quote you some studies tomorrow that might show some benefits. However, I just want to take this opportunity to point out that it isn’t as relevant to point out the limited benefits of this product, as it is to identify how misleading their advertising is.

The problem is the assumption people will make about the immune system they are referring to. People hear that phrase and think “the common cold” or other respiratory and bodily infections. That’s the conclusion they want you to reach. Ridiculous. What is the FCC thinking letting them run this commercial?

DAN-ACTIVE

2007-05-03T16:57:00.000-04:00

I wanted to write a post about the number of drug and drug industry-related ads you see on TV, and I do want to talk about direct-to-consumer advertising and what isn’t being done about it.

But then I saw a commercial and I just feel compelled to write about it. It was for Dannon Yogurt’s product “DanActive”. This commercial is hilarious. It starts out with a family sitting around a table and the father is reading the newspaper. He suddenly announces a startling factoid in the newspaper: “It says here that stress….(LONG PAUSE)…can weaken our immune system!” (Cue scary music).

Well, GAWWWWWLLL-LEE! Thanks for telling me Gomer Pyle. I can see being compelled to tell my whole family this incredibly shocking bit of news. I’m sure nobody ever noticed that you tend to get sick when you're under a lot of stress and feeling run down. I’m so riveted at this point, I keep watching with bated breath.

Then their seventeen year old daughter announces knowingly from the refrigerator “Annnnd… about 70% of our our imuuuune (she drags out the word, as if to say ‘Dad, you are such a dummy. Everyone knows this’) system is in our digestive tract.” And just in case you can’t hear her, this sentence is planted along the bottom of the screen. AND just in case you didn’t see THAT, a huge number “70%” graphic appears on the screen along the left. I’m so glad a teenager is up on current medical knowledge. Heck, I didn’t even know that and I’m an internist. She also gives her father a bit of a seductive look. Left me a little disturbed, I have to say.

Then the father helpfully offers this information, glancing back at his newspaper: “Apparently, a culture called L. casei immunitas (rhymes with ‘gravitas’, I guess) can help. It’s clinically proven to help strengthen your body’s defense system.” The paper breaks away to an impressive animated sequence of purple thingies being magnetized or something. I’m not quite sure.

The rest of the commercial is not very interesting, and at the end the graphic reads “DAnActive! Help strengthen your body’s defenses”

Wow! I’m no longer sure if they are trying to sell me food… or medicine! What about their claims? Does DAnActive indeed strengthen your immune system, as the narrator and play actors suggest? Can I get a boost? Can I counteract the stress effect on that 70% of my GI tract?

I visited the website and perused some of their citations and I’m not too impressed. I’ll speak more about it tomorrow, but I wouldn’t start downing a ton of DAnActive at the first sign of a cold.

UNSAFE DISCHARGE

2007-05-01T16:01:00.000-04:00

I work in a nursing home and a patient who was admitted after a hospitalization for alcohol withdrawal is apparently being considered for discharge. However, he is not participating well in his rehab, and the physical therapists are writing that he is “unsteady” and “at high risk of falls”.

Fine. So they are looking to me to discharge him and I’m like “PT is writing that this guy isn’t steady and you want me to just sign off on his discharge?” The head of PT insists this is fine, and that “It’s up to the doctor to discharge”. Right in front of a family member. Thanks a lot for selling me out.

I can just see what will happen. He goes home, falls, hits his head, is found days later in a coma. Then I’m dragged into court with some lowlife attorney saying “Well, YOU’RE the doctor, YOU should have known it wasn’t safe to send this man home.” None of these ancillary staff people can understand this level of liability. At a “multidisciplinary meeting” (similar to having root canal, but no anesthesia) I ask “Do you have a med alert bracelet”? Get this: the patient doesn’t even have a PHONE! And I’m the only one who asked this. The social worker didn’t know.

I just hate this trend where doctors have become social workers. Even in the office, you have to consider not just the treatment, but the COST of the drug. You don’t just consider the test, but which LAB you have to send the patient so their insurance will cover the test. This is not what I was trained to do, and I don’t understand how medical doctors became responsible for so many of these issues. No wonder we don’t have time to keep up on new developments or talk with the patient.

PDUFA

2007-04-30T20:02:00.000-04:00

In future posts I will detail more about the history of the FDA and its makeup, but I want to comment on the recent illuminating editorials published in this week’s NEJM.

Let me say first that I am not a Communist and I am not a believer that government can fix all of society’s ills. I like freedom in general and am not a fan of too much government interference.

Except in areas where an industry cannot police itself. For instance, it’s pretty clear after Enron and all of the post dating options scandals that Wall Street cannot police itself. Obviously they need MORE regulation, NOT less.

Well, when it comes to the drug approval process, I guess you could say it’s an argument between freedom to have access to drugs, and restriction in the name of public safety. It was an environment of lawlessness depicted in books like Upton Sinclair’s “The Jungle” that led to President Theodore Roosevelt signing the Wiley Act in 1906, which created the agency that eventually became known as the FDA. The need to prevent interstate adulteration of foods and drugs was rampant. The industry needed POLICING!

Fast forward to 1992, and things are a lot better. But the FDA is understaffed. Their budget is not large enough. Congress can only appropriate 125 million dollars for their “Drug Regulation and Safety” division, not nearly enough resources to adequately study all the new drug applications. Also, AIDS activists are demonstrating in Washington because they want access to new, potentially life-saving medicines, and the understaffed, under funded FDA is taking too long to approve these drugs. Whatever can be done to resolve this crisis.

Well, our 102nd Congress had an idea (majority of Senate were Democrats, by the way). They passed the Prescription Drug User Fee Act, or PDUFA. (I like to call it “P-douche-A). Thanks to this bit of legislation, the pharmaceutical industry would now be PAYING THE SALARIES OF FDA EMPLOYEES!! Let’s repeat that: the very industry that the FDA would be policing, was PAYING THEIR SALARIES! If anyone thinks this is a good idea, after this whole Ketek debacle, then I must be on the wrong planet. The act has a lifespan of five years and we’re currently on PDUFA III. But here’s what is key: even though we now know the FDA is in a sorry state in light of these troubling reports, Congress is going to do… NOTHING! In fact, according to the editorial, it looks like reapproval is a done deal once the act expires on September 30th. They love the idea of all that free money from the “user fees” (read: Pharma grift). But guess what? That money isn’t free.

I’ll talk more about PDUFA in future posts.

MORE FDA NONSENSE

2007-04-27T17:25:00.000-04:00

As a follow up to my original post about the FDA approval of Ketek, I did myself a favor and listened to the 16 minute interview Dr. David Ross gave to Rachel Gotbaum on the NEJM website. My goodness, this man deserves a medal of freedom way more than Wolfowitz and Tenet.

I plan to talk more about the FDA in future posts (its becoming my personal mission), but I just want to highlight some of the things Ross said in this interview.

Apparently, the fraud that occurred with Sanofi Aventis’ safety study (you know, the one where the top enroller is in a federal prison, and the second top enroller…is ALSO going to prison)… the company KNEW ABOUT IT and DIDN’T TELL ANYONE!!! What the f&%$!!! Is anyone going to jail for this? When confronted, they basically said “We’re sorry, and we promise we won’t do it anymore.” And the FDA claims in their letter to the Journal they only had “preliminary” evidence that fraud occurred at the approval committees. But, GUESS WHAT??? Dr. Ross says that that’s a bunch of BULLS%^&$!!! They knew the whole time!

In January of this year, the FDA wisely withdrew the indications of AECB and acute sinusitis from the Ketek label because “the risks outweigh the benefits”. Thank goodness they realized it after three long years. BUT WAIT…Dr. Ross told them exactly that…IN 2003!!!!! When he presented his opinion, he was told by his manager to “soften” up his report.

Why would his manager ask such a thing, the interviewer posits. And that’s when Dr. Ross issues my favorite phrase of the interview. He says that as of 10 years ago, the FDA’s mission has changed, and now there is… are you ready?... a “culture of approval”! Yes, that’s what we need at the nation’s safety-in-drugs watchdog.. a culture of approval.

The interview is a tour-de-force. I was speechless. He never mentions von Eschenbech, or any top person at the FDA by name because he is obviously too much of a gentleman or statesman. But one cannot deny that based on this report, the FDA are:
1)liars
2)greedy
3)lazy
4)EVIL!

Why do I say “evil”? Well, I don’t know what else to call approving a shoddy drug that led to 4 people dying of liver failure and dozens of others getting liver toxicity NEEDLESSLY!! This wasn’t like they made a medical mistake. They KNOWINGLY approved a drug based on flawed safety data made by a company who covered up the fraud.

As Neil Rogers would say “UN-believable!”

ASK YOUR DOCTOR ABOUT....

2007-04-26T14:07:00.000-04:00

When I was a little kid, I saw an episode of 20/20 where they did an expose on doctors who had defaulted on their student loans. (I think it was John Stossel). And they followed some doctors to their front door and asked why they were such deadbeats! Now, I grant you, defaulting on a student loan isn’t a stand up thing to do. But let’s put this in perspective: According to the Health and Human Services website (click here), approximately 150 million dollars in HEAL loans (now discontinued) is still owed by professionals, and guess how much of that is from allopathic doctors…19 million! So 90% of these defaulted HEAL loans is owed from non-physicians. The New York Times doesn't highlight this, as the title of this article from 1981 clearly indictaes who their beef is with. “Those deadbeat doctors” they scolded.

I mention this, not to talk about the student loans racket (we can take that up another day), but to give you an idea about how doctors are generally portrayed in the media, and how the media can make it more difficult for doctors to practice medicine. A recent article appeared in the Archives of Internal Medicine examining the effects of aspirin on mortality in women, and looked specifically at the effects on cardiovascular disease and cancer. I can’t link to the article, but the conclusion was that there was a 43% reduction in the risk of mortality from cardiovascular disease with the use of aspirin! That’s great! The Associated Press started their press release thusly:

Aspirin in low to moderate doses may lower the risk of death in women, particularly those who are older and prone to heart disease, a 24-year study of nearly 80,000 women suggests

Fantastic! Oh, but wait, this result disagrees directly with FIVE other good studies that said there is NO benefit for women from aspirin for cardiovascular disease. What gives? The AP doesn’t really specify. They do say this:

However, experts cautioned that the results are not definitive and that women should not take aspirin as a health preventive without talking to their doctor.

Nice! They manage to weasel out of it by putting it on the doctor to sort out the confusion. Thank you, o’ glorious AP! I guess they didn’t want to enter into a boring discussion about why observational studies aren’t so good, and how superior, placebo-controlled trials like the Woman’s Health Study are often more conservative in their findings, but also more reliable. No, why bother. Let’s just let a patient read this item, then he can scratch his head, and inundate his doctor with a bunch of conflicting advice. Or, maybe the patient will just throw up his hands and say “Gee, the doctors can’t even agree with themselves. So screw it. They probably don’t even know what they’re doing.”

Why did the Associated Press even write this piece? It doesn’t change the current thinking that aspirin does not prevent primary coronary disease in women and this information only confuses patients. The reason is the AP has to write articles for junk newspapers so we all have something to read on the subway.

This is just one example of studies published in the mainstream press, with no responsibility taken by the media for the disinformation that can spread. Some might argue that a well-informed patient is a better off one. That may be true. But with limited expertise, this knowledge can hamper patient care, as illustrated above. Also, the public doesn’t realize that one study alone proves nothing! Because the mainstream media don’t want to mention this uninteresting fact!

Please, a plea from me to the media: STOP making things worse!!! Leave the conclusions and the education of patients to scientists and doctors.

FOCUS!

2007-04-25T18:05:00.000-04:00

Just thought I’d share a recent bizarre experience.

I was invited by a company called Schlesinger Associates to participate in some kind of focus group or something, for which they would pay me 175 bucks (pre tax). In retrospect, it wasn’t enough, but anyway, I went to the address sometime in the afternoon. It was being held at an advertising firm in midtown, near the Manhattan Mall. I was led through a labyrinth of cubicles and was thanking GOD I don’t work in one of those.

I was placed in a medium sized boardroom by an unattractive young woman. It was just me and her, so I got nervous. Then I was told we were being filmed and there people in the NEXT ROOM watching me and my responses. Can you say “interrogation”?

Ostensibly, I knew the topic was vaccines, but because I’m not in an office setting (yet), I’ve never met the vaccine reps of any company. So I get questions like this:

“When you think of Merck vaccines, what animal do you think of and why?”

Huh?

I had no idea what to say. I mean NONE! So I think I just said “leopard”. Leopard?? HAH!

Then she asked what animal do I think of when I think of Sanofi Aventis vaccines.

Oh jeez. I think I said “Owl”. They are very wise, aren’t they???

Then I was shown three plasterboards full of pictures that appear to have been taken in the 70’s, and asked which three pictures reminded me the most of the vaccine division of Merck. I don’t know about you, but I usually do NOT think of ANYTHING when I think of a vaccine maker.

I spent about thirty minutes making up a bunch of crap, was asked to fill out some paperwork, was handed an envelope filled with cash, and I booked it OUT of there.

So this is one of the places the $9 billion spent by the pharmaceutical companies per year on advertising goes: paying advertising firms to ask doctors what kind of animal Merck reminds them of. Ridiculous.

Tomorrow I’ll speak about how the media hurts doctors and practicing medicine.

Acu-PUNK-ture

2007-04-24T15:16:00.000-04:00

While the Journal of the American Medical Association has lost tons of credibility over the last few years, it is still cited and sought-after by many doctors looking to get published, is quoted in the news, and is widely read. So it is very anger-inducing to see them pander to the lowest rung of society…those who believe in homeopathy/quackery.

Their “Clinical Crossroads” section in this weeks’ issue is especially ulcer-inciting. The mere title alone gives me dyspepsia “A 60 year old woman Considering Acupuncture for knee pain”. If the article was simply two lines that said “Acupuncture is bogus and a waste of money. No doctor should recommend it” I might have enjoyed the article and even applauded the authors of JAMA.

However, instead I find the following disturbing comments. I’ll just list two of my “favorites”.First, and I cannot explain what possible reason they could have for doing this, they actually have the patient describe their scenario. (In this case, an active 60-ish female with knee pain).And I’m not just talking about describing their symptoms. She tells a classroom of eager medical students the following blather:

“I think there is a placebo effect and I think its curious. But that doesn’t
bother me. That doesn’t mean it doesn’t work. I think the process of our
brains is so interesting, and I don’t get it at all. But I’m okay with
that. If somebody told me it was just a “placebo effect” – fine.”

I see. She doesn’t understand the “brain process”, but she finds it so interesting. Why are we quoting this genius who hasn’t practiced medicine one day in her life and apparently is so stupid, even though she accepts it could all be a placebo effect, she’s STILL willing to pay for something she KNOWS is bogus? (I didn’t include the previous paragraph, where she complains about how much the sessions cost, and that you have to have a lot of them to achieve success… gee, doesn’t that sound an awful lot like a SCAM???) I can’t believe the editors printed this crap. And listen to Dr. Brian Berman pander to this class of rejects. Here’s a brilliant quote:

" To deal with the pain, Mrs. A emphasized that she felt it
important for physicians to take a holistic approach, with
emphasis on the mind-body interconnection. I agree with her. "

I added the boldface for emphasis. This jackass just sold out every allopathic doctor who stands against quackery. He probably sells growth hormone and does that cartilage removal procedure that was discredited years ago. (click here). These people should burn in hell.

THE FDA IS SICK AND NEEDS HELP BADLY

2007-04-23T20:24:00.000-04:00

This is my first post to a blog. Hopefully I can vent here and no one will really care, right? I mean, no fact checking, no angry reprisals, just an unhealthy explosion of rage. I don't know where to begin, so I'll begin in the middle.

For anyone who didn’t know that our government and the FDA have become corrupt and rotten just needs to read the excellent editorial in this weeks’ New England Journal of Medicine by Dr. David B Ross. Just click here.

Essentially, that great American Dr. Andrew von Eschenbech (you remember him, he’s the same douchebag who blocked Barr pharmaceuticals approval of Plan B contraception for women, check here) allowed Ketek, the bogus unnecessary antibiotic on the market in August 2004 (do we really need another drug to treat sinusitis and URI’s that don’t need treatment anyway) , which was a freaking bonanza for Sanofi Aventis. (stock went from mid 30’s in 2004 to above 45 by 2006). Even after July 2006 rolled around and the FDA was aware of 35 cases of liver toxicity and four deaths, as well as a front page expose by the New York Times (click here), this subhuman group of losers didn’t remove the drug from the market. Even after they realized that Sanofi’s so-called “post marketing” safety analysis consisted of physicians committing fraud (one of them is doing 5 years in a federal prison for this because she just MADE UP patients for her income) they continued to cite this study when safety concerns were raised. They finally were forced to stop citing this so-called "study" when that magical phrase was floated…”Congressional Oversight Committee”.

Von Eschenbech and the whole lot of them need to go away, FAR away. But god forbid the Bush-meister or anyone in our current pathetic over bloated government does anything to protect its citizens. Anyone who saw “The Constant Gardener” better wake up and realize that its not just African kids getting TB who are being used as lab rats, its US!