Archive for June, 2014

Surgical Consultation — when is the right time?

Hhammerwithnailow to make a surgeon cry:  “I don’t want surgery.  What should I do about my hip pain?”  Surgeons are faced with this question every day.  Most of the time the answer is “well, when you are ready you can always come back.”  To be blunt, surgeons are trained to do surgery and surgeons lose money when they spend time doing something else.  In fact, they often don’t have much experience with the “non-operative” management of many conditions.

Think about the problem.   Would you ask a butcher what he would recommend for a vegetarian meal?  Would you ask a home builder about the best apartment to rent?  Would you ask a car mechanic about where to drive your car for a vacation?  It is possible the butcher, home builder or car mechanic will have a good answer but chances are not too great.  So why would this be different with surgeons or other specialists?

The general rule is to ask someone a medical questions who does not have a vested interest in the answer.  Or to do a good job of investigating symptoms on the Internet before getting a consultation so you can ask good questions and be “a little” skeptical.  A primary care doctor’s office is the first place to pose the question.   If the primary care office in uncertain about a diagnosis then a higher level consultation is in order — the question to primary care should be “who would best be able to guide me to the next step?”  Like, “I am having some mild hip pain.  I don’t want to consider surgery yet.  What non-operative treatment is available?”

Recently a friend was having knee pain.  She saw her primary care provider who suggested cutting back on hiking.  That did not seem very high tech so she saw a surgeon who recommended surgery.  Since the knee MRI was normal she was skeptical.  She took some Tylenol and a few weeks later the pain was gone.  The old saying “if you have a hammer then everything looks like a nail” is very true in the procedural world.

Another example comes from gastroenterology.  If a patient has gas and bloating which do you think a gastroenterologist will do first:  a $1000 colonoscopy or trial of a dietary change?  — you guessed it, often the colonoscopy!  Worse,  if the colonoscopy is normal you will likely be sent to primary care to try some dietary changes and some lab tests.  The appropriate route to take is to let primary care suggest the diet changes, get some lab tests and simple x-rays.  Then, if the problem is still not solved go for the colonoscopy.

In health care systems where physicians have a  financial incentive to provide quality and follow evidence-based guidelines the number of unnecessary procedures declines.  Surgical complications are probably higher than you realize.  Taking time to seek answers before getting that surgical consultation is very important.

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Patented Medications — pay-for-delay & evergreening

patentedBrand-name or patented medications cost much more than generic medications.  One would think some other inventor would dream up an alternative to sell at a lower price.  One would also think once the patent expires generics would be be quickly shipped to pharmacies.  But, as usual, it’s more complicated than you think and compounded by corporate deals not really in the consumer’s interest.

Patents are for “novel, useful and not obvious” inventions and the exclusive right to sell the item lasts for 20 years in the U.S..  Unless, someone invents something similar that the original patent owner did not think of.  Also, the the patent owner can request an extension for various reasons (adjudicated in the courts which usually takes at least a year).  Drugs are such inventions.  Some of the patented drugs are very profitable (blockbuster drugs) making millions and sometimes billions of dollars.

Big pharmaceutical companies depend on patents for their very existence.  The high cost of drug development and FDA approval is recovered during the 20 years of a new drug sales — some say it is often recovered in just 10 years.  The patents have become so expansive that other inventors are only able to find a bio similar product that can withstand intense legal action for patent infringement about 15% of the time.  But, those 15% spend so much money in legal matters they hardly see any advantage to marketing early.

When the patent runs out the price of a drug can drop 1000% as generic manufacturers enter the market.  All patients wish this would happen sooner.

Megan Thompson of PBS presented a video segment about the practices of drug companies on 6/28/14.   She told about “pay-for-delay” which is a method of preventing bio-similar products from being marketed by paying generic makers millions of dollars a year to delay marketing until the patent runs our (or longer).   She also told about “evergreening” which is a technique used near the end of a patent:  the drug price is increased substantially while a patented bio-similar product made by the same company is marketed at a slightly lower price.  Doctors trying to help lower cost change patients to the similar product and the patient never knows that in a short time the original drug becomes generic and much less expensive.

According to the FTC the combined “pay-for-delay” and “evergreening” cost consumers billions of dollars and make billions of dollars in drug company profit.

What needs to be done:

  1. Start a linear profit limitation starting at drug patent year 1 (20% above manufacturing cost) and ending at year 20 (5% profit limitation).
  2. Notification of patients by pharmacies about lower cost bio-similar products as soon as they come out.
  3. Eliminate “pay-for-delay” and drug patent extensions.

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Advance Directives — end of life care

eskimoWhat is quality end-of-life care?  That can be a hard question because it depends on where a person lives, what the society expects, what the society can deliver and religious beliefs.  The Eskimo idea of putting grandma on an iceberg and sending her out with the tide is one view.   This primitive Eskimo practice is not without feeling or philosophy and focuses on the basics.  The family loves grandma, the family is in jeopardy trying to provide care and food,  and death should be painless and peaceful.

A modern society would add respect for a person’s wishes — such as religious views, desire for medical care, burial and distribution of assets.  But, despite the willingness of modern society to follow a person’s end-of-life requests a huge majority do not make end-of-life wishes known leaving family and doctors to just guess.  And, the result is expensive medical care and tremendous anxiety for the family — was that really a cultural advancement?

To try to make it easy for patients to make end-of-life medical care requests doctors have encouraged patients to provide them with “advance directives” — some statement in advance of death about what type and quantity of care is wanted at the end of life.  For many years the “living will” has been the vehicle for those requests.  As people fill out their will regarding property they often will fill out a “living will” with statements about what care they want or don’t want.

The “living will” has had problems because it was often filled out in a lawyer’s office without regard to the actual health of the patient or any understanding of advancing science or the grey area of incurable disease.

In the past 10 years a more rational approach has been growing in the form of “Medical Orders for Scope of Care”.  Which likewise is a legal document but one which is a true medical order issued by a licensed physician and discussed with the patient to match their wishes.  Click on the links to see examples:  IPOST, MOST and POLST.

Laura Landro of the Wall Street Journal wrote her story “Patients’ End-of-Life Wishes Granted, Study Finds” on 6/9/14  about an article in the Journal of the American Geriatrics Society:

Fromme, E. K., Zive, D., Schmidt, T. A., Cook, J. N. B. and Tolle, S. W. (2014), Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon. Journal of the American Geriatrics Society. doi: 10.1111/jgs.12889

The essence of the article is that the health care system in Oregon does actually follow the POLST form requests.

There are several legal documents essential for someone approaching end-of-life:

  1. A will or trust.  Make bank accounts “payable on death” to some person.  Make sure securities are designated “transfer on death” to some person.
  2. A living will or MOST form (the latter is probably better)
  3. A power of attorney for health care form
  4. A power of attorney for property form
  5. A HIPPA form to designate who may have access to medical information.
  6. Identification documents: birth certificate, marriage certificate, social security card, state issued ID card (like a drivers license), health insurance card, and military discharge papers  — give copies to your power of attorney.
  7. Make sure the executor of your estate or trustee knows where to find a will,  trust documents,  bank information, life insurance policies, pension  information, funeral arrangements, deeds, and securities.


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