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Tuesday, September 30, 2003

Drug Rep Tales #1 

The folks from Boehringer Ingelheim were in this week.
They explained their ARB (Micardis) and COX (Mobic) options relative to the competition in the two classes.
I told them I considered the ACE's and acetaminophen their competition.
They were bewildered.

Sunday, September 28, 2003

Weapons Grade Arrogance #1 

True story.
Last year the NEJM published an article that concluded: “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure” (N Engl J Med 2002; 347:81-88, Jul 11, 2002).
So…I thought the hospital quality committee should discuss the implications of this because chondroplasties are regularly performed.
I did not want to ambush the orthopedist on the committee. When we talked before the meeting about the article, he said:
1. “I already know about this”.
2. “I’m active in my national organization and we are busy calling and faxing to minimize the consequences”.
3. “We need to educate the primary care doctors not to believe the conclusion”.
4. “I don’t do surgeries that don’t work”.

Then, the last thing he said before hanging up:
I haven’t read the article. Do you mind faxing over a copy?

My Laws of Medicine 

1. New treatments are better than old treatments.
2. Doing something is better than nothing.

Since doctors don't know so many things, they resolve their own anxiety by recommending dubious interventions. Why is it so hard to say, "I don't know"? Plus, for some important medical questions, why can't we say, "Nobody knows"?

So, applying the Laws of Medicine explains why:
Doctor's say "the patient made me", and
Patient's say "the doctor recommended it".

When emotions trump science #1 

The local paper has the usual emotional appeal for a prostate cancer screening program.
They say:
1. "Putting men to the test saves lives".
2. "That's because the earlier prostate cancer is detected, the better our chance at beating it".
3. "A prostate exam, combined with...a PSA...is the most effective method for early detection".
4. "Crucial early detection improves diagnosis and treatment choices".

I say:
1. We don't know that yet.
2. The principle is true but it isn't proven for this cancer with this test.
3. True, but the only outcome that matters (death) is the issue. Besides, some people are harmed.
4. Except the "choice" has more to do with which specialist you are seeing, e.g. "if you ask the house painter if your house needs painting...".

I don't mind doing the shared decision making. It just takes longer than it should because of this kind of (mis)information.
Even drug company ads are required to include important negatives.
Unless the patient already has his mind made up, I give him a handout Prostate Cancer Screening Counseling Tools -- AAFP and tell him we can add the blood work later. Without the take home paperwork he isn't innoculated from others that weren't in the room when we had the conversation.

Saturday, September 27, 2003

Nature vs. Nuture 

I was born a skeptic.
Then, I graduated from the 21st grade, making me an educated skeptic.
Now, years of private practice and Evidence Based Medicine CME make me a trained skeptic.

Competing standards is an oxymoron 

Much of the stress in my professional life is either:
1. Primary care vs. speciality care, or
2. Evidence Based Medicine vs. conventional medicine

Dealing with patients is easy. Motivating doctors is hard.

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