Bigger, Better, Faster – The Ethos of American Medicine
My lab coat pocket holds two pens, a Xanax pen and a Pharma free pen. The only difference between the two is the Xanax pen is much nicer, although they serve the same purpose. There’s a central dogma that runs through UC Davis’ medical school class: Pharma is an evil corporate entity. Whether this is entirely true is hard to say.
I had lunch today with a preceptor and two drug reps selling SSRIs and drugs for PD. After the required ice breaker conversation about the upcoming holiday season, I had a refreshingly candid conversation with the reps. We mostly talked about the SSRI’s. The guy was honest. He showed us charts showing that the drug was effective at treating depression on a head-to-head trial with another drug. Then he showed us that the side effect profile of the drug he was promoting was much worse and that the doses used for the trial would probably not be tolerated well by most patients. In addition, he showed us that the study conducted by the company was skewed because it carried efficacy of the drug after patients dropped out of the study due to side effects, which made the drug seem a lot more effective than it actually was in reality. He wasn’t trying to sell the drug to us.
I learned a lot of useful facts that I didn’t learn in medical school. I learned half-lives of the most popular drugs, the most popular drugs on the market, who is using what, etc. I know that as a physician, I should be keeping up with the latest literature, but I couldn’t help but think that I would surely love to have this guy coming around every few weeks to update me.
I’ve got to admit, the advertising was slick. He provided lots of free trial samples of antidepressants. Since patients respond differently to drugs, it didn’t seem like a bad idea to have patients try out the sample if another drug didn’t work. If it didn’t work, no harm done, if it treated their depression, then great.
There are so many SSRI’s. They’re all in the same class, so they should all work the same in patients, right? One of the biggest assumptions held in medicine is the idea of class effect. The medicine camp is in many ways highly divided on this issue. Metoprolol was shown to save lives in CHF, so the generic atenolol must too. There are some who refuse to prescribe the generic because the tests were carried out in the brand name drug. I wonder how safe it is to assume that all drugs are created equal. Patients trust our word and believe us when we say the drugs are identical. Why is it that Baycol (Cerivastatin) led to more problems than the other drugs in its class? It’s hard to say. It seems very easy for patients and doctors alike to get caught up in the thinking that newer is better. Patients want to be the guy on the commercial playing with the blue balloon.
It’s a very dangerous path to tread, allowing a drug rep to tell us which drugs are better. There were definitely moments where I was uncomfortable. Certain insurance companies were not covering the drug in its formulary. The drug rep made note to get to work on the Blues. Sometimes it isn’t clear how to help our patients or even how to do no harm.
In trying to understand how best to treat our patients, how do we avoid the risk of turning the art of medicine into the business of medicine?
-bender
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