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Friday, October 23, 2009

First Do No Harm, and Do it Cheaply!

Sometimes the most frustrating thing about being a doctor is watching some of the things my other colleagues do. Specifically I am talking about drug prescribing habits.

Back when I was a family practitioner, I was constantly inundated with pharmaceutical representatives, so many in fact that I eventually had to limit the number of them I would see each week. Now, I have nothing against drug reps and unlike so many today, I have nothing against all those "evil" drug companies.

Evil drug companies are a good thing. They do research. They invent and perfect many new drugs. I marvel at all the new and wonderful things that have been invented since I started practicing 30 years ago. As with everything else in a free market society, results and new inventions come with a price tag. Many of these new drugs are very expensive. Again I will not criticize the companies. They had to invest millions of dollars in researching effectiveness and safety. These companies are owned by stockholders (you and me and everyone else that has IRA's and 401K's) and the companies are beholding to those stockholders. The stockholders expect profits and dividends. Without profits the companies won't be around very long. I suppose you've noticed that most of those on the left take pleasure in demonizing the drug companies, but think where we'd be if we didn't have all those wonderful medicines that increase our lifespan and reduce pain and suffering! Those on the left I guess would have us go back to a time where people died of illnesses we consider trivial today.

The job of the drug rep is to visit the doctor, give a presentation to the doctor concerning new drugs, and ultimately try to convince the doctor to prescribe their new drug. Realize that the drug rep is generally going to present information that will cast a favorable light on their new drug. Realize that sometimes the studies they will show us may not have been performed in the most scientific manner. It is up to us to always be skeptical and one question that I always asked was. "How much does it cost the patient?"

Unfortunately, many of my colleagues and to a greater degree nurse practitioners seem to be mesmerized by the claims of drug reps and don't bother to investigate the validity of claims. Furthermore, a bunch of them seem to give no thought to the expense of the medicines they are prescribing.

Understand that out of every 100 or so patients a family practice doc sees, that probably 80 of them will have complaints that in reality require no attention. They will get better if you do nothing. Out of the remaining 20 percent perhaps three or four will have really bad stuff happening and may in fact die if you don't do something. The rest of the 20 percent will require varying degrees of medical attention to return them to good health or at least status quo. Part of the art of medicine is deciding between who is really sick and who is just worried.

Also, most of the 80 percent who are going to get better no matter what, expect YOU TO DO SOMETHING, so in the interest of good customer relations many times we need to invent some kind of good treatment. This brings us back to the number one rule of medicine which says, "First do no harm." I might add to that, "First do no harm and do it cheaply."

Now you can't really blame us for this. The "you gotta do something" philosophy is part of the culture and it starts at the top with all the Bozos in congress. "We gotta do something! We gotta do something! We gotta get a bill! We gotta get a bill!" How many stupid and intrusive laws have been created out of the "let's get something done mentality"? Alas I digress…………..

It never fails but when a drug rep comes around with a brand new fancy antibiotic, in a very few days you'll see people with colds and flu and a variety of other minor ailments receiving that brand new antibiotic usually at a price of between 50 and 100 dollars and sometimes more. Of course, the patient will take this new expensive antibiotic, and after a week or 10 days, they will be all better. "Oh! What a glorious new antibiotic that was!" they will say.

I have to just shake my head. If the same person had taken a sugar pill, I know in my heart they would have been better in the same length of time, and they would have had an extra 50 or 100 bucks to spend on beer, cigarettes, or pizzas. I have always said, "If you're going to try and kill a virus with an antibiotic, at least use a cheap antibiotic."

The sad truth is that the new high priced antibiotic should have been reserved for one of those really sick folks in the 20 percent crowd.

Back in the 1930's and 40's when sulfa and penicillin came along, those drugs killed just about every bacterium that crawled. Over the years as antibiotics have been prescribed more and more for less and less serious illnesses, antibiotic resistance has skyrocketed. Now days we have "superbacteria" which are resistant to most every antibiotic. Those evil drug companies face a constant struggle to develop new and more powerful antibiotics to fight the resistant bacterial strains. As the new drugs are overused by healthcare professionals, those same drugs also lose their effectiveness due to resistance. It is a vicious spiral so it seems.

Speaking of antibiotics, I am of the opinion that for most "run of the mill" events, generic antibiotics work just fine. In fact with a few notable exceptions generic drugs work just as well as brands and they are vastly cheaper.

Generic ampicillin, ciprofloxin, or doxycycline, will only cost you a few bucks at the pharmacy and in most cases will do everything the new 100 dollar supercolossal antibiotic will do. I take simvastatin (Zocor) for cholesterol. Before it went generic a month's supply was almost 100 bucks. Now I can get the same drug in generic form for about 6 bucks. I see ads on TV all the time for things like Crestor and Lipitor….fancy names at fancy prices. There are no convincing studies that these drugs are any better than my generic simvastatin. My last LDL cholesterol (the bad kind) was 62. I don't think I could do much better with a brand.

So here we are in the 21st century griping about the high price of American medicine. Who is to blame? I blame our congress and our culture and the nanny state mentality that seemingly has engulfed us. I blame insurance mandates that force insurance companies to sell us coverages at inflated prices that we don't want. I blame regulations that won't allow us to purchase health insurance across state lines. I blame trial lawyers for obvious reasons. Finally, I blame many of my colleagues for ordering expensive tests and prescribing expensive medicine when more economical choices would suffice.

In medicine as with every other endeavor in life, a little common sense will go a long way.

The next time your doc or (gasp!) nurse practitioner wants to write you a 100 dollar antibiotic prescription, ask 2 questions:

1.Are you trying to kill a virus with this?
2.Will a cheap generic drug work just as well?

The nurse practitioner will probably break into tears and tell you to rush to the emergency room. The doctor will either get mad at you, agree that the generic will probably be fine, or take time to explain to you why the brand name would be better in this case. If the doc gets mad, it's time to find a different doctor.

Keep Smiling!


  1. That was a good informative post Grouch. I always had suspected something like this, but to have it more or less confirmed is great. I was a dental tech in the navy many years ago, too many to mention here. I would often have the duty on weekends at the clinic at the Naval Air Station at Kingsville, TX. The dental officers were not required to stay on base on the weekends and the particular one on duty could be reached only by phone. So we often found ourselves giving emergency treatment such as putting temp. sedative filling in aching teeth and of course passing out APC's sure you know what they are. I had some I had dyed purple using a common lab stain and I would give the swabby with the bad tooth ache four of the regular APC's and one purple one and instruct him to take the white ones and only as a last measure to take the purple and to flush it down the drain if not used. The surprising thing is that many told be the white ones had no effect, but upon taking the purple one, immediate relief. I was a young 19 year old those days , but did have some fun in and out of the clinic.

  2. Interesting about the purple APC's. Proof positive of the placebo effect. When I first became a doc, codeine was the big drug for mild to moderate pain. Later on, hydrocodone came on the scene. No doubt about it that hydros are superior to codeine. They are more effective, cause less nausea and less constipation. Unfortunately the abuse potential is much greater.

    I remember one particular drug rep that came around years ago marketing his hydrocodone product. It was a BIG, mean looking, red and black capsule. I commented that it really looked like some SERIOUS medicine. In fact they had done research on the size and color of the capsules and the big red and black capsule was the preferred package.

    Today, I have more or less stopped writing for hydros, due to the abuse problem. In fact I have pretty much gone back to codeine. It was good enough in the old days so I guess it's just fine now.

  3. Nice article. Both what you say Grouch and what Ron says has been proven time and time again over the years. I don't see why others in the medical profession don't always try to give the least expensive drug to their patients.

    I remember when we had our office, we would save up all those samples the drug reps left with us for those patients who had no extra funds to buy meds with. You would always write the cheapest prescriptions for everybody.

    Deborah F. Hamilton
    Right Truth

  4. Indeed, I have always tried to hep out patients in need whenever I can.

    Nevertheless, I am accused of being a racist and a greedy SOB by the likes of Lizzard's lunatic daughters and apparently most on the left and in the Obama administration.......

    Funny thing......I sleep just fine and I'm comfortable in my own skin!

  5. Well put and well said! I wholeheartedly agree.
    However, you still ARE a racist bastard! BUT, that's one of your endearing qualities!