Money and medicine: the Nexium swindle

If you live in the United States, you have almost certainly encountered advertisements for Nexium (esomeprazole), a prescription medication for heartburn relief. Its ad slogan is "the purple pill." (If you live in any other developed country, your government will have forbidden advertising a prescription medication over the television.)

Nexium is a drug that shouldn't exist. It contains the exact same active ingredient*, in the exact same amount, as an older drug, Prilosec. Prilosec (omeprazole) is currently available over-the-counter as a relatively inexpensive generic drug. But Nexium is currently the third-highest-selling prescription medication in the U.S., with sales of over $6 billion a year.

How could this have happened?

The abbreviated version of the story is that years ago, AstraZeneca, which originally manufactured Prilosec, recognized that it would lose billions of dollars in sales once Prilosec lost its patent protection. And so, it developed Nexium and set in motion an enormous advertising campaign. It gave incentives to doctors and patients who switched their prescriptions from Prilosec to Nexium. The plan worked beautifully. This "Nexium swindle" is just one of many unethical but legal practices in the pharmaceutical industry that each year net tens of billions (possibly hundreds of billions) of extra revenue.

Many issues in health care (doctor shortages, expensive health insurance, steep medical school tuition, difficulty in getting a primary care physician, burnout amongst medical providers) really could be solved with more money. And yet Congress, under pressure from the pharmaceutical lobby, has mandated that Medicare pay full price for prescription medications. Congress also forbade Medicare from keeping a formulary of preferred drugs. It amounts to a massive ongoing handout to the pharmaceutical industry.

We ought to stop paying for useless drugs like Nexium, which have excellent and dramatically less expensive alternatives. If every patient on Nexium were switched to Prilosec (which is virtually the same drug), there would be enough money to pay for every current medical student's tuition, with billions of dollars to spare. And that's just one drug of many.

America is being scammed, and very few people realize it.
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 *The key difference between the two drugs is that omeprazole contains an inactive ingredient that is absent in esomeprazole. For those who know a bit of organic chemistry, omeprazole contains a racemic mixture while esomeprazole has only the active enantiomer. Unsurprisingly, the manufacturer has had a difficult time showing any difference in effectiveness between drugs.

"The Woman Who Decided to Die", by Ronald Munson

Perhaps I feel partial to this book because Prof. Munson's introduction to medical practice came the same way mine did: through the lens of clinical ethics. Munson is not a physician, but a bioethicist. His book, "The Woman Who Decided to Die," features 10 vignettes of striking, yet representative ethical predicaments that he has encountered over his career. Munson is a gifted writer, and this book benefits from his succinct, rich, and approachable form of narrative.

The format of the chapters is straightforward: in each, he tells the story of a patient he has worked with. Then, he devotes a couple of pages to the ethical issues inherent to the case, and how doctors approach these issues clinically. For example, a convicted murderer is admitted to the ICU with a failing heart. Prof. Munson is called in for an emergency consultation to determine whether the patient should be put on the transplant list. Should a murderer get a heart before someone innocent?

Perhaps surprisingly for a book about ethics, the book vividly portrays the patient's stories, through the help of lengthy interviews with the patients. Munson also conveys very well the art of medicine. Through his writing we witness the thought process going through the minds of doctors, and the delicate and careful ways that they elicit information from their patients and provide guidance. The book discusses complex issues in medicine in a way that non-scientists can understand, which is rare.

Prof. Munson has written an excellent book. I heartily recommend it as an introduction to clinical medicine and bioethics.

Now, go pee in this cup

Some moments in medical school are surreal.

Our morning lecture concerned urinalysis (a standard set of important laboratory tests done on urine samples). We were all issued specimen cups and instructed to obtain urine samples (i.e. go pee in our cups). Throughout lecture, students slipped out of the auditorium and returned toting transparent containers that now were partly filled. When lecture ended, we tromped upstairs, specimen cups still in hand, and then as a group performed medical assays on our urine. Since most people's urine was normal, we hunted for classmates whose urine had abnormal findings, like crystals, blood, nitrites, or white blood cells.

It's entirely sensible that this activity was conducted the way it was. We need to learn how to perform urinalysis, and for technical reasons the urine ought to be fresh. We're at a stage in our training in which we're expected to be professional and comfortable handling bodily fluids.

But the image of me and my classmates, walking the halls of our school each carrying a plastic cup filled with his own urine, is pretty weird. Just another day in the life of a medical student.

Needless suffering

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I attended a talk by Dr. Howard Koh, the current Assistant Secretary for Health. While practicing as a physician, he encountered too much of what he called "needless suffering." He gave as an example a young father whose potentially-treatable cancer had been diagnosed too late, because he lacked health insurance. Dr. Koh decide that he ought to enter public health and policy, so that he could improve the way health care is delivered and help many lives.

Many of our country's children suffer needlessly, whether from violence, from poverty, from abuse, from preventable diseases, from motor vehicle accidents, from broken schools, from obesity, from broken homes, from lack of opportunity, and on and on. I say "needlessly" because many of these problems could be at least partly fixed, if only we made doing so more of a priority.

And yet we are reversing past gains. The life expectancy for certain segments of our population has been dropping over the past years. For example, the life expectancy of white women without a high school diploma was 5 years less in 2008 than it was in 1990. We are needlessly losing ground.

Our country has united in mourning the 20 children and 6 adults in Newtown, CT whose lives were cut short. Our profound feeling of loss ought to remind us that life is precious, and that one of our highest callings is to love our fellow man and protect our youngest. I hope that their memory will compel us to alleviate that suffering which needlessly afflicts those among us. Our work is cut out for us.

Book recommendations

I like reading books about medicine, and I have found some of them particularly gripping and enlightening. You might enjoy them too. All of these books were written for a general audience.

Practice of medicine
-"Complications," by Atul Gawande
-"Incidental Findings," by Danielle Ofri
-"Better," by Atul Gawande

Cancer
"The Emperor of All Maladies," by Siddartha Mukherjee

Neurology
"The Man Who Mistook His Wife for a Hat," by Oliver Sacks

Medical ethics
-"The Woman Who Decided to Die," by Ronald Munson

Medicine in literature
-"The Plague," by Albert Camus

Big Pharma
-"White Coat, Black Hat," by Carl Elliott
-"The Truth about the Drug Companies," by Marcia Angell

Medical errors
-"Internal Bleeding," by Robert Wachter and Kaveh Shojania

Infectious disease
-"The Great Influenza," by John Barry
-"The Coming Plague," by Laurie Garrett
-"The Hot Zone," by Richard Preston
-"House on Fire: The Fight to Eradicate Smallpox," by William Foege

Endocrinology
-"Why Zebras Don't Get Ulcers," by Robert Sapolsky

Medicine during wartime
-"Long Walk Through War," by Klaus Huebner

Emergency medicine
-"The Blood of Strangers," by Frank Huyler

Today's events

I was touched by our president's heartfelt remarks on today's shooting at a Connecticut elementary school:



In reflecting upon this tragedy, I see the deceased not only as victims of gun violence but as victims of mental illness. Those of sound mind do not massacre children.

As we reflect on how we can prevent future violence, I submit that in addition to tightening up our gun-control laws (why can people still lawfully obtain high-capacity magazines?), we might combat criminal insanity by strengthening our country's debilitated and woefully underfunded social support programs. Making mental health treatment more accessible will prevent some would-be shooters from ever having the intention to kill.

My thoughts are with the victims and their families.

(from "Willa's World")

Money and medicine: medical schools and primary care

I attended a talk by the dean of admissions of one of the most competitive medical schools nationwide. The topic was primary care and community health. He talked at length about how not enough medical students were entering primary care. He put up some graphs showing that the most lucrative specialties tend to be the most competitive ones, with primary care among the lowest-paying and least-competitive. He said that medical schools need to be making primary care more appealing. And he talked about how, in his long tenure as dean of admissions, he has been steadfastly committed to selecting those applicants who are committed to becoming the next generation of leaders in primary care.

I went up to the dean afterwards and alluded to the fact that nearly all graduates from his medical school go into medical specialties instead of primary care. Has his school considered creating a loan forgiveness program for students who pursue careers in primary care, giving them an added incentive to enter the field?

His response: "There's no need for such a program, because I'm confident that our medical students don't choose their specialties based on financial considerations."

Me: "But during your talk you put up a graph showing that medical students nationwide do exactly that."

Dean of admissions: "Our graduates have some of the lowest debt levels in the country, so financial constraints aren't a concern."

Me: "If financial constraints aren't a concern, and if you're admitting students based on their likelihood of going into primary care, then why are so many of those admitted students going into specialties? Is it because it's difficult to predict what specialty an applicant will eventually pursue?"

Dean of admissions: "Not at all. We're quite good at picking the right students..."

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And so, this fruitless conversation dragged on for longer than it should have.

The dean of admissions may well care passionately about primary care—after all, he cared enough to give a talk on that topic. But his school certainly doesn't see its mission as training primary care doctors, a notion borne out by the careers its graduates enter. And why would the school care about primary care? Primary care doctors tend not to make the big-deal research discoveries that net Nobel Prizes. They tend not to accrue the sort of wealth that would someday allow them to endow professorships. They tend not to invent new procedures and new drugs. Their work goes largely unnoticed, except by the patients they care for.

If schools truly cared about training primary care doctors, then they would reduce the financial barriers to entering primary care. They could do so by defraying the tuition of those who commit to enter primary care, or by forgiving some of the loans of those students who enter primary care. In fact, some top law schools do exactly this for those students who commit to entering careers in public service or as public defenders. Some business schools do it for MBAs who work for non-profits.

But I don't think most medical schools care, and this ambivalence rubs off on its students. It's one of the contributors to the dearth of American medical students entering primary care.

More on money and medicine in subsequent posts.

Money and medicine, introduction

From a well-written Business Week article on concierge medicine [emphasis mine]:

The [Affordable Care Act] will enable 30 million previously uninsured people to get coverage through an expansion of Medicaid. They’ll need primary care, but it’s not yet clear who will give it to them. By 2020, the Association of American Medical Colleges estimates, there will be 45,000 fewer primary-care doctors than the U.S. needs. “For the last 13 years, very few students have been going into it,” says Patrick Dowling, chairman of the department of family medicine at the University of California-Los Angeles’s David Geffen School of Medicine. “What motivates medical school students is income, just like everyone else.”  

What's supposed to set physicians apart from other professions is a deeply-held code of ethics, which demands that one place the patient's interests ahead of one's own. If Prof. Dowling is correct that income truly is what motivates medical students, "just like everyone else," then this code of ethics no longer applies. Medicine is simply a business, its physicians no different from financiers and salesmen. It appears that Prof. Dowling has ceased to believe in his profession.

In my next posts, I will explore money and medicine. What motivates medical students, if not income? Why, when our country spends the most (per person, in absolute expenditure, and as share of GDP) on health care in the world, is America's health so lackluster? Where does the money go? How can the system be improved? What will the Affordable Care Act do to medicine? I also invite you to write a comment about what topics might interest you.

A sad day

The purpose of the present Convention is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity.

—from the United Nations Convention on the Rights of Persons With Disabilities, an international treaty that came up for ratification in the Senate yesterday. 126 countries have already ratified.

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This is one of the saddest days I’ve seen in almost 28 years in the Senate, and it needs to be a wake-up call about a broken institution that’s letting down the American people.

—Sen. John Kerry (D-MA), after Republican senators yesterday voted down the ratification of the treaty.

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According to the Kaiser Family Foundation, other international treaties pertinent to global health that the Senate has also declined to ratify:

• the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW);
• the Convention on the Rights of the Child (CRC);
• the Convention on Biological Diversity;
• the Kyoto Protocol to the United Nations Framework Convention on Climate Change;
• the Stockholm Convention on Persistent Organic Pollutants (POPs);
• the WHO Framework Convention on Tobacco Control (WHO FCTC);
• the Cartagena Protocol on Biosafety to the United Nations Convention on Biological Diversity;
• the Convention on the Protection and Use of Transboundary Watercourses and International Lakes (Water Convention);
• the London Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes; and
• the Ottawa Treaty (Mine Ban Treaty).

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The United States can hardly consider itself a world leader in health when it abandons so many worthy global health efforts. And now, in rejecting the United Nations Convention on the Rights of Persons With Disabilities, we have deserted the cause of those least able to help themselves. A sad day indeed.

This is your brain on football

From a previous post in January:

Football seems to subject its players to enough physical and neurological risk that I expect I'll discourage my future patients from joining a competitive football team. Friends of mine who played Division I college football loved it and have gone on to play professionally. They continue to live and breathe football. But I noticed a toll—frequent concussions, dramatic injuries and surgeries, shocking addiction to painkillers, and a difficulty in balancing the competing demands of being a student and of being a quasi-professional athlete.

Scientists are finding that the constant hits (even "microtraumas" that don't rise to the level of concussions) that football players endure can cause chronic traumatic encephalopathy (CTE). CTE is a progressive, untreatable, dramatic, and ultimately fatal decay of the brain that can only be diagnosed post-mortem. Researchers are increasingly conducting autopsies on NFL players and college football players, and they are finding shockingly widespread evidence of CTE. Even deceased players in their 20s and 30s are turning up with CTE, which is otherwise seen only in the elderly. The science in this field is preliminary, yet it is increasingly clear that professional, college, and high school football is a tremendously risky endeavor.

I really do enjoy gridiron football, and on the brisk evening of a big college game I was one of the shirtless guys in the stands wearing body paint. Yet recently I've stopped attending games and I even feel conflicted about cheering my home team while I watch on TV. Wouldn't it make me a hypocrite to say one thing to my patients and do another? Am I taking all of this too seriously?

Moments ago, a big-deal paper out of Boston University (BU) was released by the journal Brain. The BU team discovered 15 previously-unknown cases of CTE in former NFL players. That means that of the 34 brains of deceased NFL players examined so far by the BU team, 33 have been found on autopsy to have CTE. The team also diagnosed CTE in some football players who didn't play football beyond college or high school, as well as in some NHL hockey players. The paper also looked at controls (patients who played sports besides hockey or pro football) and found few with CTE. The team also catalogued the devastating neurological symptoms suffered by the players with CTE, like depression, explosivity, and dementia. It strikes me as a thorough and well-done paper with major findings.

In my mind, the release of this paper is a watershed moment. The science on CTE is in. Football clearly destroys some of its players' brains. The questions at this point are how many of its players are affected, and how badly.

I don't feel conflicted anymore. Until the sport changes, I'm done with following football.