Thursday, August 26, 2010

Join The NPA!

As physicians, we have many opportunities to join organizations of all kinds—trade and professional organizations, fraternal organizations, social groups, etc. And if my schedule is typical of others’, I’m sure you already feel overwhelmed by work obligations, finding time for family and friends and leisure activities. So I am aware that when I ask you to consider joining another organization it is necessary to explain what the organization is, what its mission is, and what makes it different from other areas of organized medicine.

The National Physicians Alliance (NPA; is a multi-specialty organization that I first learned about early in 2009. I can’t remember how I found them initially, but as I looked over the organization’s website I was struck by its mission and its dedication to re-establishing core values of medicine: service, advocacy and integrity. The NPA’s introductory video ( struck many chords for me. As a family physician who has spent all my career working with underserved patients, I have been struck by the inequalities and health disparities that currently exist in our health care system. I have been very concerned about working to bring quality health care to those who lack access through “standard” pathways. I was thrilled with the discovery of a group whose care beliefs and mission statement aligned so well with my goals and ideals ( The NPA's guiding principles include placing patients' best interests above all else, addressing the bio-psycho-social influences on health and focusing on community wellness as well as individual patient health; and emphasizing professional and collaborative approaches to care. Recently, the NPA has been an active voice in the health care reform debate, and has advocated for separating physicians from PhRMA and industry influence. These are positions not seen often enough or heard loud enough in more traditional medical organizations.

Physicians need to stay engaged in organized medicine. I feel that the VAFP and the AAFP represent me well on many professional fronts: payment and health care delivery reform, advocating for the specialty as a career and as a profession at state and national levels. However, by the nature of many large medical organizations, direct advocacy has been a smaller part of the VAFP and AAFP missions. Personally, this leaves something lacking. As is the case for so many of us, I entered medical school to make a difference. Medicine is a service career, and I feel that physicians must work to care for patients in any way we can. This can range from direct clinical care, formal political activities (such as contacting legislative leaders and key policymakers), teaching medical students and residents all the way to more direct advocacy such as writing letters to the editor, speaking with local media outlets, participating in public events to promote care and wellness for all.

To this end, I have become increasingly involved in the NPA’s efforts to push for better health for patients and a more fair and just health care system that adequately addresses the needs of all Americans, including the marginalized and the underprivileged. I am hoping to find other family physicians in Virginia who share this interest and who are interested in establishing a local action network (LAN) in order to further the NPA's national agenda while also establishing a group to address and act upon issues of local interest and importance. The NPA describes the roles of LANs as:

"The NPA's Local Networks are critical partners in the work of the national organization.  Some Local Networks work on issues championed by NPA on the national level, while others focus on more specific local issues that are consonant with the NPA mission.  This unique model allows NPA to partner with groups of physicians who are interested in our vision and could benefit from the organizational resources of the NPA. Local Networks, in turn, help to enhance the mission of the NPA by focusing on specific issues about which their members feel passionate and by expanding the network of physicians who find their professional home at the NPA."

With this year’s passage of health care reform and the challenges and opportunities inherent in its implementation, these are exciting (and sometimes scary) times to be a physician. Even as our health care system is poised to improve health for all Americans, the final outcome is far from certain. I have found the NPA gives me a voice towards advocacy on behalf of patients that energizes me and that has made me more willing to step forward during these turbulent times. I feel that I am doing the right thing, by my oath to always put patients’ wellness first and by my belief that as physicians our voices need to be heard. I hope that you agree with me, and I hope that you are willing to join me.

Tuesday, August 17, 2010

Oh, By The Way...New Blog!

Since I clearly don't have enough on my plate yet, the collaborative Social Media Healthcare blog is going live, with the first post tonight.  Hopefully it will become a site for discussion, thought, and collaborative discussion.  If you have the time and interest, check it out.

A Pause, And A (Somewhat) New Beginning

As might have become amply evident at this point, this blog is not following the path its name implied.  When I started writing here, way back when, I was hoping to discuss issues surrounding health care in underserved and marginalized communities.  However, with health care reform last year and early this year, as well as many opportunities to comment on issues of the day, my plans have been diverted.

I still hope to discuss issues surrounding underserved communities and health care, but it will evidently be through a broader, health care reform perspective.  I think this is still relevant, considering that health care reform will change the landscape for health care in and for marginalized parts of the US, but I wanted to bring this out in the open in case the blog name/title deceives.

Meanwhile, my professional situation has changed somewhat.  Rather than working full-time in Southside Richmond,  I am now splitting time between that community practice and the family medicine faculty practice at the medical center.  This change will hopefully be a positive move: I'll be more involved in teaching, can start thinking more about research ideas, and can be a resource to students who might have interest in family medicine as a career.  The kicker, though, is that I will not be working as often with underserved or uninsured patients.  The faculty practice usually does not work with the hospital's patient assistance program.  The department has been very generous, and has made it such that any patient I was already seeing who has coverage through the patient assistance program will be able to continue seeing me, but I won't be taking new patients covered through that program.  As a balance, I will be helping staff a medical and pharmacy student teaching clinic at a free clinic on Southside. 

Although I am excited about this, I feel a little conflicted: I have talked the talk about the need for docs to work with patients who lack access to care that I feel self-conscious about walking the walk to a different practice site.  I believe that working with the free clinic and with the largely Spanish-speaking, mostly Medicaid-covered community on Southside will continue to drive me as my mission.  But it will take time to adjust.

This family medicine department is my home department: this is the medical school from which I graduated, and the department is the one with which my residency was affiliated.  I feel very welcome here, and have found many kindred spirits.  So I move on, sort of, but I also settle in.  But I will always keep working to do what I think is right for patients: both those I directly care for, and for what I perceive as the greater good.

Sunday, August 15, 2010

Yes, PhRMA Can Be Considered A Bad Player

Recently, over on one of the site's contributors wrote a post asking if drug companies and the PhRMA industry deserve to be considered bad guys/bad players in health care.  The writer's answer is no, PhRMA and drug companies should no be considered villains.  He notes the profit the companies make, but defends this on the need to make profits off of new products in order to ensure the ongoing supply of new medications and treatments for illnesses.  He contends that without such financial security, pharmaceutical companies will stop pushing the boundaries of drug development and instead will produce a large number of "me-too" drugs that offer little added value to health care.

Unfortunately, the author does not seem to accurately appreciate the true environment in which big PhRMA operates.  Marcia Angell, in her book The Truth about the Drug Companies has already undercut most of this post's author's claims.  Angell points out that much "research and development" (R&D) money spent by PhRMA is spent on turning out nothing but me-too drugs.  Do we really need a 7th or 8th cholesterol pill, or the 6th member of an established class of blood pressure pills?  It's  true that these meds may provide incremental benefits for a small number of people, but they truly offer precious little to our choices of drug therapy.  Even worse, many of these me-too medications are small chemical tweaks of the companies' own medications that are going off-patent (meaning the company will make much less money off of them).  So, we get Nexium as Prilosec goes generic, Pristiq replaces Effexor, Clarinex picks up for Claritin.  There is no convincing evidence that these medication changes benefit health in any way, but they cost much more than the generic versions the are trying to supplant and keep the patent's profits safe for a while longer.  However, all these me-too drugs and second generation patent-extenders have to be treated as new medications, resulting in significant R&D costs that increase medication costs and do not really improve anyone's health (outside of the financial health of the companies and investors).

The writer laments that if we demonize PhRMA we might end up with "Another drug for heartburn that is no better than all the others on the shelf" or "lots of drugs that we don’t really need."  However, somehow he doesn't realize that we are already exactly there--because PhRMA can make money hand over fist under this system.  New meds are compared against placebo (no treatment) instead of being tested against already-established treatments.  So long as the new med is literally better than nothing, then it can be approved and marketed.

Even worse, truly cutting edge research is usually too expensive for PhRMA to pay for on its own.  Instead, this type of research is often government-funded (including NIH funds) and is carried out in universities (including state-funded universities).  Once the research gets close to a point where it can be leveraged into therapy, PhRMA can buy the patent and develop their medication.  Then, they can sell a product developed with public money right back to us with a much higher price tag.  Maybe PhRMA is working on that vaccine against cancer the author mentioned.  I doubt it.  More likely, they're waiting until NIH and/or university-funded research gets close, then they'll swoop in and take the credit and the profit.

We also get lots of lifestyle medications that help symptoms but don't necessarily save lives or improve health very much.  Medications for heartburn (such as Nexium), allergies (Clarinex), erectile dysfunction (Viagra) and various cosmetic uses (such as Vaniqa) are incredibly expensive and cost much money to develop but typically offer minimal benefits in the big picture.

So, no: I don't feel bad about attacking big PhRMA.  I have no worry that they will suddenly cease their "lifesaving" R&D because I think relatively little of what they do qualifies as such.  (I can't tell you how much of PhRMA's R&D is true fundamental research--they haven't released that info in the past.)  Instead, I look at the ridiculous costs for me-too drugs offering little added value.  I look at the fact that new cancer treatments can cost tens of thousands of dollars yearly.  I look at PhRMA's aggressive direct-to-consumer advertising.  And I look at the paucity of genuinely new developments that would stand to benefit the millions of people across the world facing life-threatening infections and chronic diseases that happen in places where people have no money.

The big PhRMA industry is a devil's bargain.  We don't have any other method in the US of getting medications produced and made available because the free market system calls for private industry filling this role.  So that's what we're stuck with, even when pharmaceutical companies are suddenly unable to supply life-saving medications.

I do want to note that I do NOT consider all the people who work for PhRMA to be bad people.  I have very good friends who work in the industry in various capacities.  But I think that PhRMA's role is a flawed one from the very top, and no number of committed and honest and hardworking people can cancel out the fact that the industry as a whole is a bad actor.

So that's the system we have, and those are the limits we face.  But let's be honest and forthright: for the occasional positive impact, big PhRMA costs us an incredible amount of money for precious little return.  In my book--and in this age of new-found awareness of the importance of cost-containment and evidence-based medicine--I feel this is enough to earn PhRMA a bad-guy label.

Friday, August 6, 2010

Some Further Thoughts On Healthcare Communication and Social Media

In an earlier post, I made a brief mention of healthcare communication and social media (HCSM).  Now, ideas for a new blog are slowly starting to come together.  This blog will be an outgrowth of a weekly Twitter conversation regarding HCSM (# HCSM, Sunday nights from 9 to 10 pm on the East Coast) and will be based on the idea of developing ideas brought up during that discussion and try to flesh things out further.  The blog will live at an eye on the site, as we hope to have content developing relatively soon.

I'm cross-posting my first comments for the SMHCOP blog here, because I think HCSM is a topic that will become increasingly relevant.

“Social media” (SocMed) is a phrase with nebulous meaning.  There are various definitions available, but the formulation that is easiest for me to understand is to consider “social media” as a group of web-based applications and services that allow user-generated content to be distributed and/or viewed online.  This would include such sites as Twitter, Facebook, YouTube and blogging sites including Blogger and Wordpress.  At their essence, each of these sites/services (and many, many other sites not mentioned) allows an individual to find a forum for making their opinions and perspectives known to the world at large.  Although the nature of these services differ widely, the common link is anyone (with luck, hard work and expertise) can add to online discussions and express their opinions while also making connections with other users—regardless of where one might be.

The speed at which SocMed is being adopted has accelerated over recent years, and as a result it is becoming a topic of interest in many different areas.  My principle interest is in determining the use of SocMed tools in health care communication.  Physicians and other providers can enhance their online presence (and possibly, their business) by actively engaging in SocMed.  Health care information, treatment recommendations, and public advisories can be distributed widely and to varied audiences through SocMed.  Patients can learn about wellness and illnesses, can join virtual communities and support groups, and can have an influential voice in SocMed in ways that may be difficult in person.  Patient advocates, researchers, and medical educators can all make contacts and exert influence and discuss ideas with new collaborators that would have been hard to identify before SocMed facilitated interactions.

I believe that SocMed’s influence is going to start effecting health care communication and health care practices in the near future.  How doctors and patients interact, how we communicate both personally and professionally is likely to change.  Use of SocMed technology and services may improve patient-oriented outcomes in a number of illnesses.  Novel educational strategies, for patients and for clinicians, will be developed and we will need to determine their appropriate uses.

I think this conversation is still in the early stages.  Significant barriers to use still exist, and conventions of use still need to be established.  How SHOULD doctors interact with patients online?  How do you ensure patient privacy and confidentiality when communicating online?  The conversation can also extend beyond web-based SocMed resources and include furthering e-mail and/or text message conversations.  All of this is still developing, but I believe this is a good time to get involved.  As physicians, if we do not help direct the process, then the process will eventually direct us. 

SocMed has the potential to empower patients, make medical care more efficient, and enhance communication in many dimensions of health care.  We should be looking at ways to ensure this will benefit all parties.

Thursday, August 5, 2010

It Is A Privilege To Be A Physician

It is all too easy, these days, to complain about a physicians' lot--especially in primary care.  We are always pressed for time.  Reimbursement is insufficient.  Insurance company billing forms and prior authorizations are ridiculous.  We put in long hours away from friends and families and never seem to get ahead.  In primary care, we see colleagues in other specialties spend less time in the office, keep more friendly hours, and came away with better pay.  There are some days when one feels it would be a better option to be anything but a physician.

Then you read things like this speech by Donald Berwick, who was recently appointed to head the Centers for Medicare & Medicaid Services (CMS).  There are some medically-related writings out there that are inspirational, insightful and help keep things in focus.  Dr. Berwick's speech is one of these writings.

I am not going to say much more, except to urge you to take the time to read the transcript linked above.  It will only take a few moments, and will make a lasting impact.  Whether in the medical field or a patient, this is moving and reminds us of key facts: the focus of health care and health care encounters should be on the patient's wellness, and that we are privileged as physicians to be given the opportunity to work with patients and to help them in their times of need. 

"What is at stake here may seem a small thing in the face of the enormous health care world you have joined.   It is as a nickel to the $2.6 trillion industry.  But that small thing is what matters.  I will tell you: it is all that matters.  All that matters is the person.  The person.  The individual.  The patient.  The poet.  The lover.  The adventurer.  The frightened soul.  The wondering mind.  The learned mind.  The Husband.  The Wife.  The Son.  The Daughter. 
[...] Those who suffer need you to be something more than a doctor; they need you to be a healer.  And, to become a healer, you must do something even more difficult than putting your white coat on.  You must take your white coat off.  You must recover, embrace, and treasure the memory of your shared, frail humanity--of the dignity in each and every soul.  When you take off that white coat in the sacred presence of those for whom you will care--in the sacred presence of people just like you--when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, and "aching" world...that has never needed healing more."