Beware of Politicians Bearing Gifts

I just read an article on Medscape.com that started my "Spider-sense tingling". I have an almost visceral mistrust of people who try to bribe you, and this seems to fall into that category. See what you think...

http://www.medscape.com/viewarticle/577700?src=mpnews&spon=34&uac=76986SV

The part I like the best is the following:

There are 4.4 billion prescriptions written annually in the United States.

The National ePrescribing Patient Safety Initiative, a coalition of health care and technology companies including Dell, Aetna, Microsoft, Google and WellPoint, has offered to provide e-prescribing software from Allscripts to any doctor for free.

On July 1, the two biggest e-prescribing networks announced that they were merging to form a single, secure, nationwide network for e-prescriptions and exchanging health data.

RxHub, a joint-venture of pharmacy-benefit managers CVS Caremark, Express Scripts and Medco Health Solutions, joined forces with SureScripts, a private company formed by the National Association of Chain Drug Stores and the National Community Pharmacists Association.

"We're really focused on seeing how we can help the market get to the elimination of the paper prescription pad," said Rick Ratliff, co-CEO of the new SureScripts-RxHub.

Uhhh...Why? And don't try to tell me that the largest drug stores, the largest medicine shipping company, and the entire computer industry are in this unholy alliance just for patient advocacy. There are billions to be made if we sheep will just fall in line. And what better way to make that happen than to use everyone's favorite bait - money?

The really hilarious bit, however, is that there is no better demonstration of just how far the medical profession has fallen than to see just how little people are willing to use for attempting to bribe us. I mean, seriously. Why don't you just spit on us while we're down. What are we, 1940s bellhops? "Hey, guys...uh...we'd really like you to buy all this new equipment. Not sure about it, huh? Well...uh...we have a couple of friends that I think might be able to talk some sense into you. Say hello to Abe Lincoln...and this is his friend George Washington."

This reminds me of an old story I heard once. Back in the day, in our recent agrarian past, everyone used mules or draft horses to plow and cultivate their fields. Eventually, someone invented the tractor. It was much more productive...when it worked. As someone who has used tractors, I can tell you first hand that you spend about as much time repairing them as using them. Anyway, the tractor manufacturers realized that they had a problem. If they introduced the tractors slowly and word got around that the tractors weren't the miraculous invention they'd been billed as, then farmers might just go back to using their well-trained and well-seasoned mules. No, that wouldn't have worked. They'd have to master the market in one explosive instant.

So they made the farmers an offer they couldn't refuse. They made even trades. Tractors for the farmers' mules, draft horses, donkeys...pretty much anything that'd pull a plow. Then they killed them. They killed them all. They buried them in mass graves. An entire generation of trained farm animals destroyed - animal genocide. Now there was no going back. They could have given the tractors away for free, for that matter. They would have a hundred generations of tractor-buying rubes to make their money back.

True story? I don't know. But it wouldn't surprise me. Caveat emptor, it's been said. I guess I'm just overly apocalyptic in my thinking, but once there are no more prescription pads, then we'll all be at the mercy of whoever sells the prescription-writing-machine.

As for me, they can have my prescription pad when they pry it from my cold, dead fingers. Or when they whip out "Andrew Jackson" to convince me.

More dangerous: Guns or Doctors? The debate rages on.

I must be on the right track with this blog. MedPageToday had a survey about whether gun control is a public health issue. Shockingly, the response was overwhelmingly "No". God bless us crazy doctors. We may save the world yet. Other than that bit of good news, the article and survey were so last week.

http://www.medpagetoday.com/Surveys/#ayk

I had a really interesting talk with a fellow physician last night at dinner. We were discussing the possibility of starting some weekend work at his clinic. I realized well into the conversation, which got really deep and intense about a lot of the things this blog is about, just how nice it is sometimes to have professional colleagues. It sort of made me feel a little better - not so isolated and alone.

May God Save Us from the Fury of the...Physicians?

Author Arlene Weintraub, in a June 27, 2008 article in BusinessWeek, made much of what was painted as an inappropriate relationship between some leaders of a smoking cessation clinic in New Jersey and the pharmaceutical giant Pfizer, maker of the immensely popular smoking cessation drug Chantix. In the article, and in the CBS Evening News piece on the same topic, this relationship was used as an example of what was described as the larger problem of "physicians on the take" from drug manufacturers. There are a few problems with the article, and with the assumptions it hand-feeds the reader.

Most consumers and potential consumers of American Medicine are not well-versed on the true nature of pharmaceutical companies, or the nature of the relationship between American clinicians and those companies - a fact that Ms. Weintraub takes full advantage of in her article. If Ms. Weintraub's implications are to be believed, then almost every physician with a pen and a prescription pad is offered a cash reward for writing a particular medication. Let me assure you that this is not the case. I have never been offered, and would never accept, such a kickback. In fact, such things are not only immoral and unethical, but are illegal. That, however, is not what occurred in this case, despite the veiled accusations.

Smoking is a known killer. Cancer is the most feared complication of this practice, but is by no means the most common or the most deadly. Elevated blood pressure, chronic lung diseases, and cardiovascular complications dwarf cancer in terms of poor health and mortality from smoking. Until Chantix, the success rate for stopping was abysmally low - somewhere around 10-15%. Chantix doubled that rate of success. Like all medications, however, Chantix had some side effects. In the vast majority of cases, these side effects were either not present, or were mild enough to be tolerated until the completion of the course of therapy. Each patient and physician had to make a decision about the risk:benefit ratio and whether treatment with Chantix was right for them. This is the way it should be. For example, much less hot-button medications also have side effect profiles that must be considered when thinking about starting treatment. Aspirin has been known, on rare occasions, to cause life-threatening Stevens-Johnson syndrome. It would be incorrect, however, to make the statement that aspirin is an unsafe medication. In fact, it has probably saved more lives (and cured more headaches), both in its modern form and its original one - willow bark - than any other pharmaceutical.

So what about the physicians so viciously attacked in the article? Were they hired guns for Chantix, subjecting hapless patients to life-threatening complications just for their own monetary gain? Many alarmists, like Ms. Weintraub, would like us to think so. In fact, they were not paid for prescribing Chantix. They were paid, like many other physicians, to give lectures about the new pharmaceutical. This is common practice. And who better to be a spokesperson for the wildly successful medication that someone who uses more of it than almost anyone else? This was the case with the UMDNJ physician and psychologist named in the article.

Allow me to give an example a little closer to home for me personally. Almost all physicians have a personal formulary. That is, they have a group of medications that they know very well and trust. In my case, either fortunately or unfortunately, depending on your perspective, my own formulary is made up almost exclusively of medications that are now generic, meaning that no pharmaceutical company is now likely to pay for their active marketing, as they are now sort of in the "public domain" for lack of a better term. If someone approached me, however, and asked me to go on a lecture tour to talk to medical students, potential patients, and other physicians about Bactrim (trimethoprim/sulfamethoxazole), for example, I would be happy and honored to do so. I believe in Bactrim. I've seen it work time and again. I've come to trust it. I also realize that it has side effects, as do all medications, and so I have familiarized myself with these and I know what to watch for and I know when to discontinue the treatment. My time has value, though, and I would expect to be compensated for the time away from my office I had to spend giving those lectures. This is the reality of the situation in which the New Jersey physicians found themselves.

There was nothing remotely inappropriate or unethical about what they did. The only mistake they made - and it is a mistake that most of us are guilty of - is underestimating the lengths to which some will go to demonize physicians and pharmaceutical companies in this new, highly-charged environment. The suggestion that somehow they placed their own avarice ahead of the welfare of their patients is more than simply wrong. It is slanderous. I do not know what agenda is being pushed by the author of this article. I have to assume that in some way, the pot is guilty of calling the kettle black. It would be interesting if she and the other alarmist journalists were held to the same level of scrutiny concerning any possible conflicts of interest they might have. I would have to assume that Ms. Weintraub benefited in some way by writing it.

There is another, more troubling aspect to this new poorly-founded alarmism. If one single person uses this ridiculous, unscientific, and misleading article as a reason to resist treatment by the best available medication for smoking cessation, and that person subsequently dies from a smoking-related disease that might have been avoided by the use of Chantix, then Ms. Weintraub and her conspirators at CBS News carry the guilt that has traditionally been borne by us physicians alone. When similar articles were written about Celebrex (celecoxib), people discontinued its use out of the fear that ensued, and resumed more traditional anti-inflammatory medications. Those older medications were (and are) felt to be more dangerous than Celebrex ever was. I have often wondered how many people have suffered or died needlessly as a result.

It is the most serious sort of business to be responsible for people's lives. That is why it is difficult to become a doctor. That is why we take an oath. And, it is likely, that is why people like Ms. Weintraub work tirelessly to lay us low - they do not believe in the kind of trust or faith we try so desperately to be worthy of. As a result, the uninformed die or are made ill. Ms. Weintraub will not be to blame - those who shout "Fire!" never are these days. As usual, physicians and the companies that make the medications we all depend on will take the blame, and we will continue to play foolishly into the hands of those who are blind leading the blind.

Our New England Schoolmarms Strike Again

In one of the few rulings by the Supreme Court that has made sense in recent memory, the self-proclaimed Third Branch of American Government ruled last week that a local ban on the keeping and bearing of firearms by the law-abiding, tax-paying residents of the District of Columbia was, in fact, unconstitutional. Duh. Not surprisingly, the academic medical community, much too busy to work to save American Healthcare from destruction by the insurance industry, and complicit in its destruction by the forces of socialism, came out against the ruling in an editorial in the most recent New England Journal of Medicine.

http://content.nejm.org/cgi/content/full/NEJMe0805629

If the sentiments expressed in the article were not so deeply-felt and so dangerous to our way of life, they would be almost laughable. It betrays the Technocratic mindset of so many in power in today's academic institutions - that somehow it is up to them to save us from ourselves. Epidemiological experiment? Hilarious. Liberty must be so incredibly irritating to these braniacs. It is so...untidy. Their silence was deafening as we the people (apparently their helpless, hapless wards) were subjected to other "epidemiological experiments" at the hands of the Highest Court - "Law enforcement officials can not be held responsible for defending people in their homes"; "Your personal property can be seized through imminent domain not only for the good of a community but also for the good of a more profitable tenant".

Where is the outrage at the New England Journal when people are attacked and out-gunned by criminals in their own homes? Where is their scientific input on the true causes of inner city violence, crime, and illiteracy - namely, the irresponsibility and even participation of those communities in those problems? Where is their backing of Bill Cosby when he addresses matters such as these? There is absolutely no doubt that those problems are at the root of the issue, but still the New England Journal remains silent. Well, silent at least until something occurs that offends them personally. Their fear of law-abiding citizens owning the firearms to protect themselves is legendary. They've always sided with the criminals in that regard. In their world, the law-abiding, ignorant sheep are supposed to look to the increasingly impotent government for everything, and remain victims of circumstance. This ruling was a slap in the face.

Their statement shows how utterly despicable and irresponsible they have become. They care nothing for the residents of Washington D.C., or any other city, town, or rural area in the country. If they did, they would use their power as the leadership of a (previously) highly-respected medical publication to educate our most vulnerable citizens about how to work and fight their way out of illness. They instead use their power to push their ultra-liberal agenda using the mantle of medical expertise to hide their true intentions. Their ridiculous opinion is thus given artificial credibility. What cowards. They know that their beliefs are losing traction, so they must package them as the "advice of the experts".

The New England Journal of Medicine thus continues to lose much of its credibility, hijacked, like so many of the great institutions of our nation by the socialist parentalism of the academic community. They are not welcome to speak for me. They should be ashamed.

Delayed Gratification - Numbers Don't Lie

I'm a little bitter. I admit that. It is difficult to be in my mid-thirties and still struggling, still living not unlike a college student. I am tired of Ramen, you know? To make it worse, I am constantly confronted with those who chose other career fields and whose lives seem so much better than mine. I see trips to Europe, new cars, big houses - all for the people that, according to our guidance counselors - "weren't going to be able to make it without a college education". I know how this sounds - jealous. Guilty as charged, I guess, but more than anything - disappointed. I'm disappointed that my work seems like it is never going to pay off. I'm disappointed that the future seems to look more bleak all the time. Most of all, I am disappointed that people are so wrong and bitter toward me for what they apparently imagine my life to be like.

Doctors are all super-wealthy. Isn't that the common notion? I suppose all professions suffer at least to some degree from the false perceptions of those outside the loop. Medicine is no exception. At least once each week, a patient that is either bitter enough or socially clueless enough to be completely honest about his feelings accuses me (usually with veiled sarcasm or in the guise of a jest) of doing extremely well for myself in my chosen career field.

Physicians have traditionally felt uncomfortable addressing this subject. I think there are a few reasons for this. One reason I feel uneasy denying this misconception is that I don't want to be further accused of whining. I guess I feel like "If this guy already thinks I'm a spoiled doctor, it'll just make things worse if he thinks I am also ungrateful for the giant imaginary fortune I am amassing". The second thought that usually creeps into my mind is the thought that if (a) he thinks all good doctors are filthy rich, and (b) I admit to continuing to live very modestly, then (c) I must be a pretty lousy doctor. Suspicion of false riches is bad enough - an accusation of professional failure is downright intolerable. Finally, and most pathetically of all, I continue to hold out hope against all evidence that someday, in the distant future, I may actually begin to reap some of the rewards from the lifetime of study and hard academic work it took to become a doctor. I would hate to jinx that. Almost all doctors are at least a little superstitious.

Eventually I'd like to discuss the loss of prestige, professional pride, respect, and sanity felt by so many of my peers. Today, though, I would like to partially tackle the false rumor that today's family doctors make a fortune.

Insurance is the obvious target, and probably is, in fact, the biggest contributor to the decline. They have made a very comfortable profit for years by frightening people into paying a middle-man for a vital service. Following Medicare's lead, they have worked to prevent physicians from working together to bargain for better rates while doing the exact same thing themselves, creating an uneven playing field. This has had a negative effect on all specialties, but has hit the already-lowest-paid primary care practitioners the hardest.

The increasing medical school debt to income ratio is another element of the decline. During a period in which medical school costs have shot up drastically, physician salaries have remained flat. For a neurosurgeon making $400K/year this is frustrating - for the primary care physician it can be devastating. It is estimated that family physicians pay up to 20% of their post-tax income for medical school loan repayment.

http://www.amsa.org/meded/AAFP.pdf?bcsi_scan_F72174411F520D17=0&bcsi_scan_filename=AAFP.pdf

This amounts to a game of catch-up for the primary care doctor, with the deck stacked against him. The average starting salary for a family physician is $120,000. A salary of $120,000 seems like a fortune to a poor kid - it did to me, at least. And perhaps it would be, except for all the hands dipping into it. At a salary of $120K, the doctor is in a fairly high tax bracket, even under today's much lower taxation levels. After taxes, the physician has about $92,300 left. The typical physician owes between $150,000 to $200,000 in school debt. The payment on that debt will be approximately $1500-$2000, even with very low interest rates, and will take the doctor 15-25 years to pay off. Take home pay? Around $71,000. And we mustn't forget about malpractice insurance, which will run at least $10K/year. After all is said and done, the physician takes home about $60,000 a year - about half of what he started with. And considering that most physicians work between 50 and 60 hours a week, that comes out to just over...are you ready?...just over $21 per hour. Just over $21/hour after 11 years of education.

Compare that with a nurse, who goes to school for 2 to 4 years, and can expect to make $50/hour before taxes, a construction laborer who makes about $18-20/hour plus overtime, an engineer...you get the picture. It will take the family doc in the scenario above about half his career just to catch up with the lifetime earnings of the laborer with a high school education and no school debt, who has been taking home $20-25K each year.

So please forgive me if I'm a little bitter. I had hoped that I would be able to enjoy some of the fruits of my many labors before retirement. But don't dare accuse me of being a "rich doctor". I just may hit you in the face.

Environmentalism - the Art of Compulsory Conservation

The world is a dirty, disgusting place. I become increasingly aware of that daily. My childish naivete yields to an increasing realization that it is more and more difficult to find any honor, any integrity, any transparency. I have become more suspicious and cynical. I feel that I've had to. You can't trust anything. And so, when I read this story from the Wall Street Journal about Richard Sandor, the so-called "Father of Carbon Credits", I felt that my suspicions about the Enviro-Banshees were at least partially confirmed.

http://online.wsj.com/article/SB120535230851631199.html?mod=%2528_pageid_%2529_topbox

Let me explain how it works, for those of you who (like me) didn't really quite get how this shell game operates. With the government's assistance, or better yet at the insistence of foreign powers (See Kyoto Treaty), arbitrary caps are set on how much carbon (in the form of CO2, especially) can be emitted by a particular company. If they fail to meet those standards, then they must buy additional carbon credits to avoid penalty - ultimately from Dr. Sandor and his cronies at the Chicago Climate Exchange. If a company does well and emits less than the standard, then they have some "carbon credits" which they can sell to a needy company to bring them into compliance. Either way, the Chicago Climate Exchange makes lots of money - either through the creation and subsequent direct sale of this new arbitrary and previously worthless currency, or through fees on the carbon trades between companies. It gets better. The caps get progressively lowered so that fewer and fewer companies are able to win, requiring them to go groveling with greater frequency to the economists, politicians, and academics at the Exchange, kissing the ring and begging enviro-indulgences. And it doesn't end in Chicago - the same bunch of mega-rich All Stars have identical trading centers across the world. Quite a racket, eh? They appear to be off to a champion start. The Exchange was opened in 2003. Dr. Richard Sandor made an estimated $260 million last year alone.

Biography of Dr. Richard Sandor:

http://www.milkeninstitute.org/about/about.taf?function=detail&Level1=ProStaff&Level2=Bio&ID=37&cat=Staff

Dr. Sandor is a recent convert to the worship of Mother Gaia, but appears to have always gravitated toward green of a different sort, at least generally. He was one of the original proponents of applying the futures market concept to interest rates. He was also instrumental in a past environmental "cap and trade" futures trading scheme similar to today's carbon trading, but during the last much over-heralded Apocalypse of the Universe, the Acid Rain scare of the 1980s.

Now I am not claiming to have any sort of special knowledge about the environment. I will tell you that as someone who is trained to read and interpret scientific studies as part of my job, I believe that there appear to be some serious flaws in the methods, results, and conclusions of those studies. The thing that bothers me about the scenario I describe above, however, is that it simply looks bad. Allow me to explain.

If a doctor accepts a pen or a dinner from a pharmaceutical representative, he is increasingly accused of being in the tank, or at least of questionable, if not unethical conduct. This is because people are very suspicious of doctors and drug companies right now. Part of that is medicine's fault for not being more critical and discerning when dealing with our partners in healthcare, the pharmaceutical companies. Part of it is the fault of over-zealous attorneys who exaggerate the problem in order to personally profit. And part of it is simply misinformation and ignorance on the part of those who make the accusations. What is the end result? I have to consider carefully how what I do with respect to pharmaceutical reps will look to the public.

I believe that there are those well-meaning souls who truly believe with every fiber of their being that our planet is perched on the edge of ruin because of man-made pollution. I respect that. I disagree, but I don't condemn them for their beliefs. But in the same way a physician has to be wary of the image he presents to the public, the growing and strengthening environmental movement should use extreme caution before making bedfellows of the kinds of people I now find are at the heart of the movement to mandate cap and trade for all industries. They, along with the ultimate self-servers, Albert Gore, Inc., are causing the environmental "Movement" to appear less of a cause and more of a cash cow for a few wealthy industrialists and Technocrats.

It is clear to me that until assurances can be made that we are not all simply being duped by Sandor's pals into funding their (and their great grandchildrens') retirements in the name of Environmental Protection, it is my duty as a responsible American and taxpayer to be resistant to the idea of making these carbon limits mandatory.

Independence Day Self-Examination

First, I would like to wish everyone who reads my blog a very happy Independence Day. The fact that I can sit here writing my unvarnished opinion on all these matters is truly a miracle, especially when you consider the series of events that had to occur in order for this to come to be.

Consider, for a moment, what was involved in that statement, the Declaration of Independence. In fact, you don't have to look much further than the title of the document itself. What does it mean to "Declare one's Independence"? One part of it is easy - we Americans have mastered it. It means, in part, to declare that you will no longer answer to authority. The first Americans stated plainly that they would rather suffer grievous loss - even die - rather than to continue to pay homage to a distant, foreign, and almost tyrannical ruler. Amazing. This collection of farmers and merchants (actually only about one third of the total population actually supported the Revolution) declared for the first time since Spartacus that they would no longer bow to the authority of their masters. No doubt many of them assumed that they would soon share Spartacus' fate.


But there is another, often overlooked element to a declaration of one's independence. Independence does not make one free from obligation, responsibility, duty, or toil. A person who is independent is simply not dependent on another. Somehow, over time, we've forgotten this critical element of our Liberty. We are great at refusing to pay homage - we are less great at actually being self-sufficient - independent if you will.


In fact, as a people, we are more dependent than ever. We depend on others for our food, for our fuel, for our security, for our retirement needs, for our health care, and even, in some cases, for our shelter. Our most basic human needs are being assumed by the Collective. I wonder, with shame, if the men who so bravely signed a defiant letter to the most powerful king on the planet at the time could have possibly foreseen a nation so socialistic, so weak, so...well...dependent. Would they be proud of us? Would they be proud of me? Would they be proud of you? Would they even recognize us? Or would they repudiate us in disgust for our failure to keep the Revolution alive?


The Revolution continues. In truth it never really ended. Even when the seeds of our Republic were sown, there were already those who felt that without a strong central government, the sheep could not survive. But that is not what I believe. I believe that there will always be a nucleus - often quiet, as now - who believe that it is the individual's responsibility and right to be truly free and responsible. I literally hope and pray that those people will rise up and reclaim what is rightfully ours - our precious, dearly-bought, God-given Liberty.


I invite each of you to examine yourselves, as I am doing this Independence Day. I beg you to measure yourselves against the bravery, selflessness, and long-sightedness of those original Patriots who first articulated our precious beliefs. And try to make our Fathers proud of you. I pray that you all have a safe, happy, and blessed day. May God Almighty bless our dear Republic, and may we continue the Revolutionary Struggle against tyranny in all its forms. Amen.