DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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Q&A 10

Here I am, back at the Q&A desk – sorting through the comments and questions. As always, the readers provide more material than I can use. Thanks to all who comment and question. Here are my highlights.

I enjoy your site, and noticed that you maintain a listing of “other medical blogs.” I thought I’d point you towards my own site, the Ectopic Brain (http://pbrain.hypermart.net ), where I maintain a “What’s New” page (http://pbrain.hypermart.net/blogger.html ) featuring news and information about the medical uses of Palm OS handhelds. Just FYI.

I had forgotten this email – but found it this morning. I have added the Ectopic Brain blog to the list on the left. For those who use Palm OS, this will be a valuable resource.

There is a reason why the real stuff will cost more and be more effective, there has been deep and serious research into it, using the best components to achieve the best possible results, generic medication may come from anywhere and the least expensive components will definetely be used. The molecules used in generic may vary just a little bit from the original, but the results will prove the difference between the two. Why pay less for your health? I’d rather buy something less this month and get what makes me feel great and healthy than saving a couple of dollars -or nothing at all -for something that makes me feel cheated and terrible. -Save in shoes, houses, etc, not in health.

This comment is wrong. Generic drugs have the same regulations from the FDA as trade drugs. The FDA maintains a site which provides information on generics – “http://www.fda.gov/cder/ob/default.htm”>Electronic Orange Book. As one researches this issue one finds that often the same manufacturer makes both the generic and tradename preparation. I do not understand the disinformation concerning generics. They do work and they do save money.

Regarding your euthanasia position. Amen. But here’s another place physicians should absolutely NOT be involved. Execution of the death penalty. How could any physician participate?

I do not think I could participate as a physician. The point is well made, and I believe that most physicians share this view.

I have read through the response from readers on omeprazole. I find them interesting and strangely one-sided. About 70% of omeprazole is being is dispensed as the generic, manufactured by Kremers Urban. Given the millions of people switched to the generic (and many having been programmed to believe generics are of poor quality) I guess I shouldn’t be surprised there are many who complain.

Having said that, I have two thoughts:

1) I have no respect for tactics used by the drug industry and wouldn’t put it past them to have orchestrated some of these responses. I worked for a state Medicaid agencies and frequently saw letters orchestrated by drug representatives (standard letter with different doc or patient name) opposing policy changes, and physician and patient letters complaining about generic failure. Medicaid programs spend millions more for Clozaril (money desperately needed elsewhere), because prescribers demand the brand – all evidence to the contrary. This may sound paranoid, but with the $10+ billion involved in PPI sales, even those companies who hold patents will eventually see their market disappear to generic omeprazole. PPIs represent a large share of many companies revenue. Falling sales mean layoffs. The drug industry is a master at controlling the message. I have looked in chat rooms used by people with depression and seen drug industry reps pumping Lexapro as a wonder drug. There must be a law against such action by a drug salesperson.

2) An aside, one of my colleagues complained when she switched to generic omeprazole, it didn’t work as well as the Prilosec. When I questioned her pattern of use, I discovered she took it with the breakfast meal. When I told her to start taking the omeprazole 30 minutes before the morning meal, the problem resolved. Many people don’t know PPIs should be take 30 minutes or so before a meal.

3) If these are legitimate drug failures, prescribers should be encouraged to report them to the FDA.

Thanks for your rants on drugs like Nexium, Clarinex etc. Many low income folks are duped by the drug industry and believe they must spend their limited discretionary income on these bogus drugs. It appears all the ethics have gone out of the ethical drug industry. Sad.

Often readers say things more elegantly than this ranter. This is such a case.

Well, I’d been dropping hints on my site for a week or so, and this week I made it official. I’m now one of Corante’s tech bloggers – they needed someone to cover drug discovery and the like, and asked me if I’d like to come over. My site’s been renamed from Lagniappe to “In the Pipeline,” which at least gives folks some idea of what it’s about.

The new URL is http://www.corante.com/pipeline. It looks a bit different from my old Blogspot site, but that’s not necessarily a bad thing. Otherwise, nothing’s changing – same topics and style as before. Same weird digressions, same lack of income, etc.

This commentary presented as a public service. I have changed the blogroll appropriately.

I have been switched to omeprazole 10 mg, but apart from slight mouth dryness I have had no other symptoms. On the contrary I am happy with the product; it has completely changed my life after the surgeon botched two hiatus hernia ops (and during the second one, accidentally tore my spleen!)

Anyway all my best wishes to fellow suffers – I know what its like!

By far the omeprazole rant has attracted the most attention of any single rant in this year of blogging. I included this positive comment, since it is in the minority.

I read your artical about patient autonomy. It was an excellent example of a physcian supporting the patient autonomy in the end stage of his life. Your approach to patient autonomy should be implemented as a routine practice.

We (medical school educators) generally are doing a much better job of teaching end of life issues. This education does include an understanding that our goal is to improve the patient’s quality of life – as they define quality of life. I am personally impressed with how our students, interns and residents understand these concepts and apply them daily at the bedside.

Consider this: as these figures reflect declining compensation, our youngest graduates are entering the profession with the highest levels of educational debt in history, facing the highest prices for housing in many markets in a generation and have the greatest need to provide for their own retirements at a time of profound weakness in the investment markets. Practice costs have never been higher and the Medicare system is planning to cut reimbursements again next year, after a 5.4% gross cut last year. That 4.2% cut proposed cut will register against many doctors own incomes as double that amount given that other overhead will not be going down. Americans have blithely counted on the energy and durability of the private practice medical delivery system to see to the needs of our citizens. We don’t have any real alternatives. Most patients really don’t think of the effects of payment cuts except as it affects their copayments and deductibles. That luxury of ignorance may end abruptly and painfully.

This kind of information will travel quickly. College students trying to make decisions about going to medical school (vs. something else) won’t ignore these reports, either. How can they? Finishing school with $200K of debt and without adequate compensation to repay the debt and to recover the opportunity costs of lengthy education and training isn’t an option for anyone but the reckless and foolish. We want the best but don’t want to pay for it, and will sue with abandon when we aren’t satisfied. We are playing with fire with this. And we will very likely get burned.

I love C. Henry’s rants. They are on target. We (society) are in trouble.

Hi, I was reading your Dec. 14, 2002 post about “Start Jogging” and you mentioned how you got shoes from a specialty shoe store. I haven’t heard of any such stores around where I live, but how would you suggest I go about finding some? I’ve seen ads for a specialty shoe store that made custom inserts for shoes, but I’m looking for actual running shoes. Were your shoes custom made or did you just buy some popular brand like Adidas or Reebok?

We happen to have a specialty running store here in Birmingham. I friend at work suggested I go there. They sell regular brands, but helped me understand which type of shoe I needed. You might be able to figure that out yourself. This article from Runner’s World should provide some valuable information – The Best Shoe for YOU! Let Runner’s World help you find the right shoe for your running needs

What advice would you give to obese or overweight kids that try to diet or exercise but it never works?

Unfortunately, I am much better at identifying this problem than solving it. Exercise regimens do require self discipline. So does changing ones eating habits. Behavior changes challenge physicians so much that we start to avoid trying – because we get such a low success rate. The only advice that I can really give is to keep trying. Sometimes it takes multiple attempts until a change can really occur.

Was just switched over from Prilosec to the Generic Omeprazole and have been taking for 12 days now. I have had diarrhea and nausea for 10 of those days. Will be seeing the doctor about it soon! Does anyone know if the doctor has to say that the patient must have the Brand or the Generic version? This has been a bad experience!

While I doubt that the generic is the problem, I can answer your question about brand versus generic. Prescription pads give physicians the right to insist on brand name or allow substitution. If you want to pay for the brand name, it is your right to ask either the physician or the pharmacist.

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This ends todays session. Try as I might, I just cannot avoid the Prilosec/omeprazole controversy. Without this blog I would not even know there was such a controversy!

Thanks again for the comments and questions. It is nice to know that my ranting induces comments and emails. That is wonderful confirmation that this blog has some worth. Thanks!!!

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