DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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Q&A 11

Late Sunday, time to clean out my comments and emails. Sorry for the delay.

I feel that ephedra is not forced upon the general public, by the companies that produce it. It is forced upon us by the media. I never knew what in the world ephedra was until the news took all of the dirt it could dig up on the herb and force fed it to me. Ephedra is no more dangerous than alchol. I have never heard of an ephedra user killing any innocent victims, I want the FDA to pretend like the people that are of age, to decide the future of our country, are capable of watching there weight or increasing energy what ever LEGAL way they want!

This comment on ephedra misses the point. Ephedra is a drug, not a food. I have several problems with the current way supplements are sold in general. Ephedra makes the point well.

We have no quality assurance mandated for supplements. Thus, the dose you take has much more randomness than the dose of any prescription (or even non-prescription) drug. When you think you are taking a specific dose of ephedra, you may or may not be taking that dose.

My other major problem with ephedra is the lack of appropriate warnings and caveats. It is possible that one could use ephedra responsibly with little danger (note that I say it is possible – that hypothesis would require testing). However, as currently marketed people take this drug without sufficient medical supervision. It can cause sudden death. Ephedra is dangerous, and therefore it should have the same regulations as any drug you might buy.

“If we had no efficacy requirement, drug companies would have the ability to assert claims without supporting data. The evidence based physician would not have the data necessary to make good decisions about drugs.”

There is a difference between an unelected bureaucracy requiring some particular standard for an efficacy claim, and longstanding law forbidding fraud. You seem to have no faith in the latter.

If a pharm supplier made false claims of efficacy, they would be criminally liable for fraud, just as is anyone distributing anything that is not subject to FDA’s particular requirements for efficacy.

I’d trust my physician’s opinion on efficacy over a bureaucracy’s any day. If I find my physician’s opinions inaccurate, I can change physicians. If I find the FDA’s pronouncements inaccurate, I can’t change government bureaucracies.

I find this an interesting argument. As I consider it, I have two problems (and hope the writer will respond). First, proving liability for fraud would require that we engage our legal system. I do not believe that our legal system can answer these questions as well as scientists answer these questions. Second, as a physician, I do not trust my opinions on efficacy as much as I trust the FDA. I do not have the data, nor the time to analyze the data if I had it.

I believe that you do misunderstand the FDA. Their analyses include physicians and statisticians. These are not bureaucratic decisions, rather scientific decision (in my opinion). Thus, while I share your distrust of bureaucracy, in this specific case I believe we do have the right bureaucracy.

Would the patient have preferred the physician have not talked to him? Is the value of the visit only in the hands-on component? I agree that the case has to be made that the physician’s time has value, whether it is spent listening, examining, performing procedures or talking. Lawyers, who do lots of talking, never seem to have to make this argument. Why is that? And for some reason–which does not seem to apply to our lawyer brethern–only the doctor’s time spent with the patient is deemed to be compensable. Try telling a lawyer that you will only pay for the time spent is his presence. The patient needs to understand that listening and giving professional advice is a service. I think that retainer-based practice, which you have argued for here in the past, would help to fix this problem.

As usual C. Henry has made the point very well. This comment reinforces everything that I have stated about our current reimbursement system.

I agree in the importance of case taking and case taking skills. But good case taking isn’t talking to the patient, it’s listening to the patient. When people tell me that the doctor they saw was “no good”, I ask why. The number one reason is, “He doesn’t listen to what I have to say. The minute I give my complaint, out comes the prescription pad and he’s writing the prescription.”

Point well made!! If all we do is talk, then shame on us. We must listen and respond to the patient. Perhaps the key here is conversation rather than lecture.

Does anyone suffer from cancer of the stomach as a result of taking Proton Pump Inhibitors ?? I read that this is a known side effect to occur on trials of the drug on mice!

This theoretical consideration has no data to support it. We have many years of PPI use now, with no epidemiological evidence of a stomach cancer – PPI association.

I’m aware of the problem that lawyers sometimes make settlments in class action suits that enrich themeselves but provide little reward to the defendants. I would like to see the problem fixed as much as you do. However, to ignore the problem of adverse drug reactions, which is a leading cause of death and injury in America, and criticize lawyers pursing the issue on behalf of their clients is a perverse set of priorities. Why doesn’t this issue get the attention it deserves from the medical profession?

Physicians worry about adverse drug reactions constantly. We are faced with a difficult situation. We must balance potential benefit against potential risk. Often patients can help with the decision making, however, many patients will not participate in the decision making process.

So we are damned if we do, and damned if we do not prescribe a specific medicine. Side effects occur. We do our best to minimize their impact, but sometimes we have an unavoidable risk.

How should we give this issue more attention? Who are you blaming – physicians, insurers, or the pharmaceutical industry?

Thanks again for the comments and questions. I still have much to answer and comment. Hopefully I can find some time again tomorrow. Keep the comments coming, it certainly makes this blog a lot more interesting!!!

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