Attitude

The longer I live, the more I realize the impact of attitude on life.

Attitude, to me, is more important than facts. It is more important than the past, than education, than money, than circumstances, than failures, than successes, than what other people think or say or do. It is more important than appearance, giftedness, or skill. It will make or break a company ... a church ... a home.

The remarkable thing is we have a choice every day regarding the attitude we will embrace for that day. We cannot change our past. We cannot change the fact that people will act in a certain way. We cannot change the inevitable.

The only thing we can do is play on the one string we have, and that is our attitude ... I am convinced that life is 10% what happens to me, and 90% how I react to it. And so it is with you ... we are in charge of our attitudes.

-- Charles Swindoll

This is what I need to think about when a patient complains to me for 15 minutes about how horrible the hospital system is and then refuses to let me examine him so that I can admit him to the hospital.

Dialysis

Anyone with end stage renal disease qualifies them for Medicare coverage. Currently this amounts to about 11 million patients in the US, with over 350,000 of them on dialysis - so about 2% of Medicare patients are on dialysis. For one patient, for one year, Medicare pays $67,000 for dialysis totally over $20 billion per year for dialysis, which takes up close to 10% of their budget. This means that 2% of Medicare patients take up close to 10% of the Medicare budget! And the numbers are only increasing.

I find this disturbing for a few reasons. For one, patients on dialysis are generally relatively sick. The 5-year mortality rate for patients on dialysis is 60%. That means that even with dialysis, a very expensive intervention, 6 out of every 10 patients on dialysis still die within 5 years.

Secondly, it's ethically questionable to spend so much money on a relatively small number of people. With a limited budget, the money could be used in countless other ways to prolong the lives or improve the health of a greater number of patients. Given the fact that 60% of patients still die within 5 years of starting dialysis, the cost-effectiveness of this intervention seems very high.

Finally, irrespective of ethics or efficacy of the treatment, can the U.S. afford this at this time? With rising rates of kidney failure and more and more patients needing dialysis, it may not be a possibility for the United States to continue paying for dialysis for all patients in the future. Not really a question I'm qualified to answer.

So what's the answer? Once someone has Medicare and is on dialysis, it's definitely ethically questionable to take away that treatment and send them on their way towards death! I don't have any great solutions, but perhaps the government will eventually have to stop providing payments for dialysis, with some sort of grandfather clause for those already on dialysis.

Of course, I'm sure if someone I cared about, or I myself, were on dialysis, my opinions and thoughts would be completely different.

Doctors and arrogance

I know a lot of arrogant doctors. I probably am an arrogant doctor. It's probably a good general statement for lawyers and businessmen too, but it's definitely a trend in doctors.

For one, I think it's a self-selecting group. Not many people can say that they want the responsibility of caring for someone else's life. And if you think about it, it takes a certain amount of arrogance to think that you are capable of doing such a thing. In fact, it takes an even greater amount of arrogance to do something wrong the first time around (potentially really affecting someone else's life) and try to do it again. But the surgeon who started the first heart transplant failed something like 5 times before he succeeded. Meaning the first 4 times, someone died. It takes a lot of guts to keep doing something like that with those potential consequences. But in the end, it can mean great strides in medicine positively affecting the lives of thousands of people.

Secondly, I think a certain amount of arrogance can be good for doctors as well as patients. If a doctor had a personality that beat themself up every time they made a mistake, they wouldn't survive. Every doctor makes mistakes once in a while, no matter how good they are. Some mistakes of course are more costly than others. But in the end, you have to be able to move past it, learn from it, and never ever do it again. On the patient care side, the last thing any patient wants to see is that his doctor is uncertain. If a doctor is undecided about a certain course of action, of course they should admit it, but once a course of action has been decided upon, the doctor should be very confident about it. I think if a doctor is visibly uncertain about something, that definitely adds to the patient's stress. I think it also makes the patient lose confidence (subconsciously) in the doctor's ability to make medical decisions, etc.

I guess whether good or bad we're stuck with it.

Drug Dinners

In med school, one of the last things we had to do was take a one-week long ethics course, which included several lectures about pharmaceutical companies and reps. One of the more interesting things they did was to take the survey of the graduating medical students right there during the lecture. We all had a wireless handheld device and when they asked us a question, we would enter our answer in a completely private and anonymous way, and the computer would tally our responses live and show the results on the big screen for everyone to see. One of their questions was "Do you think the majority of students in this room can be influenced by drug reps and pharmaceutical companies in the future?" Something like 60-70% of students said "yes." The next question was "Do you think you yourself could be influenced by drug reps and pharmaceutical companies in the future?" This time only 30% of students said "yes."

I think this one little survey told us a lot about how drug companies work and why their tactics work on doctors.

The medical school also had an ex-pharm rep come and talk to us about the tactics they use. Most doctors and medical students I know believe that they can't be influenced by things like free food or dinners, much less free pads of paper or pens or clipboards (or anything else) that is given to them by drug reps, or at the very least, that the influence is minimal. But the drug reps and pharma companies wouldn't be doing this if it wasn't working, right? And that's basically what the ex-drug rep told us. Pens and pads of paper alone, labeled of course with the drug logo of choice, will change prescription practices 20%. I may have that figure slightly off, but that is the figure she quoted. This doesn't even take into account other types of gifts, free samples for patients, free dinners they offer, filling up gas tanks, honorariums for speaking, travel costs for conferences, etc. I can't find it online, but apparently the pharmaceutical companies have amassed actual data regarding how well these tactics work. Amazing.

On an unrelated note, the ex-drug rep also told us that they used to hire pharmacists as pharmaceutical representatives. However, now they've started to hire people without scientific backgrounds for several reasons. For one, if there was an argument about the validity of a certain drug between the rep and the doctors, and the doctors were backed by evidence, the pharmacists would eventually come around to agree with the doctors. Secondly, it seems that a pharmacist background isn't really necessary to sell these drugs or to make their tactics work. This New York Times article seems to say it pretty well.

I think it's great that the University of Pennsylvania Health System (UPHS), which includes my hospital - Pennsylvania Hospital - has banned all drug-rep-related activities within the hospital. I think some of the outpatient practices and satellite clinics (especially private ones) have some immunity to this rule, but overall this is a good move and hopefully will set some precedent for other hospitals and practices.

All this being said, I am a poor resident and I went to my first drug dinner the other week, and it was delicious. :) To be completely honest, the speaker gave a 30-minute presentation and all I remember is that the drug was a new one for hypertension. I do remember I had a crab cake appetizer, some vegetable dumplings, seared salmon, and steak for dinner. I guess that tells you my priorities...

Being on elective

I feel like I'm drowning in free time. They let the preliminary students basically do whatever they want for their elective months (we get three months a year) and I'm choosing to finish up my research with the radiation oncology department at Penn. Not only do I really like the research, but my hours are soooo much better than when I'm doing a floor month. It's pretty much 9 to 5, it's closer to home, and the time I have to work is more flexible. For example, if I have to take an hour during the day to go to a doctor's appointment, I can do that! Also, all my weekends are free, which means I can make some of those weddings and ultimate tournaments this month.

I think it's going to be a great month and a little hard to go back.

Dinner last night

was really good. I don't have time to cook anymore, so when I do, I really enjoy it. Yesterday we set up an interactive appetizer: spring rolls. I showed people how to soften the wrapper. Then we had an assortment of ingredients you could put in. Bean threads, bean sprouts, thai basil and thai mint were the basis, usually with some hoi-sin sauce. Then you could put any number of additional things - we had enoki mushrooms sauteed with a lot of garlic, green onions, jalapeno peppers, different hot sauces, fish sauce, or dumpling sauce. There may have been more, but it was a pretty good spread.

For dinner, we had three dishes. Chinese broccoli sauteed with oyster sauce, honey walnut shrimp and chicken with cashews. I think everything was a big hit. There were 2 and a half pounds of chicken, and 2 and a half pounds of shrimp. By the end of the night, the shrimp were totally gone, and considering we had 8 people, I think that's pretty impressive. We all stuffed our faces.