Welcome…

Shannon, Kirk, welcome to the Lake.

Thank you for being here today, Shannon. Hi, Kirk!

Shannon, welcome, and thanks for your book.

I appreciate your joining us here today.

And I’m looking forward to introducing your book to the med students I teach – what a great explanation of our complex, broken “system”.

And what great cautionary tales, as well.

I stay away for Doctors.

Shannon, as you’ve discussed your book (and your work) with health professionals and patients, what responses have most surprised you?

Welcome, Steve-AR – hope the OR was good to you this week.

While we wait on Shannon — what about the “overtreatment” aspect of the book, Kirk? What systemic problems does it attribute the tendency to “overtreat” to, and does that jibe with your experience?

Welcome Shannon

Welcome Shannon. Hi Kirk.

And – though too little care kills – too much care can be equally deadly.

Well – reading *that’s* not good for my restless-leg syndrome…

It’s the lurking proofreader:

“grove of livig trees” should be “living”

“why do we kamed the decisions we come to” …beats me…

In case people want to Digg this they probably should be fixed.

Shannon describes the paradox of lethal abundence in a land of medical scarcity.

My perspective is a weird one: mostly from a major UC med school, where the docs were for all intents and purposes on fixed incomes no matter how much work they did; some from watching folks form both ends of the economic spectrum consume health care.

Shannon cites a specific example (bone marrow transplant for breast cancer patients) of a general problem: we docs – with the best of intentions – will rush to offer a new treatment for a terrible problem.

And – as with high dose chemo/BMT for breast cancer – the new treatment can be even more terrible than the problem.

I came on to an oncology team as BMT was replaced by stem cell transplant – and had a first hand experience of the wrenching forces when a new treatment pops up for folks with no other hope.

Kirk,while we are waiting – have you heard about the trend for doctors to actually sell the drugs out of their offices? Your thoughts.

Oy! Hadn’t heard of that one.

Does your book deal with things like many more hysterectomies are done in the South than in the Northeast? Or about doctors prescribing random tests? I just hate to go to regular M.D.s with their agendas and their office staff designed to keep you away from the doctor. For me, it’s like a study in frustration to start dealing with them. So, I went to one recently for a referral for a follow-up bone density test, which he agreed was a good idea. Then I wanted lung function testing after having been a smoker for forty-seven years and he was not really wanting to do that, but was pushing a colonoscopy. And kept pushing it even when I said I don’t have a history of gastrointestinal problems. Or is your book dealing with other issues?

It was in a Washington Post article this last year. I have some problems with it.

That sounds like an idea particularly prone to abuse. I wasn’t aware that was happening.

One of the very real systeminc problems Shannon describes is MD greed, and I wan’t to directly admit the truth of her words.

Medical payments are skewed towards paying for “procedures” (physical interventions”) as opposed to “skull work” (thinking and talking). For many “proceduralists”, the more procedures they do, the more they make.

I’m sure not saying this motivates all proceduralists – but I’ve certainly known some who seemed quite far down this path.

Urgent Care type of providers in CA – the doc prescribes, when you check out, the meds are dispensed and its all on one bill. Credit cards accepted.

The issue of “outcome based” medicine is a topic that people don’t want to talk about when “single payer” is discussed. Health care dollars have to be “rationed” and using outcomes is the best way to do it, IMO. Now it is rationed based on socio-economic status. But rationing of medical care is the third rail of “universal care”. IIRC the Canadian system is heavily outcome based and it workd very well.

Shannon will be joining us shortly.

So would a colonoscopy have been something the doctor would have done himself if I’d agreed to it or would that be something he’d have referred out?

Thanks, Bev!

Hmmm… I wonder what the “doc in a box” charges for a simple antibiotic that you can get for $4 at the pharmacy at WalMart?

Bev, I’m really concerned about ANY economic incentives for docs to treat.

The worst are psychiatrists (with respect to taking industry money in response to merely writing prescriptions for a drug.) To me, that’s bribery.

Oncology also proved vulnerable to skewing care for “drug money” from treatments – oncologists must to give IV drugs in the office/infusion center, and thus have impeccaable reasons for doing so.

The requirement, however, sets up all sorts of unfortunate reinforcements that could distort evidence-based decision making.

Aside from IV drugs or drugs that must be administered in the office, I don’t see why MD’s are in the drug selling business (unless they are in rural areas without pharmacies providing meds at cost) – except to make money.

Kirk, Shannon, What is the definition of “Overtreated”

Welcome, Shannon! Hi Kirk!

I am not a physician, but I teach basic science to first-year medical students. This should be a very enlightening discussion.

Hi, Shannon here. I’m going to be a little slow at first, getting the hang of doing this online.

thanks for the welcome messages.

As for doctors selling drugs directly out of their offices, this has long been the practice in oncology, where the cancer doctor buys chemotherapy drugs at wholesale and then bills insurers for a retail price. it helps many doctors cover the cost of nurses, etc. But it has led to some financial incentives to prescribe chemo when it’s either the wrong drug but more profitable, or to continue chemo even past the point of diminsihing returns.

These days, dermotologists are selling cosmetic products, including botox, which is a drug.

Colonoscopy is good; I have had several. Usually done by a Gastroenterologist or a Surgeon.

greenwarrior, that wholly depends on whether your doc has the skills and facility access to do a colonoscopy.

Shannon describes at length how – depending on the economic structure of the doc’s practice setting – he may have economic incentives from referring for a given procedure, or he may have incentives not to refer.

Either could distort medical decision-making away from what is the patient’s best interest.

Kirk and/or Shannon, is there any way for a patient to find out who the good doctors are? It’s been my experience, after working for docs for 30+ years, that while they whisper among themselves about who the butchers are they would sooner be hanged, drawn and quartered than let that information out of the docs’ network. And how do folks like me delicately advise people to “for the love of God, DON’T go to HIM?”

Yes, the book looks at geographic variation of spending and particular practices. hysterectomy is a particularly interesting case since it was one of the surgeries that Jack Wennberg looked at back in the seventies and eighties and found wide variation even within a single state or region. wennberg is one of the heroes of the book, and indeed of modern medicine.

Shannon, welcome.

When you’ve had a moment (or several) to catch up, please feel free to address any question that strikes your fancy or simply share what’s on you mind.

Hello friends. I have been suspicious as well as curious about colonoscopies — my sister (nurse) in a small Nebr. town where part time Dr.s or PAs still do pretty much know most people, was called and called and called until she finally relented and had the colonoscopy just to make them happy, her ins. covered pretty well. I too have had calls in the same way. It made me think this was a way of making some money and yet do some possibly preventive good. Was it the procedure of the year, or decade or are the results truly justified. Have some other horror stories too along those lines, I find I do not trust medicine anymore than I do government nowdays and feel so sad. ?????

Medical payments are skewed towards paying for “procedures” (physical interventions”) as opposed to “skull work” (thinking and talking). For many “proceduralists”, the more procedures they do, the more they make.

I agree that this is a serious problem.

Billing by time, rather than piecework, could do a lot to eliminate this counterproductive incentive. It would also eliminate the incentive for 15-second “consultations”.

That would, of course, create problems of its own.

I don’t think doctors as a group are any greedier than anybody else. Some are, some aren’t, but the financial incentives in a fee for service reimbursement system all point in one direction, which is more utilization — more procedures, office visits, tests — rather than better care.

we ration care irrationally in this country — we don’t give people care who can’t pay. But there is so much waste in our system — probably 20 to 30 percent of the $2.1 trillion we spend — that I dont’ think we have to talk about rationing in the classic sense for a long time. rationing is when you deny people care that could help them because it’s too expensive.

Yep. It is unrealistic to expect people to not be influenced by such powerful economic incentives.

Do you think a time-based medical billing system like that used by most attorneys could be workable?

Shannon, I agree with you – docs are just people, and show the whole spectrum of human frailties and capacities. I wanted to get the economic self-interest issue out in the open first as I find it’s often at the front of lay concerns about medical decision making.

And I should stress that “greed” was my emotionally laden term, and not reflective of your careful and thorough prose and analysis.

Colonoscpies are generally done by gastroenterologists (at least, that’s who you want to do your colonoscopy). Your primary care physician may prescribe one when you reach 50 becuase that’s the standard of practice right now, but your PCP isn’t making money from it.

Now, that said, it’s not entirely clear that screening colonoscopies are bringing down mortality rates for colon cancer. but that is a much much longer discussion.

Great honor to have you here Shannon.

I know unscrupulous psychiatrists shoehorn especially poor Medicaid patients into the most serious diagnoses. The pharmaceuticals pay bonuses to the shrinks, just like a sales person getting a commission. Frequently those meds can run to around $6,000 a year and often the patients are not taking them. The psychiatrist, the pharmacist, and the pharmaceutical manufacturer are happy, because they are getting paid by the taxpayers.

Hello friends. I have been suspicious as well as curious about colonoscopies

Colon Cancer is the second or third leading cause of death from Ca. Colon Ca is one of the few Cancers that can be prevented. If people followed the guide lines for getting a colonoscopy, most cases of Colon Ca could be prevented.

Overtreated is sort of a fancy word for “unnecessary care.”

Shannon, I wonder why they’re prescribing colonoscopies if they’re not bringing down mortality rates and not making money from them. Any ideas?

Shannon, when I first sat down with your book I kept reading the 20-30% figure and wondering where you came up with it.

Then you told me.

Can you let folks here at the Lake know how you came to that conclusion?

You persuaded me – and gave me hope that the 20-30% you identify (together with the 20-30 siphoned off by Big Insurance) could fund the end to our health care disaster.

Do you think that advertising prescription medications incessantly on TV has any effect? I know that patients come into our practice demanding the latest thing that they’ve seen on the tube, and get quite miffed if it’s not prescribed. Also, what about the frenzy to kill every germ everywhere with hand sanitizers, air sanitizers, food sanitizers, etc., etc., etc.? Aren’t we just breeding up much more resistant bugs?

I dunno, I think you can just say, don’t go to that doctor.
Seriously, I don’t know of any reliable guide to the “right” doctor. regional magazines like the Washingtonian, a wash. DC magazine, or New York magazine, have their annual “best doctors” isuses, but they are based on reputation surveys, which i think are just silly. Doctors can often identify their colleagues who are really incompetent, but they don’t necessarily know who’s delivering the most evidence-based care.

Not having read the book yet, I’m hoping the answer defines what this is about.

Most of the time physicians are recommending colonoscopies becuase they beleive they are a good thing. Maybe they are, maybe they aren’t. we’ll have to wait for the results of a very large trial now being conducted by the NIH. One thing is certain: if colonoscopies do reduce your risk of dying prematurely of colon cancer, it’s not going to be by a lot. The same is true for most cancer screening tests — they either havent’ been shown to reduce mortality (PSA, CT for lung cancer), or if there is any evidence they reduce mortality, it’s a relatively small reduction (mammography, colonoscopy). The one screening test that really works is the Pap smear.

That’s legal??! (Re; docs selling meds.)

if pharma companies are paying pscyhiatrists to prescribe that’s a kickback, and it’s illegal.

Maybe they reduce mortality. the best estimate is that you ahve to do a lot of colonoscopies to save one life. If I’m remembering correctly the number needed to treat is on the order of 1000. The number needed to harm from perforated bowel is much fewer.

I’m going to guess it’s wasted money due to millions of billing offices, utilization review offices, getting insurance to pre-approve, which can take hours of a nurse’s time.
Huge amounts of money that could otherwise be spent on medical care.

1. Doctor’s kill their mistakes.
2. Doctors in Isreal went on strike some years back. The death rate dropped.
3. Very few Doctors use the scientific method for diagnosis, and just guess.

Can you talk a bit about the way that pharmaceutical companies know what drugs individual doctors are prescribing, and how they incentify them to overprescribe?

That nobody is taking this on (i.e., the data mining that allows pharmaceutical companies to have this info) seems pretty outrageous.

And, some suspect, some level of “dirt” is necessary for the immune system to develop properly in the young.

Shannon, among the refs Bev sent me was one in which I recall you looking at the US News & World Repost hospital ratings (and such ratings in general) with a very skeptical eye.

I really appreciated your clear view. I used to be on the student governance of the Association of American Medical Colleges – and spent a few days over a few years snowed in with various deans, heads of specialty societies, and hospitals in the Washington Hilton – watching buses and cars slide backwards down Connecticut Ave.

As the drinks flowed, the guys (’cause in the mid to late ’80s they were all guys) started ribbing each other about the hospital ratings. The whole joke was that even the Deans and hospital directors knew we had no way to measure the quality of the simplest medical care, with rare exceptions.

And twenty years later, those basic assessments of efficacy – does the treatment actually work? – still seem to live outside the orbit of much of medical practice

As my med students move from the world of evidence based medicine in training to clinical practice, the most observant have been shocked to see the relative lack of concern for “outcomes assessment” as care systems change in response to economic forces.

I hope they all can read you book soon – you provide a very sobering picture of how often we docs make decisions about care without direct evidence about the effects – for good or ill – of what we decide.

Kirk, the 20-30 percent figure comes from studies of geographic variation in spending. If you look at how much Medicare spends per patient in different parts of the country, it varies by a factor of three. If you look at per capita variation among hospitals, high-spending hospitals are spending four times mroe than low spending hospitals.

For instance, a heart attack in Salt Lake costs $4,000, and double that, $8,000 in Los Angeles.You might think, well, duh, everything costs more in LA than it does in Salt Lake, but the difference in what Medicare pays doesn’t vary that much from place to place.

Well, maybe the difference is due to how sick people are in LA versus Salt Lake. Maybe heart attack patients in LA have more “co-morbidities” on average — more accompanying diseases like diabetes — that make them more expensive. But the differences in level of illness can only account for about 4 percent of the variation.

what’s different then? The sheer amount of care delivered in LA versus Salt Lake. the problem is, the extra care in LA doesn’t lead to better outcomes. It’s unnecessary.

When you look at all this geographic variation, the unnecessary care amounts to 20-30 percent of the total.

Health care seems to be a bit of a crap shoot, it depends on so many variables.

In general, how much faith would you put in US health care, knowing what you know? What is best, what is worst?

you bet direct to consumer drug advertising has an effect. it’s huge. the drug industry reaps on the order of $3.00 for every dollar spent on an ad.

Hey Kirk, you wrote
“Now – for all the psych diagnoses – a specific validated instrument allows one to make accurate diagnoses by asking specific questions from a flowchart. The instrument has a very high inter-rater reliability, and is easy to use.”

Which instrument are you talking about? I have a semi-professional interest. Does it control for drug use/abuse?

Bob in HI

Do you discuss how our ‘free market’ health care system compares to countries with national health care? Are the protocols and treatment incentives different for these groups?

the amount of money our system wastes on overhead is over and above the amount wasted on overtreatment.

that’s why I am very optimistic about health care reform. There’s a piggybank full of $700 billion jsut waiting to be saved.

Well, I’ve always believed that.

Shannon, thanks for your clear and elegant explanation of the fiscal costs of overtreatment.

1. airline pilots kill their mistakes too.
2. death rates go up and down for a lot of reasons.
3. only about half of the stuff doctors do is backed up by valid scientific evidence. that’s why we need a Manhattan project of medicla evidence, a publically funded effort to find out what works, what doesn’t and for which patients.

Do you discuss how our ‘free market’ health care system compares to countries with national health care? Are the protocols and treatment incentives different for these groups?

I don’t understand how you can have anything close to “free market” healthcare without pricing transparency

the drug industry knows down to the pill what doctors prescribe. They buy this information from data mining companies, and it allows the drug rep to tailor their marketing approach and to identify “high prescribers” and reward them subtly with things like nice dinners.

There are people taking on the drug industry’s influence over medicine, including several journalists. but it’s a tough fight, since so many academic physicians and community doctors are on the take.

I have a friend who was diagnosed with Stage IV Ovarian cancer many years ago..she ended up going to an oncology treatment center in Virginia, I think; anyway the thing is this:

She was told she had to take a long, strong chemo and radiation regime…but she thought her case was pretty hopeless, so she refused all of it except for one chemo treatment and one radiation treatment. She is alive today. Apparently, in those days they were really over-doing the chemo and radiation dosages, and because of her bizarre case results the treatment dosages were revised….or so she tells me.

Hence the scare quotes.

The reason I ask is that my mother broke her ankle while in England and as a paying customer (with insurance) she was given a private room — also the Drs. there kept moving her feet the first couple of days before putting it in a cast. She understood that the treatment in the US was to immobilize the ankle first. Her experience was that she was able to shorten her recovery time by 2 weeks thanks to the treatment she got overseas.

I would love to see my book used in medical school curricula — though it might be a bit dismaying for young students just starting out.

the critical issue here is, as you say, outcomes measurement. It’s hard to do, but it needs to be done if we are going to have a prayer of paying doctors and hospitals on the basis of how WELL they care for patients, rather than for how much care they deliver.

We’re pelting you with questions, and I don’t expect you can answer all of them. I really appreciated your description of the deadly consequences of assuming “more is better”, and also loved your take on the ever-growing number of psych diagnoses in successive DSM’s.

If you have time, would you like to share more about your observations on the proliferation of psychotropic prescribing for adolescents / young adults?

[I’m quite skeptical, but then I grew up before adolesence had become a disease to be treated until the insurance reached the benefit limit….]

Welcome to FDL: If we think of the medical community as an industry, when a pattern of abuse within an industry becomes widely known, the initial response of those within the industry is “we can regulate ourselves.” Some of the problems described here appear to be unsound medical practices — doing/prescribing stuff without confirmation that it works — and other things are just unethical — the quasi bribery wrt to Drs. selling drugs.

So the question is, what is this industry proposing to police itself, to deal with the conflicts and the unsound practices — and why or why won’t that be enough?

Don’t most insurance deals have lifetime maximums for mental health treatment?

And couldn’t this treatment be a way for the companies to just get things over with so there is no further recourse?

(Only partly snark in that question)

How much faith would I put in the health system? over the course of hte five years it has taken to write this book from earliest glimmerings to the finished product, I have become more and more wary of medicine. that makes me sad, in a way, becuase I still think the ideals of medicine are some of the highest — to ease suffering, to cure when you can, to comfort the sick and dying. And I don’t want anyone to think that I dismiss the great strides medicine has made over the last century. Doctors can cure some things. They can save lives. If I had a heart attack, I would rather have it now than 25 years ago. But there’s a great deal of slop in the system, and it’s the slop that worries me.

I have a question,I’m not sure it’s pertinent to your book, though.

In Britain are there less operations for things like restless leg syndrome?
I ask because an elderly in-law had an operation for this, and never really regained his health. I think he regretted having had the surgery.

I am 63 and have chronic back pain.My pain mgt.Dr.referred me to to a ruematiot Atrhritis Specialist because she noticed a patch of psoriasis on my knee.The specialist ordered a battery of X-rays of my hands and sacrum,told me that I had psoriatic arthritis,and prescribed methotrexate(a low dose).IHe told me that this drug is used in Chemo for cancer patients,but this was a low enough dose not to have any severe side effects if I took extra folic acid.All this before the test results were back.
When the results were back I was told there was no arthritis other than slight sacral arthritis which could be considered normal for my age.
I did not start on the meds and am very glad I did not as I think this is part of the problem of medical ove-medicating.This and other incidents have made me very leary of Doctors.I believe that these kinds of over medicating and over diagnosis have set me up to ignore symptoms that could be dangerous,even life threatening.

I discuss other countries only a little. The central problem with our “free market” system is that the market doesn’t work in health care. Many of the economic assumptions that hold true for other goods and services simply don’t apply in medicine. In our health care system, for example, the supply of medical resources drives the amount of care that gets delivered, rather than the actual needs of patients. And just becuase something costs more in our system doesn’t mean it’s of higher quality.

Shannon,
Around the time of WW-II, the Federal Government hired “County Agents” to travel around their counties, discussing with farmers the latest evidence for agricultural best practices. I know about it because my grandfather was one of them. Nowadays, of course, such an agent would probably be outsourced to seed companies, big companies like Cargill, farm equipment operators like John Deere, and could not be trusted to be independent.

I can see the need for a modern medical equivalent: Medical agents who would discuss new medications and other treatment procedures with General Care physicians, nurse practitioners, etc. But how to pay for it without selling out to the big drug industry or other major commercial interests?

Would there be any way for this kind of go-between to have the right kind of training and independence? Would it be a worthwhile thing to create?

Bob in HI

Shannon and/or Kirk, do you think there is any causal relationship to the sudden uptick in things like asthma (when I was a kid I can’t think of a single kid I knew who had asthma) and the constant barrage of chemicals from fast food/prepared food/antibiotics in feed animals and milk?

From the New York Times, June 2007

Psychiatrists Top List in Drug Maker Gifts

WASHINGTON, June 26 — As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty.

How this money may be influencing psychiatrists and other doctors has become one of the most contentious issues in health care. For instance, the more psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for whom the drugs are especially risky and mostly unapproved.

Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

I’m so glad you are bringing this up.

Docs can opt-out of the ID system, too – I’m trying to educate colleagues about this.

[Most want to opt out - and a few want all the goodies Medco’s all seeing eye could bring them.]

We’re such primates – we learn from mimicry. I saw UCLA pretty much chase drug reps out of medical education, and other schools are doing the same. When the students see the docs refuse the bribes meals – and talk about why – they follow the primate in the long white coat.

Works with peers, too. Why, at the Central MH clinic in Santa Clara County, the drug reps are no longer allowed in the lobby. All it took was for one doc to refuse to allow them to approach him when he came to the lobby for patients…

(Sends a horrible class message, too – the drug reps often sport surgically sculpted faces, teeth, and chests, and are wearing expensive suits. Talking to them before taking the patient – on the patient’s appointment time – sends an unmistakeable message about the doc’s priority and values.

Let the public health patient without the fancy clothes wait – I’ve got well-off friends who will buy things for me.)

Psychiatry is one of the areas of medicine most susceptible to bullshit, I fear, because so little of it can be pinned down. The drug industry has taken advantage of this by trying to influence everything from prescribing habits of doctors to the definition of disease. We have expanded the definition of illness while narrowing the number of people who are considered “normal.” The expansion of the number of psychiatric diseases is just one example of how normal is being defined out of existence, in part by the drug industry. Very few of the “expert panels” in psychiatry are made up of doctors who have no financial ties to the industry.

I’ve been told by a therapist I respect not to let a child ever be officially diagnosed with anything like ADD or bi-polar disorder because s/he will be a)targeted by drug companies for the rest of his life b) will never be able to get insurance because of pre-existing condition and c) the diagnosis might be wrong but s/he will never be able to get out from under it.

In your experience, does this sound true? This isn’t the same thing as overtreating.

Surgery for restless leg sydrome? You got me on that one. Kirk? I have no idea what on earth this could be.

Psychiatry is one of the areas of medicine most susceptible to bullshit.

Yes, part of that has to do with the overlap with substance abuse issues.

Unscrupulous psychiatrists can eliminate clinical testing (by psychologists) from the process. A lot of the clinical testing that’s available can take some of the “bullshit” out of it.

I imagine that the advances in such things as orthopedic surgery are of some benefit. For example, a few years ago, I broke my radius, the wrist end totally broke off. If I had this break as a child, I think my arm would have been disabled to some degree. However, they inserted pins to keep the bone in place, and I think I have about 98% use of it, just missing some strength, but not significant.

My father has metastatic colon cancer. He is from a family of colon cancer, and medical disbelievers. As a result he has refused any chemo or other treatment, besides surgery. He has been living with a high quality of life, not compromised by side effects and such for almost 3 years. Of course, until recently the cancer was confined to the few tumors. And now he has inoperable nodes. . .so his time is uncertain. But it would do nothing for him to take treatment that is incompatible with his beliefs. He would be miserable.

I have not had a colonoscopy, pretty much all the rest of my family have had it. But all of the relatives have been near/past 80 when diagnosed, so I am very interested in your info on the screening. . .

I’m probably wrong on this, but it is my impression that “Restless Leg Syndrome” has been recently debunked as being a legitimate ailment, and that it was invented by the drug companies to “fit” the drugs they made up.

Interesting point. I’m struck that we use a business model to evaluate health care in this country, talking about health care ‘consumers’ and the like. I’m not sure our society is very good at evaluating outcome-based anything, though. Look at education for example. That’s not to say we shouldn’t pay more attention to the model of success we are using.

That’s very interesting about your mother and her ankle. Thanks for sharing it.

He was operated on by a vascular surgeon. I’m not sure what all was done.

I know many doctors who just say no. they don’t see reps, and they don’t take drug company money to speak, to lecture, to consult.

I worked in the medical field for many years, and it was my experience that the drug reps (usually good-looking women) went around peddling their goods. The doctors bought into the drugs and readily prescribed them…the doctors never bothered to open the PDR to see what kinds of drug interactions or contraindications there might be. Jeez.

WRT psych meds, as you point out in Overtreated, one of the most pernicious aspects of the problem is that the vast majority of prescriptions for psychotropic meds are written by non-psychiatrists.

There aren’t enough shrinks doing psychopharm to take up the slack ( and I could fill a psychopharm practice here in SF in a few weeks, from what I’m told), so I don’t think I have turf problems here.

I sure see a lot of suffering, though – the antidepressants make bipolar disorder symptoms worse, and the mean lag between starting treatment and being diagnoses with bipolar is twelve miserable years.

Knowing that most shrinks aren’t using validated diagnostic instruments, I’m damn certain the vast majority of non-psychiatrists aren’t, so the vast prescribing of psycotropics by non-shrinks frightens me.

Anyone interested in this should also watch the excellent episode of Frontline that was on this week, “The Medicated Child.” It showed families where the parents explained that the medications were the only things that kept their families functioning, but also clearly showed children with severe and long lasting side effects from medication.

One thing that was made clear was that doctors were essentially making guesses as to what the diagnosis might be based on what the parents reported, and then prescribed medication based on that. It was really scary to watch!

There was one doctor who was trying to organize pediatric psychiatry along the lines of what pediatric oncology did in the 70s (and continue to do). Basically, all child cancer patients are enrolled in research studies, and data is kept on their treatments and outcomes. Childhood cancer went from being a very quick death sentence to 90% curable (confess I have no idea of what the definition of cure is in this context.)

Question – I took Abnormal Psychology recently, and the professor impressed upon us is that the big problem the psychiatric profession has to face is that mental health patients are very bad reporters of their own medical and personal histories. Is there away around this? It’s not just the doctors who are experimenting. A lifetime medical record would be one way around this.

Me neither.

One of the smartest docs I’ve ever met is the (recently retired) oncologist I teach with – we’ve discussed RLS treatments at length (family members) and no mention of surgery. Totally new to me, too.

Children being diagnosed with ADD and bipolar is actually a perfect example of overdiagnosis and overtreatment. There are some children who do have a real, biological condition that keeps them from being able to pay attention, and bipolar disease is real. But the steep and rapid increase in the diagnoses of these diseases, in children as young as toddlers, and then the treatment of those children with powerful psychiatric drugs, is I think one of the great tragedies of our time.

I’ll give you a personal example. My bright, active 12 year old was having trouble concentrating when he was in 2nd grade. his teacher pulled me in and said the school was going to want a consultation with his pediatrician. there was only one reason for a consult, and that was to get a prescription. I told her he was never going on drugs, but I would do anything she wanted me to do to help him learn to focus. So we worked together, and he did a little better, and by the time he hit 3rd grade he was a model student. he didn’t have ADD. He was a boy and he had to grow up a little more to be ready for school. In a perfect world I probably wouldn’t have sent him to school until he was 8 years old, which was when he was ready.

Are you saying that a colonoscopy can perforate the bowel?

restless leg syndrome exists, but it’s probably a lot more rare than the ads on TV want you to think. And it is very poorly understood.

There was an article in the New York Times Magazine a few months ago by a psychiatrist who took drug company “consulting” fees in exchange for shilling their drugs to other psychiatrists, but then had a change of heart when he realized how destructive it was to his ability to treat his patients appropriately.

I urge you to watch the Frontline piece.

Perforation is the major risk of a colonoscopy.

I had a friend with colon cancer. She lived a long time with it, but in the end, what really killed her was the perforation of her bowel from her last colonoscopy.

What if the child truly does have the condition in question and truly does need medication?

Kirk is right — the majority of psych meds are prescribed by PCPs, who aren’t trained well in psych diagnoses, and who are under pressure from patients who see an ad on TV about “social anxiety” and come to the office asking for a prescription for an SSRI.

Daniel Carlatt’s piece in the NY Times Magazine was excellent and a good read. You might also take a look at a piece by Carl Elliott in the Atlantic Monthly called “Drug Pushers.”

I think that the TV ads on drugs are unethical.What`s your take?

the right medication can really help. the problem is getting a real diagnosis.

I’d like to see direct to consumer advertising, both print and broadcast, banned. It is hard to see how it is improving health. Short of an outright ban, the ads should be made to conform to strict guidelines for accuracy and full disclosure of side effects and efficacy.

I have also heard of a book called Manufacture of Madnesswhich addresses psychiatry`s over-diagnosing.

I would be very interested to hear more about this case — the colon cancer patient who died from the colonoscopy. Can you email me off-list?

mailto:brownlee at overtreated dot com

thanks!

You got that one right. I won’t step up on the soapbox, but I will say I’ve seen far too many children and teens diagnosed and medicated for ADHD when they actually have anxiety disorders due to trauma. It’s infuriating.

An underlying issue unmentioned thus far is: taking time fully to interview the patient. Unless we really listen (and ask and ask) and are curious about EVERYTHING, we can’t rely on our diagnoses.

Thanks for your reply.I totally agree .

I so agree with your comment. I knew folks on the staff of UCLA’s Child Psych Inpatient Service – and they were always full and beseiged by a waiting list of admissions. They treated kids with very serious, devastating biology.

The neurologist on the clinical faculty (basically private practice model) with the office next to mine was the same.

As an adult psychiatrist, I simply didn’t accept patients for ADD/ADHD treatment – despite having to piss off people by turning down referrals.

And the folks I knew on the Child Service and the doc with the office next door were (and are) aghast to see a whole culture rushing to embrace serious brain problems. None of these docs – or I would want a loved one with severe neurobehavioral symptoms.

Personally, I didn’t know which was grosser – the very savvy parents/kids from affluent West LA families angling for a diagnosis (ADD) with an eye on getting performance enhancing drugs (and longer test times) or the sleazy docs who ran to take their money.

Again, some few folks really do need psychostimulants to enhance cortical function enough to allow inhibitory nervous system function.

Aside from those few, in LA the adolescent ADD/ADHD industry at best seemed to be how upper-middle class kids buy legal speed – and at worst poured stimulants into kids with bipolar disorder, making their lives hell for years.

Having said all that – for kids/adolescents who meet robust diagnostic criteria for bipolar disorder – diagnosis and treatment of symptoms compromising life functions is the only I know to alleviate far greaer suffering.

Now there’s one to ponder…

Doctor/pharmacists? Or a “standard model” business partnership thereof?

And, say, air pollution. And stress.

Good evening –

I am a nursing supervisor at an inner-city hospital. I’m a new arrival, I hope the question didn’t get brought up already.

I think there is a lot of overtreatment of patients in the end-of-life stages, ranging from unnecessary to unethical. I really have a hard time trying to discuss where we consider drawing a line on expensive interventions and just focus on care and comfort. Your take?

The drug industry spends billions on marketing to physicians — through drug reps, advertising in medical journals, biased research, and underwriting continuing medical education course. They don’t spend that money for nothing — all the marketing works. There’s a large body of literature that shows that the more contact doctors have with reps and biased CME courses, the more likely they are to prescribe “irrationally,” which means less on the basis of evidence. IN other words, they are susceptible to the marketing messages. I think we are all susceptible to marketing, which is why manufacturers spend money on it. But I would rather have a drug prescribed on the basis of the best available science than on which drug rep brought the nicest catered lunch to a doctor’s office.

Shannon, on pps 236-237 (1st edition) you describe the mismatch between the medication “studies” that are performed vs David Eddy’s assessment that only 15% of what docs do is backed up by valid evidence.

If you have time, could you elaborate?

wow, if your family doesn’t get colon cancer until they hit 80, that’s pretty darned good as far as living a full life!

There has been a lot of information lately about autism, the high occurance, etc. Is there also more bi-polar disorder now than in prior generations? What other incidences are higher?

It makes me sad and it seems criminal to me to drug up children and adolescents and really interfere with their normal growing adjustments. Is there any oversight except the doctors themselves? Well, I guess our elected federal reps are also in Big Pharma’s pockets. This feels really sickening.

Kirk, thanks for offering your on-the-ground perspective. (I feel like I’m always peering at medicine from the outside, nose pressed to the glass.)

Wouldn’t it be lovely for us if they formed an association so we could know who they are? Their motto could be “Just Say No”.

Shannon, I just hope I’m not talking too much in your Book Salon. Our readers get to hear from me all too often – your presnce here is really a gift.

wow, if your family doesn’t get colon cancer until they hit 80, that’s pretty darned good as far as living a full life!

I have had three relatives die of colon ca in their eighties..It is still a bad way to die even if you are eighty. I would rather have my polyps removed in my 60’s and 70’s and die of an MI in my 80’s.

That’s a really good question, Fern. I don’t know. But what Shannon said jives with what my friend said and also our pediatrician.

Shannon, my step-mom was an elementary school teacher for 30 years. The year she retired, the district instituted a new policy – during work time, boys & girls were allowed to move around, and do their work standing at one of the new tall tables in each classroom. My step-mom says it was the most amazing “reform” she’d seen in her entire career. Almost immediately, discipline in her classroom was almost never needed. Mostly boys took to the tables but some girls did, too.

One of the proincipals my son has had told me behaving at school was a very unnatural attitude for chldren to take and he worried about the ones who never ever got in trouble

Yes, while I realize the colon cancer risk is high, I am much more concerned about osteoporosis which has made my mother’s life far more miserable for the last 15 years than any cancer I have seen in the family.

I see the ads for the bone-builders. . .I am taking one of them. I hope it keeps me from that misery.

Many years ago, there was a woman who lived below me in an apartment in Israel who used to visit me very regularly and had been depressed/suicidal for a long time. Shortly after starting to take the meds a doctor prescribed, she actually did kill herself.

kirk, you asked about David Eddy’s estimate that only 15 percent of medicine is backed up by valid evidence (”valid” meaning “likely to be true”). Dr. Eddy has now backed away from that number and the Institute of Medicine’s estimate that about half of medicine has evidence behind it is probably a better figure. What the figure means is this: we need good science to know what works in medicine and what doesn’t, becuase it is very easy to fool ourselves into thinking something works when it doesn’t.

I’ll give a specific example: for many years doctors gave heart disease patients drugs that are related to novacaine (the drug that dentists use to deaden your teeth and gums). for heart patients, the drugs were thought to reduce the risk of death from arhythmia, or irregular heart beats. And the drugs did reduce arhythmia. As a friend of mine once put it, “We thought we were doing God’s work, saving patients’ lives when we gave the drugs.”

Finally, somebody did a clinical trial comparing patients who got the drugs to those who didn’t, and what do you suppose they found? The drugs INCREASED the risk of death.

It is easy to be fooled into thinking something works when it doesn’t, and you need to do some science to find out if the assumption holds true.

that’s a very interesting idea — they could have their own professional organization.

A colleague and I are getting ready to release a list of these doctors to our fellow journalists, so they can use them as sources for stories.

Shannon thank you for coming to the Lake and sharing your book and experience with us.

this is a terrible tragedy. Doctors are now becoming increasingly aware that agitation can be a side effect of the antidepressants, and in some patients the agitation can be so awful it leads patients to suicide. Kirk can probably comment more knowledgeably about this situation than I can.

Bev,

thanks so much for having me! And thanks to all of you for submitting your interesting questions and comments. Anybody who reads the book who wants to send me a comment is welcome to go to my website, http://www.overtreated.com.

Shannon

There are several sites and blogs dealing with real evidence in medicine – check them out to see if there is anything behind a treatment or medication:

http://www.jr2.ox.ac.uk/bandolier/
http://www.quackwatch.com/
http://www.badscience.net/

and others.

Thank you for visiting today. I look forward to the book.

Thank you so much, Shannon, this was a really enlightening discussion.

and thanks host Kirk!

I have recently been doing a lot of reading regarding vaccinations. Are you aware of any of the evidence relative to the damage done? Not just with regard to possible connections to autism but other damage as well. I breed dogs and have cut back significantly and see a huge improvement in over health in my more recent puppies. There was a study by a Scottish or Canandian vet who found 85% of vet visits were within 90 days of vaccinations. Is there any evidence of similar effects in children. After all the amount of vaccinations given to babies is mind boggling to me.

Seconded.

Antidepressants and suicidality is a tragic subject and a fascinating question.

Three ways anti-depressants seem to induce suicide/death:

1) side effect: akathesia (terrible subjective restlessness) “I feel like my body won’t be still”. In the most severe form, sleep is intolerable and an already miserable person has no escape whatsoever except (as they perceive) death.

2) side effect: increased thoughts about suicide (most notable – as Shannon discusses – with Effexor…which I try never to start in any patient, for this reason and for withdrawal problems).

3) treatment effect: “manic switch”. Patients with bipolar disorder often find antidepressants kindle a manic episode. As mania symptoms often include impulsivity, racing thoughts, decreased concentration (and hence judgement), and increased risk-taking behavior, mania and motor vehicles may be lethal.

[Note - although “manic switch” was definitely noted with the pre-SSRI antidepressants, akathesia appears to have been far less common that with the SSRI’s]

Appropriate diagnosis (requiring time) AND patient education (requiring more time) are essential for the safe use of antidepressants. Unfortunately, “more time” is precisely what the current reimbursement system generally refuses to offer.

Shannon, thanks for your time here to day and for the masterful research and excellent writing you give us in Overtreated.

If you haven’t bought the book yet – there is a link on the top of the page. It is a good read for anyone interested in the medicine we’re taking. Thanks again Shannon for coming to the Lake.

thank you very much for the response kirk.

great post, Shannon and Kirk. well worth it! thank you!

Thanks for pointing out the link to Shannon’s book. If pups only buy one book on health care this year (or this decade), I hope it will be Overtreated. It’s that good.

Thanks, Shannon and Kirk! Lots to think about in how I teach my medical students.

Thanks Shannon and Kirk — looks like I have another book to add to my growing list :-)

Kirk,

Glad you could do a post on a subject for which you have real expertise.

Maybe you should stick to medicine.

I stay away from doctors too. You should hear conversations from my co-workers. Their lives are a pharmacopoeia of drugs and tests. They can name all their medications, dosages, uses, tests results (more opportunity to prescribe more drugs). Not only that but they share their prescriptions! Do they eat right? No. Do they exercise? No.

Do they call in sick regularly? Yes. Do they catch everything going around? Yes.

I haven’t missed a day of work in more years that I can remember.

Kirk, This seems to have gotten passed over:

Hey Kirk, you wrote
“Now – for all the psych diagnoses – a specific validated instrument allows one to make accurate diagnoses by asking specific questions from a flowchart. The instrument has a very high inter-rater reliability, and is easy to use.”

Which instrument are you talking about? I have a semi-professional interest. Does it control for drug use/abuse?

Bob in HI

I’d like to know, also . . .

BTW, I just clicked through the link to Amazon.com, and ordered a new copy of the book. My order confirmation said they are out of stock (??!!?) and will ship when available. That doesn’t seem right. Is there someone who can rattle their cage on this?

Thanks oregondave (and bobschacht).

The massive Epidemiogic Catchment Area Survey’s validated instrument is the DIS.

No disrespect to the ECA and their friend the DIS, but the SCID series may offer even better specificity/sensitivity/inter-rater reliability in non-academic use.

And just when you thought it was safe to get back in the testing booth….

DIS fans take heart – further field work with the DIS has begotten the CIDI.

And you thought the psych diagnoses were proliferating?

(anxiety nerd note – for academic use with anxiety/affective disorder patients, the ADIS-R may be most useful. Please see pp 165-167 of Panic Disorder: A Critical Analysis by Richard J McNally for more detail than a body should want to know…)

Hope this helps!

Epidemiologic

jeebus