Doctors prescribing drugs

In my experience, primary care physicians are very responsible in providing their patients with the correct medications and education. Being a news article, it is easy to cite a few examples of patients that are unaware to skew towards a general opinion rather than an official study supported by lots of data from a balanced group of subjects. The majority of my patients that are taking medications are mostly aware of their drug names and why they are taking them, and some also know the exact dosages. It is true that the majority are for high cholesterol, blood pressure, anti-coagulants, diabetic medication, etc. There are many drugs that can be prescribed, however there are fine differences in the mechanisms of the drugs, so the physicians may prescribe a drug, but then change the prescription due to the medication's effects of that patient's blood chemistry, exam, etc to titrate them for the best effect on their patient. I feel that they are putting the patient's best interest first, especially since there is no tort reform. The rise in pharm sales can be attributed to patients asking for a specific drug by name, but it will not be prescribed unless it is the right drug for them. In the case where many drugs can work, if a patient feels more satisfaction for a certain drug name, it will probably be prescribed. Otherwise, it is just new technological advancements that are helping patients live longer than the had in the past and a new generation in which Prevention is the mode of operation.

It used to be that a patient would have a heart attack before medication was prescribed. Now, we have many indicators to help prevent heart attacks. So instead of a patient having a heart attack/stroke and living 10 years longer the previous generation after the attack and dealing with the repercussions of that heart attack, we are moving towards a generation of patients living 20 years longer than the previous generation, but not having that heart attack and living a normal life. With the baby boomer generation taking bp/cholesterol/anticoagulants/diabetic meds younger than the current older generation, we can expect them to live even longer with less ailments. When patients live longer than they are supposed to, new ailments arise however, that never had before been seen because they would be dead in the past. So, new medications will need to be prescribed/developed.

It's true that American's are also not healthy and they do rely are on multiple drugs to live longer, but not because they are hypochondriacs (its malpractice to prescribe drugs that pts don't need, plus insurance won't cover it without a diagnosis backed with exam information), but because they would be dead otherwise or living miserably having survived a medical emergency.
In general, most doctors do try to prescribe generics when they can. On prescription forms you check a box that says "Generic Substitute" which is checked 99% of the time unless the patient feels better with a prescription name, i.e Hydrocodone 5/500 vs. Vicodin.

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Plenty of drugs are prescribed that have nothing to do with extending life, yet are quite expensive: antihistamines or other immunomodulators, digestive medications, sleeping pills, penis pills, PMS pills, behavioral drugs, and anti-depressants (unless for severe suicide risk, though teens taking anti-depressants may actually increase their risk of suicide, but of course patients who are prescribed anti-depressants are more likely to attempt suicide anyway: http://www.redorbit.com/news/health/731343/new_look_at_antidepressant_suicide_risk/index.html). Yes those drugs may improve a patient's quality of life (either marginally or significantly), but they are not a matter of life and death.

Drugs are one of several factors contributing to the huge drop in cardiovascular-related mortality. Fewer Americans smoke (I also believe alcohol consumption is down) and there is more education about healthful living and eating vs. the previous generation. Our diagnostic technologies have improved, so hypertension can be detected and addressed earlier. It's not just these wonder drugs that are making Americans live into their 80s. And if the drugs were so great, why is it that America is the most pill-popping nation per capita, yet our overall life expectancy is ranked 24th worldwide (see my previous email "Health care overhaul potpourri")?

It's naive to think that drugs are only prescribed out of critical medical necessity. Plenty of doctors prescribe drugs off-label (as in, for indications not officially approved by the FDA), because some data shows the drug could help, but in that case the prescribing doc is responsible for any adverse effects (since thorough safety/efficacy tests have not been conducted). Maybe they help the patients by doing so, and maybe it's excessive. Not all doctors are greedy con men, and not all doctors are saints. There's a mix of the two and plenty in between. Insurance and Medicare don't have the time and resources to scrutinize every Rx. The CDC said that 14M Americans misused their Rx's in 2004, resulting in 20,000 deaths. So obviously they were using the wrong drug, or not taking it properly, so either they are junkies or their physicians/pharmacists did not properly Rx or educate them on the risks.

The Centers for Medicare & Medicaid Services reported that 30% of the nursing home population is receiving an antipsychotic, yet 21% of those cases do not suffer from psychosis. In 2007 doctors filled more than 45 million prescriptions for an antipsychotic, according to IMS Health. Yet there are only 2.4 million schizophrenic patients (for whom the drugs were originally intended), according to the National Institute of Mental Health.

http://www.businessweek.com/debateroom/archives/2008/06/stop_casual_rx.html

Yes it is malpractice to Rx a drug that the patient doesn't need, and guess what - malpractice occurs a lot in America (~14K settlements paid out each year, either valid or frivolous, though few are drug-related). The attached report (I can't vouch for the data since I haven't read it all and am unfamiliar with the org, but just food for thought) suggests that malpractice settlements are not the bogeyman that physicians make them out to be. Before federal anti-kickback laws were enacted in 1972 & 1989 (42 CFR Part 1001), pharma companies were routinely paying for doctor's gifts, posh meals, and junkets to conferences in Hawaii (and some of it persists today). Why would they do that? They have a business to run and can't afford to throw money away as goodwill. They are investing in quid pro quo obviously. This is from the New England Journal of Medicine (scary stuff actually), written by doctors:

Interactions between drug companies and doctors are pervasive. Relationships begin in medical school, continue during residency training, and persist throughout physicians' careers. The pervasiveness of these interactions results in part from a huge investment by the pharmaceutical industry in marketing. In 2002, the industry expended 33 percent of its revenues on "selling and administration."12 In 2001, one company, Novartis, reported spending 36 percent of its revenues on marketing alone.2 The marketing expenditures of the drug industry have been estimated variously at $12 billion to $15 billion yearly, or $8,000 to $15,000 per physician.7,8,13 In 2001, the industry's sales force of drug detailers, whose job is to meet individually with physicians and promote company products, numbered nearly 90,000 in the United States2,8 — 1 salesperson for every 4.7 office-based physicians.8

Moynihan14 catalogued 16 different ways in which drug companies relate directly or indirectly with doctors. These range from the seemingly trivial (e.g., the ubiquitous dispensing of gifts such as pens and pads with drug names inscribed) to the much more troubling (e.g., the ghostwriting of articles for academic physicians, the payment of large honoraria and consulting fees to prominent physicians who extol the virtues of company products, and the support of lavish trips and entertainment for physicians who commonly prescribe company products).
Surveys of residents indicate that they receive an average of six gifts from pharmaceutical companies annually.15 In a survey of 106 directors of emergency-department programs in 2002, 41 percent responded that their programs allowed residents to be taught by representatives of drug companies, 35 percent reported that residents received free industry samples at work, and 29 percent said that residents' travel to meetings was sometimes dependent on the availability of company support.16 According to another report, residents in a psychiatry program in Toronto attended up to 70 lunches that had been sponsored by drug companies and received 75 promotional items over the course of one year.17

... As many as 59 percent of the authors of clinical guidelines endorsed by many professional associations have had financial relationships with companies whose drugs might be affected by those guidelines.23

... In a very thorough review of the literature on the effects of interactions with drug companies on physician behavior, Wazana15 identified 16 relevant studies. These studies found that a wide variety of interactions — meetings with company representatives; the receipt of gifts, free drug samples, and free meals; company support for travel to and lodging at educational events; attendance at lectures by representatives of pharmaceutical companies; acceptance of honoraria; and other relationships — were associated with changes in physicians' use of medications. Involved physicians were more likely to request the inclusion of the company's drugs on hospital or health maintenance organization formularies, more likely to prescribe the company's products, and less likely to prescribe generic medications. The resulting changes in the use of medication were often costly and "nonrational" in that the newly prescribed or requested drugs had no therapeutic advantage over the alternatives. Interestingly, several studies have found that the larger the number of gifts that physicians received, the more likely they were to believe that gifts did not affect their prescribing behavior.15,28

http://content.nejm.org/cgi/content/full/351/18/1885?ijkey=8tzMb5l1u.Np2&keytype=ref&siteid=nejm

So if doctors can enjoy millions of dollars of gifts/assistance/what-have-you from pharma companies and still prescribe their products ethically and scientifically, then medical school is really worth the $40k/year.