Richard Chudacoff, MD

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On January 16, 2012, the Obama administration announced their intention to require pharmaceutical companies to report all payments made to physicians for consulting, research, and speaking as well as money spent for travel and entertainment. ObGyn.net blogger Richard Chudacoff, MD, FACOG, responds to the news 


What a great idea!!! Stupendous! Fantastic! Awe-inspiring!! Finally!!  Accountability!!! Let’s villainize doctors once again. Those greedy schumcks:  those bad, bad doctors who are always scheming and conniving behind patient’s backs to make a quick buck at the expense of the poor, defenseless insurance companies. LET’S KILL THEM ALL!!!

Wow, it sounds like a 1940s propaganda machine. Talk about deflecting blame and the pot calling the kettle black. Okay, maybe not totally innocent, but for the most part doctors are not villains. I mean…when did the doctor become the villain, the patient become the victim and the government become the savior?

Actually, I think we did it to ourselves years ago, when we abdicated our self-governance and gave it to the AMA (read: insurance companies). Then the government took it from them, in exchange for giving them CPT and ICD authority (and revenue) and it has been all downhill after that.

In 2011 12,242 lobbyists spent $2.47 billion dollars in Washington. $2,470,000,000--that's nearly two and a half f’ing 

 dollars. All 535 members of congress, each Senator and Representative averaged about $46,000,000. EACH. Forty-six f’ing million dollars spent by lobbyists per government representative. As far as health interest lobbyist, it was a measly $478.5 million, or $90,000 per representative.

So what is the big deal? Oh, CBS ran an expos on Pharma payments to physicians. Why some greedy doctors, doing research and lectures even got paid up to $500,000 according to CBS and other sources. Some doctors, getting pens and sticky pads write for a brand named drugs instead of a generic medicine, they say.  Some doctors do research, and then go around the country lecturing on said research, trying to convince unsuspecting, ignorant, gullible doctors to use a brand name drug instead of the generic drug, they say. Oh, the horror, the horror.

The website project.probulica.org estimated that $761.3 million were paid to doctors in 2011. Well, the closest number I can find is there were 661,400 doctors in the US in 2008. Let’s just assume the number is the same today. That means each doctor was paid a whopping $1,150. Yep, Eleven hundred and fifty f’ing dollars. Weeeeeee……….let’s party dudes.

Um, wait. That is it? $1,150. And at 35% tax rate, that is, um, $747.50. So, Pharma gave each congressman $90,000 who now wants to prevent Pharma from giving each doctor $747.50. Whoa? Doctors aren’t villains, people. Doctors are downright stupid.

And what is Obama and Congress worried about. Hmmm. Let’s see: the average generic drug costs $6.00 and they are afraid doctors might write for a brand name drug which averages $24. That is an increase of 400 percent.  The problem, especially in hormones, level-sensitive drugs, and anti-depressants, at least in my experience, is that most generics don’t work as well as the drug they tried to copy. Studies state that generics can have as much as a 20% difference in bio-equivalency versus the name brand drugs, so they are 

 clinically equivalent. That may be good for antibiotics or NSAIDs, but do you want your daughter on a low-dose OCP that is 20% less effective? Do you want your aunt or grandmother on a generic antidepressant or cardiac med that is 20% more toxic? Well, I don’t.

The other problem is that dispensing name brand drugs would be a 400% decrease to the insurance company profits, if they were forced to pay for medications that actually worked…and saved lives. Ah, lives….those pesky things that cost insurance companies, who are about to gain so much from Obama care: money.  The 4,525 lobbyists from the health care insurance companies, roughly 8 per congressman, spent $3.47 billion to influence the Obamacare discussion, or roughly $6.5 million per congressman. Damn right they want a 400% reduction in pharmaceutical costs.

So, a doctor, worried about a patient, will write for a name brand drug. The pharmacist (don’t forget about them) automatically, without asking the patient or doctor, immediately changes the drug to a generic, unless written, multiple times, ad nauseum, that they cannot substitute for a generic drug.

Oh, wait though; can the pharmacist receive gifts, dinners, trips, etc. from generic pharmaceutical companies? Yep, sure can. Nothing in the Pharma Code and Guidelines that prevents it.  Wait, really? What the h-e-double-hockey-stick is that all about? No data on the internet about how much money generic manufacturers are giving pharmacies and pharmacists….not one word. Makes you wonder, huh?

So, let me see… the bad guy (doctors: $747.50) are forcing the victim (patient: $24) to take brand name drugs (20% better or safer) while the savior (congress $46,000,000-$90,000-$6,500,000) protects the victim, and requires them to take a generic drug (20% more toxic or less effective). And WE are the villains???? Am I missing something?

Perhaps it is time that each member of the congress declares all their earnings and gifts to the American public. STOP LAUGHING!!! I’m serious.

It reminds me of a time I was playing golf with a friend of mine, an electrical contractor, who was working on the City Center in Las Vegas. He invited me because they needed a fourth. My friend and another guy, also an electrical contractor, were invited to play golf by an electrical materials supplier-golf, balls, drinks, food, dinner. (I, on the other hand, had to pay my own way.)

Somehow during the round of golf our conversation came around to pharmaceutical companies and I told him that these companies could no longer take me out to the golf course. Why?, he asked. I replied that the government/insurance company was concerned that I might write for a $300 name brand drug when a $50 generic drug might work just as well. He started laughing. He told me that just between the two electrical contractors they had $70 million worth of business that the supplier wanted, so he was paying $500 each for the day of golf to get their contracts (I think he did get the contracts, too.) He also said that most of the work was government related.

In a recorded conversation Dallas Mavericks owner Mark Cuban once talked about why he sold radio.com for $1 billion. He learned in his MBA schooling that during negotiations one should always look around the room and see who the sucker is. If you can't figure out who is the sucker, then most likely it is you.

Well, fellow suckers, we never even got into the room to look around. Perhaps we can all band together, take our $747.50, and buy our own politicians. Nah, trying to get doctors to band together is like herding cats. We are victims of our own stupidity, we allow others to define us, we allow others to brand us, and we allow others to rule us.

It is what it is: no more pencils, no more books no more teacher’s dirty looks (whoops, wrong song and dance)….just greedy looks from our fine politician while they protect the American way of life.

Articles

ObGyn.net blogger Richard Chudacoff, MD, FACOG, responds to the news that new health care laws will require pharmaceutical companies to disclose all payments to doctors.

Requiring Pharma to Disclose Payments Paints Doctors as Villains

While morning sickness can occur in up to 70% of all pregnancies, it is usually 	more troublesome than serious. The more severe and disturbing condition, hyperemesis gravidarum, may complicate 	up to .3% of pregnancies, causing physiological changes that may effect the mother and fetus. Maternal weight loss, 	dehydration, electrolyte imbalances, acid-base disturbances leading to renal and hepatic injury have all been reported 	in extreme cases. Persistent vomiting can lead to Mallory-Weiss tears and nutritional deficiencies may lead to 	Wernicke’s encephalopathy.  

Prematurity, low birth weight and a slight increase of central nervous system 	and integumentary malformations have been reported in fetuses of mothers affected with hyperemesis gravidarum. 	An increase risk of testicular cancer in male patients of mothers with hyperemesis gravidarum during their pregnancy 	has also been reported in the urology literature.  

Hyperemesis gravidarum should be considered when all other causes of persistent 	nausea and vomiting have been ruled out. Pyelonephritis, pancreatitis, cholecystitis, hepatitis, appendicitis, 	gastroenteritis, peptic ulcer disease, thyrotoxicosis, and hyperthyroidism can present in similar fashions, with 	intractable nausea and vomiting, and are treatable conditions. Late presenters need also to be ruled out for HELLP 	syndrome and other causes of hepatic and central nervous system dysfunction.  

The etiology of hyperemesis gravidarum is not well understood. Hormonal causes 	related to human chorionic gonadotropin, estradiol, progesterone, adrenal hormones and pituitary hormones have 	been proposed, but currently there is no conclusive evidence implicating any specific substance. Psychological 	and social factors influence this disease, such as in unwanted pregnancies, although this syndrome is not limited 	to unwanted pregnancies. Young, unwed mothers whom are felt to have "sinned" and therefore harassed by 	their parents, are common sufferers of this syndrome. Remarkable improvement with hospitalization is often noted 	in such cases, with rapid relapses once released to the home environment. Hysterical and immature personalities 	can predispose one to this condition. 

The diagnostic work-up must always start with confirmation of a viable, intrauterine 	pregnancy. Gestational trophoblastic neoplasia can present with hyperemesis gravidarum in up to 30% of cases. Electrolytes, 	liver function tests, thyroid function tests, creatinine, blood urea nitrogen, urinalysis and a complete blood 	count are some of the studies that need consideration in the work-up. 

Once the diagnosis is made, treatment consists of mainly supportive care. Intravenous 	fluid, up to 5 to 6 liters per day using the appropriate amounts of sodium, potassium, chloride, lactate or bicarbonate,  glucose and water, are primarily used in correcting the hypovolemia, electrolyte and acid-base imbalances, and 	ketosis,. Until vomiting is controlled, these patients should be maintained as NPO. A low dose, continuous infusion 	of an antiemetic, such as promethazine, can have beneficial effects. Vitamins, including thiamine, can be added 	to supplement the intravenous fluids. Patients should be maintained NPO for at least 48 hours after all symptoms 	and vomiting have ceased, to prevent rapid regress. Initiate PO intake with neutral fluids and a small, bland, 	dry, carbohydrate diet, in frequent intervals. Avoid noxious stimuli such as unpleasant odors. Reassurance and 	emotional support is important at this time, and psychological counseling can be initiated once symptoms have abated. 

Patients with intractable, prolonged vomiting may be treated with nasogastric 	enteral feedings, peripheral parenteral nutrition, or total parenteral nutrition. Rarely is interruption of pregnancy 	necessary. 

Oral medications have long been the main stay of out-patient treatment. Until 	forced off the market Bendectin (pyridoxine-vitamin B-6 (10mg) and doxylamine succinate (10 mg)), a category B 	medication, was efficacious and safe for both mother and fetus. This formula can be reproduced over-the-counter 	using Unisom Nighttime Sleep Aid (25 mg) (not Maximum Strength Unisom Sleepgels, which contains diphenhydramine 	hydrochloride) one half tablet and Vitamin B-6 (25 mg) one half tablet, each in the morning and afternoon, and 	one tablet each at bedtime, as needed. Useful category C medications are prochlorperazine, promethazine, trimethobenzamide, 	and droperidol., although because of their category designation, informed consent should be obtained on all patients 	treated with the above medications.

    1. Briggs G, Freeman R, Yaffe S: Drugs in Pregnancy and Lactation, 2nd edition. Baltimore, Williams and Wilkins, 1986

    2. Creasy R, Resnik R: Maternal-Fetal Medicine: Principles and Practice, 2nd edition. Philadelphia, W.B. Saunders, 1989

    3. Gabbe S, Neibyl J, Simpson J; Obstetrics: Normal and Problem Pregnancies, 2nd edition, Churchill Livingstone, 1991

    4. Cunningham F, MacDonald P, Gant N: Williams Obstetrics, 18th edition. Appleton and Lange, 1989

    5. Greenspoon J, Rosen D, Ault M: Use Of The Peripherally Inserted Central Catheter For Parenteral Nutrition During Pregnancy. Obstetrics and Gynecology 1993;81:831-4

    6. Hsu J, Clark-Glena R, Nelson D, Kim C: Nasogastric Enteral Feeding In The Management Of Hyperemesis Gravidarum. Obstetrics and Gynecology 1996;88:343-346 

While morning sickness can occur in up to 70% of all pregnancies, it is usually more troublesome than serious. The more severe and disturbing condition, hyperemesis gravidarum, may complicate up to .3% of pregnancies, causing physiological changes that may effect the mother and fetus.

Author | Richard Chudacoff, MD

Articles

Requiring Pharma to Disclose Payments Paints Doctors as Villains

Hyperemesis Gravidarum