What Are We Doing?

Two encounters today made me pause and reflect about what we really are doing to our patients and to the health care system.

The first one was a pharmaceutical representative in the clinic hallway. He tried to engage me in a conversation about the latest medication for overactive bladder.

“How much does it cost?” I asked innocently.

“It’s covered by most insurance companies”, he replied.

“I don’t care, I’d like to know what it costs”, I insisted.

“I don’t know”, he said.

“Even medications that are covered by insurance have a cost to somebody. In the end we all pay for medications. I never prescribe anything without knowing roughly what it costs, because I have a responsibility to my patients and to the system to know that and keep it in mind when I choose a medication.” I surprised myself a little with the emphatic tone in my voice. After all, didn’t I leave Sweden twenty-nine years ago because of being fed up with socialized medicine?

“I’ll have that information next time”, he said meekly.

“Never mind, I’ll get it online”, I said. One minute later, as he was packing up his laptop and his handouts I saw him again as I passed down the hall on my way to the next patient.

“$139 a month”, I told him.

“Oh”, he said sheepishly.

The second encounter  was a new patient visit. Mrs. Schmidt had just moved here from downstate to be closer to her daughter. A stylish woman in her mid-seventies, she had a fairly straightforward history and medication list. The only unusual thing I noted was that she was taking a combined estrogen-progesterone pill at her age. 

“What is the reason for your hormone treatment?” I asked. “Did you have trouble with hot flashes?”

“No, my doctor thought it would be good for my heart and my cholesterol”, she answered.

“Well, that was the thinking, but we now know that hormone replacement therapy can increase a woman’s risk for breast cancer, and doesn’t protect women from heart disease. It actually seems to increase the risk of strokes and heart attacks”, I said, not sure how she would take my disagreeing with her previous doctor.

“Well, then I’m happy to stop it”, she said. “I’m only taking half of a tablet anyway. 

“Great, one less medicine”, I concluded. I made a mental note of the fact that her doctor had continued to refill this prescription for seven years, even after the Women’s Health Initiative study found that such hormone treatment did the opposite of what the medical establishment had believed.

Postmenopausal hormone treatment has been around for fifty years, and many people saw estrogen as a wonder drug that promised prolonged youth and vitality. It is very humbling that it took half a century, longer than the careers of most physicians, to find the truth.

I often wonder which of today’s wonder drugs will ultimately be proven not only useless but actually harmful. There are a few I worry about.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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