A Country Doctor Writes:

Archive Page 154

Suddenly Expensive Generics

Published August 29, 2014 Opinions 6 Comments

Fran Barker called today. She was in a panic because the cost of her monthly prescription of 150 mg amitriptyline tablets had gone up to $130 from $13 the month before.

Amitriptyline has been available in this country since 1961, and the 100 mg strength was on Walmart’s list of $4/month drugs the last time I looked at it a few months ago.

I called Fran’s pharmacy. Two of the 75 mg tablets would be less expensive, about $75 for a one month supply, but this would still be a hardship for Fran, who is disabled and lacks prescription coverage.

A few months ago I read that the older, generic statin drugs for cholesterol were suddenly not on Walmart’s $4 list due to sudden price increases by the manufacturers.

Something similar happened to insulin a few years ago – it went from a few dollars to $80 per vial without any explanation that I was aware of.

I have Googled around a few times to try to find out what is happening, or what people think is happening, but the dramatic price increases I have run into don’t seem to be getting much press.

It appears to me that the pharmaceutical companies have stopped their price competition, possibly by secretly dividing up the market and definitely by limiting supplies. If that is true, antitrust laws are likely being broken. Meanwhile, people with chronic illnesses are being squeezed financially even more than they already have been.

Generic drugs used to be a low margin product for manufacturers, but a major profit for drug stores. With newer generics, whose brand name competitors are still on the market, pharmacies may buy them for 10% of what they pay for the brand and sell them for 70% of the brand name price. Now, with their purchase prices going up on one generic after another, their markup is likely shrinking to the levels of brand name drugs. This will likely drive independent pharmacies out of business.

We already had a great deal of mystery and intrigue around pharmaceutical pricing and actual insurance payments for prescription drugs. Just like doctors and patients have trouble figuring out how much MRIs and artificial knee joints cost, the real cost of pharmaceuticals is often unobtainable. I can try to choose lower cost medications by looking up the average retail cost on Epocrates, but insurance companies and drug manufacturers often negotiate deals that make favored otherwise expensive drugs cost less than non-favored drugs with lower published prices.

This whole drug price situation is really the stuff of mobster movies. Or imagine a sitcom about what happens when gasoline (petrol) prices increase by 900% overnight. That wouldn’t be funny for very long. People would complain loudly about being held hostage or extorted.

But is anybody complaining about what is happening now with drug prices? Am I just not hearing about it because I gave up watching TV? Or am I an early voice in the wilderness? You tell me…

“I Also Tame Wild Horses”

Published August 28, 2014 Progress Notes 1 Comment

Autumn’s 17 month old nephew from out of town had been visiting with us in the office the other day. He sat in his mother’s arms as Autumn showed her sister, April, around the clinic. We had made brief eye contact then. He had the hesitant look of quiet amazement as he looked around our busy office. I minimized the EMR on my big computer screen and showed him the picture of my white Arabian horse standing next to me, all bundled up in my thick leather jacket with a blaze orange vest over it. Dylan’s eyes locked on to the screen as the two women talked. They stayed locked on and he didn’t seem to register my attempts to make contact. After a few minutes, April signaled she had to be going. Autumn and I both waved and Dylan strained his neck, gaze still fixated on my computer screen as his mother turned around and stepped into the hallway.

Friday, Dylan was in my schedule for fever and vomiting. Both his mother and father were there and Autumn was in the room with them.

Dylan didn’t appear to be all that sick. I sat slouched on my stool while I took the history and then slowly moved closer to the exam table and began to examine Dylan in his aunt’s arms.

Autumn and April commented from the beginning on how difficult Dylan usually is to examine. I plodded along slowly without any protests. I checked his neck for enlarged lymph nodes and carefully pulled the stethoscope from the pocket of my long white lab coat.

“I don’t believe that he’s okay with you doing that”, his mother said as I listened to his heart and lungs. I squeezed his belly very gently as I told his mother that his lungs sounded nice and clear. His abdomen was absolutely soft and he didn’t seem bothered by my palpation.

Next, I slowly pulled my pocket otoscope from the holster on my belt. Dylan watched intently as I unfolded the instrument.

“See how this works”, I said in a low voice and turned the light on. I aimed it first at my left hand and wiggled the light a little. Dylan’s eyes followed my movements. When I aimed the light at the Disney figure on his shirt, he looked down, and his chin touched his chest. Slowly, I reached past the exam table and pulled an otoscope tip from the wall dispenser. “Let’s check your ears”, I said while I attached the otoscope tip.

Dylan’s eyes followed every move I made. I aimed the light at my own hand again, then I quietly reached over and looked in his ear while I very carefully pulled just a little at the tip of his outer ear. As he started to tighten his muscles I let go and pulled away. “That one looks okay”, I said as April and Autumn stood next to Dylan with wide eyes and open mouths.

His other ear looked fine, too. He didn’t tense up at all this time. I said “let’s check your mouth” and cocked my head up a little to be able to look through the lower portion of my bifocals. Dylan also looked up a bit, and his jaw muscles relaxed. Gently, I touched the sides of his mouth and opened mine a little. He opened his mouth in the same fashion and I pulled lightly on his jaw and his mouth fell wide open. I got a quick look at his tonsils and I could see that his mucous membranes were moist and normal in color.

“He looks fine. I think he just has a viral infection, so as long as he keeps taking in fluids and doesn’t develop any other symptoms, he should be okay”, I reassured his parents.

“He’s never let anyone examine him without fussing or crying”, April said. “I know”, Autumn chimed in. “He’s always been impossible to examine.” Turning directly to me, she continued: “I always knew you were good with kids, but this was truly amazing!”

“I also tame wild horses”, I said, overcome by an uncharacteristic impulse of flamboyance.

As I thought about my words, it seemed that the analogy is obvious. People talk of the “techniques” they use when dealing with mistrusting, unbroken rescue horses, sullen teenagers or toddlers with fear of doctors, but I never thought of any of it as technique. Approaching another creature requires genuine respect and connection, and it can’t be completely taught or analyzed.

After I ended up with my rescued Arabian princess and got to know her by just hanging out with her, sitting quietly in the barn cold winter evenings and sultry summer nights, she has come to trust me, and I her. When she was ill and too despondent to return from the frozen pasture during her first ice storm, I trundled out to her with halter and lead rope for the very first time, and she followed me willingly back to the barn.

Later, I have read about just this way of relating with horses, not by dominating them, but by earning their trust and respect. Carolyn Resnick calls it “The Waterhole Rituals”. The first and most crucial step is to place yourself near the horse without fixating on it, and enter a frame of mind that is peaceful and gentle. If you just do that, any horse will seek you out to make your acquaintance.

Approaching a sick child, or just a fearful one, requires the same frame of mind. There may be techniques to learn, like listening to the lungs right away, before any crying starts, and saving the throat exam for last, because if the child does start crying, you’ll see the throat anyway, and without effort. But those are superficial and secondary considerations. The kind, gentle and healing presence isn’t something you need schooling to learn. It is just a matter of having your heart in the right place. I also think it is important to connect on a level some people may refer to as “energy”; Dylan, the amazed visitor from another world, that of a gentle and curious seventeen month old, responds better to a quietly plodding softspoken “energy” or demeanor, while some older children with mischief in the back of their minds relax and connect better with a grandfatherly doctor with a twinkle in his eye and a joke up his sleeve.

As my practice has matured, I see fewer children than I used to, but I cherish the opportunities I do have to see young children. It’s like dusting off your old bicycle and going for a spin – you never forget how to do it.

The Great Imposter

Published August 26, 2014 Progress Notes 4 Comments

“I hate to leave you with such an unfinished workup”, my senior colleague, Dr. Wilford Brown, said three Thursdays ago. He was going on vacation and Norman Sprague had just been in to see him with a one day history of a strange pain near his right shoulder blade.

Mr. Sprague is a 68 year old retired accountant with rheumatism and diabetes. Dr. Brown ordered some bloodwork and a chest X-ray and told the patient to stay in touch with me about his symptoms.

“I wonder if it’s early shingles”, Dr. Brown told me.

The next day I got the negative wet read of the chest X-ray and a bunch of normal blood tests and a phone message from Mr. Sprague that he was getting some nausea. I told Autumn to have him come in to get reexamined.

Norman didn’t have a fever, and he didn’t have a rash or any alteration of skin sensation on his torso. His lymph nodes and breath sounds were normal and his abdomen was soft. But if I pressed hard enough over his gallbladder, he did hurt – that was obvious from his facial expression. He told me the pain was also I the lower front of his chest now, to the right of his sternum just by his lowest rib. It was relentlessly steady and unaffected by movements or deep breathing. He denied any shortness of breath. He told me was nauseous but still able to eat a little, and he had not vomited. His ribs weren’t tender. His bowels were normal and his urine had normal color.

I ordered a gallbladder ultrasound. There were no gallstones, but the radiologist said there was a suggestion of sludge in the gallbladder and the common bile duct was at the upper limit of normal size.

I called one of our local surgeons. He suggested doing a plain HIDA scan. Because of the national shortage of cholecystokinine, that is the only type of biliary scan we can get right now. The test showed that the gallbladder filled normally, but the tracer was slow to travel down the bile ducts and into the duodenum.

Last Monday, Norman met with the surgeon, who called and said he was pretty sure the pain was biliary, but also told me that over the weekend before the consultation, Norman had developed shortness of breath and dizzines. I asked him to send Norman over so I could reassess him.

He was not all that short of breath and did not have a cough, but his breathing had changed since I saw him last. He admitted that he had had some difficulty shopping at Walmart since last winter because he felt “out of shape” pushing a cart up and down the aisles. He also described his right-sided chest pain as more severe, but still unrelated to movement and breathing.

He had dizziness and a hint of nystagmus only when turning his head to the left in a supine position with an otherwise normal ENT and neuro exam, so I was comfortable ascribing his dizziness to Benign Positional Vertigo.

His oxygen saturation was normal and his EKG was unchanged from three years ago.

I ordered a PE protocol contrast chest CT, which did not show any pulmonary emboli, but it did show mildly enlarged mediastinal lymph nodes and three nodules peripherally in the right lung, the largest one just over an inch. I had also ordered an abdominal CT, which was perfectly normal. The nuclear stress test I also ordered that day came back normal. By that time I had called Cityside Pulmonary Associates. They promised to look over the images and get back to us with an appointment.

Norman Sprague called back two days later. He had received a call from the pulmonary office, telling him he was on a cancellation list, but only had a firm appointment for the first week in October.

I called the thoracic surgery group at Cityside and got to talk with Dan Grossman. He looked at the images and when I asked him if a video assisted thoracoscopy was an option for getting a tissue diagnosis, he said, yes, but bronchoscopy would be better. I told him about the long want to see a pulmonologist.

“Either we or they will see him sooner”, Dan said. I’ll get back to you. Twenty minutes later he called me back. “It’s all set, Roger White will see him on Friday and do a scope then.”

Norman had his bronchoscopy. The needle aspirates were benign and the washings and cultures negative. Dr. White’s note listed sarcoidosis and methotrexate related lung disease as the top differential diagnoses, and he thought a PET CT would be the next step, and maybe a percutaneous needle biopsy of the distal lesions.

Today I met with Norman and his wife to go over the results that had come in after the bronchoscopy. As I reexamined his abdomen, he was more tender in the right upper quadrant than before, and when I lifted up the back of his shirt there was a red spot with a small, raised center, not a blister but more of a papule.

“Ouch, that’s sore”, he said.

And so I leave Norman Sprague in the competent hands of Dr. Brown, who returns from his vacation tomorrow. Norman’s lung nodules and lymphadenopathy still remain to be diagnosed, and he still may have gallbladder disease, but he also, again, has the original working diagnosis of herpes zoster, the great imposter.

Less is More, More or Less

Published August 15, 2014 Reflections 4 Comments

Cholesterol is bad. Cholesterol is an essential building block for important hormones.

Eggs are bad. Eggs are a complete protein food.

Salt is bad. Salt is essential for life.

High blood pressure kills people. No blood pressure defines death.

High blood sugar causes eye and kidney damage. Low blood sugar causes falls, fractures and car wrecks.

Low potassium causes heart rhythm problems. High potassium causes heart rhythm problems.

Too little vitamin B-12 causes nerve damage. Too much vitamin B-12 causes nerve damage.

The ancient physicians, from Hippocrates in Greece to the Yellow Emperor in China, to Ekiken in Japan and Charaka in India, all spoke of the virtues of moderation.

Why do we in our culture go to excess in our pursuit of wellness? We always seem to want to classify foods and nutrients as either good or bad. Depending on how we classify them, we go to excess in consuming them or we deprive ourselves of even necessary amounts of them.

There is even a newish disease, defining the extremes of such behavior, “orthorexia nervosa”.

The latest scuttlebutt of this sort is the new findings that low sodium diets are associated with greater risk of ending up dead than moderate salt diets. The editorial about the studies published in this week’s New England Journal of Medicine made me late for my nightly rounds to check on the barn animals Wednesday night. The piece was interesting, but ultimately no more enlightening than reciting the old adages “everything in moderation” and “nothing to excess”.

Somehow, we here in America have been conditioned to seek expert guidance over our own common sense or our Grandmothers’ advice. We listen to Government advice about drinking eight glasses of water per day whether we are joggers in Memphis during August or mailmen in Anchorage during January. We even listen to medical experts in unrelated fields who promote the latest nutrition and supplement fads on TV for their own profit.

The problem with turning the findings of scientific studies into practical advice or medical treatments is that science only produces data. “Data-driven” has become a buzzword today, just like “evidence based”, or a new one I heard recently, “evidence supported”.

What is wrong with both “data” and “evidence” is that neither entity equals truth, value, practicality or “wisdom”, not to mention the “fact” that the scientific “evidence” has changed many times over about a great many things just in the last few decades. If people wearing astronaut-like Ebola suits are less likely to also get the flu, does that mean we should all wear them during the winter months? Probably not. If tall bachelors have more dates than short ones, should we issue platform shoes to the vertically challenged (my very first blog post)? It was tried to a degree in the 1980’s, but never quite worked out.

Data is meaningless without context or “big picture”. Medical research, by its nature, analyzes small and easily defined parameters within the vast systems we call health and disease. What makes perfect sense to do for the well-being of one corner of our anatomy or physiology may have disastrous consequences for another and possibly for the whole organism. Each scientific study only aims at illuminating one small aspect of life. Only with an understanding of the bigger picture can we decide how to use the nuggets of “fact” science produces.

Even more than a view of the big picture is required to truly make use of data: Common sense, trivial as that may sound, is required when making judgements and setting priorities. This is what has gone missing in our collective enthusiasm at the advances of science in the past century. My Grandmother, who would have been 114 this year, but only lived to be 96, already knew that a little salt, fat or sugar never hurt anyone, but eating anything to excess was not healthy.

Both Hippocrates and Grandma, without the advantages of scientific data, knew in their hearts by virtue of their common sense what science has finally seemed to confirm.

We, as a culture, need to take advantage of both our shared, ancient wisdom and the advances of science, but either one without the other is likely to sometimes lead us astray.

Semmelweis’ analysis of why midwives’ postpartum infection rates were only a fraction of doctors’ and medical students’ is an example of science serving to explain what common sense already knew: Touching the dead before delivering babies made bad things happen.

Population studies, on the other hand, where we seek to find out if vegetarians, salt fiends, runners, nurses or yoga practitioners are healthier than others after decades of doing what they do are so fraught with uncontrollable variables that we are likely to be confused; it took twenty years to find out that postmenopausal estrogen treatment didn’t decrease heart attack rates in older women as the experts had speculated. Too many years of a good thing turned out to be bad.

My Grandmother could have told us that taking drugs to thwart aging didn’t make any sense. So could Hippocrates. They both had common sense. We need to cultivate ours in order to properly make use of today’s exponentially increasing amount of data.

Come to think of it, data seems to be a little bit like salt: Either too little or too much can be debilitating. We should let our common sense regulate our consumption.

Calling Mrs. Kafka

Published August 11, 2014 Progress Notes 1 Comment

“Prior Authorizations, Mrs. Kafka. May I have your name and the patient’s policy number.”

“My name is Country Doctor, and I don’t have the patient’s number but I have her husband’s – it is 123456789”.

“Thank you, Doctor. This is for Harry Black?”

“Well, no, it’s for his wife, Harriet. We asked for a PA for Lyrica for her, but it was approved for him instead, even though the forms we sent you clearly stated her name.”

“I see that Harry is approved for one year.”

“Yes, but he doesn’t need it. He has no diagnosis and no symptoms. Someone at your end reversed the names, because the application was for Harriet. I have a copy right here in front of me. So can we just get this approval switched over to her name instead?”

“I’m sorry, we can’t.”

“But why?”

“She’s a different patient.”

“But everything we sent in was on her. You were the ones who put it under his name instead. It was your mistake and I’m asking that you correct your mistake.”

“I’m sorry, but we have to process Harriet’s Prior Authorization separately. What is her diagnosis?”

(Sigh)

“Postherpetic neuralgia.”

“Is she currently taking Lyrica for this?”

“Yes.”

“I don’t see any pharmacy claims for Lyrica in her profile.”

“That’s because you don’t pay for it. That’s why you and I are talking right now, isn’t it? She’s been using samples.”

“Lyrica is not covered for that diagnosis. Studies have shown that other drugs usually control symptoms…”

“Now, wait a minute, your company already approved it for that indication when you looked at the paperwork we sent in before, all that happened was that you misread the name of the patient! And if you didn’t read her papers and still approved it for her husband with no diagnosis at all, you can’t exactly say you’re following any firm principles there at MegaScripts!”

“I’m sorry, Doctor. We have to process her request from the beginning.”

“This woman has suffered for two months and has taken several other drugs before getting any relief -amitriptyline, gabapentin, and she’s on Effexor, so there is no point in trying Cymbalta. If you can’t or won’t correct your own mistake, and if you can’t accept what I’m telling you now, I just can’t sit here and argue any longer with you. I’ve got patients waiting. Just tell me where to fax the information.”

“The number is 1-888-000-6666. Now, did you say she had tried ga-ba-pen-tin?”

“Yes, that’s what I said, and that’s what I wrote on the form we already sent you!”

“All right, hold on, Doctor. I’m getting an approval here. O.K., I have a number for you. It is 9921465. And it’s good until August 12, 2015.”

“Thank you!”

(Sigh)

“You’re welcome. Is there anything else I can do for you?”

“No, that’s all I have time for today, even if I needed anything more from you.”

“Then, you have a nice day and thanks for calling MegaScripts.”

(Click)

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