Saturday 28 November 2015

Advertising drugs directly to the public.

     In recent years American pharmaceutical companies direct-to-consumer advertising has become increasingly intrusive, aggressive and misleading to the extent that it is driving consumer demand for their product and that is their objective.  The success of the strategy is supported by the almost five billion dollars last year spent by the drug companies on dtc advertising.   Unfortunately Canadians are plugged into U.S. TV much of the  time and are bombarded with this material although that sort of advertising is not permitted in Canada.  In the last few years before my retirement the increase in patients coming into the office with requests for specific medications that they had seen advertised on television was remarkable.  The requests or demands were often inappropriate and for off-label conditions (i.e. not approved by the FDA or Health Canada) suggested in carefully couched advertisements.   This unethical practice, which is banned in most countries in the world, makes a physicians life difficult as, in a volume family practice at least, it can consume time and effort in explaining why this is not a suitable treatment for the patient.  One of the easier ways I found in dealing with the situation was to pull  my smart phone out of my shirt pocket and read the list of drug interactions and of side effects, many ending in "sudden death".  This was quite effective most of the time, nevertheless one was just compelled to say no sometimes. This sort of advertising certainly damages big pharma by presenting the picture that their sole objective is to sell drugs and to  put additional  pressure on physicians already bombarded with sales strategies.
       The  American Medical Association has voted in favour of a ban on direct-to-consumer advertising, so perhaps in the  near future I will  no longer have to listen to the tasteless advertisements on diarrhea, hemorrhoids and the like over my dinner.
Let me know if you enjoy ads relating to similar complaints to the above over your meals!

Direct-to-consumer (DTC) advertising should be banned in order to reduce the demand for expensive, unnecessary drug treatments, the American Medical Association’s (AMA) House of Delegates voted on Tuesday.
“Today’s vote in support of an advertising ban reflects concerns among physicians about the negative impact of commercially-driven promotions, and the role that marketing costs play in fueling escalating drug prices,” AMA board chair-elect Patrice A. Harris, MD, MA, said in a statement issued after the vote at the association’s interim meeting here. “Direct-to-consumer advertising also inflates demand for new and more expensive drugs, even when these drugs may not be appropriate.”
The policy also advocates for a campaign to urge prescription drug affordability — including demanding more competition in the drug industry — and for urging more transparency in drug costs; it also calls for convening a physician task force on the issue.
“Physicians strive to provide the best possible care to their patients, but increases in drug prices can impact the ability of physicians to offer their patients the best drug treatments,” said Harris. “Patient care can be compromised and delayed when prescription drugs are unaffordable and subject to coverage limitations by the patient’s health plan. In a worst-case scenario, patients forego necessary treatments when drugs are too expensive.”
Banning DTC advertising would be a really good idea, said Sunny Linnebur, PharmD, associate professor of clinical pharmacy at the University of Colorado Skaggs School of Pharmacy, in Aurora. “I can see the potential risks that occur when patients watch commercials and immediately think they need to be on that medication,” she said in a phone interview.
“Number one, it puts pressure on providers — doctors, nurse practitioners, and physician assistants — to prescribe those medications. Number two, patients are not always in the best place to make decisions about which medications they should and should not take, and commercials are targeting patients and can make them think that medicine is for them, when it’s not safe for them.”
In addition, such ads can increase providers’ workloads because “we [may] have to discuss medications that were never going to be on the table to begin with,” said Linnebur.
David Holdford, PhD, professor of pharmacotherapy and outcomes science at Virginia Commonwealth University, in Richmond, said that although too much money is being spent on marketing and too little on drug research and development, it’s doubtful that banning DTC ads will serve to either increase spending on drug research or bring down the price of drugs.
“DTC spending is approximately $3 billion per year — 11% of all promotional spending,” he said in an email, citing a report by the Pew Charitable Trusts. “Direct-to-provider [advertising] is the other 89%.”
“MDs are still in control of the prescription pad,” Holdford said. “They do not have to prescribe for heavily promoted DTC drugs, but they do. In fact, studies consistently show that physicians are not cost-effective in their prescribing behaviors.”
The AMA has grappled with the DTC issue before. In April, the association wrote to the Centers for Medicare and Medicaid Services complaining about the misuse of Medicare’s annual wellness visit by commercial firms that promote whole-body scans as a means of disease prevention.
“We note that some consumer groups have asked the Federal Trade Commission to investigate the direct-to-consumer marketing of some of these commercial entities on the grounds that their advertisements contain false or misleading representations or material omissions,” wrote the AMA along with several other physician organizations. “This raises serious concerns for us about potential program integrity threats that these entities may pose to Medicare.”
The FDA also has been studying the issue for some time. In 2003, the agency presented results from surveys of patients and physicians, which found that of 500 doctors surveyed, 60% said that when they discussed a medication with a patient who had seen an ad for it, the ad had no beneficial affect on the discussion. And fewer than 20% said their patients understood how to get more information about a drug as a result of seeing an ad for it.
In other meeting news, the House of Delegates also passed resolutions in support of:
  • Revising quality standards and Meaningful Use requirements to make the program more streamlined and less burdensome.
  • Passing federal, bipartisan legislation to speed up paramedic training for returning veterans who received emergency medical training while in the military.
  • Developing model state legislation to increase use of prescription drug monitoring programs (PDMPs). “The AMA strongly supports ensuring patient privacy protections, interstate interoperability of PDMPs as well as improving the functionality and workflow of these tools to help physicians make informed prescribing decisions,” the association said in a statement.
  • Lifting a Congressional ban on coverage of in vitro fertilization treatment by the Department of Veterans Affairs. Current law prohibits the department from covering this service, even though it is covered for active-duty military.

In addition, the delegates called on the federal government to analyze the consolidation of the health insurance industry over the last 5 to 10 years before approving any further mergers.
last updated

Wednesday 25 November 2015

New Health Hazzards.

The Prime Minister seems more concerned with making a 'warm and fuzzy' gesture than he is about causing potential health and other hazards to Canadians.  Instead of carrying out appropriate health and security investigations of the twenty-five thousand refugees before admitting them to Canada, he is determined to ignore the inherent risks in the situation  and to "meet his deadlines", regardless of the consequences.  Apart from the obvious security issues, which he must be well aware of, there are health issues of which he is apparently ignorant.   Before going into the specific issues, let me point out the state of the Canadian Health Care system, using a report that the Department of Health has quoted itself: 

"With regards to international comparison, the 2014 Commonwealth Fund report on the health system performance of 11 countries ranked Canada 10th overall, indicated particularly low scores in quality, safety, access, timeliness, efficiency and equity.17 "
Commonwealth Fund, Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares
Internationally, 2014 Update.

Note the broad range of care in which we are at the bottom of the heap.  The much vaunted health care system of which we were once so justly proud is now near the bottom of the heap in the most developed countries.  Canadians are frequently awaiting appointments for periods that much exceed the bounds of safety.  We should be ashamed of ourselves and trying to  upgrade.  Instead the Province of Ontario is cutting services and doctors salaries quite shamelessly.   An additional twenty-five thousand refugees may not seem much of an additional burden until one realizes that these folks have not had the prophylactic care and immunizations that Canadians take for granted and there is a very real possibility of introducing  diseases that are entirely foreign to our population.   Apart from measles and polio and other vacccine preventable diseases that have almost been wiped out in our country (though the anti-vaxxers are doing their best to undermine their total eradication), there are diseases which Canadians have never even heard of.  We have no idea of the diseases that may be carried into Canada until the refugees are adequately screened.  Let's look at a few:                1. Middle East respiratory syndrome MERS-coV.  A virus infection with a high mortality rate.  This is a new virus which we still know little about, but it looks dangerous, spreads from person to person and is associated with considerable mortality.

2.Malaria.  Although not as prevalent as at one time malaria is still a risk and is becoming increasingly resistant to the anti-malarial medications.

3. Leishmaniasis.  A parasite that effects animals and humans and is not rare in Syria.

4.Dengue fever.  A mosquito transmitted fever that can deteriorate into the often fatal Dengue Haemorrhagic Fever.

5.Vaccination deficiency.      Diseases almost wiped out in Canada by widespread vaccination will be re-introduced by a population that is frequently unvaccinated.  Further, the irresponsible and ignorant attitude of the growing anti-vaccination population is resulting in a waning of the herd immunity that we enjoy.  Expect to see measles and other childhood diseases popping up, including some like polio and TB. 

   I am concerned that Canadians in need of health care, who often are put at risk by having to wait unacceptably long times to obtain the care that they need, may find that their much loved  health system is growing ever more tardy and  falling below first world standards.

And don't think a few Jihadi sleepers won't be among the immigrants.  


Sunday 22 November 2015

Minister for Science?

    Mr Trudeau has appointed a Science Minister with very questionable credentials.  Her name is Dr. Kirsty Duncan and her doctorate is in geography, but this did  not prevent her from presenting herself as an expert in both neurology and virology. It is true that Dr. Duncan contributed to a panel that was awarded a Nobel Prize for its work on climate change.  She played a major part in organizing an expedition in the late 1990s to find frozen samples of the epidemic 1918 flu.  It was a futile event which  eventually led to nothing apart from acrimony and ill will.  Her greatest fiasco was her commitment to a treatment for multiple sclerosis due to a hypothetical condition  known as chronic cerebrospinal venous insufficiency — CCSVI described by Dr. Paolo Zamboni.   This was supposed to be due to narrowing of the veins in the neck restricting drainage.  Dr. Zamboni corrected this surgically.   Duncan continued to support the treatment long after it had been proved useless and deteriorated into a cult philosophy, just as she had disputed the judgement of world class virologists in her previous endevour.

 “This is the most curious appointment since Caligula named his horse as consul,” scoffed McGill University’s Dr. Michael Rasminsky, calling the Zamboni ideas “profoundly non-scientific.”    Her behaviour in a number areas would not seem to have been conducive to nurturing the scientific method.  I will be monitoring her leadership and activities as will many others over the next few years.

Let me know if you have any  views on this appointment.

Thursday 19 November 2015

Medical Murderer ?.

    When people ask me why I am opposed to euthanasia, I explain to them I am not opposed to euthanasia, I am  opposed to killing patients being regarded as a physicians responsibility. That directly contravenes the healing role.  If society decides it wishes death on demand to be available, which it does in Canada, then  it is the democratic right of citizens to take this option.  It becomes the responsibility of the state to make this available, but it does not have the right to force physicians to terminate life.  There are some who will find this perfectly acceptable, but to include this as an expectation of all physicians will damage the medical profession irreparably.
       It would  be relatively easy to train a corps of 'terminators' who would  not need to be physicians at all, in  the technical details of the procedure.  Once the guidelines were laid down the decision could be made by a designated group and the 'terminator' could administer the deadly potion.  There is no reason at all that the protocol would require a physician and in fact I don't think it should.       
     Dr. Marc Van Hoey is President of Belgium's Flemish death with dignity association and one of the country's most active practitioners of euthanasia, performing between fifteen and twenty a year.  He has become the first physician to face possible criminal prosecution, for giving an eighty-five year old fit woman, at her request a glass of lethal syrup to drink.  (Yes, it's that easy, doesn't need a doctor at all.)  Her daughter had died and she no longer wanted to live.  Thus, there was no medical reason for her termination   It is possible  he will face prosecution for violating Belgium's euthanasia laws.
   Carine Brochier, project manager of the Brussels based European Institute for Bioethics said, "It's an illusion to believe  you can control what goes on between a doctor  and a patient in a room."  In Belgium, patients who have been diagnosed with depression have been terminated.  Dr. Van Hoey himself said that it was possible to  skirt the requirements for a written request from  the patient.  It would appear that there is considerable laxity about the required second medical opinion and an additional psychiatric opinion, if death is not imminent. Physicians who allow themselves to become part of the termination team will be on a slippery slope that can only damage the profession.  It is shameful that the College of Physicians and Surgeons are lacking the moral fibre to  apologetically  support those physicians who do have those principles.      
What do you think?      


Sunday 15 November 2015

The Brain Computer Interface Pt 2.

        A while ago I wrote about the brain-computer interface, where man meets machine.   Last year, Dr. Phil Kennedy, a sixty seven year old neurologist emulated many of the great physicians of the past in  using  himself as  a guinea pig in  the cause of advancing science and humanity.  Dr. Kennedy had electrodes implanted into his brain to establish a connection between his brain  and a computer.  At his own expense and  of course outside the U.S., he had the surgery performed at a cost of $25,000.  
        Kennedy's aim was to build a speech decoder that could translate the signals produced by the neurons by transforming imagined speech into actual words coming  out  of a speech synthesizer.   He decided to do this because he could not get adequate funding and could not find research subjects and his whole research project of many years was about to die.  He presented the studies of his own brain at  the Society for Neuroscience in Chicago.  His finding were greeted with interest as well as criticism for carrying out invasive research on himself.  He developed an electrode of gold wires in a container with a blend of growth factors that induced neuron growth.  He eventually got FDA approval to implant electrodes in patients so paralysed that they could not even speak.  He oversaw implantation in at least five severely paralysed patients, who could turn a switch on  or off, or move a cursor on a screen by just thinking.  Because 'locked-in' people cannot communicate it became very difficult to provide the detailed information that the FDA demanded and they withdrew their permission despite Kennedy's publications in reputable journals.  He needed a patient with sufficient speech to be able to confirm what he was thinking when a particular batch  of neurons fired.  Kennedy decided that he needed a subject who could speak sufficiently to corroborate the similarity of the neural relationship between speaking sounds and thinking them.  He couldn't find a volunteer for the surgery, so he decided that he would have to do  it himself.  He had designed the electrodes and just had to find a neurosurgeon to implant them He knew that would be impossible to arrange in  the U.S. for reasons I don't have to explain.
     He arranged his surgery at a small hospital in Belize, well outside the purview of the FDA.  He had his skull opened and the electrodes implanted.  Some thought the procedure unwise, but in days of yore it was not unheard of for physicians to try new treatments out on themselves before subjecting their patients to the risk.  After returning home, Kennedy worked in  his speech lab recording his neuronal activity as he repeated certain sounds out loud and then imagining saying them.  He says he determined that different combinations of the neurons he was recording from consistently fired every time he spoke certain sounds aloud, and also fired when he imagined speaking them—a relationship that is potentially key to developing a thought decoder for speech.  Others had used only electrodes placed outside the skull which was obviously much less sensitive and we will also examine their work later .   Unfortunately, Kennedy had to cut his experiment short for medical reasons related to his skull incision.   He did, fortunately, get four weeks of good data which he is continuing to work on.    I will be reporting on the progress of this science-fiction like work by Kennedy and others.

Wednesday 4 November 2015

The declining Health Care System. Pt 2.

"With regards to international comparison, the 2014 Commonwealth Fund report on the health system performance of 11 countries ranked Canada 10th overall, indicated particularly low scores in quality, safety, access, timeliness, efficiency and equity.17 "
Commonwealth Fund, Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares
Internationally, 2014 Update

So what are the administridiots proposing to remedy this awful situation?

The same old cheese! 
 Primary Health Care is the cornerstone.
Well, no kidding!  The College of Family Physicians was promoting that since the 60s. In those days we used to say that would lead to better, more organized care that would be less expensive and that consultative services would be appropriately planned, avoiding unnecessary consultations and expenses.  Further, we flattered ourselves by thinking that personal relationships and continuity of care were the patients primary considerations when, in fact, convenience was what was rated most highly.
      The Ministry of Health janissaries  are saying exactly the same things, offering nothing new other than their prolix memoranda.
      It then  goes on to answer the four aforementioned questions (discussed in a previous blog) with answers that only gives rise to further questions. 
Electronic Medical Record adoption
There are currently more than 11,600 primary care providers enrolled in an EMR
adoption program, representing coverage for more than 10 million Ontarians.  This is simply a statement of fact.  There is as yet no evidence to indicate that the EMR, as it is currently set up has contributed to the quality of medical care.  Nor has it contributed to the patient - doctor rapport.  It has certainly contributed to the much lamented increase in cost of care.
      The discussion goes on  to bemoan the lack of funds and the growing geriatric population and the long wait times, inaccessible after hours services and difficulties for various groups to access various services.  It mentions efforts in the past (similar, it would seem, to their present effort) that that failed to  achieve the goals.  The previous expert advisory committee produced over a hundred recommendations and by the their own admission this group found them  not to have achieved noteworthy success. I have no  doubt that these efforts cost a great deal  despite their failure to address the problem satisfactorily. So far there is no reason to anticipate greater success with the present efforts.  There is little doubt that it also will cost a great deal. 
     Here are their recommendations:
1. Groupings of Ontarians will be formed based on geography, akin to the assignment of students within the public school system. Citizens within each grouping are assigned to a primary care group (PCG) and then rostered to a primary care provider (physician or nurse practitioner) contracted by the PCG.
2.    Each PCG will develop a system of coordinating the capacity of the delivery models in their region to ensure unattached patients are connected to a provider, thus ensuring universal access. 
3. A system for managing exceptions will be developed. For example, patients with pre-existing relationships with providers who reside outside the PCG catchment area could be included in a neighbouring PCG allocation through PCG to PCG transfer payment agreements. Such a system could also be used to address commuters, seasonal vacationers, and patients accessing specialized primary care services (e.g., a falls prevention clinic, primary care of the elderly) in a neighboring PCG, or patients needing particular culturally sensitive care delivery. 
4. Patients difficult to assign (e.g., those without permanent housing or without health cards) will be identified and assigned to the PCG in collaboration with Public Health, community health centres and the local municipal services. The funding formula would reflect the needs of this patient group; however, it is recognized that supplemental funding may be required.
    I have little doubt that all these machinations will result in the generation of a whole additional cadre of well rewarded administrators.   
    Funny, seems like the system I left in NHS in Britain in 1963!! 
 Make a comment if you have any views.

Tuesday 3 November 2015

So who's crazy?

     Have we gone completely crazy?
Luke Magnotta murdered a Concordia student, Jun Lin, under the most horrible circumstances. He was sentenced to life in prison. He now occupies a ? cell  (I know what those 'cells' are like and they are nothing like a cell) in his Quebec prison, decorated with pinups (he has a 'thing' for Marilyn Monroe, would you believe?) and via the letters he writes describes his life.  He enjoys keeping fit, reading, the prison food, which he describes as decent and casual clothes.  He further describes relaxing with art, music, sports and reading.  he described 'just bought Celine Dion's album and a lot of others.  I have a stereo and a portable for when I suntan outside'. He compares it to a University
     He corresponds with a number of outsiders some of whom send him money.  All in all, he seems to be having an enjoyable life  and making a reputation for himself, both within Corrections Canada and outside,  I am very familiar with Corrections Canada and how it works.  Always excessively lenient, it seems to have become worse.  I can tell you that many aged Canadians receive far inferior medical and general care than the often evil parasites that political correctness seems to favour.
     So who's crazy.  If we reward a pattern of behaviour we should not  be surprised to find it increases.     I think it s time for the people of Canada to re-think the meaning of justice and to correct some of the absurdities they have condoned.
     Personally, I think it is time to re-institute the death penalty.