Wednesday, March 11, 2009

Two Excellent Essays from the Front Lines

The very nice feature that appears in each issue of Health Affairs, called "Narrative Matters," in the current issue features two excellent essays on medicine's relationships with Pharma. Both provide a great vantage point from "in the trenches" (and I admit to being biased because the vantage point in each case stresses my own field of family medicine, even if in an embarrassing light in one instance).

First, Dr. Jonathan Han, director of a satellite family medicine clinic in a Pennsylvania steel-mill town that is affiliated with a large university center, tells us about the problem of drug samples for his indigent patients: He provides a carefully nuanced analysis of the reform policy approved by the big university center, restricting the influence from drug reps and eliminating "free" samples--and how it blew out of the water the carefully crafted compromise plan that his clinical had cobbled together a few years previously, both recognizing all the dangers and downsides of relying on samples for their neediest patients, and yet also recognizing the reality that some of these patients simply could not be helped without access to samples.

In what I take to be a happy ending to the story, docs like Dr. Han complained, and the big U center eventually modified its strict policy so as to allow for these local efforts. Before anyone declares this a victory for the pro-industry side ("see! this just proves that Pharma is helpful and it makes no sense to cut off contact with them") , I challenge you to read all the fine print about how carefully crafted the sample policy was that these front-line providers developed. They agonized over every detail and every downside--a far cry from the casual "let's just run down to the sample cupboard and give you a few pills" approach taken in most offices--including the office described by medical student Melinda Morton.

Before Melinda, one more point on Dr. Han. I was struck by how he managed to include virtually every relevant viewpoint in this brief essay--including how he feels angry at being made an enabler, that by putting his finger in the dyke and giving samples to some of the neediest patients, he's indirectly aiding the persistence of a broken national health non-system that refuses to fix what needs to be fixed. We could use a lot more docs with his breadth of vision.

Now for Melinda Morton's essay: She portrays her typical days working in a family medicine clinic rotation. She idealistically had taken the No Free Lunch pledge as a pre-clinical medical student--refusing to take any gifts, including food, provided by drug reps. As she works hard all day with no time to grab lunch till late in the afternoon, and as she finds lavish lunches daily spread out in the break room in the clinic, with enough tantalizing food to feed all the staff and half the Russian Army, she finds her principles and resolve gradually waning. (She might have appreciated a rule once explained to me by a family medicine colleague in a residency clinic where I worked. According to the Robert Darios Timed Evaporation Rule, if you let the drug lunch sit out on the counter for at least two hours, all the deleterious industry influence has evaporated; and so you can then chow down with a clean conscience. How much salmonella has grown in that time period I leave others to calculate.)

Ms. Morton is most eloquent on what an uphill struggle it is for her to try to maintain her principles. (As she runs out the door of the clinic to grab a snack at a local food store, so that she does not have to eat the drug lunch, staff members keep trying to remind her about the lunch, as if she must be at least mildly demented.) Why, she wonders, does her own medical school seem dedicated to perpetuating the status quo and to making it so hard for students like her not to go along? This is a "must read" for medical students and all who teach them.

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