Thursday, April 23, 2009

A Little Help Please?

Vaccinations are an important tool for keeping people healthy. Like many family physicians, I give vaccines to my patients. Unfortunately, also like many other family physicians, giving vaccines is often not cost-effective and in some cases, a money-losing endeavor.

Part of the problem is that some vaccines cannot be purchased as a single dose. That leads physicians to decide if they should buy 10 doses of one vaccine just to immunize one child, and hope that they can use up the rest before they expire. This becomes a problem when a vaccine's wholesale costs run over $80 per dose, such as for Prevnar.

This is an e-mail I got from Dr. Jean Antonucci to her physician friends asking for some help. She has been trying to buy a single dose of Prevnar to finish immunizing one of her patients. But Wyeth, the manufacturer, only sells Prevnar in boxes of 10 doses:
So help me out here. I got a call from Wyeth — from a David Ross. Wyeth sells single dose Prevnar in other countries where "there is low demand". They are not very open to doing that here.

I told this man, "Look, this is a win-win. You want to sell Prevnar, I want to buy it." He goes on and on about how he cannot believe practices would need so few doses over a few years. So I say, OK, look, help me out here! I tell him about primary care. I point out that I ANSWERED the phone!! He repeatedly tries to deflect me — "This is about reimbursement". Well, no it isn't. Blue Cross pays for the vaccine just fine. It does not pay for 9 doses sitting in the fridge rotting.

SO anyway I say, here is an alternative. Sell it to Cardinal Health. THEY supply my drugstore. The drugstore will buy 10 doses from you and lots of us can use them.

He then says, well, he would have to know that there was more than one doctor in the USA who had need for small amounts of Prevnar. So aha! I say, oh really?? How many do you need to hear from? I have 700 friends.

"Uh uh, I dunno."

So PLEASE call up David Ross (484-865-6057) and plead the case to sell Prevnar EITHER to drugstores OR in single dose units to physicians. PLEASE?

Love, Jean

I called Mr. Ross and left a voice message saying I am a family doctor who would also like to be able to buy Prevnar in a single dose. If anyone else out there is in a similar situation, you might want to give him a call, too.

If nothing else, it may help one child get their Prevnar. And if he gets a lot of calls, maybe a lot of children across America will finally be able to get their vaccines from their local primary care doctor.

Saturday, April 18, 2009


I met Beatrice (not her real name) a little more than 2 years ago. She had just turned 90, and her daughter brought her in because she had been feeling a little more tired and short of breath lately. As she put it, she was having problems "getting going" in the morning. She had rarely been to a regular medical doctor, preferring homeopaths, in line with her beliefs as a Christian Scientist.

Up until a year before, she had been living for 19 years in Ojai, CA, 9 of them with her husband who passed away 10 years earlier of lung cancer. She had been active and doing yoga up until 1 year earlier when she fell and broke her arm. Ever since then, she had been living in an assisted living facility closer to her daughter. She had also been developing signs of Alzheimer's dementia over the past 4 years.

Beatrice was a pleasant and cheerful woman who acknowledged having some memory problems but kept repeating over and over again how “grateful” she was for her life so far. She proudly told how she was one of the first female bank tellers before she became a permanent homemaker. She also mentioned how throughout her life she never liked to take medicine or see doctors.

After examining her, I discovered that she had atrial fibrillation causing mild congestive heart failure, which was also the cause of her shortness of breath and fatigue. She also scored 13 out of 30 on her Mini-Mental State Exam, consistent with moderate dementia. Beatrice went home without any medications because her daughter wanted more time to think about what to do next. This first visit took 90 minutes.

After a series of e-mail communications and a follow up visit, we agreed to start Beatrice on some medication to help her breathe better. Over the next few months, she gradually improved with medication to the point where she was breathing comfortably again. Her daughter told me that while Beatrice couldn’t remember anything about what we had talked about, she did remember me and liked me.

I would see Beatrice several times for follow up over the next 12 months, and even though she couldn’t remember what she had for breakfast, each time she would smile and say how “grateful” she was for everything. That seemed to be the one thing she would never forget. She remained stable as far as her breathing but her dementia continued to worsen ever so slowly, and eventually she started having trouble with agitation and even remembering who her daughters were sometimes.

Unfortunately, this happens all too often with many elderly patients in this day and age. Even as you wonder if this is the kind of life they, or anyone, would want to have, it is often too hard to stop giving medications that you know are helping to keep someone alive.

In a typical busy doctor’s office, there just isn’t enough time to talk about what is really important to her or her family. It would just be assumed that we should just do our best to keep her heart from going into rapid A-fib and developing congestive heart failure, and to do otherwise would be unmerciful. And so, Beatrice would continue to take her Digoxin and Lasix, and her mind would continue to gradually wither away, losing bits and pieces of herself as time went on.

And eventually she would get a stroke and lose her ability to walk, speak or feed herself. Or she would fall trying to get out of bed in the middle of the night and break her hip. And she would end up bedridden and develop pressure ulcers on her fragile skin. And finally, if she didn't die of something else first, she would end up in a “persistent vegetative state”, her self-awareness gone, left with only a thin, frail body curled up in a nursing home bed, kept from malfunctioning further with well-intentioned medications, waiting to die.

That is, she would have if she had received care as usual.

Instead, I had long discussions with Beatrice’s two daughters that started 9 months ago, in person, by phone and by e-mail. We discussed the likely outcomes of continued treatment along with that of stopping treatment. We discussed adding medications to treat her agitation and anxiety and their potential side effects. We discussed what Beatrice valued in life, what her preferences would have been and what she would have chosen for herself, if she were able. We discussed their concerns that their mother not suffer.

After 4 months of discussion and reflection, her daughters decided that a palliative approach was what their mother would have wanted and started inquiries into hospice programs. A month later, she had enrolled with a hospice program, and I stopped directing her medical care, since the hospice program already had a physician.

Yesterday, I received an e-mail from Beatrice’s daughter saying that, after a few weeks of terminal agitation, her mother had passed away peacefully.

I’d like to think that Beatrice was grateful to go this way.

I'd be grateful if every primary care physician could be given the time and paid for the time to do the right thing for their elderly patients, rather than give "care as usual".

Friday, April 03, 2009

Pre-existing condition of being human

This article by syndicated columnist Ellen Goodman from yesterday's Washington Post gives a nice summary of what ails our current US healthcare non-system: "The Care in Health Care":
I was tickled to hear that the insurance industry is beginning to commence to start to think about lifting bans on the pre-existing conditions that keep a slew of Americans from getting health coverage. This has always been on the deep end of a pretty wacky system.

But there is a pre-existing condition that hasn't garnered nearly as much attention in the health care debate. It's the condition we all share: being a human being. As opposed to, say, being an organism subdivided into parts and scattered over the medical landscape from neurology to podiatry.

The current system makes it hard for people to get care for their whole body, much less their whole self (mind and body). The balance between splitters and lumpers has been tipped to the splitters by a wide margin for some time now.

Consider one of the least secret medical records in the country: the erosion of primary care doctors. A half-century ago, we had an equal number of generalists and specialists. Today there are two specialists for every generalist.

In clear view and with all undeliberate speed, we developed a system that rewards procedures over primary care. As analyst Robert Blendon puts it bluntly, "It's absolutely clear that payment systems have been negotiated that reward specialty time and use of equipment." The incentives tip toward the kind of medicine that is performed with hands, tools and technology over the medicine that is practiced with eyes, ears, and mind.

The average generalist now earns 55 percent less than the average specialist. Many students apply to medical school to connect with and take care of sick people. They graduate to become what one doctor slyly calls "proceduralists." They enter with a strong desire to look after families and exit with a ticket to X-ray femurs.
Read the entire article here.

She gets it. More and more people are finally getting the message that no meaningful healthcare reform will take place without fixing primary care first. And to fix primary care, you need to fix the system so that it will encourage, and not discourage, doctors from going into primary care. Otherwise we will continue to have too many doctors who look at you primarily as a body part rather than a human being.