At 03:04 4/10/02 +1000, George wrote:
Yes indeed, some
technology is good and some is not so good. I think problems can arise when,
because of *commercial considerations*, potentially "good" technology ends
up harming those it was meant to help. Antibiotics, for example, have an
enormously positive role to play in treatment of infection. However, i suspect
that there would be little doubt that antibiotics have been overused by much
of the medical profession over the years and as a consequence people have
been unnecessarily exposed to risk of side effects, often minor but, sometimes,
not so minor e.g. amoxicillin induced glomerulonephritis and anaphylaxis,
and broad spectrum antibiotic induced toxic megacolon. Also, overuse of antibiotics
has lead to the current crisis in antibiotic resistance.
"Commercial considerations" involve the way that antibiotics are marketed
to the medical profession so as to maximise antibiotic prescribing, thus maximise
antibiotic sales, thus maximise company profit. A company manufacturing pharmaceuticals
has a number of obligations. One obligation is to market and advertise their
products truthfully, ethically and responsibly. The other obligation is to
maximise profit for its share-holders. This can, and often does, present
a major conflict of interests. I'm not sure that "making profit" takes the
back seat all that often.
Ian Musgrave replied:
Again, this depends on what you
mean by "much of the medical profession". Almost as soon as antibiotic
resistance become known, the large teaching hospitals put extra restrictions
on antibiotic use, this was followed by appropriate restrictions in smaller
hospitals, and then gradually diffused out into the GP community. Starting
(and still continuing) in the 80's there was a campaign to teach GP's about
appropriate antibiotic prescribing (which has also evolved into the quality
use of medicines campaign, applying to prescribing generally, but antibiotic
use is still an important education focus).
The current crisis in antibiotic resistance stems from a number of factors
1) Holdout GP's who still prescribe antibiotics innappropriately
2) Patients who _demand_ some sort of pill for coughs and colds, and badger their GP's into prescribing antibiotics
3) Patients who do not complete the prescribed course of antibiotics
4) Bugs being a lot better at both evolution and horizontal gene transfer than anyone ever suspected.
The "they" who though antibiotics were a good thing were also the "they"
who worked out the appropriate utilization regimes (which some GP's and patients
ignore) and the appropriate dosing regimes (which some patients ignore). In
this circumstance it is inappropriate to blame "them" when people ignore their
advice.
George replied:
> Again, this depends on what you mean by "much of the medical profession".
Well, I suspect that there might be figures on this but I don't know how to obtain these figures. However, considering "someone" or "some organisation" felt that a mass media campaign was necessary to alert people to the fact that they *don't need* an antibiotic for the common cold, makes me suspect that the figures for antibiotic over-prescribing would be substantial.
snip,Yes, once the situation became known appropriate change and an attempt to manage the situation began in *publicly funded* institutions.
> Almost as soon as antibiotic resistance become known, the large teaching
> hospitals put extra restrictions on antibiotic use, this was followed by
> appropriate restrictions in smaller hospitals,
snip,The fact that a large-scale, long-term campaign was *even necessary* to "teach" GP's how to manage probably one of the most common problems seen in general practice, i.e., treatment of infection ( and the most common infections treated probably being throat infection and ear infection) is absolutely frightening.
>Starting (and still continuing) in the 80's
> there was a campaign to teach GP's about appropriate antibiotic prescribing
> (which has also evolved into the quality use of medicines campaign,
> applying to prescribing generally, but antibiotic use is still an important
> education focus).
The fact that the campaign directed towards the medical profession was probably not particularly successful, evidenced by the fact that the campaign has now gone directly to the public in the form of advertisements advising them that they don't need an antibiotic for the common cold, I find also to be quite amazing.
snip,Yes, the gp's fault but still worth wondering why they do it. It's incredibly that some gp's still do this.
> The current crisis in antibiotic resistance stems from a number of factors
> 1) Holdout GP's who still prescribe antibiotics inappropriately
snip,Doctor: well, Mr. X, you have a viral infection and an antibiotic isn't necessary.
> 2) Patients who _demand_ some sort of pill for coughs and colds, and badger
> their GP's into prescribing antibiotics
Mr. X: but I demand one and I’m going to badger you until you give me one.
Doctor: ok, here is your prescription for an antibiotic which you don't need
Yes, the gp's fault again. I suspect one reason some doctors do this is for expediency i.e. economic reasons. The more patients in and out of the office, the more signatures on Medicare vouchers.snip,perhaps, at least, both patients and doctor's fault here. Yes, some patient's probably don't finish a course of antibiotics for reasons perhaps known only to them. But I suspect there are also a percentage who haven't been given specific instructions as to how to take their antibiotics and for how long.
> 3) Patients who do not complete the prescribed course of antibiotics.snip,Well, I'm presuming that antibiotic resistance is going to occur sooner or later. The misuse of antibiotics though has meant that antibiotic resistance has occurred much, much sooner than was ever expected and probably much, much sooner than should have occurred.
> 4) Bugs being a lot better at both evolution and horizontal gene transfer
> than anyone ever suspected.
> The "they" who though antibiotics were a good thing were also the "they"
> who worked out the appropriate utilization regimes (which some GP's and
> patients ignore) and the appropriate dosing regimes (which some patients ignore).
Indeed, what does happen before a drug gets into the hands (onto the skin, under the tongue, into the gut etc.) of a consumer?
An article entitled Buying Science, Selling Drugs from http://www.healthmatters.org.uk/stories/morgan.html gives much food for thought. I've reproduced most of it below. The full text is at the above url
George
Buying science, selling drugs Steve Morgan, Morris Barer and Robert Evans explain how drug companies systematically manipulate scientific research in pursuit of profit According to standard economic theory the behaviour of private firms is driven by the desire to make as much money as possible. For drug companies, which have extraordinarily high fixed costs and low variable costs of production, the route to profitability is through sales.
At least part of the selling process in the pharmaceutical industry involves creating and disseminating scientific evidence about the merits of a product. In an ideal world, corporate investment in clinical research would facilitate prescribing decisions based on objective evaluations of scientific evidence on safety, efficacy and cost-effectiveness. Reality, alas, intrudes.
Pharmaceutical companies are not educational charities, investing in disinterested product evaluation. Science and objectivity are of interest to a private, for-profit corporation only insofar as they further the drive for profits. In fact, to the discomfort of many economists, economic theory does not rule out destroying scientific information or producing false information as a means of pursuing the profit objective, just as it does not rule out contaminating the environment, using child labour or selling known carcinogens. Consider, for example, the long and sordid history of the tobacco industry.
In the pharmaceutical sector, it may be profitable for a firm to promote bias in the creation, evaluation and dissemination of information so as to encourage sales - provided that such behaviour is either undetected or carries penalties that are outweighed by its profit potential.
The picture that has emerged from the clinical sciences overwhelmingly suggests that such practices are profitable because they routinely occur in the pharmaceutical industry.1 Despite scientific pretences; drug companies have injected various forms of bias into virtually every aspect of the product evaluation process.
They begin at the front line, courting practising physicians - most notoriously by proffering gifts: complimentary meals, travel, gifts and entertainment all have a documented impact on prescribing, increasing the use of the sponsor's products regardless of appropriateness.2,3 If gifts and other inducements did not affect prescribing behaviour, economic theory (and common sense) predicts that they would not be offered.
Not only do firms influence the process by which evidence is disseminated - putting their 'spin' on whatever the findings may be - they also influence how the evidence is created in the first place. If investment in clinical sciences can be orchestrated in a way that generates favourable findings - which, in turn, generate more sales - economic theory predicts that firms will so orchestrate their investments. And indeed, using financial, contractual and legal means, drug manufacturers retain a degree of control over clinical research far greater than most people realise.
The most obvious mechanisms through which the evidence can be biased occur in drug trials sponsored by corporations.10 Trial sponsors commonly control the research question, selection of patients, and other means to control the evaluation. Combined, these have documented effects on empirical findings. Clinical trials funded by drug companies are more likely than non-industry funded trials to generate 'scientific evidence' that favours the funding company's product, and the data is more favourably interpreted by those with financial ties to related drug companies.11
Drug companies are also very careful about what aspects of their studies reach the public domain.12,13 Since the clinical data generated by industry-funded drug trials is proprietary, it is seldom open to competitive or public scrutiny. Secrecy, however, is the antithesis of good, transparent science. It not only undermines the external review processes for studies that are 'made public', but it also engenders reporting biases because positive results are more likely to get published and are frequently published multiple times.13-15 The evidence put before the public is far rosier than the actual experiences of test subjects would suggest.
Hospitals and universities have too often tacitly acquiesced to such practices by permitting contract-based research on terms inimical to good science and patients' interests.16 It should not be surprising, in a time of declining public funding, that universities and hospitals are willing to accept research contracts with strict disclosure and confidentiality clauses and/or methodological flaws. Pharmaceutical companies are a major source of revenue upon which hospitals and universities increasingly depend.
In addition to fees paid on contract for specific studies, drug companies give large corporate grants to public institutions. These for-profit firms do not engage in hand-outs without reasons tied, directly or indirectly, back to the corporate bottom line. Gifts to public institutions from a drug company raises that company's image and serves as a means through which it can influence the decisions of universities and hospitals.
Even when drug companies are not the sponsors of research studies, they use lawsuits and other means to influence what is studied and what is reported. Legal threats, regardless of their merit, are increasingly being used as a means by which the drug industry silences recalcitrant researchers.17-21 Lawsuits significantly raise the anticipated costs of conducting and publishing clinical research that yield results 'unfriendly' to the objectives of manufacturers.
Even if individual researchers under legal attack win in the courts, they lose considerable time, energy and money, and are put at a disadvantage in research competitions with their peers.17,20 Other researchers note this. It is hard to gauge how much critical research is 'chilled' as a result, but such chilling is a plausible company objective - 'punish one to teach a thousand'.
Evidence-biased medicine Drug companies have also launched legal actions against those who conduct independent evaluations and publish clinical guidelines.
In 1997, Bristol-Myers Squibb sought an injunction to prevent the Canadian Coordinating Office of Health Technology Assessment (CCOHTA) from releasing a summary report on drugs to lower blood cholesterol.
They were unsuccessful at trial, and on appeal, and received a judicial rebuke. But they effectively shut down CCOHTA for a year and drained its budget. Meanwhile they preserved their leading market position, generating revenues that undoubtedly more than covered their legal expenses.
Increasingly, the industry is simply leaving the academics behind by having drug trials designed, managed and reported by private, for-profit contract research organisations. In 1991, academic centres accounted for 80 per cent of industry-funded clinical trials; in 1998 they accounted for only 40 per cent.22-24 Private research firms picked up the difference. The ostensible reason for this change is that private firms can conduct research more quickly than universities and hospitals. This is clearly of interest to firms who wish to get the maximum number of market days out of their fixed-term patents.
But a second advantage of contract research is that the firm can retain complete control over questions, methods, data and publications, without hindrance from academic review processes. While academic researchers and clinicians may still be involved, no individual will have sufficient grasp of the overall project to be able to question methods or see warning signs in data coming in from all participating centres.
Professional medical writers frequently write up the results of privately contracted research. The articles are then published under the names of prominent researchers or clinicians paid a fee for reviewing the manuscript and attaching their names. The practice of ghost-written papers published under 'honorary' authorships has become so pervasive, and the belief that this reduces accountability for research is so strong, that some medical journals now require that authors list their contribution to the research.25
Using profit-making organisations to conduct research on behalf of drug companies, and using public relations firms to put media 'spin' on the results and coordinate their publication, completes the process by which the industry has infiltrated every stage of the modern research enterprise. Faced with this infiltration, patient welfare and scientific process are simply overwhelmed by the profit objective of the pharmaceutical companies. Private practitioners have become more-than-willing pawns in this process, often putting their own financial and academic interests ahead of their patients' interests. In the private, contract-based research setting, data gathering is conducted by ordinary practising physicians.22-24 The fees paid for enlisting patients in these studies, together with bonuses for meeting recruitment targets and deadlines, can amount to hundreds of thousands of dollars a year.24 In this context the notion of supplier-induced demand takes on a whole new complexion. Inappropriate treatment occurring under heavy financial incentives appears to be a form of 'collateral damage' acceptable to the doctors, contract research organisations and funding drug companies.
Contract research for profit is a recent development, but all the other marketing practices described above are decades old. Documentation of attempts to generate biased clinical evidence for marketing purposes dates back decades. As early as the mid-1950s, public commissions of inquiry in Canada, the US and the UK all received testimonies of industry efforts to introduce bias into the prescribing process, not only by the ubiquitous practice of giving gifts and other benefits to prescribing physicians, but through financing articles in journals intended for prescribing doctors, and influencing their content.26-28
Then, as now, drug companies: sponsored drug trials; hand-picked investigators depending on the degree of quality needed (for example, picking young investigators of little or no reputation to study the more dubious drugs); discouraged the publication of unfavourable results; used multiple trials at different centres to raise awareness of a drug before its market launch; and published results multiple times (both before and after the drug's launch) so as to hamper those searching for scientific evidence.
As Yale political scientist Ted Marmor has noted, 'Nothing that is regular is stupid.' These practices are profitable.
References 1. Barer ML, McGrail KM et al (eds) (2000) Tales From the Other Drug Wars: Proceedings from the 12th Annual Health Policy Conference. Centre for Health Services and Policy Research, UBC. www.chspr.ubc.ca [26 September 2000]
2. Wazana A. (2000) Physicians and the pharmaceutical industry: Is a gift ever just a gift? JAMA; 283 (3): 373-280.
3. Lexchin J. (1993) Interactions between physicians and the pharmaceutical industry: what does the literature say? Can Med Assoc J; 149 (10): 1401-1407.
4. Guyatt G. (1994) Academic medicine and the pharmaceutical industry: a cautionary tale. Can Med Assoc J; 150(6): 951-953.
5. Glassman PA et al (1999) Pharmaceutical advertising revenue and physician organizations: how much is too much? Est J Med; 171 (4): 234-238.
6. Mabin DC. (1995) BMJ should declare its own conflict of interest. BMJ; 311: 878.
7. Ubel PA, et al (1995) Acceptance of external funds by physician organizations: issues and policy options. J Gen Intern Med; 10: 624-630.
8. Sheldon TA, Smith GD. (1993) Consensus conferences as drug promotion. The Lancet; 341 (8837): 100-103.
9. Spingarn RW, Berlin JA, Strom BL. (1996) When pharmaceutical manufacturers' employees present grand rounds, what do residents remember? Acad Med; 71: 86-88.
10. Bero LA, Rennie D. (1996) Influences on the Quality of Public Drug Studies. Int J Technol Assess Health Care; 12 (2): 209-237.
11. Brill-Edwards M. (2000) Canada's Health Protection Branch: Whose Health, What Protection? In Tales From the Other Drug Wars: Proceedings from the 12th Annual Health Policy Conference, Barer ML, McGrail KM et al. (eds.) Centre for Health Services and Policy Research, UBC 2000; www.chspr.ubc.ca [26 September 2000]
12. Wahlbeck K, Adams C. (1999) Beyond conflict of interest: Sponsored drug trials show more-favourable outcomes. BMJ; 318 (7181): 465.
13. Rosenberg SA. (1996) Secrecy in medical research. N Engl J Med; 334 (6): 392-4.
14. Rennie D. (1999) Fair conduct and fair reporting of clinical trials. JAMA; 282 (18): 1766-1768.
15. Johansen HK, Gotxche PC. (1999) Problems in the design and reporting of trials of antifungal agents encountered during meta-analysis. JAMA; 282 (18): 1752-1759.
16. Angell M. (2000) Is academic medicine for sale? N Engl J Med; 342 (20): 1516-1518.
17. Shuchman M. (2000) Consequences of blowing the whistle in medical research. Ann Intern Med; 132 (12): 1013-1014
18. Hemminiki E, Hailey D, Koivusalo M. (1999) The courts - a challenge to health technology assessment. Science; 285 (5425): 203-204.
19. Hailey D. (2000) Scientific harassment by pharmaceutical companies: time to stop. Can Med Assoc J; 162 (2): 212-213.
20. Evans RG. (2000) Uses and abuses of research and the research process. In Barer ML, McGrail KM et al. (eds) Tales From the Other Drug Wars: Proceedings from the 12th Annual Health Policy Conference. Centre for Health Services and Policy Research, UBC 2000; www.chspr.ubc.ca [26 September 2000]
21. Rich P. (1999) Re-evaluating guidelines: clash between researcher and drug company shows need for further clarification of the process. Medical Post; 25 (41): cover, 64.
22. Rettig R. (2000) The industrialization of clinical research. Health Affairs; 19 (2): 129-146.
23. Bodenheimer T. (2000) Uneasy alliance - clinical investigators and the pharmaceutical industry. N Engl J Med; 342 (29): 1539.
24. Eichenwald K, Kolata G. (1999) Drug trials hide conflicts for doctors. New York Times; May 16, 1999.
25. Rennie D, Flanagin A, Yank V. (2000) The contribution of authors. JAMA; 284 (1): 89-91.
26. Lang RW. (1974) The Politics of Drugs: A comparative pressure-group study of the Canadian Pharmaceutical Manufacturers Association and the Association of the British Pharmaceutical Industry. England: Saxon House.
27. Temin P. (1980) Taking Your Medicine: Drug Regulation in the United States. Cambridge: Harvard University Press.
28. Restrictive Trade Practices Commission (1963) Report Concerning the Manufacture, Distribution and Sale of Drugs. Ottawa: Queen's Printer.
Steve Morgan, Morris Barer and Robert Evans are academics at the Centre for Health Services and Policy Research, University of British ColumbiaZero Sum added:
On Friday 04 October 2002 11:49, George wrote:
> > 2) Patients who _demand_ some sort of pill for coughs and colds, and badger their GP's into prescribing antibiotics
>
> doctor: well, mr x, you have a viral infection and an antibiotic isn't necessary.
> mr x: but i demand one and i'm going to badger you until you give me one.
> doctor: ok, here is your prescription for an antibiotic which you don't need>
Ian Musgrove responded:George replied:
> > Again, this depends on what you mean by "much of the medical profession".Try the AMA, or check with The Australian Prescriber.
>Well, I suspect that there might be figures on this but I don't know how to
>obtain these figures.
>However, considering "someone" or "some organisation"
>felt that a mass media campaign was necessary to alert people to the fact
>that they *don't need* an antibiotic for the common cold, makes me suspect
>that the figures for antibiotic over-prescribing would be substantial.
No. I don't have the actual figures here with me at home, but from memory the figures are of the order of about 5% of GP's are over prescribing. However, the potential impact of this small number is so large that we have to put the effort in to reach them.
>snip,And privately funded institutions, the key was having active research staff, not funding source.
> > Almost as soon as antibiotic resistance become known, the large teaching
> > hospitals put extra restrictions on antibiotic use, this was followed by
> > appropriate restrictions in smaller hospitals,
>Yes, once the situation became known appropriate change and an attempt to
>manage the situation began in *publicly funded* institutions.
>snip,Strange as it may seem, there are doctors practicing who went to medical school more than 20 years ago, or even 30 years ago. Since those doctors graduated, the nature of infections, and the incidence of secondary infections has changed substantially, and the new management procedures are not those they learnt at medical school (though appropriate in those years). Continuing education in any profession is a pain in the bum, and it is very hard to organise for medical doctors, especially given the rate of change of medical information and the sheer volume of information.
> >Starting (and still continuing) in the 80's
> > there was a campaign to teach GP's about appropriate antibiotic prescribing
> > (which has also evolved into the quality use of medicines campaign,
> > applying to prescribing generally, but antibiotic use is still an important
> > education focus).
>The fact that a large-scale, long-term campaign was *even necessary* to
>"teach" GP's how to manage probably one of the most common problems seen in >general practise,
>i.e., treatment of infection (and the most commonThe most common illness seen in most practices is high blood pressure, followed by arthritis, followed by influenza. Throat and ear infections are relatively minor.
>infections treated probably being throat infection and ear infection) is
>absolutely frightening.
>The fact that the campaign directed towards the medical profession wasNo, that was specifically developed because of the number of patients demanding antibiotic treatments. You would be surprised by the number of people who aren't aware that colds are caused by viruses (despite the number of ads on TV), or that antibiotics are not useful against viruses (or even who aren't aware that the earth orbits the sun). _Never_ underestimate the degree of ignorance out there.
>probably not particularly successful, evidenced by the fact that the
>campaign has now gone directly to the public in the form of advertisements
>advising them that they don't need an antibiotic for the common cold, I find
>also to be quite amazing.
>snip,Habit and "that's what I learnt in medical school" mentalities are hard to shake.
> > The current crisis in antibiotic resistance stems from a number of factors
> > 1) Holdout GP's who still prescribe antibiotics inappropriately
>Yes, the gp's fault but still worth wondering why they do it. It's
>incredibly that some gp's still do this.
>snip,You obviously have never had to suffer through some of these patients
> > 2) Patients who _demand_ some sort of pill for coughs and colds, and badger
> > their GP's into prescribing antibiotics
>doctor: well, Mr. x, you have a viral infection and an antibiotic isn't necessary.
>Mr. X: but I demand one and I’m going to badger you until you give me one.
>doctor: ok, here is your prescription for an antibiotic which you don't need
>Yes, the gp's fault again. I suspect one reason some doctors do this is forNo, again. Many, patients _expect_ treatment, and get quite narky if you don't give it too them (and it can be very, very difficult to talk them out of it), again, you have never had to deal with these people.
>expediency i.e. economic reasons. The more patients in and out of the
>office, the more signatures on Medicare vouchers.
>snip,No. This is a serious problem. We have tried all sorts of ways to get people to take their medication properly, but no matter how simple of idiot proof you make the instructions, there are a substantial number of people who just don't take them, even when they have been impressed with the seriousness of it.
> > 3) Patients who do not complete the prescribed course of antibiotics.
>perhaps, at least, both patients and doctor's fault here.
>Yes, someYou suspect wrongly.
>patient's probably don't finish a course of antibiotics for reasons perhaps
>known only to them. But I suspect there are also a percentage who haven't
>been given specific instructions as to how to take their antibiotics and for
>how long.
>snip,But it is happening sooner in part because bugs can speed up their mutation rates, no-one suspected there could be hyper-mutators, but there are, and they speed up the evolution of drug resistance a thousand fold. In the case of extended beta lactams, resistance developed within a year of them entering the clinic, this was astoundingly rapid. Similarly, horizontal gene transfer was a bit of a shock, and speeds up transmission of newly evolved resistance genes.
> > 4) Bugs being a lot better at both evolution and horizontal gene transfer
> > than anyone ever suspected.
>Well, I'm presuming that antibiotic resistance is going to occur sooner or later.
>The misuse of antibiotics though has meant that antibiotic resistanceLots, which is why you have the TGA, ASCEPT, the AMA, the Quality Use of Medicines group, and the PBAB keeping a stern eye on drug evaluation, licensing, and advertising. This is however tangential to your claims of the majority of the medical profession misusing antibiotics.
>has occurred much, much sooner than was ever expected and probably much,
>much sooner than should have occurred. >
> > The "they" who though antibiotics were a good thing were also the "they"
> > who worked out the appropriate utilization regimes (which some GP's and
> > patients ignore) and the appropriate dosing regimes (which some patients
> > ignore).
>Indeed, what does happen before a drug gets into the hands (onto the skin,
>under the tongue, into the gut etc.) of a consumer?
snip,5% does indeed amount to a lot of doctors. Given Australia has about 18,000 general practitioners then somewhere around 1,000 are overprescribing antibiotics. And I'd certainly agree that the impact from these overprescribers would be very significant indeed.
> >However, considering "someone" or "some organisation"
> >felt that a mass media campaign was necessary to alert people to the fact
> >that they *don't need* an antibiotic for the common cold, makes me suspect
> >that the figures for antibiotic over-prescribing would be substantial.
> No. I don't have the actual figures here with me at home, but from memory
> the figures are of the order of about 5% of GP's are over prescribing.
> However, the potential impact of this small number is so large that we have
> to put the effort in to reach them.
> >snip,
> > >Starting (and still continuing) in the 80's
> > > there was a campaign to teach GP's about appropriate antibiotic prescribing
> > > (which has also evolved into the quality use of medicines campaign,
> > > applying to prescribing generally, but antibiotic use is still an important
> > > education focus).
> >The fact that a large-scale, long-term campaign was *even necessary* to
> >"teach" GP's how to manage probably one of the most common problems seen in
> >general practise,
> Strange as it may seem, there are doctors practicing who went to medical
> school more than 20 years ago, or even 30 years ago. Since those doctors
> graduated, the nature of infections, and the incidence of secondary
> infections, has changed substantially, and the new management procedures
> are not those they learnt at medical school (though appropriate in those
> years). Continuing education in any profession is a pain in the bum, and it
> is very hard to organise for medical doctors, especially given the rate of
> change of medical information and the sheer volume of information.
snip,Yes but a patient "demanding" an antibiotic and a doctor prescribing that antibiotic are 2 different things. One of any doctor's responsibility is to take the time to explain to the patient precisely why the antibiotic is not necessary etc., etc. Though I do understand that there would be situations, such as Chris Lawson suggested, where a patient's demands, a doctor's skills (clinical/communicative etc.), as well as the specific details of the particular interaction would need to all be taken into account.
> >i.e., treatment of infection ( and the most common
> >infections treated probably being throat infection and ear infection) is
> >absolutely frightening
> The most common illness seen in most practices is high blood pressure,
> followed by arthritis, followed by influenza. Throat and ear infections are
> relatively minor.
> >The fact that the campaign directed towards the medical profession was
> >probably not particularly successful, evidenced by the fact that the
> >campaign has now gone directly to the public in the form of advertisements
> >advising them that they don't need an antibiotic for the common cold, i find
> >also to be quite amazing.
> No, that was specifically developed because of the number of patients
> demanding antibiotic treatments.
snip,Yes, i understand what you are saying. Yet, isn't one of the roles of the general practitioner to be informing their patient's of current thinking in terms of treatment of sore throat etc. and why an antibiotic is not necessary, and even potentially harmful. I would have thought that if doctors, on the whole, do this regularly in a one to one situation then the consumer group "as a whole" would be getting the message.
>You would be surprised by the number of
> people who aren't aware that colds are caused by viruses (despite the
> number of ads on TV), or that antibiotics are not useful against viruses
> (or even who aren't aware that the earth orbits the sun). _Never_
> underestimate the degree of ignorance out there.
snip,
> > > The current crisis in antibiotic resistance stems from a number of factors
> > > 1) Holdout GP's who still prescribe antibiotics inappropriately
> >Yes, the gp's fault but still worth wondering why they do it. It's
> >incredibly that some gp's still do this.
> Habit and "that's what I learnt in medical school" mentatlities are hard to
> shake.
snip,
> >Yes, some
> >patient's probably don't finish a course of antibiotics for reasons perhaps
> >known only to them. But i suspect there are also a percentage who haven't
> >been given specific instructions as to how to take their antibiotics and for
> >how long.
> You suspect wrongly.
Zero Sum responded:Chris Lawson posted:
I'm probably wasting my time responding to this, but here goes anyway.
At 11:49 4/10/02 +1000, George wrote:> Again, this depends on what you mean by "much of the medical profession".
>Well, i suspect that there might be figures on this but i don't know how to
>obtain these figures. However, considering "someone" or "some organisation"
>felt that a mass media campaign was necessary to alert people to the fact
>that they *don't need* an antibiotic for the common cold, makes me suspect
>that the figures for antibiotic over-prescribing would be substantial.
There are some figures on over-prescribing but there are better figures on antibiotic resistance rates, and it was these that led to the education campaigns.
>Yes, once the situation became known appropriate change and an attempt to
>manage the situation began in *publicly funded* institutions.
Many hospitals are privately funded, and these have also worked at improving antibiotic use.
>The fact that a large-scale, long-term campaign was *even necessary* to
>"teach" GP's how to manage probably one of the most common problems seen in
>general practise, i.e., treatment of infection ( and the most common
>infections treated probably being throat infection and ear infection) is
>absolutely frightening.
Well, you could subscribe to the theory that every doctor should be immediately aware of every important medical fact presumably through psychic powers, or you could subscribe to the theory that there are more scientific papers published in medicine than anyone has time to read. One estimate I saw based on the average annual publication load was that if you read three papers a day, at the end of a year there would still be a century's reading ahead of you. Given that it is impossible for any doctor to read all the published research, there is clearly a role for governments in circulating information about important matters of public health. This means education campaigns. It is not frightening at all.
>The fact that the campaign directed towards the medical profession was
>probably not particularly successful, evidenced by the fact that the
>campaign has now gone directly to the public in the form of advertisements
>advising them that they don't need an antibiotic for the common cold, i find
>also to be quite amazing.
This is not true. The doctors' education campaign was highly successful, but it did not change the prescribing habits of *all* doctors, and it did not change the *public* perception that antibiotics were the standard treatment of colds. The public campaign was a very good idea because it reduced the pressure on GPs to prescribe for demanding patients. And it reduced the number of patients who would say "stupid doctor wouldn't give me what I need, I'll go find one who will." And it stopped a lot of people from visiting the doctor in the first place and draining the Medicare purse in the process. Again, there is nothing amazing about this; it is just good sense.
>snip,
> > The current crisis in antibiotic resistance stems from a number of factors
> > 1) Holdout GP's who still prescribe antibiotics innapropriately
>Yes, the gp's fault but still worth wondering why they do it. It's
>incredibly that some gp's still do this.
I agree there. It amazes me that there are still GPs who routinely prescribe antibiotics for colds. But then there are still pharmacists who sell quackery. And lawyers who screw up cases. And bus drivers who drink on the job. And scientists who publish fraudulent findings. And journals who publish papers against the recommendations of their referees...
>snip,
> > 2) Patients who _demand_ some sort of pill for coughs and colds, and badger
> > their GP's into prescribing antibiotics
>doctor: well, mr x, you have a viral infection and an antibiotic isn't necessary.
>mr x: but i demand one and i'm going to badger you until you give me one.
>doctor: ok, here is your prescription for an antibiotic which you don't need
>Yes, the gp's fault again. I suspect one reason some doctors do this is for >expediency i.e. economic reasons. The more patients in and out of the
>office, the more signatures on medicare vouchers.
You have not had the experience that I have of a patient demanding antibiotics, and on being told they were not necessary, having him leap to his feet and scream for five minutes about how I was risking his life. (He still didn't get his script, but it was more out of bloody-mindedness on my part than clinical assessment after that performance.) You have obviously not had the experience of a mother weeping because her child hasn't slept for three nights and is desperate for any sort of treatment even if it has a low chance of success. (She did get the script.) And you forget that most GPs find it very difficult emotionally to refuse help even when you know that the treatment is not likely to be helpful. And while there will be some GPs who prescribe out of economic expediency, this would be uncommon.
I don't know what line of work you are in, but have you *never* done something you don't personally believe in to satisfy a customer?
> > 3) Patients who do not complete the prescribed course of antibiotics.
>perhaps, at least, both patients and doctor's fault here.
>Yes, some patient's probably don't finish a course of antibiotics for reasons perhaps >known only to them. But i suspect there are also a percentage who haven't been given >specific instructions as to how to take their antibiotics and for how long.
Fewer than half of people finish their course even when they have been told to finish it by the GP and the pharmacist and it is written in big letters on the box that they need to finish it. Of course, this is the GP's fault.
>snip,
> > 4) Bugs being a lot better at both evolution and horizontal gene transfer
> > than anyone ever suspected.
>Well, I'm presuming that antibiotic resistance is going to occur sooner or
>later. The misuse of antibiotics though has meant that antibiotic resistance
>has occurred much, much sooner than was ever expected and probably much,
>much sooner than should have occurred.
I'll agree there. But the majority of serious antibiotic resistance takes place in the hospital setting. Vancomycin resistant E. Coli is one of the new nasties -- and vancomycin has never been available to general practitioners. And this is not to blame the hospitals -- there are fairly intractable reasons why these things happen in the hospital setting.> > The "they" who though antibiotics were a good thing were also the "they"
> > who worked out the appropriate utilization regimes (which some GP's and
> > patients ignore) and the appropriate dosing regimes (which some patients
> > ignore).
>Indeed, what does happen before a drug gets into the hands (onto the skin,
>under the tongue, into the gut etc.) of a consumer?
>An article entitled Buying Science, Selling Drugs from >http://www.healthmatters.org.uk/stories/morgan.html gives much food for
>thought. I've reproduced most of it below. The full text is at the above url
This is a very important issue -- but I would point out that the problem has been raised by medical scientists long before the media got wind of it, and it was medical scientists and journals who have fought this sort of corporate slanting. The problem is a long way from fixed, but there have already been significant improvements due largely to brave researchers (one of whom blew the whistle last year despite grave personal risk -- Peter Macinnis probably remembers her name) and medical journals (especially the BMJ and NEJM).
[And in response to Geoff's complaints about his experiences with an ear infection: I'm afraid that ear infections are virtually always bacterial, not viral, although they are commonly precipitated by a viral throat infection. The treatment of ear infections is controversial, but even organisations that have pushed hard to reduce the over-prescription of antibiotics recognise that otitis media is a difficult case and that you cannot make a blanket recommendation for or against antibiotic use in this instance. The fact that two treatments of antibiotic failed does not mean that the prescriptions were inappropriate. And while the doctor who said he (or she) could not be held responsible for the consequences of not taking antibiotics may have been heavy-handed, he (or she) is quite correct in that untreated otitis media can result in mastoiditis (a serious and very difficult infection to treat) and meningitis (which is even more serious) and death (which is about as serious as you can get). While these complications are rare, they are possible. It's also possible to get side effects from antibiotics, some of which are serious themselves. All of which is to say that antibiotic use in otitis media is NOT a simple and obvious medical issue. A really good resource for these sort of problems is the Australian Prescriber website. It's written for doctors, so some of it may be difficult to interpret, but it is very matter-of-fact and evidence-based.]
I don't wish to defend the prescribing of every GP. I wouldn't even defend every script I've written in the past. But I do find it irritating when people jump up and down about how evil/stupid/greedy GPs are because they are not each and every one of them perfect, when people automatically assign deep moral failure (evil/stupid/greedy) to any imperfections, and when people use education campaigns designed to improve performance as proof of how evil/stupid/greedy GPs are for needing them. I'd be interested to see how they'd feel if they were to work under those expectations.
The vast majority of GPs are hard-working, highly-educated, and extremely ethical, as are most professions and trades. According the federal Health Department's own figures (ie according to federal bureaucrats), the Medicare rebates for GP consultations are about *half* what they should be. When the previous Health Minister was asked at a public meeting what he was going to do about the underpayment of GPs, he said (again I stress that this was at a public meeting) that he was going to do nothing about it because the public perception was such that he wouldn't lose any votes over it. Can you imagine any other minister saying that about any other profession and it not being front page news? Imagine if Brendan Nelson was to say that university lecturers are underpaid but he wasn't going to pay them any more because there's no political damage in continuing to underpay them? It's true, of course, and everyone knows it, but if Nelson was to actually *say* it, he'd be in deep, deep damage control. Well Wooldridge *did* say it, in public, on the record, in the lead-up to the last election, about GPs. And the only reports were in the medical media. Wooldridge was absolutely right. His understanding of the media attitude and popular opinion of doctors was just as precise as Howard's understanding of the Tampa fiasco. I find it very discouraging to have the evidence of that attitude rubbed in my face on a regular basis.
> I don't wish to defend the prescribing of every GP. I wouldn't evenI agree with this. My post was not meant to be an attack on the medical profession, but the transfer of inappropriate blame to the patient. That does not mean that blaming the doctor is not also inappropriate.
> defend every script I've written in the past. But I do find it
> irritating when people jump up and down about how evil/stupid/greedy
> GPs are because they are not each and every one of them perfect,
> when people automatically assign deep moral failure
> (evil/stupid/greedy) .....
Gerald Cairnes responded:
I could not agree more with what you say but neither has it had much effect on the policy of allowing the feeding of ABs to stock a far more insidious practise than any perceived over prescribing by doctors in my view. For Wolfie's benefit natural GM will ensure he gets a dose of the altered organisms in due course, in fact like all of us he has almost certainly already been GM'ed.
Another aspect is the case of my dying father who is still hanging in there to the surprise of everyone. He wants to die he is an old soldier who understands death and has seen lots of death and does not fear it. During very rare and brief spells of awareness he can barely move his arm more than a few centimetres, just enough to make the gesture of cutting his throat and point to his feeding tube clearly indicating he wishes to have it turned off. This has all sorts of moral and legal difficulties for the dedicated religious staff who are nursing him.
He contracted pneumonia and was put on ABs and it was not doing anything not surprising in a worn out body I instructed the ABs to be withdrawn and fully expect the the "old mans' friend" to supervene but we were all wrong he recovered to continue his misery. Then he got an infection around the PEG tube with three different bugs streps etc. and ABs were administered again and once again there was little response. We expected that peritonitis would give him the release he wanted but when the ABs were withdrawn the infection subsided and so the misery continues not to mention the massive unnecessary expense this is costing the Community. Multiply this over the Community at large at it must amount to an enormous unnecessary cost. Nothing is black and white there are "shades of grey" but there is a sore need for doctors to be given greater freedom from the fear of stupid blind administrative and or religious policies in these matters.
If Ruth and I were able to cope with him we would take him home and help him to die and God Help any bureaucrat who decides that he/she has to interfere in our affairs should such a thing happen they will find out just how politically dangerous I can be, so far I have only be "frittering around the border" to paraphrase a certain past PM. Unfortunately it is not likely to happen.
I hope if there are any of the List members with the right connections they will shove this story up the noses and any other orifice of the sanctimonious John Howard and Kevin Andrews! Twisted specimens of humanity!!
For Georges' benefit, doctors in private practice run a business like any other and have a need to be more that just medical practitioners, often enough when a patient can't get what he/she wants they will go to another who will give it to them and the practice suffers. I remember discussing this effect with a young GP who had started a new practice where he had to get his numbers up to a critical mass and he was bemoaning the fact that he had to make such choices just to get started. It is not easy!!!
Sorry in the interests of bandwidth, I have snipped most of your message as I agree with you and everyone should already have it.
At 05:18 5/10/02 +1000, George wrote:
>That figure of 5% that i quoted was supplied by ian musgrave in response to
>my query about what percentage of doctors inappropriately prescribe
>antibiotics for viral infections.
In response to a post by George, Chris Lawson wrote:
At 12:16 6/10/02 +1000, George wrote:A big topic. Won't go there now.
>Perhaps it is time to reconsider the concept of general practise entirely and explore the
>question of whether such a creature as a general practitioner can continue
>to exist in light of all the knowledge that he is required to firstly learn,
>and then remain up to date on.
>Chris, you make valid arguments that prescribing an antibiotic might takeNope. This is not the way consultations work out. I can't explain it any better than to say that this is not the way things happen except in exceptional cases.
>longer than not prescribing one. However, it's also possible that a
>discussion about why an antibiotic is not useful for a 'flu, followed by an
>explanation about the differences between viral infections and bacterial
>ones, followed by a response to the query, "but my previous doctor *always*
>prescribed antibiotics for me when i had the 'flu", followed by a response
>to the query, "was my previous doctor doing the wrong thing?", followed by a
>response to the question, "do you think that my previous doctor was managing
>my hypertension correctly, my diabetes correctly, my arthritis correctly
>etc., etc.?", followed by a response to the query "should i ring my daughter
>and tell her to stop going to Dr. Smith?", might actually take longer than
>checking for allergies, asking and advising about the oral contraceptive and
>then discussing medicine details.
>Is a small and biased sample (whether based on personal experience or not)In my opinion, yes.
>more, or less, useful than 3rd hand conjecture?
>I do. A friend works about 30hrs per week at about $75 dollars an hour. ThisI'm glad you know someone who feels this way. I don't know anyone. Good luck to him.
>is $2250 a week or $117,000 a year. Take out medical indemnity (about
>$4,000), holidays, sick days ($10,000), take out an extra $5,000 for
>sundries and that leaves him with about $100,000 a year for a 30 hr. week.
George posted, in reply to Toby:
> > Yet, 5% of gp's, (1000 out of 18,000) according to Ian Musgrave are over
> > prescribing antibiotics. I'm not sure I’d call them "highly educated" Or are
> > we dealing with a question of ethics?
> It might be as simple as being a matter of statistics and their misuse.
> There probably some who are over-prescribing antibiotics if they are in the
> top 5% of prescribers of antibiotics and probably some that are not. Merely
> being in the top 5% does not prove very much. Regrettably, the Health
> Insurance Commission seems unable to distinguish between being a top
> prescriber and over-prescribing, but what would you expect with an
> accountant's approach to medicine?
Actually, Toby, that figure of 5% was a figure that Ian Musgrave quoted in
relation to the percentage of gp's who inappropriately prescribed antibiotics
for viral infections. I made some further comments about this in an earlier
post in response to a post of Karen’s.
snip,
> It seems to be more concerning that many doctors are unable to get their
> drug strengths and dosages right. Enough doctors on enough occasions get it
> badly enough wrong to wonder why more people don't have prescription drug problems.
A friend who is in second year training for nursing has enormous difficulties
working out tablet numbers, drip rates etc. She showed me her manual which
gives a number of examples followed by some questions and asked if I could
help her. When I checked it out only very elementary mathematics is required
to works out drug doses and drip rates etc. She told me that she was absolutely
*terrible* in mathematics at school. There is no math/science prerequisite
to enter nursing and I wonder if the same applies to medicine. I'm pretty
sure that no prerequisite was required to enter medicine in the past (at
least at UNSW-a friend having entered medicine at UNSW some 20 years ago
with marks obtained from non-science/maths subjects) but I don't know what
the prerequisites are now. I guess there would be a percentage of doctors
around who just don't have a "knack" for maths.
snip
>Computers help, or are starting to. Dispensing pharmacists help,
> as long as they are on the ball or using THEIR computers and the patient is
> getting their scripts at the same place all the time.
A friend was commenting on having prescription printing software. He uses
a program called "medical director", I think. The big draw back for him is
that the software is absolutely full of advertisements. After he has plugged
in the information that's needed for the prescription, and before the script
is printed, the screen fills with a full page add for some drug or other
and stays on the screen for some 10 or so secs. He tells me that he finds
it so annoying that he either turns his screen away or looks away when this
is about to happen.
snip,
> The addition of a computer to assist in prescription writing is both an
> asset and a liability. My current GP, who seems to be a good diagnostician,
> spends about five minutes of the consultation picking his way over the
> keyboard trying to write a script. Referrals are worse. I have suggested
> he might like to hand the keyboard over and let someone who can touch type
> (some of the time) have a go, but he is impervious to all approaches,
> refuses to attend a typing course and seems intent on making his principal
> constraint to productivity the use of the computer that some manager has told him he must use.
I was chatting to my local vet. about this because the practise he works
in is "computerised". It's not his practise, he works on salary/commission.
He tells me that he has heard of some software whereby someone handwrites
directly onto a computer "pad" and the software translates the handwriting
into type and stores it as type in the computer. He seems to feel that that
particular technology will be available soon and he is quite looking forward
to it.
Tamara added:
The computer also saves their arse!! A friend of mine had a client come in and she prescribed XYZ for her and typed up the report, and as this was a case required a follow up visit, an appointment was made. On the
appropriate date, the client did not show up and she rang her to check her absence. Months later the client launched legal action against my friend for misdiagnosis (Lumps and bumps case). Luckily they were able to show via computer records that the client had not returned for the follow up check which probably would have corrected the error.
Chris Lawson replied:
At 17:18 5/10/02 +1000, George
wrote:
>Now, yes I agree that people in *any* occupation can't be perfect but there
>are some aspects of medicine where I'd expect the incidence of error to be
>as close to zero as possible. That antibiotics are not useful in the
>treatment of viral infections is so basic and fundamental a "fact" in
>medicine that to excuse a few percentage of doctors for inappropriately
>prescribing antibiotics (mitigating factors aside) because "nobody's
>perfect" is equivalent to excusing a small percentage of anaesthetists for
>forgetting to turn the oxygen valve on for an anaesthetised patient because
>"nobody's perfect", or to excusing a small percentage of solicitors who
>don't properly witness people's wills because "nobody's perfect".
>BTW, Chris L, if you are reading this, what do you think could be possible
>reasons that these "hold-out" doctors continue to inappropriately prescribe
>antibiotics for viral infections?
ONE: I don't know the figures for inappropriate prescribing. I'll take Ian's
figure as a given, but one must be wary with these sort of figures. The sort
of people who collect these figures are health bureaucrats, and while they
have an agenda of reducing antibiotic usage, they also have an agenda of
reducing pharmaceutical costs. While the Australian health bureaucrats are
extremely good, they have been known to make recommendations that are not
always appropriate (and since they are collecting these figures, it is worth
asking exactly how they decide what is inappropriate prescribing). Also,
while it may be true that 5% of antibiotic scripts are inappropriate, it
may not be true that 5% of doctors are routinely prescribing antibiotics
for colds. All it would take is a small minority of doctors to generate a
large number of inappropriate scripts; also there may well be doctors who
usually prescribe appropriately, but occasionally do not -- and these will
push up the number of scripts without representing "holdouts". Which is not
to say Ian's figure is wrong, but that I'd need to know more about it to
judge.
TWO: While inappropriate prescribing of antibiotics by GPs is a bad thing,
it is in no way comparable to anaesthetists routinely forgetting to turn
on oxygen. I don't know enough about the role of solicitors in witnessing
wills to pass comment, but I reiterate that *you* are the one trying to allocate
moral blame. I never said that doctors should be allowed to prescribe inappropriately
because nobody's perfect. I was trying to get you to understand that the
situation is not a simple, cut-and-dried moral issue where bad prescribers
are evil, money-hungry bastards. You have generously moved past that position,
I see, but you are still primarily concerned with finding moral blame and
denying excuses.
THREE: I do not know why some doctors have resisted the call to change antibiotic
prescribing. Here are my thoughts. Some of the reason is that the clinical
problem *isn't* as obvious as people make out -- there is no accurate method
of determining whether an infection is viral or bacterial on clinical grounds,
despite the way it is usually presented in the media. There is confusion
over the best method of treating ear infections. There is always the possibility
that an untreated streptococcal throat infection will cause kidney disease
or rheumatic heart disease. In the light of recent litigation, some doctors
feel pressured to avoid individual disasters rather than address community-level
concerns such as antibiotic resistance. I know from personal experience that
if a patient has a bad outcome, one tends to be more cautious about that
for a while afterwards, even if the outcome was unrelated to one's own clinical
treatment. So it may be that some of these "holdouts" are doctors who have
seen a patient have permanent heart damage because they weren't given penicillin.
But as I say, all this is conjecture. I don't claim to understand why some
people still prescribe antibiotics routinely for the common cold, and even
if I did, I wouldn't use it as an excuse for them to continue.
