Thursday, June 19, 2008

Electronic Health Records too Expensive

A survey sponsored by the Federal Government and the Robert Wood Johnson Foundation and published online by New England Journal of Medicine suggests that costs of adaptation of EHR (also called EMRs and PHRs and MDRs) by the medical community are a road block to wide adaptation of EHR. This is ironic since EHRs are supposed to cut costs from the health care system.

The detailed study briefly mentions that the number of years in practice was taken into account when analyzing the results, but does not provide detailed data broken down by this variable. It is highly probable that physicians in practice 1-20 years are much more likely to use EMR than those in practice 21-40 years and beyond. Older physicians are less computer savvy, were not “raised” on computers, and have a more difficult time adapting to EMR, e-Prescribing and even computerized practice management systems. Additionally, when younger physicians join a mature practice they are likely to push the senior physicians in the practice into a computerization process. As a result, the “4%” mentioned in this article may be innacurate if the doctors surveyed tended to be on the “older” side. is currently performing an online physician survey on the subject of EMR. The physicians who participate in our surveys tend to be more computer friendly, and our preliminary results indicate a much higher EMR implementation than the 4% mentioned in this article.

Some additional interesting data from our survey reveals that only 53% of doctors who purchased an EMR system find that it is of benefit to their practice efficiency and that it was worth the cost of purchase and maintenance. Only 50% of doctors felt that their EMR system helped them provide better care for their patients. (No wonder that EMR hasn’t taken off). 69% of physicians polled were in favor of having a secure and privacy-protected universal, online EMR system.

Interestingly, 11% of physicians have found that patients are asking for copies of their medical records for the purpose of posting them on line on systems such as Microsoft HealthVault and GoogleHealth. This could become a major new trend and indicates that Google’s and Microsoft’s strategies are working. (If this trend mushrooms, many doctors’ offices may be overwhelmed by fulfilling the numerous requests for copies of their medical records).

We will be posting the results of this June 2008 survey soon. To view our October 2007 survey on EMR and Healthvault visit this link.

Robert Cykiert, M.D.

Eye on Genentech: Similar drug, 40 times more expensive

Genentech is restricting the use of its cancer drug Avastin, which is also widely used for patients with wet macular degeneration. There is suspicion that Genentech is doing this because Avastin competes directly with its other wet macular degeneration drug called Lucentis. Avastin costs about $50 per dose and Lucentis costs about $2,000 per dose. You can read more about this saga that has drawn the attention of FDA and senate investigators at Jacob Goldstein's WSJ blog.

As an ophthalmologist, I have seen incredible results in patients who are being treated for wet macular degeneration with Lucentis and Avastin.

Most ophthalmologists and retinal specialists seem to think that the two drugs are equivalent, but there are some anecdotal reports that Lucentis may be the preferred initial treatment, and Avastin may work better for follow up treatments, since most of these patients need monthly injections of these drugs into their eyes. performed an online physician survey of ophthalmologists to find out what their preferences are. The December 2007 poll revealed that doctors preferred Avastin over Lucentis by a 2 to 1 margin. 84% believed that Avastin and Lucentis were equivalent medications, and 94% of ophthalmologists said that Genentech should not place any restrictions on the sale or distribution of Avastin to ophthalmologists or pharmacies that prepare Avastin for use by ophthalmologists.

Click here to see survey results.

We’re all awaiting the results of the NIH study to find out what’s best for our patients.

Robert Cykiert, M.D.

Friday, June 6, 2008

Pfizer's Failure to Communicate

The Wall Street Journal Blog by Avery Johnson reported that Pfizer invited the media, including the WSJ Health Blog, to a roundtable about Chantix at the company’s 42nd Street HQ. The purpose of the meeting was to send the following message regarding recent negative Chantix media reports:

#1 Smoking is a serious health problem that kills people.

#2 Most of the adverse events that have been reported recently are already in the Chantix label.

#3 Smokers who are trying to quit can be depressed and irritable.

#4 Paying close attention to adverse-event reports helps the FDA and Pfizer enhance drug safety.

As I noted previously, all of the Chantix-related side effects are also known to be associated with cigarette smoking and cigarette smoking cessation withdrawal.

I’m glad to see that Pfizer called a round table to clear up this issue with the media.

However, Pfizer needs to also communicate MUCH better with its physician customers since they are the ones who write prescriptions for Chantix, and have to face the anxious and nervous patients who read the worrisome media reports. The same patients that lead to the media reports!

Last time I looked, no one at the Wall Street Journal blog was writing scripts for Chantix.

Pfizer management needs to understand the physician communication concept much better or all the other Wall Street analysts will be following Goldman Sachs’ lead.

Robert Cykiert, M.D.

Thursday, June 5, 2008

I’d like to see Pfizer rate Goldman for a change

The Wall Street Journal Blog by Scott Hensley reports that
Goldman Sachs lowered rating of Pfizer stock from buy to neutral.

Let’s not forget that Goldman Sachs is down over 30% since November 2007 because of the mismanagement in the entire banking sector. If the Fed+Chase’s bailout of Bear Sterns had not occurred, then Goldmans Sachs' stock may have sunk far lower than Pfizer's.

It fascinates me to see how financial institutions and investment bankers rate stocks and trigger market fluctuations in that sector, that many capitalize on.

I’d like to see Pfizer rate Goldman for a change.

By the way, much of Pfizer’s Chantix problems, and other pharmaceutical company misfortunes can be attributed to spending more time with Wall Street analysts than they do with their most important customers--physicians.

Doctors wrote prescriptions for about $270 billion in 2007. They control pharmaceutical sales to a great degree, yet pharma tends to ignore them and not communicate well when bad news comes out about a particular drug or class of drugs. The failure to communicate leaves doctors to make decisions based on sometimes exaggerated or sensationalized media reports rather than science from the drug manufacturers. The classic example is the recent Vytorin debacle which we’ve written about here.

The pharmaceutical sector will come back most likely sooner rather than later since health is the most important thing to humans, and advances made by pharma are responsible for much of our good health and extended longevity in recent decades. Clearly there is much more work that needs to be done.

However, I don’t think we’ll need to see the government bailing out Pfizer.

Robert Cykiert, M.D.

Putting the cart before the horse

Wall Street Journal reports that congress is working to force doctors to switch from hand-writing prescriptions to using new digital technology referred to as E-Prescribing.

E-Prescribing like all e-Things sounds great until you try to implement it. The problem with e-Prescribing at this time is that there is no one standard that doctors can adhere to, and no assurance that current platforms and protocols will persist.

One of the main reasons that physicians are not buying into electronic medical records is that they do not want to make a huge initial investment, pay for maintaining the system, and invest huge time in training staff only to find out that the government or some insurance industry group changes the standard in a year or two making their expensive systems obsolete.

A minority of physicians already have e-Prescribing in place, but it has limited value for the patient because the doctor’s system is tied to their office, and current pharmacy that the patient uses. If a patient goes to another doctor or switches from Rite Aid to CVS, then all the e-Pharmacy-Records become worthless.

Ideally, as with electronic medical records, there should be an online, universal e-drug-record that is accessible to all treating physicians, pharmacies and hospitals.

Bottom line: before the government mandates e-Prescribing and penalizes paper-prescribers, it should set a standard.

Robert Cykiert, M.D.

Monday, June 2, 2008

Another failure to communicate with Doctors

In a Wall Street Journal Blog, Jacob Goldstein talks about Anemia drugs sold by Amgen and J&J (Aranesp, Procrit and Epogen) that may stimulate the growth of tumors in some cancer patients. Research suggests a genetic link that could potentially be used as a biomarker to figure which patients should and should not receive those drugs.

At the end of the WSJ article, Goldstein quotes Tony Blau, the lead researcher who said that “The definitive answer to this question lies locked in the files of pathologists’ offices.”

What a shame.

If drug companies had better communications with doctors, research on what works and what does not could be significantly enhanced. performed a February 2008 online physician survey of oncologists and hematologists on the subject of Aranesp, Procrit and Epogen prescribing practices. See detailed survey and results.

65.6% of doctors agreed that certain dosages of these drugs resulted in more rapid growth of certain cancers and a decreased cancer survival rate. Consequently, about 66% of doctors have either reduced the dosages they prescribe, or reduced the number of patients they prescribe the drugs to, or reduced drug usage in certain cancer patients.

Amgen and Johnson & Johnson should do more prompt research on this issue and get answers as quickly as possible since many doctors are clearly nervous about using these drugs. Ironically, the answers are probably "locked in the files of pathologists’ offices."

The longer doctors are kept uninformed, the more likely they will be influenced by media reports as opposed to science, as occurred in the Vytorin debacle. See Analysis of Vytorin Surveys.

Failure to communicate promptly and effectively with physicians will certainly cause further erosion of sales of these drugs, as is occurring with Vytorin.

Robert Cykiert, M.D.

Yogurt for everyone except doctors

As a sign of our times, the Wall Street Journal blog
noted that Eli Lilly had a white sign at their Oncology meeting in Chicago with the following message:

Food, beverages and/or meals will not be provided by Eli Lilly and Company for the following parties:

* Physicians and individuals with prescribing authority in Minnesota in order to comply with Minnesota statutes

* Government employees in New York (both city and state) in order to comply with New York statutes

Particularly tempting was the frozen yogurt that everyone could have except Minnesota doctors and NY government employees.

Lilly’s sign prohibiting free frozen yogurt to MN doctors is a clever way to make a point, tongue in cheek. Free pizza, and other trinkets have no effect whatsoever on physician prescribing patterns since doctors receive the “gifts” from all the companies. Therefore, no one company has an advantage. If you ban all trinkets by all companies in all states then the pharmaceutical companies will simply divert those marketing funds to things like DTC, eDetailing, and online sponsorship of CME courses. A much better way to deal with pharma gifts to doctors is to require all medical companies to post all gifts on their public web sites. The transparency will keep everyone honest. performed a December 2007 online physician survey of 290 doctors in various specialties to determine their views on medical company marketing to doctors. Click to view survey.

While 40.5% of doctors agreed that medical companies shouldn’t give any gifts, 71.6% said that doctors are not influenced by these small gift items. It seems like detailed public posting of all gifts with specification of doctor recipients would keep everyone honest. I checked Lilly’s web site--don’t see the frozen yogurt listed there yet.

Our publicly posted surveys are performed on randomly selected physicians, the doctors fill them out voluntarily and are not identifiable, and are completely anonymous. Therefore, the doctors have no incentive or advantage to give false or misleading answers in the survey. Doctors then read our publicly posted surveys to see what their colleagues are thinking on major issues in healthcare. It’s one of the few effective ways that doctors can take the pulse of their colleagues on controversial issues that affect their livelihoods and affect patient care.

Thursday, May 29, 2008

Vytoringate keeps hurting Vytorin sales

Vytoringae keeps punishing... Schering-Plough's SEC filing shows a continuing drop of Vytorin prescriptions. No bottom in sight.

Based on our health care market research via online physician surveys of cardiologists, internists and GPs who prescribe cholesterol drugs, we predict at least a 50% drop in Vytorin/ Zetia sales. Our recent physician survey in April-May 2008 shows that 50% of doctors have stopped prescribing Vytorin or have reduced prescriptions. This, despite the fact that most doctors thought Vytorin is effective and would prescribe it for themselves and family members. How ironic, good will squandered by pharma missteps.

Click here to view this survey for details.

Our surveys also reveal that the reason doctors are reducing Vytorin prescriptions is related to poor communications with Merck and Schering-Plough, and negative media reports which have a growing influence on doctors’ prescribing decisions in the absence of good communications between doctors and the pharmaceutical companies.

For an in depth analysis of our survey results see Vytoringate: A Failure to Communicate with Doctors. We even suggest a way for pharma to stop it's self inflicted slippery slope and restore trust.

As we previously mentioned, John McCain joined this controversy (see Wall Street Journal Blog). Senator McCain’s physicians seem to also have made their treatment decisions based on the same influences that affected doctors in our survey.

As long as medical companies fail to communicate with their most important customers— physicians—the media and other external forces will have increasing control over prescription sales and pharmaceutical company profits.

Robert Cykiert, M.D.

Tuesday, May 27, 2008

Pilots and smoking

Federal regulators ruled that Pfizer’s smoking-cessation drug Chantix can't be used by pilots and air-traffic controllers. See more details at the Wall Street Journal Blog

Chantix has been under scrutiny for a while for psychiatric side effects. A report this week also suggested that the drug may be associated with physical problems including seizures. Pfizer has said such potential problems are rare, and are already noted on the drug’s label. More than five million people have taken Chantix in the U.S., Pfizer said.

Smoking and smoking cessation have a high association with depression and suicide - So, is it the Chantix or the cigarettes? Smoking is also the leading cause of heart disease, heart attacks and strokes -
So, is it the cigarettes or the Chantix? Smokers also have increased risks of seizures and more dangerous consequences of their seizures - So, is it the cigarettes or the Chantix?

Clearly, for the vast majority of people, Chantix is a far better option and much lower risk than cigarettes. However, no drug is perfect, and no drug is for everyone. Glaxo has offered free Commit nicotine lozenges to pilots. That’s a reasonable alternative option for pilots and good PR for Glaxo, while Pfizer is taking a hit and until we get more data on Chantix.

Lets hope Altria-Philip Morris doesn’t take Glaxo’s lead and offer free Marlboros to pilots.

Robert Cykiert, M.D.

John McCain and Vytoringate

John McCain is now part of the Vytorin controversey, called Vytoringate by the media! He was apparently switched to generic statin (simvastatin) after the Vytorin study was presented at the American College of Cardiology meeting. See more details and discussion at Wall Street Journal Blog.

Looks like McCain’s doctors were as confused as most cardiologists, internists and family practitioners are about Vytorin, the ENHANCE study, and the American College of Cardiology expert panel’s recommendations. Poor communications with physicians and mixed signals from Merck and Schering-Plough resulted in much media hype, and now many physicians, including McCain’s, are confused about how to treat elevated cholesterol and LDL.

For two decades it’s been assumed that lowering cholesterol and LDL reduces the risk of heart attack and stroke. This has been documented with outcome studies for Mevacor, Lipitor, Zocor and other drugs. From the ENHANCE study we know Vytorin reduces lipids better than simvastatin alone. However, the ENHANCE study introduced a new controversey when it was shown that Vytorin does not reduce carotid artery plaque better than Zocor alone. Checking for reduction of carotid artery plaque using ultrasound was something that had not been done in previous studies, but somehow everyone expected to correlate reduction in lipids with reduction in artery plaque. Failure to show the correlation between reduction in artery plaque and cholesterol raised many questions about over 20 years of assumptions on the role of cholesterol and cholesterol lowering drugs (a multi-billion dollar industry).

Luckily, the ENHANCE study did NOT show that Vytorin is in any way harmful or worse than Zocor alone.

The simmering new scientific questions about heart disease and the role of cholesterol combined with suspicious behavior by two large pharmaceuticals has resulted in Vytoringate, a media feeding frenzy, and confusion by doctors who treat heart disease. The two pharmaceutical companies failed to communicate with their most important customers: the doctors who prescribe their medications! Needless to say, those doctors stopped prescribing on a large scale and sales dropped about 50% and billions of dollars of share holder equity for the two companies vanished almost overnight. performed healthcare market research via an online physician survey of physicians who treat high cholesterol First in Jan 2008 and then in May 2008, and found that approximately 50% of doctors stopped prescribing Vytorin since the ENHANCE study and the media’s Vytoringate coverage. You can view the results of this public survey here. Note there is also an analysis of the two surveys as one of the links on that page.

So, I wonder what possible rationale could there be for MCain’s doctors to replace his Vytorin with simvastatin and allow his LDL cholesterol to rise from 83 on Vytorin to 123 without Vytorin?

Was it confusion? Risk aversion? You be the judge.

Robert Cykiert, M.D.

Thursday, May 22, 2008

Full disclosure is coming

Everyone seems to be supporting a new bill backed by Senator Chuck Grassley (R-Iowa) and Senator Herb Kohl (D-Wisc.) that will require companies to disclose payments to doctors who received $500 or more from a single company over the course of a year, starting in 2011. More on this in Jacob Goldstein's WSJ blog.

This is a good law, but why wait till 2011? What Doctors Think performed an online physician survey of over 100 orthopedists and general surgeons in February 2008, and asked them “Should medical companies publicly disclose their consulting agreements with physicians, and specifically indicate what payments or inducements they give to physicians?” (See question #12).
Not surprisingly, 78% of doctors answered YES to this question. Doctors and medical companies should have nothing to hide regarding their business deals. Our healthcare market research confirms that.
Robert Cykiert, M.D.

Saturday, May 17, 2008

Tour de Tobacco

Lance Armstrong, seven-time winner of the Tour de France is on a warpath against cancer with his 5th Livestrong Day, He is doing a yeoman's job in fighting cancer, but he could do a lot more relatively easily by leveraging his access to the media to publicize how cigarettes are the leading cause of cancer by far, and by putting pressure on the tobacco companies to stop all marketing of their deadly products. In Lance's editorial in the Wall Street Journal,, he states that the public should "Ask your local, state and national lawmakers what steps they'll take against tobacco, the number one cause of cancer..." Unfortunately, the public has insufficient clout with legislators to enact changes, and more importantly the public does not have the media access that Lance has, as witnessed by his ability to author an editorial in the Journal. Imagine how effective Lance could be if he appeared on Oprah, Letterman, Leno, Larry King, etc., spoke out against tobacco companies, and put pressure on legislators to ban all tobacco advertising. The US government in its NIH web site, , (page 7) states that Tobacco use is the leading preventable cause of premature death in the United States. Each year, more than 440,000 Americans die of tobacco-related disease, accounting for 1 in every 5 deaths. Cigarette smoking is responsible for more than 30 percent of cancer deaths annually in the United States. Smoking also contributes substantially to deaths from heart disease, stroke, and chronic obstructive pulmonary disease... From 1995 to 1999, estimated annual smoking-attributable economic costs in the United States were $75.5 billion for direct medical care for adults and $81.9 billion for lost productivity." According to the US federal Trade Commission,, tobacco "Advertising and promotional expenditures… (were) $15.15 billion in 2003… $14.15 billion in 2004, and… $13.11 billion in 2005." In contrast, according to the National Cancer Institute,, “the Nation’s principal agency for cancer research… The NCI’s total budget for Fiscal Year 2005 was $4.83 billion. The NCI will invest an estimated $4.79 billion during Fiscal Year 2006. The budget is expected to decrease to $4.75 billion in Fiscal Year 2007.” The tobacco companies are therefore spending three times as much on tobacco advertising than the government spends on cancer research. Additionally, tobacco companies have so far donated $2.5 million to federal candidates and parties for the 2008 election. Go to for donation details by company and politician. It’s no wonder that we’re losing the war on cancer. Lance is one of the few people that can single-handedly end the insanity. Doing that would be a greater accomplishment than winning the Tour seven more times!

Robert Cykiert, M.D.

May 16, 2008

Thursday, May 8, 2008

Bedside Manner vs. Medical Talent

In a recent Wall Street Journal Health Blog, Jacob Goldstein discusses the importance of doctor etiquette referring to Harvard psychiatrist Michael Kahn's New England Journal of Medicine article that proposes 6 rules for doctor behavior.

Etiquette should be at the bottom of the list of what patients want when they are in the hospital. The #1 priority while you’re in a hospital is to be discharged as soon as possible in a healthier state than when you were admitted. You need a smart, diligent, caring, hard-working, talented physician in charge of your care and/or surgery. The doctor could have the best etiquette in town, but if s/he doesn’t have the skills and determination then you are in trouble.

Etiquette may make your hospital stay more appealing, but it is not the benchmark you want to measure. I know some physician colleagues who have great etiquette skills, but I wouldn’t have them take care of me, and then I know some others who have no “bedside manner” at all, but take incredible care of their patients.

Lets not forget our priorities. If the doctor has proper etiquette then that’s icing on the cake. You can’t always have your cake and eat it too.

Robert Cykiert, M.D.

Tuesday, May 6, 2008

Pharma shifts to eDetailing and doctors like it

As pipelines shrink, patents expire, generics grow (see story), the FDA becomes more cautious and conservative, consumer groups complain more about drug prices, the government investigates marketing practices, and stockholders get more angst, the pharmaceutical companies have no choice but to reduce their costs to compete and survive. Sales reps will be cut first because they are much more expensive than new web-based technologies that can offer a higher ROI.

In a January 2008 "What Doctors Think" performed an online physician survey of 230 doctors in various specialties. 44% of surveyed doctors said that ‘email with web site links’ pharma-marketing was the least intrusive on their practice and time. Only 6% of doctors said that sales rep detailing was least intrusive. 9% said that meals with sales reps was least intrusive.

As doctors’ incomes slide, and they spend much less time with sales reps, eDetailing (email and the web) is clearly the strategy for pharmaceutical companies to shift to. It’s far less expensive, much more effective and is more socio-economically acceptable--think green.

When asked what was the most effective way for a pharmaceutical company to notify a doctor of a new FDA drug approval, 57% of polled doctors said ‘email with link to web site’, whereas only 37% said a ’sales rep visit’. When asked “what form of medical company marketing would LEAST escalate national health care costs,” 64% said ‘email with links to web sites’ whereas only 5% said ’sales reps’.

The full healthcare market research survey can be viewed

An analysis of the shift from detailing to eDetailing can be found

Merck is seeing the prescription-writing on the wall. Other pharmaceutical companies will shortly follow the growing trend.

Robert Cykiert, M.D.
Robert Cykiert, M.D.

Thursday, May 1, 2008

No Smoking

According to the American Cancer Society (ACS) there will be 1.4 million new cases of cancer in the USA in 2008. ( Go to">
and download the excellent Powerpoint presentation for detailed cancer statistics). Lung and bronchial cancer will account for 14-15% of these new cases. Additionally, the ACS predicts 566,000 deaths from cancer in 2008. Lung cancer will account for 26% of all cancer deaths for women, and 31% of all cancer deaths for men. The ACS also says that “Smoking is responsible for about 87% of lung cancer deaths” and that “Cigarettes kill more Americans than alcohol, car accidents, suicide, AIDS, homicide, and illegal drugs combined” — see

Simple arithmetic shows that approximately 20% of Medicare’s cancer expenditures, or $4 billion, are for lung cancer caused by cigarettes. (Medicare’s expenditures for treating heart disease and emphysema secondary to cigarettes is probably another $10 billion, based on ACS data for heart and emphysema related deaths). Medicare Trustees recently reported that “Medicare hospital insurance spending is forecast to exceed tax revenues for 2008 and all future years and the fund will be exhausted in 2019″ And that’s just Medicare! Health insurance and out of pocket expenses for treating lung cancer, heart disease and emphysema in people under Medicare age probably accounts for another $10-15 billion dollars in cigarette related expenditures. Clearly Medicare spending on tobacco related diseases is the main reason for Medicare’s hastened insolvency.

How long are we going to allow tobacco to bankrupt Medicare and the healthcare system? The high cost of cancer drugs is minuscule compared to the damage being done by cigarettes.

Why are the presidential candidates not discussing tobacco--the leading cause of disease, death and healthcare expenditures in the USA by far?

Robert Cykiert, M.D.
Comment by Robert Cykiert, M.D.

Monday, April 28, 2008

No pharm pizza for doctors

The Association of American Medical Colleges came out with recommendations today that would ban all pharmaceutical company gifts to physicians and medical students, including items as inexpensive as pizza lunches for a doctor’s office.

Let me explain why banning pizza, pens, post-it-notes, and other "chachkes" for doctors won't accomplish anything. First of all, doctors and medical students should know better than to eat high cholesterol pizza. Secondly, it's not only one drug company that buys pizza for the doctors - every pharmaceutical company that has competing products buys pizza for the physicians and office staff - so the net result is no one company has an advantage in influencing doctors because they all buy the pizza! Perhaps the one that orders extra pizza toppings wins? (I'm partial to mushrooms if any pharma reps are reading this). If you think that banning pizza universally will reduce the cost of pharmaceuticals for consumers, then you've got your head buried in pizza dough. Drug companies will simply use the pizza savings for other forms of marketing like more extravagant booths at medical meetings, more distribution of peer-reviewed articles for off-label marketing, and more eDetailing. So, unless the government bans all pharmaceutical marketing by all companies there will be no net savings, merely a transfer of funds from one form of marketing to another. Additionally, the medical schools need to be careful about what they wish for since many of them receive up to 16% of their funding from pharmaceutical companies as revealed by this NPR survey done in 2005:

So if doctors and medical students shouldn't accept pizza, then the medical school shouldn't as well. Right? Also, medical schools receive a great deal of funding for their Continuing Medical Education activities from pharmaceutical companies. See this report "Medical schools and societies saw the highest commercial funding increase of any of the provider groups, drawing 8% and 7% increases, respectively." So medical schools should not accept CME funding from pharmaceutical companies - right?

And, in a study published in the Journal of the American Medical Association in October 17,2007, it was found that "two-thirds (60%) of department chairs had some form of personal relationship with industry, including serving as a consultant (27%), a member of a scientific advisory board (27%), a paid speaker (14%), an officer (7%), a founder (9%), or a member of the board of directors (11%). Two-thirds (67%) of departments as administrative units had relationships with industry." See the full article at So, all medical school department chairpeople should give up all of their pharmaceutical industry associations as well. Right?

'What Doctors Think' performed an online physician survey of 230 USA doctors in various specialties in January 2008 to determine what their views were on pharma and medical device company marketing. 60% of doctors believe that physicians should not accept any gifts from pharma reps, but 72% said that phsyicians were not improperly influenced or coerced by any gifts given. 55% of doctors were in favor of pharma companies being required by law to publicly post all gifts to physicians. The complete survey can be viewed at

In summary, to be fair, if you end pizza gifts to doctors, as per the recommendations of the Association of American Medical Colleges, then you should stop pharma from contributing ALL funding to medical schools. That would be a mistake since many schools derive great benefit from pharmaceutical company grants, funding, donations and other gifts. All that money would probably wind up being spent in DTC ads if they weren't given to doctors and medical schools. I'd rather eat pizza than see more DTC ads.
Robert Cykiert, M.D.

Sunday, April 27, 2008

FDA focuses on LASIK

LASIK is an excellent procedure as proven by millions of satisfied people who’ve had this procedure done in the USA in the last decade. A recent worldwide review of literature on LASIK revealed that there is a 95% satisfaction rate with the procedure
That’s why NASA has aproved LASIK for astronauts and other branches of the military have approved LASIK for people in the armed forces. However, no procedure is perfect, and there are always risks to any surgery, just as there are risks to driving a car or flying in a plane (although those risks are not told to people who buy cars or fly in planes – it is assumed by the auto and airline industry that travelers know that).

The FDA has apparently received 140 complaint letters from patients in the last 8 years citing various forms of dissatisfaction with their LASIK results. Before we discuss dissatisfaction with LASIK, we must define what we mean by dissatisfaction. The media has devoted much coverage to the FDA-LASIK story this past week, but most of it is in the form of short anecdotes where there is not enough time to discuss important details – as seen on my CBS News Interview from April 24, 2008

There are several possibilities for why patients may not be satisfied with the results of their LASIK procedure. Some of these are preventable and some are not. The 1st type of dissatisfaction is a poor result due to laser or equipment malfunction. This is extremely rare with current state-of-the-art laser technology, but can occasionally occur. If the malfunction occurs because of improper maintenance of equipment, then that is preventable, however, if the malfunction occurs unpredictably, then that cannot be avoided. Fortunately, equipment malfunction because of poor maintenance is extremely rare in the USA, and unpredictable malfunction is rarer.

The 2nd type of dissatisfaction occurs because of less than meticulous pre-LASIK screening of patients. There are multiple parameters that must be evaluated before a patient is determined to be a good candidate for LASIK. These include the degree of nearsightedness, farsightedness and astigmatism that requires correction, the curvature of the central and peripheral cornea and the expected postoperative corneal curvature, the corneal thickness, the pupil size in light and dark environment, the degree of dryness of the eye if any, and several other eye health and systemic health criteria. If all the preoperative parameters for LASIK are carefully and meticulously evaluated preoperatively, then inappropriate candidates can usually be excluded with great certainty.

The 3rd type of dissatisfaction may occur because of a poor result due to surgeon error during the procedure. This is also a very uncommon event since surgeons go through elaborate training to be certified to perform LASIK, however, very rarely surgeon errors can occur even with highly experienced surgeons who have performed hundreds or thousands of LASIK procedures.

The 4th type of dissatisfaction stems from patients having unrealistic expectations from LASIK. I have come across patients who expect to see golf balls 350 yards away after having LASIK, and 50+ year-old patients who expect that they will be able to read without reading glasses after correction of their distance vision via LASIK. The latter is not possible because everyone in that age group has presbyopia, and requires reading glasses if their distance vision is fully corrected in both eyes with LASIK. Some patients have the unrealistic expectation that their vision can be guaranteed to become 20/15 or 20/20 (without glasses or contact lenses) after LASIK. While in the vast majority of cases this is achieved, because of biologic variability of corneas and their reaction to laser light, some patients will only achieve 20/25 or 20/30 vision from LASIK, and some will need a second or enhancement procedure to fine tune their vision. Patients with unrealistic expectations can be screened out before they have LASIK by having lengthy, detailed discussions with them prior to the procedure to make sure they understand what LASIK accomplishes, and that guarantees are not possible.

A 5th form of dissatisfaction can arise in the extremely rare event where a patient is a perfect candidate, the procedure is done perfectly by an experienced surgeon with the latest highly maintained equipment, yet the patient has less than optimal results because of idiosyncratic healing of their eyes after LASIK.

All 5 forms of dissatisfaction discussed above are covered in a LASIK consent form which every patient should read carefully and discuss with their surgeon preoperatively. It has been my experience after 12 years of performing LASIK and Laser Vision Correction, that if the appropriate meticulous preoperative screening is done, if the latest state of the art equipment is maintained properly, if the procedure is done by an experienced surgeon, and if the patient is educated regarding proper expectations from LASIK then the LASIK satisfaction rate approaches very close to 99+%.

Nothing in medicine is 100%. I think that the FDA panel will find this as well.

Robert Cykiert, M.D.
April 26, 2008

Thursday, April 24, 2008

Chantix: Friend or Foe for cigarette smokers?

Chantix was approved by the FDA in May 2006. It's a unique drug manufactured by Pfizer that helps smokers get over their cigarette addiction:

However, in Novemeber 2007 the FDA warned that some people who take Chantix become agitated, depressed and even suicidal:

The Associated Press has publicized this by reporting on a patient with severe depression from Chantix on April 23, 2008:

I think we’re losing sight of the real issue by being myopic about Chantix. The real culprit is tobacco, not Pfizer or Chantix. Chantix was created to deal with the severe physical and psychological addiction caused by tobacco/nicotine. Tobacco is the leading cause of cancer and heart disease in the USA, and probably the rest of the world. Tobacco kills more than 400,000 people a year in the USA according to US Government/CDC statistics:
To put that in perspective, think of this shocking statistic: Tobacco kills 100 times more Americans every year than have been killed in the Iraq war in the last 5 years. Yet, for some strange reason there is very little, or no media attention to the 400,000 avoidable annual casualties at home. Why is that? Any mortality or morbidity from Chantix should really be attributed to tobacco as well.

It’s time that the government banned all marketing and advertising of tobacco products. There’s no excuse for banning tobacco TV ads and permitting advertisements in magazines, billboards, direct mail and other venues. For those who argue that there is a First Amendment right to advertise tobacco, please remember that there is also a Sixth Commandment: Though Shalt Not Kill. In this case the Commandment wins over the Amendment.

The media should also help spread the word about tobacco. Oprah, as a public service, should have an anti-tobacco show at least once a month till the tobacco companies are embarrassed and humiliated into stopping ALL tobacco advertising in the USA and internationally. People who have side effects from Chantix or have tried to commit suicide from Chantix can also appear on Oprah to emphasize that this is a tobacco related problem. She should invite guests with tobacco-related heart disease, emphysema and lung cancer on the show who can tell their cigarette induced horror stories. MTV should have a similar program once a month. MySpace and FaceBook should have anti-tobacco ads on each of their millions of web pages so that they can get the message across to the next generation. Stopping all tobacco advertising in the USA will also single-handedly reduce the USA healthcare budget and Medicare expenditures more than any other cost saving program!
Robert Cykiert, M.D.
April 24, 2008

Tuesday, April 22, 2008

Who's right? The FDA or the AMA?

The AMA, in a commentary in its Journal of the American Medical Association,, announced that it is against the FDA's recent preliminary ruling that allows pharmaceutical companies to distribute peer-reviewed literature to doctors regarding off-label use of medications It’s odd that the AMA does not trust practicing physicians to evaluate peer-reviewed literature from respected medical journals in the process of discerning whether a pharmaceutical is effective in managing a disease state. After 4 years of college, doctors go to medical school for 4 years and then do 3-7 years of additional training as interns, residents and fellows to become competent physicians with good judgment. Does the AMA think that an article distributed by a pharmaceutical rep will sway a physician to prescribe a drug incorrectly, or for a condition that it was not intended for? Doctors have sufficient common sense, knowledge and experience to realize that one article from a journal does not make gospel, and we all know that for every article making a point there is another article that disputes the point. We also know that pharma reps are obviously biased to some degree, and we realize that before we use a medication off-label we need additional ample evidence in the form of other articles, lectures and communications with colleagues. Physicians don’t need blinders. The more communications we are exposed to, the more likely we will make the right treatment decisions for our patients. The FDA is right on this one.
Robert Cykiert, M.D.

Sunday, April 20, 2008

Vytorin and Cholesterol Conundrums

In recent months The New York Times,, and Wall Street Journal,, published many articles on the controversial Vytorin -ENHANCE clinical trials and the possibility that Vytorin and Zetia were not effective in reducing carotid artery (and coronary artery) plaque, even though they were effective in reducing serum cholesterol. If lowering cholesterol does not reduce coronary artery plaque, then there may be a fallacy in the entire theory that reduction of cholesterol leads to reduction of heart attacks. Or more likely, the ENHANCE study may have not been designed properly since the group of patients that Vytorin was tested on had a genetic, familial disorder that caused elevated cholesterol, and the patients were pre-treated for elevated cholesterol prior to ENHANCE. The genetic disorder may also account for variation in plaque distribution and growth in the surrogate carotid arteries that were studied in the ENHANCE trial. In view of that, correlating the results of the ENHANCE study to the average patient who has elevated cholesterol secondary to age, being overweight, having a poor diet and leading a sedentary life style, may not be valid. Our healthcare marketing research in the form an online physician survey of cardiologists
reveals that 68% of cardiologists believe that the group of patients that Vytorin was tested on was not reflective of the average patient who has non-familial elevated cholesterol (see questions #8). However, cardiologists have ambivalent feelings towards Vytorin since there was a 10% reduction in the number of cardiologists who would use Vytorin for themselves or family members after the ENHANCE study was released (see questions #12-13). In summary, it seems like the debate is dying down on whether the ENHANCE study was an accurate gauge of whether Vytorin works as it should or is advertised. It seems like all the parties involved (Schering-Plough/Merck, cardiologists who ran the study, American College of Cardiology expert panel, FDA, Wall Street analysts) were less than competent at times, had occasional conflicts of interest, and were sometimes influenced by their egos rather than facts. The real issue will probably boil down to whether Merck and Schering-Plough delayed release of data to hide something or whether the data was so poor that it could not be objectively evaluated to draw significant conclusions. I suspect the latter. Time will tell as the IMPROVE IT study,, due in 2012 will reveal whether Vytorin and Zetia reduce the incidence of heart attacks and strokes in the study population. Even then, the study population for these drugs will be questioned.
Robert Cykiert, M.D.

Electronic Medical Records - EMR

Now that Microsoft, Google and RevolutionHealth are all getting into the EMR business, many people are concerned about the safety and security of their health records online, and whether they should place their records online. EMR is inevitable. The question is who will control it. The technology required for safeguarding protected information is available, but has to be applied properly. If Google and Microsoft want to be the storehouses of EMR then they will have to deal with HIPAA just like doctors, hospitals, clinics, etc. Otherwise, all of Britney Spears’ records will be online for the whole world to see. Currently patients upload their records to HealthVault so Microsoft is technically exempt from HIPAA regulations since patients are not bound by HIPAA laws, only healthcare providers are. However, if Microsft’s and Google’s partners (Mayo Clinic, Johns Hopkins, Columbia Presbyterian) upload records to Microsoft’s servers then Microsoft will be required by federal law to sign HIPAA agreements with these medical institutions which are already HIPAA-regulated. The security and privacy systems can and will be instituted once these organizations upload medical records. And, they will be safe. When was the last time your bank account or credit card account was broken into on Citibank’s or American Express’s servers? By the way, current paper medical records have almost no security at all. Ask the cleaning and maintenance people who have access to them on a daily basis in hundreds of thousands of doctors’ offices all over the USA. Online EMR can certainly be more secure than that. ‘What Doctors Think’ performed healthcare market research in December 2007 on the subject of EMR. We performed an online physician survey of nearly 500 primary care physicians scattered across the USA to find out their views on EMR and HealthVault. The results can be found at sults
In question 20 we asked doctors which EMR vendor they would be most comfortable with. Microsoft won with 23%. The federal government came in with 13%, WebMD was third with 11%, and Google was fourth with 9%. However this survey was completed before Google’s announcement a few months ago. Personally, I believe that Medicare should create a Universal online EMR that should be used for every Medicare patient. Since virtually every senior citizen and physician in the USA is in Medicare’s billing/financial database, building an EMR on top of that would not be an insurmountable project. Ultimately a Medicare EMR that every physician and hospital had access to, and that patients would be required to join as part of receiving Medicare benefits, would save the government tens of billions of dollars over the years and would save the entire Medicare System from collapsing in the long run. The Medicare EMR could then serve as the template and basis for EMR systems used by non-Medicare patients as well, operated in conjunction with Medicaid, private insurers, HMOs etc. The current fragmented system with literally hundreds of different EMR companies selling systems to doctors and hospitals that don’t “talk” to each other is wasteful and will cost billions to overhaul in 5-10 years. All of the millions of dollars in federal and state government grants currently being dished out to test various EMR systems is also counterproductive. The only EMR that will work efficiently, benefit patients and save tens of billions of dollars is a universal, online system. Microsoft and Google are on the right track but haven’t figured out the details yet. Additionally, MSFT and GOOG are marketing to consumers instead of doctors. This is a backwards approach as well since doctors have access to thousands of records that they can upload to servers, whereas patients can only upload one at a time, and most patients don’t know what’s important to upload and what’s not. Perhaps MSFT and GOOG don’t want to deal with doctors because that forces them to deal with HIPAA laws. It’s unavoidable if they want to be players.
Robert Cykiert, M.D.

Who cares what doctors think?

Doctors directly influence more than a third of the entire USA health care economy. Consider these important facts:

  • 902,000: number of physicians in the USA in 2005
  • $2.1 trillion: USA healthcare expenditures in 2006
  • $274 billion: sales of physician-prescribed medications in 2006
  • $587 billion: cost of various patient services and devices ordered by physicians and healthcare providers in 2004

Doctors directly control nearly $1 trillion in USA healthcare expenditures, and act as the foundation of our health care system. Doctors influence millions of patients to spend billions of dollars. Doctors have huge personal purchasing power since many are also entrepreneurs with substantial incomes, and doctors typically require sophisticated equipment costing thousands to millions just to equip a single practice.

Doctors are also enormous connectors! Many teach in universities, all require continuous medical education, and typically work through hospitals where they interact with a variety of people and companies unequaled by any other profession.

Whether you are doing market research on medical devices, pharmaceuticals, medical education or on other healthcare issues, doctor survey results will help you make the right business decisions.

We help you reach out to the doctors who are your most important customers, and you can gain priceless information at an extremely low cost. When you conduct doctor surveys, you gain insights that reveal trends shaping the medical industry and your business. You may also get new customers, since cleverly designed surveys can also be used to influence physician thinking about your company, products and services.

Can you think of a more influential group in society? What doctors think really matters!