Tour de Tobacco

Lance Armstrong, seven-time winner of the Tour de France is on a warpath against cancer with his 5^th Livestrong Day, http://blogs.wsj.com/health/?s=armstrong&x=0&y=0. 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, http://online.wsj.com/article/SB121063754261486825.html?mod=WSJBlog, 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, http://consensus.nih.gov/2006/TobaccoStatementFinal090506.pdf , (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, http://www.ftc.gov/opa/2007/04/cigaretterpt.shtm, 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, http://www.cancer.gov/cancertopics/factsheet/NCI/research-funding, “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 http://www.opensecrets.org/industries/contrib.php?ind=A02&cycle=2008 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.

WhatDoctorsThink.com

May 16, 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.
WhatDoctorsThink.com
DoctorNet.com

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 whatdoctorsthink.com.


An analysis of the shift from detailing to eDetailing can be found doctornet.com/e-detailingarticle1.html.

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

Robert Cykiert, M.D.
President,
WhatDoctorsThink.com
DoctorNet.com
Robert Cykiert, M.D.

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
http://www.cancer.org/docroot/PRO/content/PRO_1_1_Cancer_Statistics_2008_Presentation.asp">www.cancer.org/docroot/PRO/content/PRO_1_1_Cancer_Statistics_2008_Presentation.asp 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 http://www.cancer.org/docroot/PED/content/PED_10_2X_Cigarette_Smoking.asp?sitearea=PED.


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″ http://www.reuters.com/article/bondsNews/idUSN2539408120080325. 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.
WhatDoctorsThink.com
Comment by Robert Cykiert, M.D.

No pharm pizza for doctors

The Association of American Medical Colleges http://www.aamc.org/research/coi/industryfunding.pdf 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: http://www.npr.org/templates/story/story.php?storyId=4696316

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 http://www.mmm-online.com/Pharma-pursued-safe-haven-for-its-CME-spend-last-year/article/24565/ "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 http://jama.ama-assn.org/cgi/content/full/298/15/1779 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 http://whatdoctorsthink.com/cgibin/comments.cgi?markettodoctors-results

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.
President,
WhatDoctorsThink.com
DoctorNet.com

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 http://ascrs.org/press_releases/World-Study-Shows-95-Percent-LASIK-Satisfaction-Rate.cfm
That’s why NASA has aproved LASIK for astronauts http://www.prnewswire.com/mnr/intralase/29864/docs/29864-AMO_NASA_Infograph_FINAL.pdf 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 http://www.cbsnews.com/sections/i_video/main500251.shtml?id=4040188n

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.
President,
WhatDoctorsThink.com
DoctorNet.com
LasikGo.com
April 26, 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: http://www.chantix.com/content/Chantix_Branded_Homepage.jsp?setShowOn=../content/Chantix_Branded_Homepage.jsp&setShowHighlightOn=../content/Chantix_Branded_Homepage.jsp.

However, in Novemeber 2007 the FDA warned that some people who take Chantix become agitated, depressed and even suicidal: http://www.fda.gov/bbs/topics/NEWS/2008/NEW01788.html.

The Associated Press has publicized this by reporting on a patient with severe depression from Chantix on April 23, 2008: http://ap.google.com/article/ALeqM5iitxY52gN51-uGrhdxaz3PkPEodQD907NDK81

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: http://www.cdc.gov/tobacco/data_statistics/factsheets/cig_smoking_mort.htm
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.
WhatDoctorsThink.com
April 24, 2008