The Daily Meds

Pharma, Pharma Everywhere

Interesting package of stories today in the L.A. Times, about drug advertising and the myriad ways in which it creeps into the way we get care in the United States.

No matter what type of media we rely on, drug ads -- or ads for some sort wellness product -- proliferate. First, there's TV, the place we're perhaps most ensnared, as we loll lazily on the couch waiting for our favorite show to start back up. When I caught the evening news last night, for just one example, there were ads for Viagra (this commercial, which sort of made me stare slack-jawed and somewhat aghast at the screen), Restasis eye drops and Activia yogurt, which apparently, uh, "reduces long intestinal transit time" (via six tasty flavors, of course).

Print ads in magazines woo us, too, with promises that life with herpes could mean soothing walks on the beach, and reminders that even if you're powerful enough to run a company or fight fires, you're not immune to deadly blood clots.

The Internet isn't free of ads, either, since glitzy buttons and banners are always beckoning surfers to click on through to check out the magic of this medication or that one. And even back in the days before ubiquitous Wi-Fi coverage (which is to say, perhaps even before your grandmother hopped on the Information Superhighway), these ads were proving the most effective of the bunch: Pharmaceutical companies spent $14 online per customer that requested the advertised drug, $197 per customer through TV ads, and $220 via print ads, according to a 2000 poll from Cyber Dialogue.

But the part that most consumers don't see so clearly is the role that pharmaceutical companies play in pitching to the doctors who hold prescribing power. Some doctors have called for their peers to stop meeting with the drug reps who visit their offices to hand out free samples and info on new meds, or to stop taking drug samples from reps. Some docs even refuse to so much as scribble notes with the flashy pens emblazoned with drug and equipment brand names.

But drug companies are making a strong push to see that their services -- and hence, their products -- are viewed as indispensable. And the efforts are carefully planned and executed, according to one of the sidebars in the Times package:

Pharmaceuticals' marketing departments look to hire "young, attractive people, quite charismatic" -- and scientific training is completely optional, says Ahari, now a researcher at the UC San Francisco's School of Pharmacy, who describes his former profession on a website (www.Pharmedout.org) devoted to exposing drug company marketing practices.

"They're looking for gender icons -- cheerleaders and ex-military types -- fun to be with, someone with whom you'd like to have a beer or watch a game," Ahari says. To establish friendship and assure access to a physician, a detailer "will scour a doctor's office for objects -- a tennis racquet, Russian novels, '70s rock music," wrote Ahari and Adriane Fugh-Berman, a Georgetown University physician, in an article published by the Public Library of Medicine in April.

Next time you go to the doctor, ask them to tell you about their practices when it comes to samples and meet-and-greets with drug reps. Did they have a brown bag turkey sandwich from home for lunch, or a catered lunch courtesy a pharmaceutical company? Is the exam room filled with notepads, posters and anatomical models stamped with brand names?

I've heard compelling arguments on both sides of this issue -- on one hand, samples often provide an endless stream of free drugs to patients who otherwise can't afford them. But some doctors say that even taking seemingly meaningless desk toy "gifts" from big pharma colors their judgment when it comes to choosing which drug to prescribe.

So tell me, how do these pitches impact you as a patient? Are you swayed by drug ads? And how do you feel about a doctor who has taken gifts before prescribing a drug or handing out samples of it? I'd like to hear from health care professionals, too, about your own feelings on sampling and pharmaceutical gifts. Where do you draw the line?

Obesity is Catching

Your friends and family are making you fat.

That's the news from a new Harvard study which will come out tomorrow in the New England Journal of Medicine. From the Washington Post, in explaining how "social networks" seem to play a role in weight gain:

The researchers found that when one spouse became obese, the other was 37 percent more likely to do so in the next two to four years, compared to other couples. If a man became obese, his brother's risk rose by 40 percent.

The risk rose even more sharply among friends -- between 57 and 171 percent, depending on whether they considered each other mutual friends. Moreover, friends affected friends' risk even when they lived far apart, and the influence cascaded through three degrees of separation before petering out, the researchers found.

Everyone's heard the adage about how getting married makes you gain weight, but this business about the role friends play in one another's weight gain is more interesting -- but not all that surprising, when you really think about it.

I certainly understand it for women -- afterall, who hasn't called up their best gal pal after a bad day, only to hear her say, "It's OK -- have some ice cream! You'll feel better!", or conned a dieting friend into breaking her willpower to split a pizza -- but I'm curious about how all that pans out among guys. Is it eating in business situations, where everyone's gathered around a buffet trough at an office meeting? Sports food, like heaps of nachos and popcorn at the stadium?

I've noticed a few different food-related social themes in my own professional and social life.

First, there's food as bonding, like the nights my co-workers and I spent gorging on a table full of food late each night at my college newspaper. It was awful stuff -- giant hunks of cheese with buttery Ritz crackers, Little Debbie snacks like Zebra Cakes, chocolate chip cookies, and maybe the occasional pack of baby carrots thrown in for piety's sake. And we ate it way past the witching hour when our bodies might have known what to do with that amount of gluttony. We ate this crap not so much because we were hungry at midnight, but because it was just, well, what you did. It was a ritual.

Then there's food (and calorie-laden cocktails) as a getting-to-know-you device. Afterall, what's the thing you do when you're making new friends and want to "audition" them? Head out for a bite to eat or a few drinks. And I can't say I've ever seen anyone order a salad in those situations. I've even been on job interview lunches where stuffing my face seemed to be part of the test!

My personal favorite: Food as celebration. Because my husband often travels for work, we tend to treat the the time he gets to spend at home like an ongoing reason to celebrate. So we go to fancy brunches and unabashedly rich dinner spots, and we each get appetzers, entrees and dessert. Clearly, no good can come of this!

There's also the comfort calories, gobbled up when you're wallowing in some sort of self-piteous sea. You're planted in front of the TV with a girlfriend or two, watching "Sixteen Candles" for the 1,219th time, passing a bowl of popcorn or a three-quarters-empty pie plate back and forth, and it just feels so... right. Because you can always get back on the healthy-eating wagon tomorrow, right?

Wrong, according to the study, whose authors found evidence that obesity is "a kind of social contagion." I'm heading to Chicago tomorrow for a conference, and I know there will be ample opportunities for food-related bonding while I'm there. I can't promise I'll back completely away from all the tasty vittles, but I'll be watching closely to see this news in action!

Kiddie Olympians

For nearly 12 years, I smelled like chlorine almost constantly. The pool chemicals turned my hair into a split-ended tangle of straw, my arms felt like noodles from pulling my way through endless yardage, and I spent far too many hours shivering in a wet bathing suit.

But under the water, I felt freer than anyplace I'd ever known.

I was a competitive swimmer, and all the years I spent doing it were, I think, among the most important things I've ever done. I wasn't a superstar, but I was good enough to win races every now and again, and since I swam distance events, I felt secretly much stronger and braver than the 95 percent of the human race who can barely  paddle from one end of a pool to the other without tip-toeing on the bottom. I learned how to compete graciously,  how to stand up to disappointment, and in the later years, as a varsity team captain, how to lead and inspire others.

Those are life skills I use everyday as an adult, and although I never dabbled seriously in any other sports as a kid or a teenager, I have no doubt that other types of athletics offer the same lessons. But youth athletics is a different ballgame than it was in the late 1980s and early 1990s when I was coming up, and I've got to wonder if the crazed intensity is much of a good thing. This article in the New York Times details one new trend among young athletes:

Because many team coaches don’t have the time or the expertise in exercise science to make their troops faster and stronger, specialty programs — part gym, part pro-training camp — have stepped in to fill the need. For roughly $35 a session, they provide rigorous conditioning for any aspiring child, regardless of ability, using the kinds of practices that have set apart athletes like Tiger Woods and the Williams sisters.

The story raises the all-important issue of burnout. Some kids, assuredly, can hack it for the long haul, but for many, killing themselves with endless hours of practice as kids may lead to total distaste for the sport come the end of high school -- to say nothing of the physical risks associated with such intense training during childhood.

I remember standing in a hallway outside the YMCA locker room when I was about 10 before swim practice one night. A klatsch of parents were hanging around oohing and ahhing over each of their budding Olympians' exploits in the pool. One of them fervently remarked, "Well, we pray every night for Atlanta in '96," as if ear plugs and latex swim caps were the idols to worship in their home. All the other parents murmured their agreement. It all seemed kind of ... strange. (Said youngster, it must be noted, did not go to the Olympics, and despite his apparent prowess as a teen, I'm not sure had any aquatic success after high school at all.)

For me, swimming was more about participating, about belonging to something, than it was about winning. I'm sure that sounds hopelessly earnest and Mr. Rogers-ie, and maybe I'll feel differently someday when I'm hauling a child around in an SUV stuffed with giant bags of ice hockey equipment or something.

Tell me, though, how you feel about kids and competition. How do you set rules about how often your kids can practice? Any things you've observed among other parents or coaches that bother you? What might you have learned from your own experiences as a young athlete?

The Mini-Clinic Solution?

I caught an interesting "By the Numbers" box in the new issue of Proto (this month's issue isn't online yet), the house-organ mag for Mass General Hospital in Boston, one of the teaching hospitals for Harvard. It's a Time, Inc. product, so it's not your usual flabby, self-promotional marketing machine. Rather, each issue is crammed full of really neat stories.

The new issue contains, among other things, a story called "Are We Running Out of Doctors?" about the shortage of primary care physicians and other medical specialists in some parts of the United States. On one end of the spectrum is Washington D.C., which has plenty of docs -- 874 per 100,000 people, or one for roughly ever 114 people. On the other lies a place like Oklahoma, which has only 196 doctors per 100,000 people. That's one doctor for about every 510 people. Since my husband lived in Oklahoma for a few years, I'll vouch -- it's a flat, seemingly endless state in which there's lots and lots of places so sparsely populated I definitely wouldn't want to get sick there.

The reasons for these disparities are myriad, and anyone with degrees in economics, higher education or health-care administration is free to weigh in here on how to crack the problem, or talk about some of the reasons why this is happening.

But the issue ties in nicely, to my mind, with the aforementioned "By the Numbers" box, which is about retail, or "mini" clinics that are increasingly being set up in locations like Wal-Mart, Target, and chain pharmacies. I wrote a piece about these clinics last year when this trend came to the Lowcountry for the first time. The clinics are usually run by nurse practitioners, with doctors available by phone for supervision or help. They're aimed at taking care of low-tech illnesses like strep throat or ear infections, or giving sports physicals or vaccinations.

According to Proto, 400 of these clinics have cropped up around the country in recent years, with another 700 slated to open by 2008 via MinuteClinic. Although the clinics are often run by non-affiliated outfits, there's clearly some cha-ching in it for the stores that house them, since as Proto notes, 90 percent of clinic visitors came for care at Target also wound up shopping. We can only presume that as soon as they were done saying "aaahhh," they realized they were out of garbage bags, needed to try out a new hair gel and had some vital kitschy picture-framing needs to attend to.

The doctors who've historically paid the bills by seeing many of those same patients have mixed feelings about these clinics, some of which take insurance, but otherwise average between $40 to $70 per visit. Here was what  Dr. Bill Hueston, chairman of the family medicine department at the Medical University of South Carolina and is the immediate past president of the South Carolina Academy of Family Physicians, told me last summer:

"If it helps the patient, then it's good. If it provides a service that we're not providing, then it's good."

But he also noted that there's some dangers associated with seeking care at miniclinics, especially if you have a chronic condition like diabetes, or take multiple medications. Thing is, there's no paper trail that shows the miniclinic staffers to your complex health history. And that could have some nasty consequences, at least until medicine adopts some sort of national electronic records database that retrieves your history with a mere swipe of, say, your fingertip (like at the Piggly-Wiggly!).

"Whenever we fragment care, by splitting it up and giving different parts of it in different places, we exponentially increase risk of making a mistake," Hueston said.

But studies show that people wait an average of five minutes less to get help at a retail clinic, and perhaps most enticingly, they'll see you on a walk-in basis. And that's a big draw. I rarely see my "regular" GP, because it seems every time I call because I'm sick thatveryday, there aren't any appointments available. Kind of weird, since they're meant to be taking care of sick people, right? But I know offices are clogged up with patients who've scheduled check-ups for conditions like diabetes, or arthritis, or any number of other ailments that rightly deserve care.

And so since I moved to South Carolina, I've made myself right at home with many a visit to Doctor's Care. I used to scoff at the idea of "doc in the box" facilities, but seriously, when you're a generally healthy person and you know what's wrong with you -- a sinus infection, say -- it can be a whole lot quicker and easier to head there than wrangling for an appointment at your doctor's office.

I've never gone to an actual retail clinic, but I wouldn't rule it out. I'd like to hear from anyone whose had experiences with these places. Why do you choose them, and what sort of experience have you had with them? Are you worried about the fragmented care issue?

Jump, Jive and Wail (The Tao of the Restless Legs)

Have you ever had something wrong with you that, when you explained it to people, made them look at you a little funny? Like, is she a total hypochondriac, or what?

I'm a generally healthy person -- never had any major ailments, and have managed to stay out of the hospital except for having my tonsils and adenoids clipped out at age seven and one harrowing ER visit when I broke my tail bone at 20 (a hideous, miserable pain that makes me wince mere to recall it).

But in 2005, I became stricken with an ailment that fits into a weird category of medicine -- you're not sick, exactly, and for that you are thankful, but things are nonetheless Not Good. It was restless legs syndrome, and it kept me awake at night, every night -- busy rearranging my legs hither and yon in the bed, propping them up on pillows and generally searching totally in vain for the one position that would just let me snooze.

But it felt like there were bugs crawling underneath my skin, and the sensation only went away when I moved my legs around. It was evil. And people thought it was weird, and probably silently wondered if I was hooked on hallucinogens. Other people I told about it nodded vigorously and shared their own tales of leg terror in the night.

My mom had suffered this same thing off and on for years, as had my grandmother. Two new studies, out this week, find that lo, RLS is genetic. Plenty of questions remain, though, about how to treat it and who actually meets the diagnostic criteria ... of which there really isn't one.

In the name of good journalism -- and a good night's sleep -- I wound up joining a restless legs syndrome treatment study at the Coastal Carolina Research Center in the fall of 2005. For several months, I took a study medication each night (it was either a time-release version of Requip, a Parkinson's disease drug that appeared to help RLS sufferers, too, or a placebo -- I still don't know which), fastidiously recorded my symptoms in a three-ring binder, and came for regular office visits to be monitored with blood work and physicals.

My symptoms ebbed and flowed over the course of the study, which I wrote a three-part series about for the P&C. My goal was larger than just getting a good night's sleep -- I also wanted to tell people about what it's like to be part of a medical research study, which are essential to testing any drugs or treatments before they can gain FDA approval or become widely used.

During the study, I obsessed constantly, about whether I was taking the real drug or a fake, and endlessly analyzed what other life factors -- stress, my husband being out of town, feeling overtired, etc. -- might be causing my jumpy legs. Although I was a model of patient compliance, I probably wasn't the ideal study participant, since I couldn't seem to let go of the mystery about which drug I was taking. And that obsession probably didn't help settle my legs down any.

When ads for Restoril started popping up all over TV and magazines later that year, I felt oddly vindicated. It was like, My pain is real! Except, by that time, my RLS had mysteriously disappeared, for which I was endlessly thankful. It pops out every now and again still today, but it's by no means the all-consuming trial it felt like a few years ago.

I went to a conference for health care journalists last spring at Dartmouth, and a trio of energetic doctors from the college's medical school (one of whom wrote this very cool book, which I recommend that everybody with, well, a body, should read) gave a talk about disease mongering, and the media's role in making people nutty and paranoid about diseases they probably don't actually have. Their case study? RLS. They make a compelling case that while it's likely a real disorder, it's probably over-diagnosed, scribbled on the chart of anyone who complains about having trouble sleeping and begs for a prescription for the meds they saw on TV.

When I wrote my RLS study series, though, I got an avalanche of email from people sharing their own stories with the disorder, or at least some convincing facsimile of it. Are any such folks out there now? What have you been doing to slay your own itchy-scratchy-bug-crawling legs?

Organic Living

I must interrupt this unacceptably long blogging hiatus -- been busy with the dead-tree product and all, but henceforth back on the wagon with the 21st century -- to discuss the issue of organics. Organic foods, that is. Specifically, the ones that are currently in some troubles for being, well, tainted or otherwise dangerous.

Veggie Booty is a strange, puffy snack food made from organic corn and coated with a vaguely vegetable-like flavoring. It's apparently a popular snack for kids, thus making the fact that it's now been linked to more than 61 cases of salmonella and recalled an especially sad thing. I've tasted it exactly once, back in 2000 when I was among taste-testers of it at Prevention magazine, where I was interning at the time. It is not, I will tell you, terribly yummy. In fact, it resembles and tastes like styrofoam packaging peanuts more than an actual foodstuff, but judging from the carts heaped with it that I've seen people pushing in Whole Foods, this stuff has quite a following.

The other item recently implicated for being dangerous to kids lately is a couple of Gerber organic baby cereals, which were discovered to contain non-dissolving clumps of cereal that may pose a choking hazard. I can't say I've ever tried this particular food item, but something tells me it's nothing parents are dying to snag tastes of themselves.

Anyway, this seems like an especially cruel group of foods to turn up with problems. Parents are buying these items for their kids because they've specifically decided -- either through research or a general sense of wanting to hedge their bets on keeping chemicals out of their kids' diets -- that organic food items are healthier than conventional choices. It also goes without saying that these foodstuffs are pricier than regular ones. But now, ironically, they're actually causing kids harm, according to Newsweek:

In April, Sydney Scheels, who turns 2 on July 28, spiked a fever of 105.3 degrees. She was stricken with diarrhea which, within five days, had become "thick, red blood," says her mom, Elex Scheels of Voorheesville, N.Y. "Her diaper rash was so terrible, she had blisters and her skin was bleeding." The family doctor soon called with the lab's diagnosis: salmonella.

I must admit I haven't really jumped on the organic train yet. Even when I see Web sites like this one, that call to me with soothing promises of how my life will somehow be better, cleaner if I just go natural. And I know all about the "dirty dozen" fruits and vegetables that are said to be the most pesticide-laden. But yet there's a container of regular -- ostensibly poisonous, if I'm to believe those claims -- strawberries sitting in my fridge as we speak.

Part of my hesitation is that organics are harder to come by, and as noted above, they aren't cheap. The other reason is that I haven't yet seen any quantifiable, noticeable health problems as a result of lifelong eating of the "dirty" picks. That's not to say I'm not suffering some sort of pesticide-spurred cellular damage rightthisverysecond, but I guess it's like wearing sunscreen ... you don't learn your lesson until you get a hideous burn, or learn you've got some type of skin cancer.

But I'd like to hear about how you make your own choices about whether to eat organic foods or non-organics. Are there any "rules" you live by when buying? What -- if any -- are your worries about eating conventional foods?

Getting Out of the Hospital

Returning home after a hospital stay should be a joyful occasion, especially if you've been critically ill. But it can also be confusing and overwhelming, especially for family caregivers. Patients routinely leave with a passel of instructions on how to take their new medications, what to eat and which doctors they'll need to see for follow-up care. They may also face a twisty schedule of physical therapy or rehabilitation for everything from car accident injuries to heart surgery. And there's probably also bills to pay, insurance rulings to untangle and new programs to sign up for.

Orchestrating all that isn't easy.

The New York Times has a great story about the role discharge planners -- sometimes social workers, sometimes nurses -- play in helping patients put together all those pieces. Hospitals, afterall, have a lot at stake when it comes to patients getting appropriate aftercare, since poor practices after hospitalization often lead to return visits, sometimes with grimmer outcomes.

But not every hospital does due diligence in taking care of business when it's time for patients to start their new life at home. The U.S. Department of Health and Human Services tracks various health-care quality indicators (ranging from how well hospitals do at administering aspirin and beta blockers, which boost survival odds, to incoming heart-attack patients to how they fare at treating people with pneumonia). This database is easy to use, and for patients with the luxury of planning their hospitalizations (which is to say, before they get sick), it can be a helpful tool for making smart decisions about where to seek care.

The statistics can also be helpful to find out how your hospital caregivers may be coming up short when preparing you to go home -- and what questions you might ask to get the right information. Here's a sample of discharge-related findings I've pulled out about Lowcountry hospitals*:

When it comes to how area hospitals do at providing discharge instructions to heart failure patients -- a disease for which instructions are considered vital -- all but one hospital exceeded the national average, which finds that 66 percent of patients get such guidance. Tops in this area among area facilities is Mt. Pleasant's East Cooper Regional Medical Center, where 88 percent get discharge instructions. At the Medical University of South Carolina, 86 percent get them. At Bon Secours St. Francis Hospital, 81 percent of heart failure patients get them, and at Roper Hospital, 75 percent of patients do. But Trident Medical Center staffers give instructions to only 38 percent of patients, according to the survey, which is based on data provided from discharges between October 2005 through September 2006.

All local hospitals (except East Cooper  and St. Francis, which both reported too few cases to be statistically significant for the survey) exceed the national average of 90 percent for the number of heart attack patients given beta blockers -- which relieve stress on the heart by and help keep blood vessels from constricting in the heart, brain, and body -- at discharge. But there's still room for improvement on this recommendation: At MUSC, for instance, 99 percent of patients get the drug, while 92 percent of Trident patients get it. At Roper 95 patients get the drug.

Nationally, 85 percent of heart failure patients are counseled about smoking cessation. All Charleston-area hospitals outperformed that statistic, but to be considered a "top hospital," federal guidelines call for a 100 percent counseling rate.

*Summerville Medical Center, which is part of Trident Health System, is not included in the survey.

Feel free to share any of your own experiences coming home -- or caring for someone else -- after a hospitalization. Anything you learned (or mistakes you made?) that could help keep other folks on track at this critical time?

Death on a Sandwich

This morning on the way to work, I spied a sign outside a restaurant that just about made me veer off the road. "Have you ever had a BLT with TEN slices of bacon?" it asked hungry passers-by, all in capital letters.

Well, no, I haven't, because I value having a heart and circulatory system that has the strength to pump blood through my body efficiently! Since this is an establishment that primarily serves ice cream, I can't say I was surprised, but seriously ... ten slices? That's nearly a whole package!

This sort of thing is what fuels South Carolina's bevvy of depressing health statistics, like the fact that more than a quarter of the population has high blood pressure, and 33 percent has high cholesterol. And 9.3 percent of the population reports having diabetes, compared to the national average of 7.1 percent. What does all this add up to? Bad stuff, and some national rankings that sure aren't something to splash around in tourism literature:

According to the 2001 CDC mortality data, South Carolina had the 23rd highest heart disease death rate in the nation and the 2nd highest stroke disease death rate. Due to these rankings and the geographic proximity of other states with high numbers of stroke deaths, South Carolina, North Carolina, and Georgia are known as the “stroke belt.” High stroke death rates in the Pee Dee and Coastal regions of South Carolina have earned this area the dubious distinction of being the “stroke buckle” of the “stroke belt.”   

Moral? Back away from the bacon!

If you're a BLT lover, though, there IS a way to pack some extra flavor onto this summertime favorite, and give your heart-health a boost in the process. Try this recipe, with some omega-3 riches from an avocado spread and turkey bacon, from the new issue of SELF Dishes (on newsstands now). My husband and I road-tested it last week, and rated it as a new fave.

Got any other healthier BLT tricks you'd care to share?

Pampering Makes Perfection?

I will be spending a good chunk of today meditating, twisting myself into a series of soothing stretches, getting massaged and having various skin-beautifying gunks smeared on my face. Those who about my little obsession will not be surprised to hear that this all sounds quite delightful to me.

And guess what? It's for work. I know! Crazy! After years spending my days steeped in grim material that I likely wouldn't typically volunteer to experience firsthand, this is pretty exciting. And so, I will go forth to this event (taking place here, with this guru, about this book) in hopes of coming out the other side relaxed and inspired enough to pen a column cracking the code on why 27 year olds (like, um, this one) are now compelled to worry if they already need to get their faces shot up with Botox. As if there isn't enough legitimately important things to worry about in our (relatively) young lives!

Stay tuned!

It Wasn't Supposed to be a Working Vacation...

... but when you're a health reporter, a brush with death at the hands of Thai food while traveling abroad sure makes for good copy. Check out the full story of my bout with food poisoning, plus some tips on how you can sick-proof your own summer travels.

Now, I hope not to think or talk about this incident again for a good long while ... because it makes me a little bit green just rereading what happened. May your own voyages be healthy and safe!