How About Taking Responsibility For the Medications You Take

Ruth Marcus seems oblivious to the fact that sedating medications, including Ambien, are frequently abused.

[Kerry] Kennedy may have taken the pill by mistake, they contended, but she ought to have known she was impaired and pulled over.

Excuse me, but maybe they should have tried taking this drug before filing criminal charges. Ambien and other sleeping pills are powerful. You take Ambien, and 15 to 30 minutes later, you begin to zonk out. A toxicologist who testified at Kennedy’s trial — for the prosecution, no less — said that someone under the influence of Ambien could fail to recognize that she was having a problem, or even to remember, later, what happened.

I think we can infer from Marcus's statement that she has taken Ambien, and thus knows how sedating it is. What Marcus probably has not seen is what happens when somebody takes Ambien and deliberately stays awake. The superficial affect is one of significant alcohol intoxication. Why do some people do that? Just as with abuse of common benzodiazepines, ecause they like the way it makes them feel, and some of them use other drugs or alcohol at the same time so that they can enjoy a magnifying effect.

Ambien may be something of an extreme case, given how quickly the sleepiness can come on, but how far would Marcus extend her "Let's assume it was an accident" rationale to other sleep aids? She draws a distinction between "medications with drowsiness as a side effect, [and] the ones whose sole purpose is sedation", but why? Many people take Benadryl to sleep, and sometimes pharmacists recommend it as a non-prescription sleep aid. Many people take opiate and opioid medications for pain, but they can be highly sedating and are commonly abused.

Marcus seems to feel that nobody who drives down a road after taking Ambien should ever face a criminal charge for driving while impaired by drugs, even if they injure or kill somebody. I have no problem working from the perspective that if you are too drugged to drive you shouldn't get behind the wheel, even if you took the wrong medication by accident. When somebody is intoxicated behind the wheel, I don't mind putting the impetus on that person to convince me both that it was a mistake and that they had no reasonable opportunity to recognize the mistake so as to get off the road. Kerry Kennedy was able to convince a jury that she took Ambien by accident, and didn't recognize its effect in time to safely stop her car. Marcus thinks that's too high a price for Kennedy and other Ambien users to pay, but it's not as if either of them are unaware of the dangers of that drug. They are both certainly aware of this case:

U.S. Rep. Patrick Kennedy said Friday that he will enter a rehabilitation program after crashing his car on Capitol Hill a day earlier....

He said in a statement Thursday evening that he was apparently disoriented at the time of the crash after taking the prescribed amounts of a sleep aid and an anti-nausea drug.

"I am deeply concerned about my reaction to the medication and my lack of knowledge of the accident that evening. But I do know enough to know that I need to seek expert help," he said Friday....

In his Thursday evening statement, Kennedy said he had returned home after final votes in the House of Representatives around midnight Wednesday and taken the sleep aid Ambien and an anti-nausea drug....

In his comments Friday, Kennedy said, "The recurrence of an addiction problem can be triggered by things that happen in every day life, such as taking a common treatment for a stomach flu.

Assuming she takes Ambien, Marcus, I expect, is very careful with Ambien due to the stories she recounts, including one that put one of her own children in danger. How many stories do we need, and how close to home do they have to hit, before we can reasonably expect people to look at their pills and read their pill bottles before swallowing a sleeping pill then getting behind the wheel of a car?

I won't argue with Marcus that manufacturers could create pill colors and shapes, or package sleep aids in a different manner, and thereby all-but-eliminate the "I was confused" defense. Perhaps at that point Marcus would accept that people intoxicated by Ambien should be subject to prosecution for driving in that condition. But for now, if people have multiple, similar-looking medications, they owe it to themselves and others not to confuse their pills. If people who have serious health conditions requiring them to juggle dozens of medications can keep their pills straight, I think it's reasonable to ask that people with minor medical conditions and two or three prescriptions to do the same, more so when incidents of carelessness will pose serious risk to themselves and others.

Obesity as a Disease

In the Washington Post, Esther J. Cepeda asks what to me seems to be an odd question about obesity:

Is obesity truly a disease that requires medical treatment and prevention, as the American Medical Association recently proclaimed? Or is it still more accurately a “condition” with too many variables and factors to shoehorn into a neat category?

Perhaps by "condition" Cepeda means "symptom"? Which would potentially put obesity in the same category as pneumonia - the cause may be a bacterial or viral infection, but you can start treating the pneumonia before you know the exact cause? Or is it because obesity has a behavioral health element, and the comment represents resistance to treating conditions with a significant psychological element as diseases? The author opines that it does not matter, "if a label with more gravitas is what it’ll take for obesity to be taken seriously, then let’s go with it", but at heart it does matter because if the public perception remains "Obesity results from a lack of willpower - if you have the strength to push away from the table it's nobody's fault but your own", the label the medical community uses has little relevance save perhaps as to determining whether and when treatment should be covered by insurance.

The author makes some good points about nutrition - most doctors know little about it, and too few doctors given any appreciable amount of counseling or information to their patients about weight.

In 1998, the National Institutes of Health recommended that health care professionals advise obese patients to lose weight. In 2011, research published in the Archives of Internal Medicine found that of participants in government health surveys, one-third of obese patients and 55 percent of overweight patients said a doctor had never told them they were overweight.

I know of doctors who believe that they fulfill the first duty by telling patients, "You should lose weight," which usually has all of the impact and relevance as, "You should stop smoking," or "You should exercise more." Making the statement isn't enough. As for the rest, yes, there are significant numbers of people in our society who are in deep denial about how they appear to other people, but I don't believe for a moment that the typical obese person is not aware that he or she carries more than a few extra pounds. For a typical obese person, being told "You're overweight" would be roughly as insightful as telling them, "Hey - you still have a pulse."

Something else to recall is that a big part of how we, as a society, perceive "overweight" has to do with societal standards of beauty, not whether or not a person has achieved a healthy weight. A copy of the Enquirer I saw yesterday at the supermarket checkout stand had a typical tabloid cover about which celebrities - as is usually the case, all women - had gained weight, and which had lost weight to the point of being skeletal, never mind that the celebrities that are "too skinny" may be starving themselves down to the size that allows them to obtain employment. Margaret Cho's account of how she was pressured to lose (too much) weight for her TV show is a couple of decades old, but remains illustrative.

Meanwhile, if you're inclined to pretend that "You should lose weight" is an easy answer, take a look at people you know - overweight, normal, skinny - and contemplate how many of them, in the absence of an illness or surgical procedure, experience or sustain a significant change in their weight. You may know somebody who lost weight and slowly (or quickly) gained it back, you may know somebody who put on weight during (for example) a pregnancy and didn't lose the weight afterward, you may see weight change associated with a physiological change (e.g., menopause), but most people remain relatively constant. From that short list, of those who lost weight and sustained that loss, take a look at how many of them gained the weight during adulthood (e.g., after a pregnancy) and were returning to baseline as opposed to having been overweight throughout their entire lives. Now contemplate the billions of dollars spent each year on diet plans, diet pills, diet supplements, and the like and ask yourself, "If that many people know that they are overweight and want to lose weight, why isn't it happening?"

It's easy enough to ridicule the diet industry as pitching easy answers. What the typical diet book or plan is really pitching, I think, is the notion that you can lose weight without being uncomfortable. The tried and true formula for losing weight is "eat less and exercise more", but people don't really want to hear that. It's not easy to do, and its not easy to sustain. Nebulous comments about "changing your lifestyle"... to include eating less and exercising more... are similarly unhelpful. I am of the opinion that the advice should be tailored to the patient, and should be concrete and case specific. Also, "eat less and exercise more" is not particularly useful advice to somebody whose level of activity will make it difficult for them to lose weight even if they're on an extremely low-calorie diet, or if their weight or other health conditions prevent them from engaging in significant physical activity.

The author suggests that part of the problem lies in "self-esteem",

Perhaps even worse: neither the medical community nor the patient population has figured out sensible, neutral ways to even approach the topic of obesity in the context of the doctor-patient relationship. Part of this can be blamed on Americans’ need to put self-esteem ahead of health, and some also rests on physicians’ bias and poor people skills.

A national survey published in a fall 2011 edition of the journal Pediatrics found that parents feel blamed and respond badly to words such as “fat,” “obese” and “extremely obese.” Parents said they’d feel more motivated if a doctor said their child had an “unhealthy weight,” a “weight problem,” or a “high BMI” (Body Mass Index).

And... we're back to the notion that most overweight people don't know that they're overweight, and that parents of overweight children don't understand that their children are overweight. Again, there are some people who live in a state of denial, but most people - adults and children - are acutely aware of their weight problems. If they're not, society is full of people who will happily draw it to their attention. If patients are more likely to respond when doctors approach the issue with a degree of sensitivity, odds are that's because of their history of acute awareness of their weight and involves the predictable human response to negative judgment on something they're ashamed of or that already caused them to experience a history of judgmental, perhaps abusive comments.

I hope that labeling obesity as a disease helps encourage a response to obesity that is focused less on surgical intervention and more on behavioral health, exercise and nutrition. I do know somebody who, after struggling with eating disorders, has stabilized for a couple of years at a healthy weight - but only after intensive psychological and nutritional counseling. To get that type of treatment you pretty much need to be starving yourself to the point that you need to be hospitalized - even if, prior to that particular manifestation of your psychological condition, you were previously "clinically obese".

Part of me thinks the entire focus is incorrect. The concept of BMI is predicated upon a somewhat average individual, and it becomes a useless measure when applied to bodybuilders. Why do we draw from that the notion that bodybuilders are the exception. We know that we can make poeple of any weight healthier by helping them engage in additional physical activity. I would not argue that we should refrain from offering nutritional advice, but during the broad range in which weight is primarily a cosmetic issue as opposed to an imminent health issue I think we should focus on trying to find people develop types and levels of physical activity that fit with their lifestyles, and which can help them avoid additional weight gain while improving their physical health and muscle tone - providing appropriate education about how the initial effect of exercise can be to increase appetite, and also to modestly increase weight as the person starts to add muscle mass. Put the focus on health, not weight.

The Return on Investment for Law, Business, and Medical School

My last post resulted from a search in which I was looking for general information about the cost of law, business and medical school, in response to what I found to be a dubious assertion from the AEI.

But it may surprise some readers to learn that the sizable rates of return for doctors appear to be less than for other professional degrees such as in business or law. Dentists and physician specialists have comparable rates of return, but primary care doctors have lower—albeit still impressive—rates of return. This is consistent with the general impression that primary care doctors are “underpaid” relative to specialists. Not surprisingly, there is a shortage of primary care doctors.

Frankly, given that the authors wrote a book on this subject, you would think that they would offer a bit more certitude than "appear to be" - the reason that readers would be surprised by the authors' assertion is that the authors "appear to be" wrong.

Upon re-examining the assertion and accompanying graph, and noting the lack of reference to sources or data beyond reference to the authors' recently published book, there didn't seen to be much of a point in tracking down the data. The authors reference "Hours-adjusted annualized internal rate of return on educational investment over a working lifetime", which I infer to mean that they divided cost of training by hours of training... although with medical school that raises the question of whether you should (or whether they did) include residency training along with medical school itself. The authors also speak of the rise in CEO pay, "rising from less than 60 times average U.S. worker compensation in 1940 to more than 100 times that average by 2004", making me wonder if the projections for the return on investment for law school are also predicated upon data that is now, to put it mildly, extremely dated and bearing little relevance to the present legal job market.

Here's the thing: when you break down the cost of getting a MBA (two years) or JD (three years) against a getting a MD (four years of medical school followed by a residency) to an hourly figure, you are intentionally distorting the cost-benefit analysis by pretending that the programs could be the same length. First, medical school is more expensive than business school or law school. Second, it's a longer program. Let's imagine an investment where you can contribute $X per year, with a rate of return that diminishes slightly with each additional year. You pick a fixed number of years, make your investment, and you're done. Your two year (business school) investment will provide a greater 'rate of return' than your four (or more) year (medical school) investment, but with a smaller contribution per year and a lower number of years of contribution, odds are you'll still look back in twenty or thirty years and think, "Wow, think how much better off I would be had I gone for that four+ year investment plan." A comparison of this type really only works if the cost of tuition is comparable and the length of the program is comparable: Once you have an MBA, you're done - you can't re-enroll for another two years in order to increase the size of your investment.

The authors' conclusions, although not atypical of the quality of AEI scholarship, verge on platitudinous:

It is well-known that much of the difference in healthcare spending between the United States and other nations can be attributed to the higher prices Americans pay for medical care. But the foregoing comparisons suggest that high prices for health labor in the United States might simply reflect higher returns to skilled labor across the board. After all, if we were “overpaying” doctors, we would expect to see a doctor surplus. Yet this is not what we observe. Paying doctors less would not benefit the country as a whole. That is, every dollar saved by consumers also would be one less dollar of income for doctors. Moreover, if doctors were paid much less, more people might get MBAs or law degrees instead. This would surely reduce health spending, but reasonable people might disagree on whether it would improve social welfare.

First the largest contributors to the cost of medical care are, from most costly to least costly, pharmaceutical costs, facilities costs and doctor salaries. If you are going to overlook the first two cost factors and suggest that we're simply looking at an American preference to give higher pay for skilled labor, you're not even trying to build a case. Physician salaries represent roughly 20% of medical costs. If we paid doctors nothing our nation's healthcare system would remain the most costly in the developed world. Medical schools routinely reject qualified applicants. We can easily expand our nation's pool of doctors by expanding medical schools, funding more residencies, and creating an easier path for foreign doctors to qualify to practice in the United States. The constraints we impose do lead to higher salaries for doctors, but through the distortion of the education and labor markets.

In terms of a "doctor surplus", there's in fact an artificial shortage of doctors in the U.S., driven in no small part by the AMA's successful obstruction of the expansion of medical schools, and also from immigration and accreditation policies that make the U.S. market unattractive to doctors in foreign nations who would otherwise be happy to practice in the U.S. Would lower salaries deter people from becoming doctors? Given that among nations in the Organization for Economic Co-operation and Development (OECD), nations other than the U.S. have significantly more doctors per capita, that would not appear to be a valid concern.

The argument that "We don't get any real savings if we pay doctors less, because every dollar saved by a consumer 'would be one less dollar of income for doctors'" - why, then, are AEI's scholars in a constant tizzy about labor unions, taxes on the wealthy, teacher salaries, whether government workers are overpaid, the minimum wage... it all comes out in the wash, right? How about this: We can legislate market distortions and subsidies that increase lawyer salaries to the tune of $1 billion per year and, when people complain, respond, "Paying lawyers less would not benefit the country as a whole, because every dollar saved by consumers also would be one less dollar of income for lawyers." Sound good?

I'll go back to something I said a few weeks ago:

You want the public to subsidize medical schools and residencies, so that you graduate with a lower debt load and, after your initial medical education, have a more comfortable lifestyle? I'm listening - if we give you that, what are you offering in return? How about we reduce compensation for medical care to an amount more in line with the amounts paid by the rest of the world? Do we have a deal?

You know what else that proposal would do? Massively increase the "return on investment" for medical school under the model described above, even though doctor salaries would drop. Go figure.

Reducing the Overutilization of Emergency Room Care

The Washington Post recently offered an editorial on the subject from an emergency physician. While some of the ideas seem a bit simplistic and underdeveloped, I'll give the author the benefit of the doubt - you can't develop multiple ideas that complex inside the confines of the Op/Ed pages. It's a discussion we need to have, so it's worth a look.

"Putting Patients in Control"

Another wrinkle in the concept of putting patients in control of their own healthcare. Not only will most lack the expertise, time, or information necessary to make a choice, they may not even be presented with a choice. That is, the choice may be made by their doctor, for reasons not disclosed to the patient. Taking a look at medical devices,

“Doctors and technology companies are working in tandem,” [Jeffrey Lerner, the CEO of the ECRI Institute] explained. “The doctor has no idea of what the cost is and the consumer has no say in what products are chosen, for example, for hip and knee replacements.” He said doctors don’t care about the prices, and hospital CEOs don’t want to fight with their medical staffs, who can take their business elsewhere if fees are reduced. One student, who works as an operating room nurse, piped up and said that she had observed doctors threatening to do just that—take their cases to another hospital.

Lerner noted that health care consumers can’t bargain and find out the price of the devices and things that were implanted during surgery. Are they really getting the highest quality, lowest price artificial knee? Contracts are secret, and hospitals or doctors can be sued if they reveal what’s in them. “The laws are being used by companies against the consumer,” he said.

The result?

Bottom line: the doctor is both the buyer and seller of medical services for the patient. It seems to us that this is an area ripe for media exploration, especially since the president is now claiming that the reform proposal “puts American families and small business owners in control of their own health care.”

The type of control described in the President's memo is on a whole different level¹ than the WSJ/Newt Gingrich-brand of control under which, save for when catastrophic coverage kicks in, patients are expected make their own decisions about care and pay out of pocket or from a HSA. Yet once you choose your doctor, your further options may disappear into the maze of contracts and non-disclosure provisions. Dr. A charges less than Dr. B, but he's contractually prohibited from explaining why? What a wonderful context for making informed choices.

No matter who is promising control, it's important to think hard about what that really means.
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1. The memo speaks of control via making insurance affordable, setting up competitive health insurance markets, imprved accountability, ending discrimination based upon pre-existing conditions, and improving the budget over the long-term; choice of procedure or medical device isn't mentioned.

Taking The Guesswork Out of Psychiatric Medicine

I stumbled across the following:

Researchers with the Centre for Addiction and Mental Health in Toronto said Tuesday they are "months away" from being able to personalize medical treatments for mentally ill patients by using genetics and brain imaging tests.

The project, called the neuroIMAGENE initiative, has been seven years in the making and will involve two evaluations — one that will use DNA testing, the other that will measure brain activity — to determine how a mentally ill patient will react to certain medications and to prescribe the best mix for treatment.

If it pans out, it will be an enormous benefit to recipients of psychotropic drugs, allowing them to avoid numerous trials of various drugs and drug mixtures "to see what works", and potentially allowing the selection of medications that minimize both dose and side effects.