Unnecessary tests, redundant consultations, the dispensing of prescription drugs in American medicine.
"We're living in a McDonald's medicine world," said Collinsville internist Tabor Kopjas, M.D. "Have it your way. And fast."
The fear of being sued among doctors is real, but how is it reshaping the practice of medicine?
More non-essential tests are being ordered by doctors because of that fear, according to Dr. Kopjas.
"Do doctors over-order tests? Absolutely," he said. "Look at what happens in the ER (emergency room) and how many CAT scans are ordered there."
The effect of not being able to rely on clinical acumen is discouraging for medical professionals, according to Dr. Kopjas.
"There is no cookbook for patient care. But when people demand you end up shotgunning. If you can't rely on your clinical gestalt because you'd better cover yourself. That's discouraging," Kopjas said.
A rash of class action lawsuits filed across the country against pharmaceutical makers alleging they knowingly marketed dangerous products has some medical experts suggesting there are too many prescriptions being written.
In the crosshairs: "super asprin" pain relievers like Vioxx and Celebrex.
"If there's a worry that doctors are over-prescribing, I would argue that the opposite is true," Dr. Kopjas said. "I would say they are under-prescribing."
Dr. Kopjas pointed to a recent "hit list" of potentially dangerous medicines issued by a Food and Drug Administration reviewer. The list included Meridia, for weight loss; Accutane for acne; Serevent for asthma; Bextra for pain and Crestor, a medicine for lowering cholesterol. The reviewer suggested Crestor could lead to renal failure.
"Crestor sales are falling into the basement," Dr. Kopjas said. "But the safety data on the drug shows it is good, the most efficacious drug to reduce cholesterol. Now doctors are refusing to write prescriptions for Crestor. They're afraid patients won't take it."
He suggests a lack of critical analysis is applied by some who interpret studies, which end up skewing public perception about a drug's safety.
"You get one or two bad outcomes and then you get your whipping boys like the Ralph Naders who latch on," Kopjas said.
Some drugs may have potential dangerous side effects, Dr. Kopjas acknowledges, but another more serious danger to the public is the lack of availability of medicines that address national health problems.
"The National Health Institute advises certain goals must be met for blood pressure, glucose and cholesterol levels. They set what the national norms should be.
"We're taking away desperately needed medicines. Now more women than men are dying of heart disease," he said.
Dr. Stephen Kappel, a Belleville orthopedic surgeon who at age 55 retired five years earlier than planned due to high malpractice insurance rates, said the practice of defensive medicine has been around for 20 years.
"It used to be that a doctor's word was what people believed. But now you almost have to take pictures to prove your results," he said.
For instance, while a clinical exam might suggest all is fine with a patient with a back problem, Dr. Kappel would often involve more treatment than his experience and training would have directed him to do.
"You may order an MRI if the patient is not satisfied, because he complains, and there might only be a 1 in 1,000 chance there actually is something else," he said.
Kappel says workers compensation patients make doctors the most wary.
"For those cases you're quicker to jump on the big tests like CT or MRI, and sooner," he said. "You definitely use tests more and rely on clinical acumen less as a back up. Not all technology is bad, but we tend to use it sooner to back up what you say."
Dr. Kappel cited a statistic that $100 billion is spent nationally for medical liability insurance payments.
"Defensive medicine. It could buy a lot of healthcare for people," he said.
Kappel's early out last January was prompted by a 170 percent malpractice insurance premium in just one year, from $60,000 to $150,000, as well as costly tail coverage which protects doctors post-retirement.
"I just didn't know what to expect," said Kappel, who is among the hundreds of doctors to leave their Metro-East practice because of the medical malpractice insurance crisis.
MADISON COUNTY RECORD
Drug makers have invested for the ailing boomers
Monday, December 06, 2004
To the Editor:
In regards to your Nov. 26 article, "Merck's Vioxx withdrawal illustrates power of regulation by trial lawyers," as we, the "baby boomer" generation ages, rheumatoid arthritis is becoming a serious medical problem affecting millions of us over 50.
Anticipating a lucrative market for prescription painkillers and anti-inflammatory medications, pharmaceutical manufacturers have invested hundreds of millions of dollars in the development of treatments for every degree of this potentially disabling medical condition.
We have produced an entire generation of investigators in medicine who believe that the only valid form of cliinical research is to perform prospective, randomized trials in which patients are randomized to receive one empiric drug combination versus another empiric drug combination. Strike that, against a placebo, not another established drug combination.
There is a mindset that pushes tens of thousands of physicians and scientists toward the goal of finding the tiniest improvements in treatment rather than genuine breakthoughs, that rewards academic achievement and publication over all else. There is a national problem in the way we treat the problem.
One must be objective and decide at what point the benefits of such drugs "truly" outweigh the risks they present. Of course, some of the risks are minor and others, though serious, are tolerable in that they are reversible, short-term or non-life threatening. Many of the risks, however, are extremely serious and are difficult to balance against relief from anything but the most severe arthritis-related symptoms. Clearly, for some people the risks may be acceptable, for others, not.
Drug companies have developed drugs aimed at the widest possible population. That is the most profitable strategy but one that ignores a basic fact in biology, people are different. Bringing a new drug product to market is an expensive business costing tens of millions of dollars. It takes place in a culture of maximum possible sales for maximum possible profit, although the fact is that most drugs don't work for most people.
Even when a drug has been approved in terms of safety and efficacy, whether it does what the label says it should do, few people realize just how poorly they perform in real life.
Gregory D. Pawelski