Patients and Doctors

I thought that Dr. Jerome Groopman's book was really relevant to some of the questions and topics that came up in last week's recitation regarding how doctors go through the process of evaluating their patients. One thing that Groopman seems to focus on is that regardless of how technically skilled or well certified a doctor may be, his or her approach towards evaluating you may miss certain possibilities. Groopman's examples include the young girl who saw multiple specialist doctors that misdiagnosed her celiac disease and doctors who utilize Bayesian analysis, a method of decision making based on algorithms and evidenced-based practice, which can fail in situations requiring novel or original analysis.

How Patients Think

I have really enjoyed reading Groopman’s book. I really related to some of the points he made in the book and many of his stories brought up my own life experiences. Reading the quote:

“A wealth of research shows that patients thought to have a psychological disorder get short shrift from internists and surgeons and gynecologists. As a result, their physical maladies are often never diagnoses or the diagnosis is delayed.” (39)

Made me think of a number of cases I am familiar with. One such case is of a friend of mine and although not directly a case of a psychological disorder, it still follows the same principle. When she was younger, her parents were going through a divorce and it was very difficult on everyone. She began to suffer from excruciating (lower) back pain and would complain about it. They took her to be checked out more than once. The doctors repeatedly (without doing a full MRI) decided that it was psychosomatic pain and/or she was faking it for attention. She had a tumor the size of a grapefruit in her spine which they finally discovered when she became paralyzed from the waist down. Pain, especially vague symptoms of pain are often taken less seriously than visible symptoms. The only symptom is patient reported and they cannot verify that symptom. So unless they find the cause, they cannot verify whether or not it is psychosomatic.

Groopman late states:

“These days, when we are not getting better, most of us return to see the doctor with ideas about what might be wrong. Our notions sometimes come from knowing a friend or relative with a similar symptom, or ideas may have been sparked by looking on the Internet. Our thoughts about our unrelieved symptoms often focus on the worst-case scenario.” (261)

Just like this quote of Groopman’s, when I began experiencing excruciating lower back pain this past summer I kept in mind the case of my friend. In my case, it began with leg pain/numbness and other symptoms, but then spread to unbearable lower back pain. Lower back pain is a fairly common symptom and is often due to “”strain” or “sprain” in the lumbar region” (226) and “90 percent improve within two to seven weeks without specific therapy”(226). However, my mind jumped to the “worst-case scenario”(261) of what if it didn’t go away on its own. What if it were like the case of my friend and it only got worse? I tried to wait it out and see if it would get better. Instead, it got slowly (and then more rapidly) worse. I scheduled an appointment to see my doctor*.

I found it interesting that Groopman learned that, “doctors desperately need patients and their families and friends to help them think. Without their help, physicians are denied key clues to what is really wrong. I learned this not as a doctor but when I was sick, when I was the patient.” (7-8). The idea that you can learn more as a patient than as a doctor I find interesting. The amount of information that my doctors would miss if I didn’t understand my medical history as well as I do is baffling. Without my mother’s probing questions at a consult for a tonsillectomy, I wouldn’t have been sent for a hematology work-up. My ENT refused to operate on me without it, which is good, because I could have bled out during the surgery without the proper medication beforehand. Being a smart patient and having smart medical minded parents has saved my organs and probably my life more than once.

(*If anyone is interested in what happened when I saw the doctor for my back, feel free to ask me via email or in class. I wound up having to have neurosurgery on my spinal cord and I have found the entire experience highly educational and fascinating. I do not mind discussing my medical oddities with people who plan to pursue medicine and might learn something from them.)

I enjoy the book How Doctors Think... it is a very easy read and informative in procedures doctors take in order to make a decision. Particularly in Chapter 5, A Mother's Challenge, I was left with a few questions. First, after Rachel wanted Shira's blood re-tested, WHY on earth would the doctor say to her, "Shira had already been tested and that retesting would require a laboratory researcher to needlessly put aside other work"?! I would be very insulted if I was in Rachel's position. Isn't that their job? No matter how much the doctor though re-testing Shira's blood would be futile, Rachel is paying for the services after all, is she not? I understand a doctor saying no to a parent in certain cases, perhaps if it is something really outrages, but I don't think blood tests are THAT insane of a request? Next question, in the kind of conference where Shira Stein's case was discussed, why is there no discussion on the "cognitive errors occurred and how they could have been remedied"? I understand the conference was to discuss Shira's case/educating doctors about arcane and important disorders, but it makes sense to discuss why something could potentially be misdiagnosed or something, no? It was the case with Shira. Misdiagnosis, so why wouldn't they discuss why it happened? Last question, what does the whole "finding a zebra" and "zebra retreat"? That didn't make sense to me or how/why it was linked to Shira.

How Do You Determine If a Doctor Is Competent?

Dr. Jerome Groopman provides an interesting insight into the world of doctors in his book “How Doctors Think.” Dr. Groopman comments on questions that I believe many people who have ever been to see a doctor have had. The most interesting subject I believe he brings up is how do you know if a doctor is truly competent or not. Dr. Groopman brings forth the fact that a doctor can be very nice, full of concern, and his patients will love him for that, However, these great attributes have little to do with his competence as a doctor. Dr. Groopman provides the example in the beginning of his book of a lady who went to multiple doctors in the course of fifteen years and was misdiagnosed or not diagnosed at all until finally one doctor discovered that she had celiac disease. He relates back to his time as a physician and recounts times where he met doctors that he didn’t believe to be best fit to be practicing doctors.

The main question is, and subject of much of our conversations during the lectures, is how can someone determine if their doctor is diagnosing them correctly or not. Of course there is not one magical technique that can help you determine this. A doctor is someone who you should trust and believe has your best medical interests in mind and constantly doubting them will not solve your issues. However, as Groopman states, no doctor is perfect and they make mistakes as well. I believe that Groopman gives great advice for patients in his epilogue to help avoid these problems of misdiagnoses, especially when you feel something is wrong and you aren’t getting the adequate amount of help to cure it. When seeking medical attention from doctors, it should be a two-way conversation. You should tell your doctor everything you know, feel, and are worried about with your ailment instead of depending on your doctor alone to discover what is wrong with you. I especially like Dr. Groopman’s advice to retell the story from the beginning. There are many things about medicine that are confusing and there aren’t always obvious correlations between what hurts and what is actually wrong with your body. By telling the whole story, it gives your doctor a better chance at picking out what could be wrong with your health and provide proper diagnoses to cure what is wrong. If you don’t feel that your doctor is providing you with the proper care after this, you should always seek a second opinion to make sure that you are getting the best care possible .

Uncertainty in How Doctors Think

Dr. Jerome Groopman's book, How Doctors Think, draws upon extensive research, interviews with the nations most esteemed physicians and surgeons, and his personal experience in the medical field in order to examine the question addressed in the text's title.  Groopman's use of various sources adds to his credibility; we are able to see the many perspectives of our health care providers. He admits that the act of providing medical care is essentially a performance, that doctors, even when uncertain in their evaluations of a patient, must present themselves in a professional, credible, and most important, in a confident way, so that the patient is able to put their trust in them. He comments on his experience as a resident at the Phillips House of Massachusetts General Hospital during the 1970s: "A few of [the physicians at Philips House] were highly skilled, but several were, at best, marginal in their clinical acumen." (I had to look up the word "acumen," which my computer dictionary defines as "the ability to make good judgments and quick decisions, typically in a particular domain") So, being well-learned is only half of the battle.  A critical skill that doctors must have is the ability to make decisions and judgements pretty much instantaneously.  When a patient enters a hospital in critical condition, there is often not enough time to explore different options for treatment, so a doctor must make a fast decision.

In his discussion of the availability heuristic (enabling a person to discover or learn something for themselves), or the "hands on" approach, Groopman explains that in making a diagnosis, many doctors are partial to the cases they see most often.  This is dangerous, since categorizing disease on a macroscopic level (using general symptoms) and using that diagnosis to decide which treatments to provide can lead to adverse, even fatal, effects on the microscopic level.  This is why patients are advised to seek attention from various doctors in order to avoid misdiagnosis and get treatment for a condition that they do not have.

As someone who wants to be a doctor, I found Groopman's book to be very interesting and helpful.  As a doctor, it is inevitable that, on a constant basis, you will be put in situations where you are uncertain.  However, it is your duty to deal with that anxiety,  make decisions that you believe will be best for your patients, and when those decisions prove to be the wrong ones, you will have to find coping mechanisms to deal with that.  Now, from a patient's perspective, you will obviously not be happy when a doctor does not diagnose you or somebody that you love in the right way.  But, this is an unfortunate reality that happens, even when dealing with the most credible of physicians. Both patients and doctors must consider the fact of uncertainty when receiving and providing treatment.

The truth is quite disturbing

“The Truth About the Drug Companies” by Dr. Marcia Angell provides insight into what is becoming if it is not already, America’s most complex and profitable industries, the drug industry. One thought which constantly reoccurred in my mind was how has this not been regulated, health, especially for the disadvantaged is not something that should be able to be treated like any other new product, something easy enough to manipulate for profit. When I read Angell’s passage regarding the top 50 drugs used by the elderly, one of the most economically restricted groups in America, was nearly $1,500 for a year supply I was deeply disturbed.

It made me think of Michael Moore’s “Sicko” scene in which weekly buses of Americans (many elderly) were driven into Canada just to refill the prescriptions they needed to function and live. I used to work in a doctor’s office and pharmaceutical reps would come by regularly. They all dressed in elegant clothing, were young, attractive and sold basically the same products. It’s disheartening to know that medicine, well being and health is an industry like any other.

Today, more and more, people are being asked to take more individual responsibility for their health care, including paying larger co pays and more deductibles. With this being the case, the industry should be regulated to the point where a drug like Claritin cannot have its price increased thirteen times. Maybe people are willing to pay a certain amount for health and life, but they should not have to. And many are not able to.

Angell describes the elderly as being the biggest victims of the health industry. Medicare is crumbling and more and more is asked out of pocket. It is a testament to how much we value our elderly in this society, which is not much at all. This is all the more frustrating if we believe Angell’s statement that only a handful of the drugs which have been produced in the last few years only a few new important drugs have been created, the rest are simply copies with slightly different formulas, different names, and astronomically different prices. Health and Drugs seem to be an industry like any other, but I don’t think they should be.

Uncertainty / Different perspectives

I began reading The Truth about the Drug Companies as a skeptic of the pharmaceutical industry and its influences upon the healthcare system, because of the prominent conflicts of interests that by nature exist between patients, doctors, insurance companies, and the pharmaceutical industry when monetary incentives are involved. I appreciated being guided through Angell's many examples and arguments, as well as the presentation of her statistical information. However, while the reading contributed to the existing feelings of unease I had about the industry, and added to my knowledge of what is involved in the current power dynamic in America concerning patented drugs, her clear subjectivity, often loaded with dramatic diction, made it difficult for me to completely trust or wholeheartedly believe what she was saying. If anything, it made me even more uncertain of the entire topic. To clarify, I find myself at the end, only a fraction closer to supporting her argument, although I remain on the same side. 

Myriad counterarguments came to mind when I was reading; I found myself highlighting and redlining at least 2-3 times a page, at least for the first 30 or so pages. Then, when these counter-arguments  were addressed by her later in the book, she often rhetorically presented the topic as a PR gimmick or industry excuse, and then brought home her points that the counterargument was not true and unsubstantiated by the numbers-- which were then laid out. Rarely did she explore the issue further. 

I was at a dinner event just today with family friends, a few of whom are a generation older and significantly involved in the pharmaceutical industry; one a C-level executive at a small biotech company. I approached them as a student, and as an individual who has no leverage or conflicting interests, to fact check the book page by page, off the record-- for two hours I read aloud at the table and heard their thoughts. I learned that the story and the dynamic are both not as two-dimensional as I felt she presented; nor is the bottom line exactly where she places it. 

It's interesting because afterwards, I can see how some of the same stories told to me from Angell's perspective could be extremely insidious. The individuals I spoke with were people who had spent their entire lives in the pharmaceutical industry-- one woman spends three days out of every week on the other side of the country, away from family, to perform quality assurance and customer service. She told me about how she was interviewing a potential job candidate from another pharmaceutical company: when she was presenting the company story, she said to the candidate, that her critical care company was about the patients. The candidate responded with flat disbelief, citing how his original company had low profit margins and sold generic drugs, while this company (I'll assign an arbitrary number) maintained 87% profits. For every $13 needed to create a unit, the company would sell for $100. How was this considering patient needs? 

I was given a point by point breakdown of the $87 profit. One component I remember in particular is a quirk of customer service: if a client (a doctor) calls the company from miles away and says that his patient is struggling and needs the inhalant immediately, the company sends it to him express, at no additional charge, in under two hours-- a service executable from any facility in the continental US. She has received handwritten thank you notes from many doctors, who have through this call managed to save lives. The cost of this express shipping is ~$20. This cuts directly into the profits for this unit; an often event in this company, specializing in critical care. Several other similar actions, including sending trained, highly paid, college-educated employees to explain the drug in person at the hospital, giving information not on the outside labeling to doctors, are also a part of the company's customer service. These services are not a part of any public advertisement or promotion, but are a given customer right whenever the situation arises, no further questions asked.

As this individual shared with her job candidate, not many companies do this-- especially if their profit margin does not allow for it. She related to me that in her opinion, product quality, customer service, and profit are intrinsically linked, and that at its heart, every corporation begins under the same umbrella of looking after their best interests.

A second person presented a hypothetical situation: if a drug costs $8 to produce, but attains a market value of $300, the first reaction from a consumer might be anger. However, the pricing is balanced by the insurance companies-- it is only able to be $300, if the health complications, quality of life, and other related factors would have ballooned the cost for the insurance company's coverage to $600. While it appears as if the company is taking way too much, in fact they could ask more, and secondly, that they are actually in the process of driving the prices down. 

To end this post: some of the claims I list here are hard to present concisely and concretely without the numbers and the facts. I can write a little more on the topic with more specific industry examples, but would vertically stretch this post even further past the word limit. What I gained from this overall introductory experience was the opinion that each of the conflicting voices must be heard and counterbalanced for the system to work functionally, to the advantage of all. I understood that Angell's book works in favor and defense of the victims of the system, but wish that it was written in a more moderate and less subjective tone both, with more material from the opposition. There was a lot of needless drama that read to me as propagandistic and detracting from the substance of her worthwhile cause. 

Are Drug Companies Alone?

I thought The Truth About Drug Companies was very well written and informative. At first, I was shocked by the deception and exploitation, by which these pharmaceutical companies function. As I continued reading, I wondered, are they really at fault? I don't want to sound like a cynic but what is so different about the way drug companies function? What sets them apart from other large industries? Yes, they do hold in their hands numerous cures and treatments, and many people depend on them to live. However, it just seems that when something has the potential to become profitable in this country, a frantic rat race will naturally emerge.

            Marcia Angell does a good job at addressing my question in the reading by stating: "If prescription drugs were like ordinary consumer goods, all this might not matter very much. But drugs are different. People depend on them for their health and even their lives". I found this quote to be quite interesting, it is true that American consumers spend over $200 billion annually on prescription drugs. But what about the food industry? According to The Food Industry Plunkett Research, Americans spend over $1 trillion a year on food and just like drugs, we need food to survive. This may be a foolish comparison, however, similar to drug companies, the food industry is not known for their honest policies and will also commit unethical acts to make a profit.

Another large industry that is expected to function in an altruistic fashion is the healthcare industry. Just to state some shocking facts, according to the Business Insider, medical bills are the responsible for over 60% of all personal bankruptcies in the United States each year. They go on to say that hospitals overcharge Americans by about $10 billion every single year. So what is it that makes these companies with such great social and moral responsibilities behave in such a perverse manner? Is it the money? Is it the norm? Is it a product of our capitalistic society or are they to blame?

The truth about drug companies

In her book, "The Truth About the Drug Companies," Marcia Angell exposes drug companies, especially the largest ones, "big pharma," as huge “marketing machines” concerned more with profits than the effects of the medication they produce. Some of her findings truly shocked me, however, more often than not, I was not surprised. For example, one point that I found particularly upsetting was in chapter 2, “The Creation of a New Drug.” When she is describing the process of how a new drug is created, she points out that in the clinical trail stage, once the drug is in the hands of big pharma, many companies will offer monetary incentives to doctors for each person they refer to the trials. Doctors could make up to $30,000 just for one patient. I fully agree with her thoughts on the dangers of this practice. She points out that a doctor will be more inclined to “enroll patients who are not really eligible” into the trials. Not only does this put the patient in serious harms way, but, as Angell explains in chapter 6, bias the results of the trials. This is only one way in which the Angell shows that the pharmaceutical companies are more concerned with their profits then the effects of the drugs they put on the market. I feel that this is definitely a reflection on not only the pharmaceutical companies, but health care in our society as a whole. If a doctor is willing to take thousands of dollars, and potentially put a patient at serious risk, how is that any different from pharmaceutical companies rigging trials to work out in their favor? I agree with Angell when she says that serious reform is needed in many areas of this industry to ensure that Americans get the drugs they need in a fair and cost efficient manner. 

Drug Companies Influence of Medical Education

In Chapter 13, How to Save the Pharmaceutical Industry - And Get Our Money's Worth, Angell proposed 7 reforms to "restore the industry to its purpose and make prescription drugs not only more affordable but better and safer". Particularly, I am interested in the 5th point, "Drug companies have too much influence over medical education about their own products (Ch. 8)". This topic interests me on a personal level because of my mother. About 7 years ago, my mother was diagnosed with lupus. The doctor had my mother start taking roughly 20 pills a day (140 pills a week), including steroids (sometimes it varied on milligrams). She gained a lot of weight, was in constant pain, sporadic numbness/pins and needle sensations, and did not receive optimal treatment when she would go see the doctor. My mothers pain sometimes reached unbearable levels to which she couldn't even get up in the morning. Most of the time when my mom went to see her doctor (let's say her name was Dr. X) and complained about the pain, rather than Dr. X changing her drug regimen, she would just prescribe my mother additional drugs to stop the effects of another; a vicious cycle. My grandmother (mother's mother) was constantly worrying about my mother and suggested she see a doctor (let's call him Dr. Y) in Guatemala (our place of birth). I think about 2 years ago was her first time seeing Dr. Y. She showed him her medical records and he ran new blood tests. The results came in; my mother never had lupus, however, she does have rheumatoid arthritis.  He took immediate action to remove her from the pills without abruptly stopping her regimen. Once she was completely done with her prior medication, he started her with new pills and now she takes about 54 a week plus a shot she has to have every 3 months. My mother, without notice, stopped seeing Dr. X, and to this day, she has never had a call from her asking her why she left or how she is doing. I think this story ties into the 5th point made by Angell because Dr. X had ties with pharmaceutical companies that influenced how she practiced.

Football and Impotence

Growing up in the South, the weekend for me basically meant one thing: football.  College football all day Saturday, NFL football all day Sunday, whether I was watching with my dad or with a friend, this was my routine since I knew what Pass Interference was. 

One thing about watching football is that while you are getting nearly four hours of quality entertainment (if you like football), you are also getting an obscene amount of ads.  As a result, I have become pretty adept at seeing right through commercials that try to appeal to a football "audience" more than others, using masculine music, titles, or celebrities appearing in the commercials. 

But one commercial was a little different, it came out in 2003, and it's this ad for Levitra, which Angell specifically mentions in her book.  I have probably seen this commercial 200 times in my life, but when it first was on the air, I was twelve.  I specifically remember asking my dad "What the hell was that?"  I think to just avoid an awkward moment he said he didn't know either.  But watching it now, the not-so-subliminal messages are hard to miss, particularly with that ball going through the tire.  However, I find it difficult to see how else an ad for this product could be done, and it is exactly that characteristic of the ad, and of drug companies in general that I find so frustrating: they are so good at what they do. 

Not only do they understand what it takes to make you think you need something (not want, need), but they are also so good at hiding from you what that thing you need actually costs you.  I vaguely remember Mike Ditka's TV spot for Levitra, but more important than actually seeing it is realizing what the drug companies have done by picking Ditka, who is a football celebrity that men not only generally like, but also have come to trust in his long career as a broadcaster after hanging up his whistle. 

Convincing men to do anything with respect to their own health is hard, getting them to admit that they have a problem in their sex life is even harder, but with respect to drug companies, it's difficult to not respect how they manage to exploit the weaknesses of the human condition, to constantly seek full satisfaction instead of dealing with our idiosyncrasies.

Biased Scientific Research

When reading about Angell's descriptions of the "scientific" studies done by pharmaceutical companies, I was disgusted, but not surprised. For example, in Chapter 5 she described how AstraZeneca compared their heartburn drug Nexium to Prilosec. However, instead of comparing equal doses of both drugs, they compared 40 milligrams of Nexium to 20 milligrams of Prilosec. This is clearly not a fair comparison, but they still managed to pass it off as scientific through their master marketing schemes.

This reminded me of an article that I recently read in the Atlantic about how widespread bias is in scientific research, particularly in medical science:

http://www.theatlantic.com/magazine/print/2010/11/lies-damned-lies-and-medical-science/8269/

This is a very disheartening article for a biology major like me, who plans to spend the rest of my life either researching or practicing medicine. However, I think that it shows the importance critically reviewing all claims, even those that shroud themselves in the legitimacy of “science.” 

I also think this brings up some of the issues that arise when finances and science are intertwined, which inevitably happens all the time because researchers need funding and companies need researchers. In any profit-driven corporation, there is often a need for certain products but due to financial constraints, these needs go unmet. For example, there is a great need for malaria drugs in impoverished places such as Central and Southern Africa but since drug companies need to make a profit, they do not use their resources to develop drugs that could easily bring an end to rampant yet easily-curable diseases such as malaria. 

However, as Angell points out, drug companies are making more than a marginal profit, but they are still unwilling to make unprofitable drugs because they don't want to disappoint their investors. This seems to me to be the heart of the issue. Drug companies should be held accountable to patients, not investors. 

A Different Kind of Industry

Marcia Angell’s The Truth About the Drug Companies provides an insight into the pharmaceutical industry, how it operates, and what we can do to change what it does. I think that the pharmaceutical industry, or Big Pharm, as Angell refers to it in the book is a prime example of the growing inequality of wealth in this country because it is a multi billion dollar company profiting off of the general population which is made up if people who make a miniscule fraction of that amount. However, unlike many other industries that make astronomical amounts of money through questionable means in this country much of the financial success of the pharmaceutical industry can be attributed to the fact that the demand for many of its products stays constant regardless of the price. If the price of coffee becomes astronomically high, most people will stop buying it and switch to a substitute good such as tea for their source of caffeine. Because the coffee industry will not get much business at an extremely high price, they will be forced to lower it in order to attract consumers. In the case of the pharmaceutical industry, if the price of a person’s medication is ridiculously expensive, he or she is forced to pay the high price or risk a wide array of health problems. For this reason I think that there should be another series of checks on industries that produce necessities, as the consumers have close to no influence on the price. In the United States it seems as if we have gotten used to the idea that medications are expensive, and for the majority of people who take few or no prescription drugs, the issue can seem distant and maybe unimportant.

On a different subject related to the book, I would be interested to see what Angell’s reaction to Obama’s recent birth control policy, which requires health insurance plans to provide birth control to women without co pays. I found a short video on the New York Times website in which Angell talks about her opposition to Obamacare because she thinks it puts too much power in the hands of private insurance companies, so my guess would be that she would not be a huge fan of this policy (http://www.nytimes.com/2012/03/20/science/a-drumbeat-on-profit-takers.html?_r=1&ref=healthinsuranceandmanagedcare# the article is mostly just about the relationship between the two doctors, but the beginning to middle of the video are worth watching if you are interested in Angel and the New England Journal of Medicine). I do think that this issue of providing drugs co pay-free is an important one in relation to Angel’s book because it illustrates the possibility of providing drugs at no cost to the consumer. Birth control pills are a special case because for many people, they come along with moral issues, so I think it would be interesting to see what would happen if a less controversial drug were provided free to everyone. Of course this does not even begin to touch the issue of the millions of people in this country who do not have health insurance, and therefore do not have access to any of these benefits or changes in policy.

Again on a different topic, I recently watched Michael Moore's documentary Sicko, which criticizes the  healthcare system in the United States. Though, like all of Moore's films, it has been heavily criticized, I would recommend watching it as it delves into many of the things that we have been discussing in class, the pharmaceutical industry included.

Deception and Action

In her book, Angell describes in detail the deception and expansion of Big Pharma and associated pharmaceutical research. While the deception remains constant and undeterred, she gives us the inspiration to do something about it. First off the bat, I would like to commend Angell for her unyielding and thoroughly analytical writing. Her two decades at the New England Journal of Medicine have obviously given her a sharp edge with which she makes a compelling arguement. So much so that it is easy for the reader to get caught up in the writing and not bring in their own comparisons and experience. She is propaganda-ish and exceedingly easy to trust, similar to way Survival of the Sickest seemed. Regardless, one cannot dismiss her experience with the industry and her crude yet informative investigative style. 

In light of this writing style, I came to agree with the points Angell made. The slide towards the commercialization and corruption of clinical research has led to a full on privately run business that is producing over $200 billion a year. Commercialization has led to investigations into the control research sponsors at these private firms can exert on the analysis and design of clinical trials. The evident distortion of outcomes and the issues of non-reporting/biased reporting are points made which would make any honest American citizen suspicious of the drugs they take. Furthermore, the increasing association between the big industry and the facilities of universities allows the private firms to buy into the best minds of the pharmaceutical industry. I was very shocked by Angell's example of the exorbitant consulting fees paid out to individual faculty members and selected scientists. More broadly however, the effects of commercialization spread out to the commercialization of universities, medical schools and to individual doctors around the nation. How can we support the integration of these companies into our very health-care system and not be knowledgeable about the scandal. These firms are taking up more power resources then they deserve from the American public. We have a name for when the cells in our body take more then they deserve: cancer.

And so I rather entirely agree with Angell. We need to change the way we manage the research, development and distribution of new drugs through public education and political action. Angell also seemed to stress that small actions will not help us. One pill isn't going to cure your cancer. However,  an intensive treatment with the full power of the public would easily stop the nonsense that is forming. In effect, we need everyone knowing and ready to act if we are to cure ourselves. Not only is the health care system and the health of the individual at risk, but also the entire scale of the medical system including universities and governments. The thought of leaving the decisions of health to the American marketplace is an appalling and frightening thought.

Socialize the Drug Companies

In “The Truth About the Drug Companies,” Marcia Angell writes about how pharmaceutical companies are deceitful because they are more concerned with making the biggest profits then improving American’s health. She goes through a variety of ways in which these companies seek to make the most money. For example, they produce “me-too,” drugs that they charge more for, even though they are not more effective. They bribe doctors into using their products. They distort research to make it seem that a drug is more effective then it actually is. Their prices are unreasonably high, and people who desperately need a certain drug are often unable to afford it. In short, these companies are atrocious and Angell does a great job at explaining this. However, the reforms she suggests, while helpful, would not solve the main problem, which is that pharmaceutical companies are a privatized institution.

In the final chapter of her book, Angell goes through a variety of reforms that would most definitely limit the power of drug companies. She writes that we should strengthen the FDA, create more oversight, regulation and transparency, and so forth. All of these reforms are great, and I think they would be an improvement to the current situation. However, Angell doesn’t get to the root of the problem. Drug companies are for-profit private institutions. Therefore, their main goal will always be to make the most amount of profit possible. They will fight regulations tooth and nail and seek any sort of loophole to increase the prices of drugs. As long as they remain a for-profit entity, drug companies will care about profits more then people.

In my opinion, drug companies should be socialized.  Angell says that the reforms she suggests would “lead to better drugs at lower prices (259).” But why should these drugs cost any money at all? It seems to me that health is a human right. Health care should not be run like a business. Every individual deserves free access to the drugs they need. This is why I believe we should transfer drug companies to the public sector and implement a public healthcare system. That is the ultimate reform.

The Truth About...How to fix what you can't change

The Truth About Drug Companies by Marcia Angell, discuses the exorbitant costs of pharmaceutical drugs in America and why this phenomenon needs further analysis. She argues that the high costs of prescription medication do not solely cover the research and development or anything vital to the making of helpful drugs, but that these costs solely enhance the profits made by companies.

As anyone could guess, many corporations are corrupt, especially in an unchecked free market system that exists today. Her focus on the fact that new life saving drugs aren’t in circulation but that 77% of new drugs approved by the FDA were “me too” drugs highlights that this is an unscrupulous business run for profit. I think the biggest point she makes were the three factors that keep this “me-too” business alive was the targeting of common lifelong conditions, the availability of paying customers and the elasticity of the market (83-85). Currently, we live in a capitalist society which after Reagan in 1980, became even more pro business with less regulation and this also sustains this system (6).

 However, it is unclear to me how this books’ decision to unpack the inequalities of capitalism as presented in the pharmaceutical world will change the system, if at all. The government can’t be inclined to regulate Big-Pharma, especially if they place money into the lobbying and political campaigns (19). Perhaps what needs to be the takeaway from this book isn’t how terrible the drug companies are (because this is how many businesses work), but what those of us as a collective can improve the system. If the biggest area of profit for drug companies is the “me too” drugs, then maybe we as people who need medicine and people who are trained as doctors need a shift away from the culture that uses pills to cure any disorder, disease or cold. As she says in the book, now even premenstrual disease is considered a disease in which the pills to manage it are watered down Prozac. Although it too late to undo the greed that is rampant in various companies and force regulation on these industries, maybe all of us can refuse to treat heartburn, PMS, and non-life threatening diseases with pills. If we boycott these products and take away from what makes profits grow, then they’d have to spend more time developing real drugs. Doctors also need to give a more holistic approach to their patients. Instead of just giving people medication for high blood pressure, diet and exercise needs to be on a prescription sheet too so that we aren’t dependent on drugs forever.  I can’t foresee any changes to big business unless the consumer asks for it, so it may be up to us at this point to change how we consume drugs and for what purposes we use them.  

Lower the Prices

The Truth About Drug Companies by Marcia Angell plants an unsettling image of the drug companies and then I realized how little I knew about the influence of these drug companies. Every time I watch the television, I see these ads and slowly they unconsciously influence me to turn to look towards name brand medicine like Claritin when someone has allergies. I had no clue how much our budget goes towards these drug companies. I never gave them a second thought, naively believing that they actually are trying to create new innovated medicine to help people. It was not until I saw commercials for new medicine, an example Clarinex, that sounded exactly like they treated you like the old drugs, continuing the example Claritin, that I was began to second guess my view of the drug companies. I started hearing grumbles about the rising cost of drugs and how there are too many "me too" drugs are out there. I realized that they are businessmen and instead of trying to help those they are ill, they are using their revenue to make themselves richer. Just last week my suite mate came into my room and complained that since her insurance did not cover the eyedrops prescribed to her, she had to pay eighty dollars out of pocket. I thought that was ridiculous that she had to pay so much for a tiny bottle but after talking to a friend who is an ophthalmologist, she claimed that is the normal price for that kind of eyedrops. I understand why it will be hard to generate change in the system but I feel that price regulation is necessary. Angell mentions that the price of Norvasc is $715 but diuretics, a pill that that is found to work better than the other drugs for hypertension, is less than forty dollars. Unfortunately, the commercials drill it into our minds that we need these name brand drugs when generics do the trick and it is much cheaper. Change must be brought forth that limit the control of the big drug companies, especially since most of the money they claim goes into R&D seem to go into marketing the drug more. Since these drugs are a necessity to us, should they not also be affordable by those who need it the most?

Why (not) medicalize?

I appreciated the "bracketing whether a phenomenon is "really" a medical problem" (10) point that Conrad made. He mentions it various times throughout the book. The first time he says:

We can examine the medicalization of human problems and bracket the question of whether they are "real" medical problems. What constitutes a real medical problem may be largely in the eyes of the beholder or in the realm of those who have the authority to define a problem as medical (3-4).

Often, when I have been exposed to the medicalization discussion/debate it often veers towards inadvertently undiagnosing people. Essentially stating that certain diagnoses are not real or over-diagnosed and therefore (at least most of) the people receiving that diagnosis don’t really have anything wrong with them. This has always been very problematic to me and I’ll come back to that point later. Also, he makes the important point that “Having a biological basis does not make something ipso facto a medical problem." (146). Often when research points to a biological cause for a phenomenon we immediately label it as a medical problem based on that evidence.

I also wanted to touch upon the effect of health insurance on medicalization. I felt that this point was eventually made towards the end of the book but seemed to be downplayed throughout. He explains that, "the fact that insurance companies won't pay for treatment of certain medical diagnoses limits its medicalization but does not necessarily undermine it, so long as medical categories are accepted and applied to problems" (11). He also mentions the bizarre situation caused by the fact that psychotherapy is not usually covered but psychiatric medications are. This places the focus more squarely on medicalization, since psychiatric drugs must be prescribed by someone with an MD. Often, doctors (such as internists or pediatricians) prescribe psychiatric medication to their patients without the patient ever seeing a mental health professional. Other times, people do see a mental health professional but cannot afford to remain in therapy on a long-term basis. Therefore behavioral or mood problems that cannot be fixed easily and quickly by psychotherapy are often treated with medication instead. Conrad towards the end of the book says:

It is worth restating that one reason for medicalization in our society is related to the way in which we finance human services. The only way individuals can get the services they want or need to be paid for is to define them as medical problems. Thus, there is an incentive to define problems as medical so that their treatment can be reimbursed by health insurance. This obviously encourages medicalization (160).

This is an incredibly important point. However, he waits until the last five pages of the book to make it. When discussing the various forces that influence medicalization, this seems an extremely important one. He mentions patient advocacy as a factor in medicalization, but seems to gloss over the bank breaking difference in whether or not they receive a medical diagnosis or not.

Environmental Determinism and its problems.

In Guns, Germs and Steel, Diamond argues that Eurasian civilization has conquered and dominated over much of our modern world not due to the product of genetics, but through environmental factors. The opportunities and necessity of the Eurasian situation have allowed their civilization to exceed beyond the necessity of superior intelligence. Consequently, the Eurasian condition resulted from a chain of developments that were only made possible by selective environmental conditions. Because Eurasia had a greater availability of suitable plants and animals for domestication, they were able to bring about an earlier advantage in comparison to other people. 

Diamond seems keen towards reviving the theory of environmental determinism. It is the view that the physical environment sets limits on human environment. It is quite the fundamentalist argument where physical geography and the climate influences the psychological mindset of people. Therein defining their behavior and culture. While this idea might have some examples where it fits in greatly such as with Native American's whose environment completely dominates their culture and behavior regardless of those activities' functionalities. However, you also get cases where the theory doesn't work such as in tropical climates where a view of the physical environment is said to cause lazy, relaxed and promiscuous attitudes. And, also falsely believed, is the after thought that the variability of weather in the middle latitudes leads to more determined and driven work ethics. 

As previously stated, Diamond seems keen on bringing this theory back to life, but which for one is very wrongly directed. Furthermore, he doesn't seem to take too far into account human evolution and the migrations of certain groups of people into Eurasia, which very well could happen much faster than their relative evolutionary progress towards adapting to their environments. 

Here is some on the theory of environmental determinism and why it is so controversial:

http://geography.about.com/od/culturalgeography/a/envdeterminism.htm

What would Weber have thought of this argument?

Jared Diamond’s Guns, Germs and Steel: The Fates of Human Societies, has been an interesting and thought-provoking read thus far. Diamond starts out the book by asking a question posed to him by a New Guinean politician, namely, “Why is it that you white people developed so much cargo and brought it to New Guinea, but we black people had little cargo of out own?” (14). He then translates this question into the entire world, asking why western Europeans came to have so much power over other groups of people in the world. To sum up his answer into one sentence, he says that this inequality is a result of western Europeans’ use and mastery of guns, germs, and steel.

Diamond’s argument seems a bit reductionist, as he narrows the factors that cause this inequality down to only guns, germs, and steel. Having recently read Max Weber, I can’t help but think about what Weber, as one of the founding fathers of sociology, would think of Diamond’s book. In contrast to Marx, who says that capitalism is developed naturally as part of a progression, Weber says that capitalism was able to develop only by the combination of numerous factors that happened to be together at the time, such as religion, culture, technological advancements, and standard of living. For instance, Weber spends a great deal of time examining the Protestant work ethic and Protestant success in the capitalist system. Though the Protestant work ethic contributed greatly to Protestant success in the market, Weber says that this value system alone could not have led to the thriving of Protestants in this system. Instead, he says that this was only possible through the correct combination of innumerable different factors, both large and small. Similarly, if Weber read Diamond’s book, I suspect that he would have agreed that European use and mastery of guns, germs, and steel played a huge role in European power over the rest of the world, but I think he would have said that there must have been many other factors that contributed to this power and inequality.

I am not really sure how I feel about Diamond’s argument yet, as I have only gotten through about a quarter of the book. At this point, the argument seems logical to me, but I am not yet convinced that these were the only three factors involved. I am very interested to see how he develops his argument throughout the rest of the book.

Why didn't native American's independently create have Guns?

In his book “Guns Germs and Steel” Jared Diamond emphasized that environment is the most significant factor in explaining why humans in different societies and different locations have developed differently. This makes complete sense, today many Sociologists believe that humans are not innately different from one another in their thought processes, but are simply equipped with different ways of responding to the same situation (Edward Said). There is nothing really controversial about Diamond’s theory.

I agree with Diamonds theory, but believe he does not place enough importance on other factors than geography in why human groups developed differently. After all, not all tropical island cultures throughout the world developed the same language, technology, cultures or tactics of war. People of the numerous islands of Polynesia may have had and have similar cultures due to their similar environmental circumstances as Diamond states. He does however neglect the influence that the sea traveling nature and constant interactions of these people may have had in their developing similar technologies and ways. Diamond in fact claims that they developed similar cultures in isolation of one another, but this is very improbable as they are known to have been extremely gifted boatmen. People on the islands of St. Kitts, Hawaii, Okinawa and the Galapagos all developed complexly different cultures despite similar climate and being small islands at sea.

One of the most interesting parts of “Guns, Germs and Steel” in my opinion was Diamonds description of the event that sparked his interest in and the publishing of his work. The statement his friend from New Guinea made regarding the different cargo Europeans and his fellow countrymen had lead Diamond to consider what caused the differences which exist in technological advantages todayand the different resources that lead to farmer agricultural societies in some places. Those people who had farmer societies developed superior types of technology. I don’t understand Diamond’s thought process when he uses the example of the Natives in America however. He mentions the disadvantages of Native Americans, but America is so rich in resources that I highly doubt the resources to build agricultural and technologically advanced societies could not have developed as they did in Europe. The question is why didn’t they? Was there actual a difference in the culture rather than resources of these people that lead to different weaponry, medicinal and architectural developments? 

Isn't it obvious?

In Guns, Germs and Steel, author Jared Diamond clearly summarizes that his main point is that “History followed different courses for different peoples because of difference’s among people’s environments, not because of biological differences among people themselves (25).” To me, this idea, and the supporting evidence that he presents in the first portion of the book, seems a little obvious. Of course the environment and geographical location have had an effect on people and how societies develop. How would it not? I think the point of the book is to explain specifically how different environments had an effect on different societies, which is valid, but it seems like the author thinks this idea is revolutionary, when it really is pretty self evident. It make sense that the Moriori and Maori peoples would develop different types of societies due to the fact that one environment encouraged agriculture while one did not. It makes sense that a climate, which allows for a society to “advance,” enough to make more effective weapons, would be able to conquer a society that doesn’t have that type of weaponry. In the chapter “Collision of Cajamarca,” Diamond goes into a long list of reasons as to why Spanish conquistador Francisco Pizarro and his army were able to conquer emperor Atahuallpa and the Incas. The Spaniards were able to get to Cajamarca by way of ship, they rode horses which was a huge advantage in battle, and so forth. Again, the fact that these advantages were caused by the environment in which the Spaniards lived in versus the environment in which the Incas lived in seems inarguable. While it’s interesting to read about this specific case, the reason behind it is not. Anyone that assumes the reason societies have developed differently is that humans have inherent biological differences is some sort of racist or extremely uninformed. Its weird to me that Diamond would think that any sort of reasonable person would even consider a biological argument to be logical, and that he would need to counter it so strongly. His argument is already a known fact.