Overdosed America (3 page)

Her husband and several other villagers listened attentively as I explained my diagnosis. But their expressions changed from hope to despair when I told them that she needed to be treated in a hospital. They said that she couldn’t go to the hospital because they did not have any money. I suggested that they take her there anyway and that someone would care for her. They said that wouldn’t work, that she would be ignored, left to die on the hospital steps. I asked how much it would cost for her to get hospital care. They said $160. The two other Americans present and I glanced at one another and agreed, without a word being spoken, that we would get the money together. Fortunately, a boat soon came by, headed in the right direction, and off she went, accompanied by our capable interpreter, who could help her with travel and hospital arrangements. The woman returned to the village three days later, weak but much improved. Her look of fear was gone. Her husband and children stared in happy disbelief when they first saw her and realized she would recover.

When I got back home, I went to my office the Sunday before resuming my normal schedule to go through the paperwork that had accumulated while I was away. Among the several 3-foot-high stacks of patients’ charts, test results, consultants’ notes, medical journals, and junk mail was the latest issue of the
Journal of the American Medical Association
(JAMA), from November 24, 1999. I noticed an article about Celebrex and one about Vioxx, the latest drugs for arthritis pain. Each article presented the results of a study sponsored by the drug’s manufacturer claiming that the drug was significantly safer than older anti-inflammatory medication, which was available in much less costly generic form.

The accompanying editorial—these are typically included in medical journals to provide expert perspective on the most noteworthy articles published in each issue—reported with unusual candor (especially since both authors had financial ties to at least one of the manufacturers of the new drugs) that neither of the new anti-inflammatory drugs provided better relief of symptoms than the older alternatives. The editorial also explained that the highly touted safety benefits of the new drugs appeared minimal in people who were not at high risk of developing serious gastrointestinal side effects. So minimal, the editorial said, that 500 such people would have to be treated for one full year with the new drugs instead of the older anti-inflammatory drugs to prevent just one serious but nonfatal stomach ulcer. Based on the difference in price between the new and older anti-inflammatory drugs, the editorial calculated that the cost of each serious ulcer thus prevented was $400,000.

Still moved by my experience in the Amazon, I wondered how many lives like that of the woman to whom I had made the house call might be saved for the cost of preventing a single nonfatal stomach ulcer by using Celebrex or Vioxx. I took out my calculator to see how many times $160 goes into $400,000. I could feel myself change when I saw the figure “2500” on the display and realized the injustice of that equation. Though I didn’t realize it at the time, this book was conceived in that moment.

This incident sensitized me to the intense marketing of these two drugs. Advertisements for them suddenly popped up everywhere. At first the ads seemed inappropriate, but quickly they claimed their place as normal fixtures of the American cultural landscape. The implication of the ads was that the (unspecified) superiority of the new drugs allowed people to enjoy activities that they had previously been unable to enjoy because of arthritic pain—though no such superiority had been found in any of the major research.

The marketing campaigns were certainly successful. In the year following the JAMA editorial, Celebrex and Vioxx were
two of the four drugs
with the greatest increase in sales. Many, if not most, of the orthopedists and rheumatologists in my community began prescribing them enthusiastically, despite the reservations expressed in the JAMA editorial. My patients were not immune to the effect of all this advertising. They increasingly requested and occasionally demanded these expensive new drugs for their arthritis symptoms and various other aches and pains, and many interpreted my reluctance to prescribe the new drugs as simply a primary care doctor’s lack of expertise or inability to keep up with the latest medical therapies. Even after I carefully explained the details of the best available scientific evidence about these drugs, not all of my patients could be convinced otherwise.

Mr. Black’s visit provides a typical example. A successful small-business owner in his mid-forties and an avid intermediate tennis player, Mr. Black came to see me because of nagging pain in his right elbow. A brief exam revealed tenderness on the outside of his elbow at the point where the tendon that extends the wrist into a backhand tennis shot attaches to the bone. I explained that the problem was epicondylar tendonitis, more commonly known as tennis elbow, which is caused by the repetitive impact of the tennis racquet hitting the ball. I made a series of recommendations that would allow the tendon to heal: use a forearm band when playing tennis to partially protect the point of insertion of the tendon into the bone from the impact of the tennis ball hitting the racquet; ice the area after playing tennis to prevent the inflammatory reaction from progressing; decrease the tension in the racquet strings and perhaps change to a more flexible racquet frame to lessen the impact of its hitting the ball; and talk to his tennis pro about possible grip or swing changes that might improve his tennis elbow (and perhaps his tennis game at the same time). Finally, if there was still no improvement after doing all of these things, I warned Mr. Black that he might have to temporarily decrease the amount of tennis he was playing to give his arm time to heal.

Mr. Black listened patiently to all my suggestions. When I was done, he said, “My friends are getting good relief from Celebrex. Would you write me a prescription for that?” I explained that, despite what the ads implied, Celebrex would not provide him with any better relief than the other anti-inflammatory drugs (commonly referred to as “nonsteroidal anti-inflammatory drugs,” or “NSAIDs” for short) and was a lot more expensive. He replied that the additional cost was not a problem, “because my insurance covers it.” Mr. Black’s belief that Celebrex would solve his problem made him unwilling, or perhaps unable, even to consider my suggestions. And he made it very clear that if I would not prescribe Celebrex, he would find a doctor who would.

I quickly thought through the possible responses to Mr. Black’s ultimatum. I didn’t want to permanently weaken our relationship of many years over a single prescription for a drug that was unnecessarily expensive but unlikely to do him harm. I wrote the prescription.

A couple of weeks later Mr. Black called my office to report that his elbow pain had not improved and to request a referral to an orthopedic surgeon. I was frustrated that he was still unwilling to do the simple things necessary to protect his elbow from the consequences of more stress than it had been designed to withstand, but I did not want to put either of us through a repeat of the last visit. If I wanted to preserve the potential of our relationship’s being helpful in the future, my only option was to acquiesce, once again. The orthopedist confirmed the obvious diagnosis of tendonitis with an MRI and sent Mr. Black for physical therapy. His elbow pain improved slowly.

In stark contrast, my relationship with Sister Marguerite is an example of the potential of
doctor and patient working together
toward the same goals. I first met Sister Marguerite after she had been brought to the emergency room by ambulance, desperately short of breath. She could barely talk as she struggled to get enough air into her lungs. Her heart was beating irregularly, at about 170 times per minute. She was in atrial fibrillation—chaotic electrical activity in the upper chambers of her heart was overriding her heart’s own natural pacemaker. Her chest x-ray showed pulmonary edema, fluid in her lungs, as a result of her heart not being able to pump blood effectively when beating so fast. All I knew about Sister Marguerite was from her chart: she was in her mid-eighties and had recently retired to the local convent after teaching school for 55 years.

At first I thought she would not survive this episode without intubation and mechanical ventilation. Fortunately, she responded quickly to intravenous medications that slowed down her heart and made her kidneys excrete much of the excess fluid in her body. Within 24 hours her breathing was almost back to normal. Blood tests showed that Sister Marguerite had suffered a small heart attack, which probably had set off the atrial fibrillation.

After she was out of the hospital, Sister Marguerite required frequent office visits to monitor her fragile medical condition. Our visits would often start with her saying, “You must be so sick of seeing me. Other people must need your attention more than me.” She was wrong on both counts. The dose of her diuretics (fluid pills) needed to be adjusted frequently to maintain the proper fluid balance. Retention of extra fluid could have caused her to go back into pulmonary edema, and even a small amount of fluid buildup in her feet and ankles for just a few days caused her unusually thin skin to break down, leaving painful skin ulcers that took months to heal. In the opposite direction, pulling too much fluid out of her body with diuretics would have prevented her kidneys from functioning properly. Her other medicines needed to be monitored closely as well: digoxin to control her heart rate; supplemental potassium to replace the potassium that the diuretics caused her kidneys to excrete; and a blood thinner, coumadin, to prevent small blood clots from forming in her irregularly beating heart that could cause a stroke. I saw Sister Marguerite every two to four weeks when things were going smoothly, and even more often when they were not.

As I attended to the technical details of her medical care, we would talk about her religious and spiritual life, her colleagues and activities in the convent, and her family, especially her grandniece, the apple of her eye. She would tell me about her former students, always with affection. She was proud of the convent where she lived with other retired nuns, and invited me to visit her there. I accepted.

When I arrived at the convent, Sister Marguerite particularly wanted to show me the chapel where she attended mass every morning and meditated every afternoon. As we entered the chapel, the sunlight was filtering through the beautiful stained-glass windows. We sat down and shared a couple of minutes of silence together. She then showed me her tidy room and gave me a tour of the grounds.

The next time she came for an office visit I built up all my courage and asked, “Sister, when you are in your chapel meditating and I am alone reflecting on the larger issues of life, do you think that we are having similar experiences?” She responded without a moment’s hesitation, “Of course we are.” Sister Marguerite’s acknowledgement of our common experience, though approached from different directions, felt like the most genuine of blessings.

The recurring focal point of Sister Marguerite’s medical care—especially the troublesome skin ulcers—became getting her well enough to participate in special activities at the convent and enjoy her next trip to her grandniece’s home. (Of all the attention that I and other doctors gave those ulcers, it was the skin care provided by a well-trained and very determined visiting nurse that helped the most.) As fragile as her health was, Sister Marguerite continued to live quite happily—albeit receiving more frequent medical care than she would have preferred—for seven years after the emergency room visit that originally brought us together.

One day, the nurse at the convent called to tell me that Sister Marguerite had died and to ask if I would come to “pronounce” her, a last rite of the medical sort. I found Sister Marguerite in her recliner, ashen and still. The nurse and one of her closest friends were already there, and soon others arrived. I felt privileged, if a little ill at ease, to be included in this sad and beautiful scene. I wanted to share with her friends just how important my relationship with Sister Marguerite had been to me, and I began to tell the story of my chapel visit. When I got to the point in the story when Sister Marguerite acknowledged our spiritual connection, all of the nuns nodded their heads, letting me know that they agreed with Sister Marguerite’s assessment. It was a beautiful conclusion to our relationship.

The contrast between the care of my two patients, Mr. Black and Sister Marguerite, could not have been greater. Of course the relationship that evolved between Sister Marguerite and me was special, but still it serves

as an example of the importance of shared values in the challenge of providing good medical care. Visiting her family, attending mass, meditating in the chapel, and being an active part of her community—these were the things that gave Sister Marguerite a sense of meaning. And these were the things that motivated her to be the recipient of a lot more medical care than she ever expected or wanted. Sister Marguerite and I were partners in her care, working together on the same project, optimizing her health so that she could continue to be active and independent. And our partnership became all the more rewarding because she was so open about the deeper values that made the project worthwhile for her.

On the other hand, the influence of the medical industry, especially the drug companies, was starting to make this kind of medical care seem antiquated. Increasingly my patients were looking to pills to keep them well instead of making the changes in their lives that evidence showed to be far more beneficial. Engaging patients in constructive dialogue about their health risks and habits—a big part of what I think is good doctoring—was becoming more difficult, and occasionally impossible. Too many visits were turning into nonproductive contests of wills, like my visit with Mr. Black, instead of evolving therapeutic alliances, like my relationship with Sister Marguerite.