When Gender Isn’t Given is a great piece on the changing attitudes and practices of medicine when a baby is born with ambiguous genitalia.

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Bacitracin, a common antibiotic found in Neosporin and other topical antibiotic creams, is named after a girl named Margaret Tracy . It was first discovered growing in a wound of Margaret infected with Bacillus subtilis.

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A short little write-up on how I hacked WordPress to work as a basic CMS, requested by some folks at PhotoMatt .

(Sorry, it’s ugly and very rushed, but if I didn’t do it quickly, it would never have gotten done at all.)

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We are all totally screwed it dry-erase/whiteboard markers end up being highly carcinogenic and rapidly fatal at age 40 or something, since I swear every med student sniffs uses them religiously.

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From Kevin MD (really great stuff lately!), a report that a) patients don’t take their necessary meds because of costs, and b) many physicians don’t ask about costs. From the Archives of Internal Medicine :

bq. About one-third of chronically ill adults who underuse medications because of the costs associated with buying the drugs, never tell their health care practitioners . . .
The underuse of essential medications, including cholesterol-lowering medications, heart medications, asthma medications and antipsychotics, has been associated with increased emergency department visits, nursing home admissions, acute psychiatric hospitalizations, and a decrease in self-reported health status, according to the article.
Of respondents who did not tell a clinician, 66 percent reported that they had not been asked about their ability to pay for prescriptions. Seventy two percent of patients who talked with their clinicians about medication costs found the conversations to be helpful. However, 31 percent said their medications were never changed to a generic or less expensive replacement. Also, only 30 percent of patients were informed of programs that help pay drug costs, and fewer people were told where to purchase less expensive medication (28 percent).

We’ve known this for awhile now, but it’s important to re-iterate. And I don’t care how good the drugs are that come to market, how effective they are at lowering cholesterol or blood pressure or controlling diabetes; if people can’t afford them, they’re absolutely, 100% worthless.

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After a glowing review of Angell’s book on Amazon.com (quote: “[The drug companies] have antagonized grannies all over the US with their work to stop reimportation of cheaper drugs into the US, a practice that has been in place for many years in Europe. And anyone in marketing or public relations can tell you that no money in the world can help you win against millions of mad grandmothers.”), Peter Rost, a VP at Pfizer, spoke out in support of reimportation , breaking ranks with Pharma’s official position of “drugs from Canada are unsafe!”

bq. We have to speak out for the people who can’t afford drugs, in favor of free trade and against a closed market. During my time responsible for a region in northern Europe, I never, not once, heard the drug industry, regulatory agencies, the government or anyone express any concern related to safety. And I think it is outright derogatory to claim that Americans would not be able to handle reimportation of drugs when the rest of the world can do this.

Pfizer’s official line: “We have a clear and consistent policy on importation. We believe it puts the health of patients at additional risk.”

Rost was previous demoted by Wyeth for telling superiors the company was defrauding foreign governments.

Peter Rost, folks. Pharma, please keep hiring him when he gets fired from Pfizer.

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I finished Marcia Angell’s buzzworthy The Truth About the Drug Companies a couple days before school started, and highly enjoyed it. I’ve wanted to write a bit on it, but never had the time. (I still don’t have the time, but whatever.) Derek Lowe has a good counterargument , and I think he’s a pretty honest, genuine researcher.

Angell makes the case that Pharma isn’t all that innovative. Every company wants to have a cholesterol-lowering drug (statin), every company wants its own Viagra. These are called “me-too” drugs. While I _do_ think there are *way* too many “me-too” drugs, I don’t think Angell acknowledges the fact that it’s good to have several versions, to account for genetic differences in patients, allergies, adverse side effects, etc. (She does acknowledge this, but too briefly in my opinion.) But the numbers don’t lie:

bq. Of the seventy-eight drugs approved by the FDA in 2002, only seventeen contained new active ingredients, and only seven of these were classified by the FDA as improvements over older drugs.

I think Angell’s examination of Pharma R&D is pretty good, too. I’m 100% sure that Dr. Lowe does quality work, and necessary work for bringing new drugs to market, but I think he downplays the importance of basic science research. The fact is that drugs _could not be discovered_ without the basic science done by universities, funded by the NIH (and therefore, taxpayers). She also goes through the processes by which AZT, Taxol, Gleevec, and Epogen. And two more bits:

bq. A recent study published in the journal Health Affairs reported than, in 1998, only about 15 percent of the scientific articles cited in patent applications for clinical medicine came from industry research, while 54 percent came from academic centers, 13 percent from government, and the rest from various other public and non-profit institutions.

bq. An unpublished internal document produced by the NIH in February 2000… revealed similar percentages. The NIH had selected the five top-selling drugs in 1995 (Zantac, Zovirax, Capoten, Vasotec, and Prozac) and found that sixteen of the seventeen key scientific papers leading to their discovery and development came from outside the industry.

It turns out that drug law allows the NIH to require drug companies to make drugs licensed from it “available to the public on reasonable terms,” but the NIH doesn’t enforce this. Angell also notes that the “$800 million per drug for R&D” number circulated comes directly from what Pharma told the researchers it cost–without releasing the documents for verification. If I were Pharma, I’d inflate my numbers, too. (The number is also doubled to include “capitalized cost,” as if the drug companies could be investing their money elsewhere instead of investing in R&D.)

We could argue R&D all day, but I think Angell is strongest in attacking the marketing procedures of Big Pharma. She goes after the slimy practices of patenting metabolites or isomers and marketing them as new drugs to consumers to create demand. (Nexium is the active isomer in Prilosec; Nexium was developed as Prilosec’s patent was running out. Clarinex is the metabolite created *by the body* when it digests Claritin. It was made for the same reason as Nexium.) One of the most amazing statistics in the book–Pharma has 88,000 sales reps currently; that’s one for every 5 or 6 doctors in the United States . Imagine if textbook publishers had a sales rep for every 6 teachers trying to push why their textbooks are better. If it’s a good drug, and effective, does it really need all this marketing?

Other good points:

* Pharma basically controls medical education, but they’re not in the education business. They’re in the drug-selling business. If they were in the business of education, they wouldn’t be giving it away for free. Pharma usually contracts out to medical education and communication companies (MECCs) to prepare the teaching materials, but they advertise to Pharma like this: “Medical education is a powerful tool that can deliver your message to key audiences, and get those audiences to take action that benefits your product.” Real educational.
* Pharma has more lobbyists in Washington DC than there are Congresspeople.
* Pharma created the fake group “Citizens for Better Medicare,” spending $65m to fight drug price regulations.
* Donald Rumsfeld was CEO, president, and chairman of a major drug firm. I had no idea!

Angell makes some good suggestions for improving the system: She notes that drugs should have to be compared to existing treatments. Right now, if your drug is any better than a sugar pill, it’s good enough. She also thinks we should do away with direct-to-consumer advertising (it’s already prohibited in most other advanced countries). We should also change the timing of patents (they should begin when the drug is released to market, not when first discovered).

You might not like some of her points, but I think most are fairly strong. Pharma is either in the business of selling drugs and maximizing its profits, or it’s not. I don’t buy for a second that it wants to provide education to patients or providers.

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I’ve been doing a number of coding and database side projects lately (including the Stanford Community Health Resource Center , basically a hacked and cracked WordPress weblog), and it’s really affected the way I think about information.

I think it’d be fascinating if we could see the way a neonate first-year med student’s brain works and stores information compared to how a second or third-year does. Medical school memorization is a challenge, I think, because you’re going from storing arrays to storing tables and databases, really.

Throughout your education, you memorize facts as arrays. That is, one piece of information corresponds to the other. It’s all linear. Capital of Kansas => Topeka. P53 => tumor suppressor. Word => Definition. But medical school changes that. It’s no longer so simple. It’s not just that _this_ equals _that_, it’s that _this_ is related to _that_ as well as _this other thing_. Or you’re required to memorize categories of information on a certain topic. Just like a database.

An example may help. For each bacteria, we have to know:

* How to diagnose it
* What syndromes causes
* How the lab identifies it
* Its antibiotic resistances
* How it causes disease
* What toxins it produces
* Where it infects
* How it is transmitted

So it’s not just the process of trying to memorize all the information that makes it so difficult; it’s the fact that you have to train your brain to start storing information differently. Boratella pertussis, the bacteria that causes Whooping Cough , isn’t just a bacteria. Now it’s a bacteria that:

* is a gram negative rod, fastidious
* causes Whooping Cough
* can be prevented with the DPT vaccine preferably; erythromycin will treat it
* produces pertussis toxin, an AB exotoxin which decreases immune function
* produces tracheal cytotoxin, which inhibits cilia
* produces adenylate cyclase toxin
* inhabits the ciliated upper respiratory epithelium
* is transmitted by aerosol particles

See what I mean? It’s a whole other ballgame.

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Last year was a cakewalk. Fish in a barrel. A walk in the park. Candy from a baby. Not that I remember any of it, but I digress.

By Tuesday, we will have had 9 days of class, 27 hours of lecture on microbiology and tumorogenesis, and we’re already up to:

* 36 drugs (27 antibacterial, 9 antiviral/antiretroviral)
* 6 bacteria
* 4 viruses

11 weeks to go. Keep on keepin’ on!

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So goes the nation, I hope. There’s been a slew of postings railing against advertising by drug companies ( GruntDoc , Dr. Bradley , MedRants , Kevin MD ), talking about the ads being misleading, inappropriate, and the drug reps being annoying and even reckless.

Hopefully the non-blogging MD world will catch on soon, too.

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