Um, Silly?

When I admit a patient, I ask them what they are taking. The nurse asks them what they are taking, and the pharmacist does, too. In the ED (happy, WhiteCoat?) we have a little section where we can mark their medications and enter new ones.

Then, when they go upstairs, I copy the medications from a computer onto an order sheet by hand with a ball point pen, making sure to press hard so it goes through the carbon paper. I then copy it again, still by hand, into a history and physical. Three lists and counting.

I then am supposed to copy it onto the daily progress note by hand with doses and frequencies every day even though we round with a pharmacist with a computer (who, you guessed it, has access to the computer list). I don't do this out of protest. Four lists, and counting.

When the patient gets transferred from the ICU to the floor, or from one floor unit to another, there is a transfer medication list that also gets copied onto a triplicate paper order sheet with a ball point pen, because there is no way to just, oh I dunno, transfer the list. So that's five and counting if there's a transfer.

Upon discharge, the nurse prints a form that has their before admission meds and their inpatient meds as well as a new place to write discharge meds, so we'll call that six. The nurse is then supposed to copy, by hand, that list onto another so-called 'RN discharge'. That's seven. I then dicatate, hopefully from one of these reliable lists, into a discharge summary that is on a different system and not automatically correlated with anything. We'll call that eight.

Eight medication lists for every hospital admission, seven if there's no discharge or transfer. If someone comes out of the ICU and then transfers at all it's up to nine. They all live in different spots. There is no automated updating except at that first step, when there's an EMR.

I know White Coat just posted about a place that uninstalled it's EMR because, admittedly, garbage in is garbage out. But what is garbage copied eight different times, with lists as long as 30? That's, hmmm, 240 chances for error. All in the name of reducing errors.

And we chide our patients for not knowing what medications they're on. We probably don't know, either.

Undue Influence?

Thought this was a great shot. On anesthesia at the VA, one of the retiring PAs brought in his pen mug from his office and these were my top choices for classics. Interesting how long big pharma has been plying MDs with free pens--not that we should be interested, it seems like we could afford our own pens. I still don't understand why MDs are interested in these. The trip to Hawaii I understand.

I've taken an oath here to avoid pharma influence. So far it's been easy. The county where I went to medical school outlawed drug reps, and my residency program has a policy of not taking any money or gifts from pharma. Just wait for the community, right?

I think the Versed pen is my favorite. I was tempted to take it, I admit.

NY Times Takes on Pharma

The New York Times has recently had two fascinating and, I think, accurate articles highlighting the relationship between doctors, health care, and pharmaceutical companies, in anemia treatment, and in antipsychotic use in children.

I posted once about problems with the use of antipsychotics, but this is a whole different issue. This is a major problem. It looks like doctor's groups in NY that were prescribing variants of EPO, which boosts red cell production and is thought to be useful in conditions like chronic kidney disease and chemotherapy, were receiving rebates from the pharmaceutical companies based on how much they gave patients to the tune of millions. Millions. Sounds a bit fishy. Getting rebates based on the drugs you give people.

Then, there's a second article about psychiatrists receiving payment from drug companies in Minnesota, which publishes such statistics unlike most states. It said the most money received by a doctor was over $600,000 in a year.

Now, I'm usually one to point out that doctors don't make as much money as CEOs, or business folks, or lawyers; in a recent book, Better, Atul Gawande pointed out that the return per year of schooling for doctors was on the order of 16%, as compared to almost 30% for business school. Still, we're not about to end up in the poor house as a profession. We should know better.

There's good evidence that these trips and gifts and, well, cold cash in bank accounts, influence prescribing practices. It seems obvious with enormous rebates, but it's true even of the pens and note pads. Ask your doctor about it. Go ahead. And check out a site that some doctors have started in protest, called No Free Lunch. It has just started a directory of providers who have pledged not to accept gifts from pharmaceutical companies.

Yes, we need drugs. Sure. But we don't need to be paid by the companies that make them. Sheesh. And we all supposedly took ethics in med school. I suppose it's easier for me; drug reps aren't allowed to visit UW physicians. I've never seen one.