What Doctors Wish Their Patients Knew - Critique of the March 2011 Consumer Reports article

First, I'm a big fan of Consumer Reports and even listed their Consumer Reports Best Buy Drugs website in my book, Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System, because of its accurate, unbiased, and money saving information in getting the right treatments for the best price.

So naturally when I saw this month's issues cover story - What Doctors Wish Their Patients Knew, I had to read it.  Overall, it was excellent and made a lot of sense.   Their conclusions were obvious to me, however, might not be as intuitive to the public (after all it is titled what doctors wish their patients knew!).

In summary, primary care doctors matter and having a long-term relationship with one can save time and money.  Respect and being courteous still matter to both doctors and patients.  Thoughtful use of the internet might overcome the resistance doctors have to patients researching information.  Generic medications, which are inexpensive and very effective for many conditions, are excellent and should be used.

A more in depth analysis reveals the following.  Primary care doctors are vitally important.  As Dr. Kevin Grumbach, professor and chair of the department of family and community medicine at the University of California San Francisco noted, "a primary-care doctor should be your partner in your overall health, not just someone you go to for minor problems or a referral to specialty care."  Indeed, that is why I went into primary care.  I prevent problems.  I diagnose problems.  On the occasion I can't solve your problem, then I need the assistance of my specialty colleagues.

I'm not a gatekeeper.  I'm not simply a referral center or an obstacle in getting you the right care.  In fact, I'm the first logical place to always get care and be your partner in keeping you healthy and well.

A long-term relationship with a primary care doctor is also important according to three-quarters of the 660 primary care doctors surveyed.  Consumer Reports found some evidence that patients who frequently switch doctors have more health problems and spend more on care.  This seems to make sense.  Having someone you know and trust to get care over a long period of time can keep you healthy and save you money.  The challenge for many Americans is trying to keep the same doctor.  Employers often switch insurance carriers to save money.  Doctors drop out of health plans.  Patients change jobs and have a different health plan or no health insurance coverage.  In other words, a primary care doctor isn't simply a commodity, but rather a vitally important relationship.  Unfortunately the health care system and the general public don't view them that way.  Practicing primary care doctors are leaving the specialty and medical students are not interested in a primary care field even though it is has potential to be one of the best choices in the future.

Respect and being courteous are two traits still valued by doctors and patients.  The majority of doctors polled felt that being respectful and courteous would help get better care.  Patients equated respect and courteousness as professionalism.  Doctors who treated them respectfully, listened to them with understanding, and spent time with them scored high.  Though professionalism scores increased more when patients felt that their doctor seemed technically competent, I find it hard to believe that patients can honestly determine who is skilled clinically.  I think my car mechanic is skilled, but I really don't truly know as I'm not a mechanic.

I'm sure patients believe I'm technically competent as I explain everything I'm doing.  For a knee examination, patients will hear me say -  I'm palpating the meniscus both the medial and lateral aspects to check for arthritis or a meniscus tear.  I'm examining the medial and lateral collateral ligaments of your knee and making sure they are intact and not strained or torn.  I'm looking for fluid in the knee and mechanics of the knee with the range of motion.  I'm checking the health and integrity of the ACL and PCL.  Instead of wondering if I'm simply waving my hands like a magician, the description of the examination demonstrates my value as a doctor.  Patients, and some doctors, have forgotten the value of taking a detailed history and a good physical examination.  There was a time doctors didn't have the imaging tests of xray, CT, or MRI.  Once I explain what I'm doing, then they understand why these tests are often unnecessary, which of course saves money and time. If showing and verbalizing our examination and thought process is professionalism, then we need to do more of it.

Although the article suggested that 80 percent of doctors felt taking a friend or relative to an office visit would be helpful, I believe this expectation to be a little unrealistic.  Unless a family member or relative is particularly worried or if the visit is very important, say a consultation with a surgeon or an oncologist, it isn't necessary to have someone else tag along.  People are incredibly busy.  Taking time out of the day to accompany someone for an appointment isn't going to happen.  The reason for this suggestion is that doctors discover patients don't typically remember everything that occurred in the office.  This point really is about providing patients a strategy to recall important information (using the mneumonic D.A.T.E. can be helpful).  

Suggestions on how to thoughtfully research information on the internet was a plus.  Besides MedlinePlus and the Mayo Clinic, one should also consider Healthcare.gov, which has a preventive app, my health finder, that gives personalized specific age and gender information on what tests are needed and appropriate (it's under the Learn About Prevention tab).  Not surprisingly due to the ease of looking information on the internet, 61 percent of patients have researched their condition.  Sadly doctors were not as enthusiastic.  Half of doctors said that online research was not helpful at all.

Physician wariness to the plethora of online information is due to the lack of respect from some patients who demand certain treatments, medications, or interventions, without understanding the nuance of a diagnosis.  It isn't as simple, though it seems like it, as putting in a bunch of diagnoses and then just then hitting Google search (or worse I'm feeling lucky).  I don't mind patients emailing me links to articles or suggest diagnoses.  In fact, I learn a lot from patients.  I do however find it difficult to treat patients who are insistent on their way or the highway and in those cases will suggest they find another doctor.  It's about a trusting partnership not just about patients who are empowered with small pieces of information.

Finally, the best part of the issue was he Best Buy Drugs section which notes that many conditions, like high cholesterol, diabetes, heartburn, allergies, and depression have very good generic prescription medications that are inexpensive and very effective.  Consumer Reports uses evidence based research to back up the claims.  The vast majority of patients I care for do fine with generic medications.  That's what I buy.  You should do fine with generic medicationas as well.  They left out my favorite online pharmacy, Healthwarehouse.com which often has pricing better than Wal-mart and Costco for many medications.

What else do doctors wish patients knew?  Vaccines are safe and underutilized.  Body scans and life line screenings really aren't worth your money.  The fountain of youth really is eating less, moving more, and not smoking, and plenty of servings of fruits and vegetables.  Cancer screening tests are for everyone, not those with family histories as the majority of people who develop cancer are the first in their family.

But of course, that might take more than just a blog post, but an entire book.

How Effective Are Generic Drugs?

A brief ABC News video titled How Effective Are Generic Drugs? provides the truth about generic drugs. For the vast majority of individuals they are equally effective and less expensive. If you truly need a brand name drug, then obviously you'll pay more.

For many however, generic is perfectly fine.

Generic Lipitor - Not Yet. Other Excellent and Less Pricey Alternatives

On a recent radio ad for LIPITOR, Pfizer's best selling cholesterol lowering medication, the announcer states two interesting points.

• There is no generic LIPITOR.
• Your doctor may ask you to switch to a less pricey alternative, but if everything is working fine with LIPITOR, why would you switch?

Indeed, why would you switch?

For a full court press, at the LIPITOR website, they've dedicated an entire section on questions you should ask your doctor as well as other things you should consider.

Now I'm all in favor of empowering individuals with information, so the wise patient needs to be a wee bit skeptical when a pharmaceutical company appears to be providing "helpful" information that promotes their product.

Let's look at each point objectively.

• LIPITOR is the #1 prescribed branded medication in the world. -- True. Number one doesn't mean it is the best. Note that the recalled VIOXX anti-inflammatory and its related CELEBREX competitor were pulled of the shelves because of research that suggested increased heart attacks compared to other less pricey alternatives, NAPROSYN. CELEXBREX was the number one prescribed anti-inflammatory on the market at the time.

• LIPITOR is FDA-approved to significantly reduce the risk of: Heart attack, Stroke, Certain kinds of heart surgeries, Chest pain. -- True. Other cholesterol lowering medications are also approved for the same indications.

• LIPITOR is one of the most widely studied medicines in the world—with more than 15 years of research.-- True. Incidentially there are other cholesterol lowering medications that have been around for even longer.

• If you switch, you may not get the same cholesterol-lowering results you get with LIPITOR. LIPITOR is proven to lower LDL ("bad" cholesterol)- 76 to 115 points, or 39%-60% (average effect depending on dose). The cholesterol level you've achieved could change. -- True. This part is a little trickier. LIPITOR is one of the most potent cholesterol lowering medications in the family of medications called STATINS. The one that lowers the most at this time is called CRESTOR (and obviously it isn't generic either). But does lower LDL (bad) cholesterol mean better outcomes, that is less likelihood of heart attack and stroke? It depends. The cholesterol lowering medication VYTORIN, which contains two cholesterol lowering medication - ZOCOR and ZETIA, actually lowered LDL cholesterol better than ZOCOR alone, yet the study which looked at how much the carotid artery (neck artery) blockage decreased showed little to no change. So lower doesn't necessarily mean better, even though intuitively we want to believe it to be the case.

Indeed the four questions that Pfizer has you ask your doctor or pharmacist really hinge on the last point.

• No generic LIPITOR. This means, you will pay more until LIPITOR goes generic.
• Is generic ZOCOR proven to lower cholesterol as well as LIPITOR. No, ZOCOR, also known as SIMVASTATIN, isn't as potent. But don't get fooled, the real question is if I reach my LDL (bad) cholesterol goal with ZOCOR or LIPITOR, is one far better than the other in protecting my heart?
• If I switch could the cholesterol level I've achieved change? Yes it can. But better question, is it possible to achieve the same change with a different medication?
• If I switch could my body respond differently? Yes, but is it also possible that it might not?

Pfizer is doing what most pharmaceutical companies do when their product will soon lose its patent and become generic. They are trying to increase loyalty to their brand, even though LIPITOR is the dominant cholesterol lowering medication in the market.

Want reasonable alternatives and analysis that is objective? Consumer Reports has a free drug report which is fantastic. Here's what they say:

Taking the evidence for effectiveness, safety, and cost into account, we have chosen four statins as Consumer Reports Best Buy Drugs:

* Generic lovastatin and pravastatin — if you need to lower "bad" (LDL) cholesterol by less than 30%
* Generic simvastatin (20mg or 40 mg) — if you need 30% or greater LDL reduction and/or have heart disease or diabetes, or if you have had a heart attack or have acute coronary syndrome and your LDL level is not highly elevated.
* Atorvastatin (Lipitor) (40mg or 80mg) — if you have had a heart attack or have acute coronary syndrome and your LDL is highly elevated; use for two years and then reconfirm need or switch to generic simvastatin. Generic pravastatin and simvastatin became available in 2006. The price of these two medicines will decline in 2007, creating a significant savings opportunity compared to brand-name statins.

There you go. This is the nuance that is heart of a candid conversation between you and your doctor. Pfizer wants you to think the LIPITOR is the only cholesterol medication for you. Medicine is never quite that black and white. Smart patients will realize that there is always a deeper story and shouldn't get fooled by 30 second sound bites. Consumer Reports does say LIPITOR is a good choice for certain conditions. Note however they also say that generic SIMVASTATIN is also for patient who has had a heart attack or acute coronary syndrome, just like LIPITOR.

So why is Pfizer pushing now? Well if you check the FDA website on medications and when they lose their patent, LIPITOR 10 mg will no longer have protection in September 2009, this year!

So if it is too expensive to continue with LIPITOR, don't worry that you aren't getting the right care. Do some research by going to the Consumer Reports website. Ask more questions than the spoonfed ones by Pfizer. It is possible that you do need LIPITOR. It is also a very good chance you don't and others will do the job just fine at keeping you healthy and perhaps saving you money so you never have to choose between your health and all of the other important things you need to take care of.