Better to Best: Thoughts on Global Health Care Systems

Support the Robin Hood Tax Campaign! The Incredible Hulk does.

Posted in Uncategorized by reshmagar on June 19, 2012

From Jennifer Flynn of Health GAP (Global Access Project)

Dear Reshma, 

What do you and Mark Ruffalo, Chris Martin, and Tom Morello have in common? You all want to see the end of the AIDS pandemic, stop climate change, ensure that we all have education, healthcare and a place to live, and you can all be a part of the launch of the U.S. Robin Hood Tax Campaign. Robin Hood has finally arrived in the United States – Check out this video for proof!
Today is the launch of the Robin Hood Tax Campaign in the United States.
Wall Street’s recklessness and the financial crisis it caused crashed our economy, and the progress we had previously made in fighting the AIDS pandemic has since been halted. But imagine if we could raise the funding we need to turn all that around–hundreds of billions of dollars not from ordinary people but from Wall Street itself.

A Robin Hood Tax on Wall Street would be a tiny tax of less than half of 1% on speculative Wall Street transactions that could generate hundreds of billions of dollars each year. The money generated could not only end the AIDS pandemic, but could create green jobs in the United States, strengthen domestic health care, education and infrastructure, and fight climate change. This tax is not a tax ON people, but a tax FOR people.

Can you help us launch this campaign successfully?

Are you in New York? Come out to our rally at NOON today in front of of JP Morgan Chase offices, at 270 Park Avenue, and join Robin Hood activists, speakers and supporters in launching this campaign.

Not in New York? Robin Hood supporters are rallying all over the country  – find the rally closest to you here.

Can you send this campaign video to everyone you know? After you watch the video, sign up to show your support for the campaign, and share it online through twitter and facebook. This afternoon, come back to the Robin Hood website to sign a petition to Obama in favor of the tax.   

Today groups across the country are joining together in the Robin Hood Tax campaign—AIDS activists, labor and community groups, faith communities, and environmental advocates.  Pushing Wall Street to pay their fair share won’t be easy: They have millions of dollars to lobby against us, but we have millions of people.

Spread the word, sign the petition and help us build the movement. Together we can turn this great idea into a brilliant reality.



Jennifer Flynn
Managing Director
Health GAP
429 West 127th Street, 2nd Floor
New York, NY 10027
mobile:  +1-917-517-5202
phone:  +1-212-537-0575
fax:  +1-212-937-5283
skype:  jenniferaliceflynn
twitter:  jenniferflynn

Information needed to treat put beyond physicians’ reach

Posted in Open Access by reshmagar on April 30, 2012

Check out the terrific article below from Logan Weygandt, a student at the Johns Hopkins Bloomberg School of Public Health on the importance of having access to scholarly research for both physicians and patients. YAY LOGAN!

Information needed to treat put beyond physicians’ reach
Free online access to medical journal articles must be the norm

By P. Logan Weygandt
8:00 a.m. EDT, April 29, 2012

In a small, rural, rust-belt town there sits a nondescript office building not far from the town square. The building is an unassuming amalgam of storefronts, offices and vacancies. Near one of the offices, there hangs a shingle: “Psychiatrist’s Office.” Patients arrive faithfully, dutifully awaiting the chance to receive comprehensive, compassionate care and the most appropriate medicine for their maladies.

My mother runs this clinic, striving to provide the best and most cost-effective medicine possible. She must avoid extraneous expenses so that her patients are able to access quality care despite the depressed economy. Without the resources to purchase all the necessary but expensive journal subscriptions, many of which cost hundreds to thousands of dollars per year, she is unable to access the most recent medical discoveries that would benefit her patients. At times, she has had to call upon me — a medical student at Johns Hopkins not yet in clinical practice — to seek out current studies and provide synopses of the most recent science. She should not have to resort to such convoluted means to obtain information that is so vital for her patients’ well-being.

In our outdated system of disseminating research papers, the information vital to human medicine sits locked behind paywalls. If you’ve ever tried to open the full text of a journal article, you’ve likely faced a prompt demanding $15-$32 per article reader fee. Two of the largest scholarly publishers, Elsevier and the American Publishing Association, have invested untold sums to push for industry-friendly legislation that would keep this lifesaving information from the hands of the physicians charged with caring for our country’s injured and ill.

Continue reading here

Don’t Pay Twice campaign featured in the British Medical Journal

Posted in Open Access by reshmagar on April 23, 2012

Don't Pay Twice campaign featured in the British Medical Journal

What’s the campaign about? For more information go to –
Thanks to the British Medical Journal for permission to put this up on (for a link to the article go here:

Earlier this year, the publishing industry attempted to take away the public’s access to taxpayer-funded research through the Research Works Act (H.R. 3699).

The bill threatened to charge the American public twice for taxpayer-funded research: once to fund the research and again to see the results. It would have deprived patients and physicians of the latest advances and slowed the pace of innovation so central to American leadership in science and technology.

Halted by the efforts of patients, students, and taxpayers, the Research Works Act was pulled by its legislative sponsors just hours after Reed Elsevier withdrew its officials support of the bill. In their strategic withdrawal, Reed Elsevier made clear it was not motivated by a change of heart, but by the overwhelming opposition and outcry, to the bill.

But the job to bring public access to taxpayer-funded research is not done. Support the Federal Research Public Access Act (H.R. 4004/S. 2096): shorten the embargo period to no more than six months, not a year, to public access and extend this practice from NIH to other key federal research agencies.

It’s the right thing for students, patients, and the economy.

Sorry for the extra-long hiatus.

Posted in Medical School (General), PharmFree by reshmagar on April 15, 2012

This year has been something else. It’s been fun, devastating, satisfying, frustrating, and more all at once. I can safely say that I am confident I chose the right career path. As sad as this may sound, I really love working at the hospital. I love saying hello and good morning and smiling to everyone who walks by and talking to patients who most of the time think I’m in high school. I love working with the whole team to figure out what’s going on with our patients. I even love the cafeteria…especially now because post-call, chocolate chip pancakes really hit the spot. So all in all, that’s good. I’m pretty relieved about all of this. Hopefully, this love will be reciprocated and my patients one day will enjoy having me as their provider.

Anyhow, I’ve neglected this blog for way too long. It’s been a very busy year and during my free time, when I had hoped to update this, I instead decided to sleep, catch up with friends, or do non-productive things like watching way too much television on my computer or go to websites like this.

But I’ll be back in two weeks. I will be officially done with third year and taking a couple years off to serve as the American Medical Students Association PharmFree Fellow and then go to grad school. I’ll definitely be updating this with various things I’m working on or the many articles/emails in my inbox that I’ve archived for later. 

In the meantime, see how your medical school did on the 2011-2012 PharmFree Scorecard in terms of their conflict of interest policies.


S. 27: Preserve Access to Affordable Generics Act

Posted in Uncategorized by reshmagar on November 15, 2011

Ending Pay-For-Delay Deals Could Raise over $5 Billion
November 8, 2011
By GoozNews
The deficit reduction “super committee” charged with coming up with $1.2 trillion in budget reductions over the next decade shouldn’t let this one pass. The Congressional Budget Office today estimated that ending drug industry “pay for delay” deals with generic manufacturers will save the federal government over $5 billion over the next decade.

The “Preserve Access to Affordable Generics Act,” sponsored Sen. Herb Kohl, D-Wis., with eight co-sponsors, including two Republicans, requires that any deal between two companies that delays production of a generic drug after a patent has expired must show that the deal is “pro competitive,” which would effectively ban the practice. The Federal Trade Commission issued a report a year ago that found 66 of these deals reached over the past half decade were costing consumers about $3.5 billion a year.

Pharmaceutical industry lobbyists succeeded in stripping an earlier version of Kohl’s bill from the health care reform law. At the time, CBO had estimated it would save the government about $2.8 billion. Now, with Lipitor coming off patent and several more blockbusters to follow, the stakes are considerably higher. The latest CBO report estimates the legislation will save Medicare and Medicaid $4 billion by lowering drug prices between 2012 and 2021. Over the same time period, the government would generate about $800 million in additional taxes and reduce administrative expenses by about $400 million.

This bill’s a no brainer. If the Super Committee recommends further cuts to Medicare and Medicaid without ending pay for delay deals or requiring drug and biotech companies to offer Medicare the same low prices they offer Medicaid, consumers and patients will know who won the behind-the-scenes lobbying battle now raging on Capitol Hill.

Why I’m even more skeptical about a Novartis exec joining the Gates Foundation

Posted in Health Rights, Human Rights, PharmFree by reshmagar on October 19, 2011

From MSF India – still unclear as to why a executive coming from a company that is trying very hard to deny access to an affordable version of a key life-saving leukemia drug is joining the Gates Foundation, an organization that prides itself in providing inexpensive vaccines and other drugs to developing countries worldwide.


Médecins Sans Frontières briefing note, 4 October 2011

Swiss pharmaceutical company Novartis issued a press statement last week in
response to the growing concerns regarding its latest legal challenge
against the Indian government. Ahead of the next hearing of the case in the
Indian Supreme Court set for 17 October 2011, Médecins Sans Frontières
addresses the issues Novartis raised in its statement.

BACKGROUND: The Supreme Court case is the final act in a legal battle over
the patentability of the salt form of the anti-cancer drug imatinib and
section 3(d) of the Indian patent law that stretches back over five years.
In 2006, the Indian patents office ruled that Novartis did not deserve a
patent for imatinib mesylate, a salt form of a life-saving cancer drug, on
the grounds that the application claimed a new form of a drug too old to be
patentable in India (see notes below). The company then embarked on a series
of lawsuits against the Indian government including the one that is
currently pending before the Supreme Court. In this case Novartis is
challenging a part of India’s patent law – Section 3(d) – which read with
other provisions of the patent law and the Madras High Court decision says
that a new form of a known medicine can only be patented if it is not
obvious and shows significantly improved therapeutic efficacy over the known

*What Novartis says: “price doesn’t affect access to medicines”.*

In its statement, Novartis writes “Acknowledging innovation by granting a
patent is unrelated to the access to medicines issue. Improving access to
medicines is a matter of making medicines available.”

This is not the entire truth. MSF has found, during its field experience in
working in many developing countries, that granting a patent has had a
direct bearing on access to affordable essential medicines. Granting a
patent on a medicine provides the patent holder with a monopoly on that
medicine, which in turn allows the company to charge a high price in the
absence of any generic competition. In fact, improving access to medicines
is a matter of not simply making the medicine available but also making it
affordable for patients and governments to buy. This is well documented.
When AIDS treatment first became available in the late 1990s, the price of
first line patented AIDS medicines was – even after discounts – US$10,439
per patient per year. Millions died in developing countries, particularly in
Africa, as prices were too high. Generic competition brought prices down
making treatment possible. In MSF’s experience, patents on medicines are a
key barrier to making medicines affordable, as it prevents access to those
who cannot afford it.

*What Novartis says: “this case will in no way impact access to medicines
to poor countries”. *

This is not true. If Novartis succeeds in weakening the interpretation of
section 3(d) for the purpose of obtaining a patent on imatinib mesylate, the
Indian Patent Office would have to apply the same standards of intellectual
property protection as wealthier countries like the US, granting far more
patents than required under international trade rules or envisioned by
India’s lawmakers.

It is not only about this particular medicine. The interpretation of the
clause has a direct bearing on the examination of patent applications
claiming salt forms, pediatric formulations and other improved formulations
of AIDS drugs, the generic versions of which are currently used by MSF in
its medical projects. This case would set a precedent in this regard.

This could lead to generic competition on many essential drugs ending
entirely and prices for these in both India and developing countries
increasing. This would have a devastating impact on not only people MSF
treats, but also on people the world over who rely on affordable medicines
manufactured in India. MSF buys 80% of the ARVs it uses to treat 170,000
people for HIV across the developing world from Indian generic
manufacturers, and donors rely on Indian sources in similar proportions.

It is crucial to preserve the public health safeguards of Indian patent law
– particularly Section 3(d). The future of generic production is largely
dependant upon the outcome this case.

Imatinib mesylate is a crucial anti-cancer drug sold by Novartis in India
for Rs.120,000 (US$ 2,400) per patient per month. Indian generic companies
sell generic versions for Rs. 8 – 10,000 ($160 – 200) per patient per month.

*What Novartis says: “Section 3(d) – as it relates to evergreening – is not
applicable at all to Glivec”. *

Novartis is seeking a patent in India on the salt form of imatinib (Glivec).
Claiming a patent on a salt form of an existing drug is a common and
well-known form of evergreening by pharmaceutical companies to extend the
patent life – and monopoly – of their drugs. And companies do this routinely
to prevent generic competition. An example of this is the AIDS drug
abacavir. Although the abacavir molecule was first developed and patented in
the 1980s, pharmaceutical company GSK applied for a patent in 1997 on
abacavir sulphate (salt form) in developing countries, with the intention of
obtaining a patent monopoly until 2017. Where the patent was granted this
has blocked access to affordable generic forms of abacavir in many
developing countries.

*What Novartis says: “Glivec has been granted a patent in nearly 40
countries and India should also follow suit”*.

This is a mistaken interpretation of international intellectual property
rules. Although the TRIPS Agreement obliges all members of the World Trade
Organization to grant patents on medicines, nothing obliges developing
countries like India to replicate patent systems of wealthy countries. An
important flexibility in this respect is the right of WTO Member States like
India to define the patentability criteria in accordance with their
particular national priorities. This is precisely what India did when it
amended its Patents Act in 2005. At the time of implementing TRIPS, India
felt that many countries were granting a large number of patents on new uses
and new forms of known medicines, which was becoming a key reason for
creating longer patent barriers and high prices in developing countries. So
along with patent protection for new innovative medicines, Indian lawmakers
introduced a specific provision, section 3(d), in its patent law that
excludes from patentability new uses and new forms of known medicines. The
system India has is not perfect, but it does prevent drug companies from
getting unjustified 20 year monopolies every time they come up with a new
use or a new form of a known medicine.

*What Novartis says: “medicines can be made available through access
safeguards in international agreements and, in the case of essential and
life-saving medicines, special pricing arrangements in developing
countries”. *

While this is correct – countries have the legal flexibility to issue
compulsory licences to generic producers on patented drugs where it hinders
access to essential medicines – measures like tiered pricing in our
experience are not the most effective way to make medicines affordable.

Novartis also seems to imply that countries can only act once patents are
granted. However, a lesser known key TRIPS flexibility is the right of a
country to take steps before a patent is granted to ensure that patent
applications on routine and obvious improvements of medicines are not
granted so that they do not disrupt supply of affordable generic medicines
to patients. India has chosen to adopt this safeguard with the introduction
of Section 3(d) in its patent law, while allowing patents to be granted on
new medicines from 2005.

*Notes for the editor: *
The basic molecule imatinib was first patented (US 5521184) in 1993. India
signed the WTO TRIPS agreement in 1995 and opened up filing of product
patent applications in India. In 1998, Novartis filed an application
1602/MAS/1998 on the mesylate salt of Imatinib. This case relates to the
1998 application.

Financial Times: Novartis executive to join Gates foundation

Posted in Health Rights, PharmFree by reshmagar on September 14, 2011

This makes me slightly uncomfortable…

September 13, 2011 9:03 pm

Novartis executive to join Gates foundation

By Andrew Jack in London

A top executive at Novartis is to join the Bill & Melinda Gates Foundation, cementing strong co-operation between leading pharmaceuticals companies and the world’s largest philanthropic organisation.

Trevor Mundel, 51, who heads of global development at the Swiss-based drug manufacturer, will in December take over as head of global health at the Seattle-based Gates Foundation, responsible for its $1.5bn annual budget, funding the development of new drugs, vaccines and diagnostics.

The decision is likely to herald fresh support for the drug companies’ commitment to tough intellectual property laws and support further Gates funding of their research, including for Novartis, which is already one of the most active in researching drugs and vaccines for diseases of the developing world.

However, it may antagonise some health advocates who have criticised patents – fiercely defended by drug companies – as providing a barrier to affordable access to medicines for the poor. Novartis has been in the forefront of the clash, as it gears up for a fresh defence of its patents in India for Glivec, a costly cancer drug.

Tido von Schoen-Angerer, director of Medecins sans Frontieres’ essential medicines campaign, said: “It is worrisome to see yet another industry executive in this powerful global health position. While he brings important skills to the Gates Foundation’s product development work, his new role is broader and includes shaping access and other health policies. The foundation will likely alienate many in the global health community, given Novartis’s relentless attacks on the Indian patent system to weaken access to affordable medicines.”

Mr Mundel becomes the second incumbent at the Gates Foundation with a background in the pharmaceuticals sector following Tachi Yamada, the former head of research at GlaxoSmithKline, who stepped down from his role as head of global health in June after five years.

Novartis is one of the drug companies with the most relevant experience for the Gates Foundation. It sells at cost large quantities of Coartem, the pioneering and highly effective malaria treatment, and donates drugs for other illnesses, including leprosy.

Mr Mundel said he had had little direct experience on drugs for the poor, stressing instead his past work on medicines, including Gilenya for multiple sclerosis and Ilaris for a rare inflammatory disease. But he highlighted his work in operating a research centre in Hyderabad in India.

“The Gates Foundation has a somewhat pharmaceutical [industry] problem or opportunity: a large portfolio of projects,” he said. “You have to accept there will be a certain attrition, find a way to focus your resources and [impose] data-driven milestones.”

AMSA Response to USTR Proposal for Trans-Pacific Partnership Agreement

Posted in Health Rights, PharmFree by reshmagar on September 14, 2011

On Tuesday, the US Trade Representative Office released a white paper with a proposal towards the Trans-Pacific Partnership Agreement. Document is attached below:

White Paper

Highlights and summary:

As part of this initiative, the Office of the United States Trade Representative (USTR) has
presented a variety of trade proposals to TPP partners that are aimed at promoting access to
medicines in TPP partner markets. These proposals are the product of a new strategic initiative,
Trade Enhancing Access to Medicines (TEAM), which is designed to deploy the tools of trade
policy to promote trade in, and reduce obstacles to, access to both innovative and generic
medicines, while supporting the innovation and intellectual property protection that is vital to
developing new medicines and achieving other medical breakthroughs.

The TEAM initiative reflects fresh thinking about trade and access to medicines. It is about
more than allowing access to medicines. It is about working with trading partners to develop
strong and common standards to help drive access – propelling the TPP countries to the front of
the line for important innovative medicines and for generic competition, while promoting U.S.
jobs and exports.

The paper goes on to list a set of goals the United States along with the countries under the TPP would address. Great goals, but not really a clear sense of how the goals would be achieved.

Knowledge Ecology International commented:
One has to read between the lines, and guess what the White House is trying to say (or avoid saying plainly). It appears as though USTR will demand TPPA partners agree to several years of exclusive rights in regulatory test data for new medicines, including biologic drugs. What we don’t know is how many years, when the clock starts to run, or how iron clad the protection is expected to be.

The Wall Street Journal published an article about this as well with an excellent comment from Peter Maybarduk, Public Citizen (+1.202 588 7755, +1. 202 390 5375,
It is insulting that USTR has released this paper on ‘access to medicines’ on the same day that it has tabled its most controversial and access-restricting provisions at the Trans-Pacific FTA negotiations — and then failed entirely to address those provisions, or the other access-restricting elements of its aggressive intellectual property proposal, in this paper. The Obama administration is heading rapidly in the wrong direction, at the expense of global public health. This paper is primarily window dressing for USTR’s pro-Big Pharma, anti-access to medicines status quo.

Another set of comments I quite enjoyed:

Sean Flynn, American University
The statement of the administration today continues its practice of actively thwarting the release of meaningful information about its positions in closed door international law making. The statement says little about what the administration’s actual trade policy on medicines issues is or what justifies it.
It does not explain any of the positions it has taken in the leaked intellectual property proposal;
It does not explain what its position is in the bracketed text on data exclusivity, patent term extensions or patent-pharmaceutical linkage;
It does not answer whether it has abandoned the May 10th agreement between the Bush administration and Congress safeguarding some TRIPS flexibilities in developing countries;
It does not include any evidence supporting how its policy positions promote access to medicines.
Thanks to leaked proposals, we know what the administration’s actual position is. This administration has endorsed a set of policy proposals in its trade negotiations with developing countries that is much worse for access to medicine concerns than those of any other past administration.
The administration is proposing to:
Grant patent rights on substances that are already discovered,
Increase in-transit seizures on medicines,
Extend monopoly rights through data protection that operate independent of patent rights,
Get rid of the so-called “May 10th” deal between the Bush Administration and Congress protecting key access to medicines flexibilities in developing countries,
Add a first ever restriction on the operation of pharmaceutical reimbursement programs as a cost saving mechanism in developing countries.
Calling this an “access to medicine” policy is Orwellian.

AMSA also released a response as well:

The American Medical Students Association (AMSA) appreciates the opportunity to offer comments on the proposed Trans Pacific Partnership Agreement (TPPA). As the nation’s oldest and largest independent organization for physicians-in-training representing more than 35,000 members, AMSA supports global health equity through international agreements that secure patients’ rights to life-saving medications in resource-poor settings and encourage investment in public health as outlined in the Doha Declaration.

AMSA strongly urges a revision of the proposed TPPA to ensure access to essential, affordable medicines for patients living in TPPA negotiating nations including the United States. It is critical countries be permitted to engage in parallel importation to ensure citizens’ access to inexpensive medications. Therefore, we recommend that the TPPA refrain from granting copyright holders the right to prohibit importation of their works. Consistent with President Obama’s 2012 budget proposal request, AMSA strongly urges that the term for data protection be limited to 7 years for biologic products. Similarly, pharmaceutical companies should not be eligible for new 20-year patents based on minor modifications to existing products that do not meaningfully benefit patients. Such provisions would allow for timely access to generic medications for suffering patients that could save lives.

When will governments and even pharmaceutical companies realize that their responsibilities should be for their constituents/clients rather than profits?

Difficult Patients.

Posted in Doctoring, Medical School (General) by reshmagar on August 30, 2011

A few weeks ago for my family medicine rotation, we were asked to write about a difficult patient encounter. I’ll share with you all what I wrote as this pretty much sums up how I feel on a daily basis on this rotation.

During my first few days at my site, I have not had an extremely difficult patient or interaction that has stuck out in my mind more than others. In fact, almost all of my patient visits have been a bit difficult in a strikingly similar way. None have been difficult because the patients have complex, multi-systemic illnesses or because they were extremely abrasive. Most of the patients have a trusting relationship with my mentors and get along with them well, regardless of their condition. Instead, I found the patients regardless of their age or background to be difficult not because of their presentation but because of what my mentor and I couldn’t do for them.

From one patient to another, I’ve seen a pretty similar problem list – high blood pressure, high cholesterol, and prediabetes/diabetes. Many also are overweight or obese. Many others used tobacco. The age of the patients ranged from elderly women who were now afflicted with COPD and other chronic conditions to teenagers just entering middle school. The blood pressure and diabetes were easy to manage by either titrating up their medication, refilling current prescriptions, or adding another to their daily cocktail when what they were already taking wasn’t cutting it. While my mentor and I were in the back discussing the patient and grabbing any samples they might need, my mentor would lean over to me and say, “Now comes the hard part. We have to talk to them about their weight/smoking.”

We always left the best for last, jokingly bringing up the smell of cigarettes we noticed as soon as we stepped into the exam room or asking them if they remembered what the doctor had discussed with them the last time (this usually was their cue to say “You told me I needed to lose weight…” and smile sheepishly). It was almost like watching a play where different patients played the same character repeating the same lines over and over again. My mentor reminds them of their promise to lose weight or stop smoking from the last visit. The patient would look away while my mentor reads out their weight changes or tells them again that they were at risk for COPD. Often times, the patient will then say, “I know, I know. I’m trying to but it’s just not working.” End scene.

Maybe it’s the comfort of knowing that the patient will return within a few weeks or months. Maybe it’s past experience of having patient after patient who comes in with increasing weight or no change in their smoking habits. Maybe it’s a mixture of both but this would be the point where my mentors give vague suggestions about how to lose weight or stop smoking – eat more fruits and vegetables, less carbohydrates and junk food, start exercising, stop eating out, stop smoking, do you want the patch, do you want Chantix, do you want gum. The patient nods along, answers appropriately before agreeing with the doctor that yes, things should change.

I find these encounters the most difficult. I always make it a point when talking to the patient about their treatment plan try to give them a concrete goal to achieve by the next visit that more often than not, surprises them, as they cannot give their usual responses. Instead, they now have to reserve to responses my mentor and I don’t like such as “no” or “I don’t know” or “maybe next time”. One patient came in for a routine follow-up exam was surprised to hear she had gained weight within the last month. I asked her further about eating and activity habits and found out that during the summer, she wasn’t working and instead sitting at home more. Additionally, although her portions at meals had become smaller, she was still eating a lot of starch-heavy foods and soda. When I told her about programs in her community that offered free group exercise classes as well as websites with recipes, she was startled and sputtered out “no” saying she could not see herself exercising in front of others. I instead tried to tailor some exercise around walking her dog and received a vague “I’ll try” to that. I left the room feeling frustrated and voiced my concerns to my mentor who nodded in commiseration and responded, “You did what you could do. She’s hopeless.”

This happened again the next day with a 17-year-old girl who reported smoking a pack-per-day since she was 13 years old. I was later shocked to find out that her mother had a similar history and now was suffering from severe COPD. I asked the girl if she would like to quit smoking to which she said she would but didn’t know how. I told her of the various options and suggested maybe trying to cut down on the number of cigarettes over the next few weeks before we saw her again. I set the goal as a half-pack per day and offered the patch. She nodded and said, “yeah, okay we’ll see.” I tried other tactics – bringing up her mother’s history and telling her that while her mother’s condition was irreversible, hers wasn’t. I also did a lung exam on her that showed decreased breath sounds and wheezing. She told me that she noticed she lost her breath often to which I responded that it was possible for her to not feel like that anymore by not smoking. At the end of the visit, despite the positive responses I had received from her, I got the feeling that she would return as she was today – looking older than she is and reeking of cigarette smoke. I could only hope that she would at least try this month and that my shpiel would be repeated again.

I tell myself I should be patient and that in time, there will be some patients who change and some who don’t. It’s difficult though to watch them walk out the door and wait for the next time they would come. It’s difficult to think that they will often walk out the door and my mentor will either wait till the next time or just give up somewhere down the line in order to preserve their relationship with the patient. I understand the reasoning behind this but I wish I could do more…or at least do something.

If only this was the perfect solution…

Posted in Medical School (General), Patient Quality and Safety by reshmagar on August 9, 2011

A while ago, many of my friends in med school posted this article from the The New York Times Health Blog – lauding the innovative method the doctor used to counsel her patient about their medications. To summarize the article, the author, a physician had a visit with one of her usual elderly patients who was chronically ill with diabetes, hypertension, and high cholesterol. Like many who are chronically ill, the patient had over time been prescribed a slew of medications which he brought to the visit and was confused as to when to take each of them. Turns out he was unable to read the pill bottles as well as the directions the doctor had written out for him the visit before. To solve this dilemma, the author worked painstakingly on a new set of directions;

Mr. M and I opened up his pill bottles. We extracted a pill from each and taped it onto a piece of paper. I drew a sun next to the ones that needed to be taken in the morning, and a moon next to the ones for nighttime. He left my office with sheet of brightly colored pills, a rainbowlike guide that I hoped would offer him access to the quality medical care he surely deserved.

I first came across this article posted on Facebook by some of my friends stating that this would be a great way to tackle non-compliance amongst patients. From my last rotations in psychiatry and Ob/Gyn, I frequently see patients struggle to take their medications at appropriate times for a variety of reasons – sometimes they just don’t like the way the medicines make them feel or feel like they don’t need them or other times, they are unable to access them due to loss of insurance or funds. I read the article hoping to find new insight into this topic only to find an interesting anecdote on patient health literacy and a good method for the patient described in the article.

Regardless, I do agree with the author’s approach to her patient in that she actually spent time to explain the medication regimen. During my first year of medical school, I worked with an Urgent Care Center physician who taught me from day one the importance of not only writing out instructions for the patient and explaining the treatment plan to them but also the need to spend time asking the patient what they understood the regimen to be. In the hospital setting and in other clinics, time is precious and often, patients leave with a stack of discharge instructions with paragraphs regarding their condition and medications as well as prescriptions they have to pick up on their own time. We often at our hospital triage see repeat patients who failed to follow-up with us as directed or pick up their medications causing their medical condition to exacerbate. They return often more sick than necessary and a new treatment plan has to be created. Some are even admitted.

In looking at the problem of health literacy, there are certain pragmatic factors to take into consideration to ensure that patients upon leaving the hospital understand their treatment. For many doctors, time is a limiting factor. In most medical practices including primary care practices, follow-up appointments last approximately 15 minutes. In this time, not only does the doctor have to address any immediate concerns that the patient has, but they also have to ask questions to ensure that they are no other health issues going on the patient may be unaware of as well as a modified physical exam. Usually, the physician also spends a minute or less going over any results and their recommendations.

Additionally, physicians often schedule patients back-to-back which means that any additional time taken with one patient going over medications takes away time from subsequent patients. With the impending shortage of primary care doctors, it is not possible right now to take on less patients. The Affordable Care Act will provide much-needed health care to millions of new patients who will all require a primary care doctor. In line with this, however, there are provisions to build more community health centers but no clear provisions to increase the number of primary care doctors. Until there are more students going into primary care and more incentives to do so such as a salaried position or less overhead costs in a private practice, doctors will probably not be able to spend an extra 15-20 minutes with patients who have complex chronic diseases along with other social issues such as being illiterate. At least, not on a regular day.

During gynecology, one of my attendings set aside one day per week for a chronic pelvic pain clinic where she tailored care for each patient that included long sessions with each person along with regular emails and phone calls. Perhaps, this is the solution in primary care we need. A day set aside for the most complex patients to spend longer amounts of time to construct a comprehensive plan. Rather than being sent to a chronic care specialist, patients who see their primary care doctor more often will get regular check-ins to ensure they understand the plan completely.

Another solution proposed has been to hire a nurse or other practitioner who after each visit will sit down with the patient to go over their treatment plan and check-in with them. This, I also do not see as realistic. With rising overhead costs from the lightbulbs and toilet paper in the practice to paying the billing specialists and receptionists and more and more primary care doctors closing their practice due to these costs, it seems unlikely that hiring someone else to sit down with patients after their visit is a sustainable solution.

Today, I start family medicine. I have no idea where I am going to be placed but I do wonder if I will encounter a similar situation to the one detailed in the New York Times health blog. I would like to think that I will spent the extra time needed but what if my attending expects me to finish the visit within a certain period of time (which has happened) before moving onto the next patient? Then what solution will work then? Will I allow the patient to walk away with a confused look on their face and a statement along the lines of “Well, if you have any questions, feel free to call or email. Okay?” That makes me uncomfortable especially after recently realizing that I am more at peace immediately constructing a flowchart plan and wanting to actively try the best algorithm as soon as possible. I am not comfortable with expectant management usually…but I guess, we’ll see what happens with this rotation.

Does anyone know of solutions to this that have worked that they’ve seen implemented? Any input on this would be much appreciated.