WHO’S YOUR DOCTOR?*

You have 13 to choose from. Well 12, surely no one is going for number 7….?

Are you avowedly old school? Or only familiar with the reboot?

I’m clearly not talking about a GP, and I worry for your social engagement if you haven’t worked it out.

I’m not tragic enough to have gone to the cinema to mix with the Whovians, nor did I turn on the TV at 4.50 am, although I was sorely tempted. However, by 2 pm Sunday, ABC iVew had delivered me a very satisfactory 70+ minutes viewing and a problem.

I was already struggling to choose between Tom Baker and David Tennant when the inimitable John Hurt was thrown into the mix. Now, the tour de force that was Peter Capaldi’s debut has made it an even more difficult choice. So, just how many favourites are allowed?

It did take me nearly an hour to stop expecting the sort of profanities he so acerbically delivered as Malcolm Tucker in In The Thick Of It, but that in no way detracted from Capaldi’s performance. I never doubted he could do it, but I am prepared to admit I would not have been surprised if it had taken a couple of episodes for it to all really gel. It didn’t, it all works so well. I think it was genius having Madame Vastra, Jenny and Strax as part of the first episode – writing for Strax must be an absolute joy. And I fully expect to see the return of River Song in this series. A LOT of River Song!

My Sunday evenings are locked in for the next little while.

*I think mine is Tennant, but I am not prepared to fully commit to that until I see a bit more of Capaldi. 

AGAIN. REALLY?

What has big pharma learned from the Vioxx debacle? Apparently nothing.

Well done Boehringer Ingelheim. You’ve tainted the entire industry.

OK, so you say that the information withheld from regulatory bodies about an optimal plasma concentration range for Pradaxa, and therefore the benefits of close monitoring, did not hold up when assessed in the context of the major clinical trial. Further, that the article in the BMJ1 is ‘biased’ and contains ‘innuendo’ and ‘misleading statements’. Entirely plausible, truly. So why withhold all the data on bleeding rates? They were specifically requested by the FDA. Why provide only the most favourable analysis when it would have been so easy to include all the analyses conducted with appropriate explanations and disclaimers? The information was going to a scientific body, not the general public.

Now it’s a ‘story’. And it is of no consequence that major regulatory bodies – including the TGA – have said that access to the information would have made no difference to the recommendation for listing. Now the underlying mistrust of the public towards most large institutions has been validated, because, rightly or wrongly, the sound bites that come out of this story and stick in the collective consciousness are:

  • a large pharmaceutical company lied to get a drug approved and make a profit
  • this drug has put patient’s lives at risks
  • it must be true because in the US the company has
    • been ordered to pay nearly $1m in fines for withholding information
    • set aside $650m to settle approximately 4,000 lawsuits related to serious bleeding.

Super effort!

 

1. Cohen D. BMJ, 2014; 349: g4670.

ONE STEP FORWARD, HOW MANY STEPS BACK?

Last week, a NSW coroner made an extraordinary finding. Extraordinary because it’s hard to believe such a finding has never been made before. Extraordinary because – at the request of the family – it was made public prior to the release of the entire report. And extraordinary because, despite the specificity of aspects of the statement, the media has failed to understand the implications of the finding, and has slipped into its usual easy ‘blame-game’ space when discussing this illness.

Last week, a NSW coroner directly linked a suicide to anorexia nervosa. But just as importantly – even more importantly really – he described this disease as ‘complex’. I don’t expect anything much to come of this. I was initially pleased that it got any media coverage at all. But that quickly turned to dismay as commentator after commentator trotted out the tired old line about ‘unrealistic media depictions of the female form’ as a ‘cause’ of anorexia.

As a society we have no difficulty accepting supposedly ‘physical’ illnesses as complex entities. No one believes that low exposure to vitamin D in childhood ‘causes’ MS. Or that a virus ‘causes’ type I diabetes; nor high salt ingestion hypertension. There is an inherent acceptance that these are complex chronic illnesses that require a coalescing of multiple factors in order to develop.

Why then are we constantly bombarded with the fallacy that a disease as complex, severe and all encompassing as anorexia nervosa can be attributed to a simple, single cause? And a cause that ignores the obvious physiological aspects at play when this disease first manifests clinically, and during relapses. Are we still, as a society, so scared of psychological illnesses that we feel obliged to take a reductionist viewpoint? We do everyone who lives with this – and other mental illnesses – a huge disservice by perpetuating the concept of simple causality, and seeking a scapegoat.

This disease is a perfect storm of physical, psychological, emotional and cognitive factors. Among those women, men, girls and boys for whom societal expectations of a particular body shape have been at play during the prodromal phase, it becomes of little consequence once the illness has taken hold.

So, I applaud the insight of Coroner Mark Douglass, and can only hope it is the beginning of something positive for the understanding of a disease with a fatality rate so heartbreakingly high we would never tolerate it for a physical illness.

Disclosure: I have had anorexia for over 20 years.

THE BUDGET

Wow.

Just wow. Cruel doesn’t even begin to cover it.

After this I’m going to confine my comments to health, but when the youth rise up and slaughter us in our beds, I’ll understand.

The PBS – officially at least – appears to have dodged a bullet vis-a-vis the Commission of Audit. That said, we have no idea what sort of pressures will be brought to bear to limit the numbers and costs of newly listed medicines.

The $7 co-payment to GPs goes far beyond the supposed ‘two middies of beer, or 1/3 of a pack of cigarettes’ for a low-income earner (nice bit of profiling Joe, way to let everyone know how you view people not earning as much as you). The first $5 is to cover the reduction in the rebate for each consultation, and the other $2 is “for the GP to do whatever they want with”. Super! That’s $50–$80 a day for the GP to cover the additional administrative costs of invoicing each patient and reporting to the government. It’s hardly a windfall. In fact, it will hardly cover costs. Is it realistic to expect those (few) practices that do bulk bill to wear the economic and emotional costs – because there will be emotional costs – of a policy that provides NOT ONE CENT for primary health care. I’m all for a government funded medical research foundation, but this is neither a sensible, nor sustainable, nor equitable way to provide it.

But the real kicker has to be the proposed changes in funding arrangements for health (and education) for the states. The outrage from the – largely Coalition – Premiers has warmed my heart. Here’s hoping they can actually present a coherent and united opposition to this measure. It, more than anything else, has the potential to substantially compromise public health in this country.

 

DOUGLAS ADAMS IS A GENIUS

Of course, that’s an obvious statement to anyone who has read him. If you haven’t, you should.

I am certain he will be, in the near future, recognised as a philosopher every bit as important as any of the ancient or 18th and 19th century philosphers whose names are familiar.

His genius lies in his ability to present really deep concepts wrapped in a fluffy jacket of humour.

While I take note of his warning (when discussing PG Wodehouse) of the dangers of taking a quote out of context and thus rendering it less wonderful, I am going to present 2 of his ideas that I find particularly fabulous.

‘Time is an illusion; lunchtime doubly so.’

What I love about this – apart from the obvious making you think about the way we commonly view time – is his use of the word ‘illusion’. He could have chosen ‘construct’. The idea would still have been communicated, but by using ‘illusion’, he imbues the idea with an emotion that would otherwise have been lacking.

SEP – somebody else’s problem. A fact so huge, so life-altering, so able to trash ideas you have held onto as gospel, that when you are confronted with it, you simply don’t acknowledge it. Beautifully illustrated in the Hitchhiker’s trilogy (5 books incidentally) when a spaceship, shaped like an Italian bistro lands in the middle of Lords Cricket Ground at the end of an international test match, and everyone ignores it.

Read Douglas Adams, he can change your life, at least for an afternoon.

THE PROBLEM WITH THE MA CODE OF CONDUCT

I’m sure everyone who works in healthcare advertising can agree that a Code of Conduct is generally a good thing. We are dealing with substances that, if used incorrectly, can cause great harm. So ensuring that the way we communicate the attributes of pharmaceutical products is balanced, fair, and most importantly correct, benefits everyone. However, I’m also sure that everyone regularly curses the increasingly ridiculous restrictions placed on us by Medicines Australia. Personally I think the nadir was when they took away our adjectives, but that’s very much a writer’s perspective.

I think the real issue is not so much that we have a highly restrictive code of conduct, but that the people who decide what can and can’t be communicated, and the manner in which that communication can and can’t be carried out seem to believe that our audience – highly educated, intelligent individuals – have the mental capacity of my 6-month old niece. No one is immune to marketing, but I have yet to meet a member of the medical profession who is unaware that when a product rep drops by, or a piece of direct mail hits the desk or the desktop, the primary purpose of that interaction is to get them to prescribe a particular product. This is not to say they cannot be led by a pretty image or engaging headline to try a new product, but if that product is not right for a patient they simply will not prescribe it.

So, we have this Code of Conduct and all of us in the advertising industry spend time and creative energy working out ways to subvert it, because that’s our job. The petty bureaucrats at MA who think they are making the world ‘safer’ for I-don’t-know-who by making it increasingly difficult to inform members of the medical profession about drugs and devices that have been approved for sale by the TGA – a body comprised primarily of scientists – cannot win this fight. Pharmaceutical products are legal, and it is legal to advertise and promote their use, and those of us who make it our business to do so have creativity on our side.