Beware the commercial bias

Over lunch I listened to plugs

For some marginal toe-nail drugs

We don’t have any more

Of the big disease score.

We’ve got shots for most of those bugs

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

The first lecture I attended at the American Academy of Family Practice Family Medicine Experience (AAFP FMX) included a very nice lunch, and an unappetizing talk on toenail fungus, or onychomycosis.  I don’t mean that the slides depicting deformed toenails took away my appetite; rather, I found the commercial bias disgusting.  We have new agents that, according to the presenters, work better than the old agents, but at best they bring a 35% cure rate.

The next lecturer, playing by the book, revealed commercial connections to several Big Pharma companies.  The presentation that followed would have bored me to tears if it hadn’t put me to sleep.  The format consisted of study after study in excruciating detail, all research sponsored by drug companies.

But the next two talks had nothing in their full disclosure statements and featured evidence-based meta-analyses with rank ordered recommendations.  One presenter qualified as a gifted teacher and a passable stand-up comedian.  He made the analogy between musculo-skeletal injuries and crime scenes: identifying the victim comes easy, but identifying the culprit takes work and wisdom.  Thus applying ice to a painful knee matters less than finding the weak muscles and tight tendons that led to the problem in the first place.

I have come to terrible cynicism regarding the American pharmaceutical industry.  They make wonderful drugs for the most venal of motives.

In a discussion over lunch, I talked to a doc who has been working in Africa for the last couple of decades.  He helped put the small pox genie back in the bottle, and is very cynical about the possibility of ending polio.  He retired into private practice but prior to a a year ago, he worked for an NGO.  Around the table we talked about how vaccinations have made the biggest changes in our business.  Most docs finishing residency now have never seen measles, mumps, polio, epiglottitis, or periorbital cellulitis.  Polio was rare when I did my training; if my sister hadn’t had it in 1953 I would never had seen it.

Scenes from a convention

I came to get learning specific

In San Diego, out by the Pacific.

I took lots of notes

and paraphrased quotes

But the coincidences were really terrific.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska and an educational trip to the AAFP Scientific Assembly in San Diego.

I walk into the San Diego Convention Center, my third time here for the American Academy of Family Practice Annual Scientific Assembly.  It still smells like San Diego, the ocean, the palms, the sea.  I stride from one end of the Center to the other, counting the steps and making note of the time, further than my commute from my cottage to the Medical Center in Petersburg, Alaska.

I have the handouts in my backpack.  In years past the book swelled from a couple of hundred pages to two thick binders.  Now they exist on a simple thumb drive.  The same backpack carries my iPad and its associated keyboard.  Last time I came I used a smaller keyboard and my Palm to take notes.  Light and easy to carry, it could beam but not email data.

Now instead of a cell phone I have a smart phone, and I download an app that gives me the course listings with times and places and lets me enter my CME (continuing medical education) credits as they happen.  When I first came to the AAFP convention the words smart phone, Wi-Fi, download, and app did not exist; wireless meant radio, usually two-way, in stodgy British, and the word router denoted an electric wood-working tool.  If you said high-speed net service you might have been laughed at but if you used the term repeatedly you would probably get locked up.

The Exhibition Hall stretches for a cavernous quarter mile inside the Convention Center.  Big Pharma, now barred by law from giving out toys, flashlights, pens, or note pads as advertising, concentrates on pitching drugs.  My Community Health Center patients, half of whom have no resources and no money, can’t afford the new drugs.  But I stop at the Lilly booth and thank the reps for their company’s generosity; they give my facility an enormous quantity of insulin for free.

The lecture on smoking cessation strategies features lackluster content and a passionless presenter.  My attention wanders, I yawn, I try to keep myself awake doing carpal tunnel stretches.  I nod off, then I fire up my iPad and read my email.  I look around and see other attendees either with eyes closed or with their faces illuminated by their portable screens.  No one pays attention.  Five minutes from the end of class I pull out my Droid to try to enter my CME credits, and find I can’t do it without a major workaround.

Even if Big Pharma can’t give us advertising freebies, they can serve us fantastic meals and hire gifted teachers to lecture us.  While I munch an outsized turkey sandwich I marvel at the teaching effectiveness of an FP from Pennsylvania.  She speaks with dynamics and enthusiasm and imparts information I’ll retain after the drug comes off patent.  Except she never mentions a new drug or even an old drug; she talks about urine sugar reabsorbtion and diabetes.

Bethany and I sit down to lunch the next day with a young doc in the Indian Health Service; she nurses her infant while we talk.  At the end I challenge her to keep track of her hours for two weeks, use that number to figure out how much she’s getting per hour and compare that rate to locum tenens.

I run into a doc I knew in residency; I run into him six times more in the course of four days.  Then I run into a doc who now teaches in that program.  In the hotel elevator I run into two more FPs who finished the program and still work in Casper.

One evening Bethany and I dine with a doctor who still works at the Practice Formerly Known As Mine.  At the end of the meal we stroll along the marina.  We come to the Vibrant Curiosity, the world’s 60^th largest yacht.  We had seen the 5 story wonder coming up Wrangell Narrows while we were in Petersburg.  We make jokes about how the owner must be following us and the next thing you know it will come cruising up Perry Creek.

True coincidence occurs but rarely.  But I don’t know what it all means.