Negotiations

Mary: "Dr. Grumpy's office, this is Mary."

Ms. Oxy: "Hi, I need to make an appointment to see Dr. Grumpy."

Mary: "I can help with that. Our next opening is..."

Ms. Oxy: "Wait, before you get to that, I need to know how many Percocets Dr. Grumpy will allow me per month."

Mary: "Did you just ask me..."

Ms. Oxy: "Because my current doc only gives me 150 a month. I'm not going to switch unless you guys make this worth my while. I'm thinking 180 Percocet per month would be enough."

Mary: "Okay, we don't work that way."

Ms. Oxy: "Of course you do. Patients are money to you people, and you need the money. All right, let's say 170 Percocet. I'll settle for that."

Mary: "I think you should stay with your current doctor. It doesn't sound like you're a good match for this practice."

Ms. Oxy: "Okay! 160 Percs a month, and I'll do co-pays in cash, will..."

Mary hung up.

50 Shades of Blue

A few months back I poked fun at Fycompa, a new epilepsy drug with an interesting side effect profile. Little did I realize I'd have the chance to do it again (different drug this time) so soon.


Like neurologists everywhere, I was surprised to hear the news Monday about a newly reported side-effect concerning the epilepsy drug Potiga.

Namely, that it makes people blue.

I'm not talking depression here, either.

Let's look at the official FDA announcement:


"FDA is warning the public that the anti-seizure medication Potiga (Ezogabine) can cause blue skin discoloration... (and) does not currently know if these changes are reversible.

The skin discoloration in the reported cases appeared as blue pigmentation, predominantly on or around the lips or in the nail beds of the fingers or toes, but more widespread involvement of the face and legs has also been reported. Scleral and conjunctival discoloration, on the white of the eye and inside eyelids, has been observed as well."


Now, with that said, I want to remind you that if you look at the side effects of ANY drug, you'll find scary shit on all of them. I'm sure I'll put patients on Potiga, and most will likely do fine. But that doesn't mean we can't have some fun with it.

For one thing, they don't even tell you what shade of blue. There are 45 of them. Some people if given the choice, would like a nice turquoise, while others would prefer royal blue. Hopefully further research will shed light on this important topic.

The interesting part is this: Let's say a patient had a choice between this drug and one with a "YOU COULD DIE FROM THIS!!!" black box warning. Felbatol, for example, while very effective for seizures, has the potential to cause TWO (not one, but TWO) great ways to die: severe liver failure and/or destruction of your bone marrow.

Yet, human nature is such that most people would prefer Felbatol, figuring the risk of death is preferable to that of turning blue. After all, death generally isn't socially embarrassing. We ALL die. But blue skin? That's just not fashionable.

Unfortunately, GSK (the drug's manufacturer) is likely going to see this as a drawback to Potiga. They'll tell their sales reps to minimize it and move on to something else. Or mumble "and they might turn blue" hurriedly under their breath.

The truth is they should turn it around, and make it a strength of their spiel. The best way to do this, as I see it, would be to go after some commercial tie-ins.

I've compiled a few modest examples:


Live theater:

Potiga is a proud sponsor of tonight's appearance by:

Blue Man Group

1960's psychedelic movies:

United Artists

To treat seizures, All You Need is Love. And Potiga.

1970's psychedelic movies:

Paramount Pictures

"Violet Beauregarde has been seizure free on Potiga. Next month she'll be endorsing juicers, too."

2000's movies:

Twentieth Century Fox

Potiga for epilepsy: It's out of this world!

2000's remakes of 1970's psychedelic movies:

Warner Brothers

Potiga is now available as chewing gum for your patients who won't swallow pills. Violet Beauregarde set a world record with it!

Music acts:

Atlantic Records

"We're both proud to be on Potiga. Otherwise we wouldn't be able to drive as safely as we do."

Historical tie-ins:

Bunker Hill: Would history be different if British officers had given their men Potiga beforehand?

Using it as an excuse...

ABC television

"No, officer, he wasn't into that sort of thing. He's that color from taking Potiga."

Currently Potiga is only approved for ages 18 and up. But maybe it will work in kids. If that happens, GSK is fortunate to have a wide range of endorsers to choose from!

Dupuis Cartoons

Shaky Smurf, Seizey Smurf, Ictal Smurf, and Aurette are all doing great on Potiga! If it's right for Papa Smurf, isn't it right for your child?

And, of course, who could forget

Sesame Street

New Potiga powder! You can sprinkle it on all your child's favorite foods! EVEN COOKIES!!!

Thank you, SMOD, for bringing this to my attention!

Tuesday guest post

Today I'm honored to have a contribution from everyone's favorite man-on-the-beat, Officer Cynical!


Today I tried to stop a woman with a revoked license. We went 10 blocks with my lights and siren going, and she acted like I wasn't there.

She finally pulled into her driveway, and rolled down her window. The alcohol fumes rolling out of the passenger compartment were almost visible. She said she'd taken "some pain pills and a few muscle relaxants and maybe some other stuff" on top of it.

I arrested her and headed downtown. On the way to jail, she said she had to go to the hospital because "the left half of my brain is numb." So, to be safe, I took her to ER.

I told the ER doc what she said, and he responded (with a straight face), "Well, that doesn't sound right". He agreed with me that it was more likely the whole brain - not just the left half - that was numb.

He went out to my squad car in the ambulance port and told her, "When whatever you're on clears, if your brain is still numb you can come back." Then he signed off on the jail clearance and we left.

Outstanding.

Memories...

Years ago, Freebase Pharmaceuticals assigned a pretty blond sales rep to my office. Like most reps, she scheduled lunches with us here and there.

One lunch, in spite of the fact that Pissy and I, and our staffs, were there, she decided to try to increase sales by aggressively coming on to me. Asking questions like:


"Does your wife ever travel and leave you alone?"

"I live on the north side. Let me give you my number,  in case you're ever in that area."

"I have a meeting near here this Saturday. Any chance you'll be at your office that day?"


The highlight, however, was what she didn't know.

This was at a time when Mary was out on maternity leave. And filling in for her was Mrs. Grumpy.

Who was sitting directly behind Miss Hooters (who she figured was just the secretary).

So, while Miss Hooters was discussing her pharmaceutical wares and underwares, my wife didn't say a word. She just made faces at me over Miss Hooter's shoulder, occasionally holding up bunny ears behind the rep's head, or the finger, or her sandwich, or whatever office supplies were within reach.

Pissy, who had the same view of the show as I did, pretended to have a coughing fit to keep from laughing, and ran out.

"Dude, does this mean I have to roll my own?"

Actual CNN headline from April 26, 2013:

Dear OBG Management,

A colleague recently sent me a cover shot of this recent issue:

It looks pretty generic on the surface. Just another medical journal. But then you look closer.

A story on surgical robots? Fine. A story about vibrators? Okay. BUT DID YOU REALLY HAVE TO JUXTAPOSE THEM LIKE THIS?

Better living through machinery

I mean, in this sense it looks like an ad for a 1950's horror flick about giant vibrators from outer space, that arrive on Earth pretending to be friendly.

 

Of course, while we're on the topic of juvenile humor, I also noticed this headline in the top right corner:

Thank you, ER's Mom!

I'm stumped

Okay, people, time to see how good you are at being armchair neurologists.

This is an unusually challenging case I saw yesterday, involving a 54 year-old lady. Her internist had referred her to me because of  some recent changes in her vision. The following is quoted verbatim from my chart note:


"She has 2 glasses prescriptions, one for near and another for distance. 1 month ago she had an annual optometry check-up, and was told she needed a new near-vision prescription. She ordered the new glasses, and picked them up last week.

Since then she finds that when she puts on the new glasses things look “funny and unclear.” This resolves with taking them off, and doesn’t occur with the distance-glasses on, or using her previous prescription."


This case really has me stumped. So if any you are able to figure out what the problem is, please write in.

Mary's desk, April 23, 2013

Guy walks in, stands at counter.

Mary: "Hi, can I help you?"

Guy: "Yeah, I want to know if I need an MRI?"

Mary: "Let me look up your chart. When did you see Dr. Grumpy?"

Guy: "I've never seen him. I just want to know if I need an MRI?"

Mary: "I really can't say, sir. I'm not a doctor, but..."

Guy: "I have this neck pain, and my right hand feels numb. So does that need an MRI?"

Mary: "...but I can set you up with an appointment to see the doctor to discuss this. We have an opening Thursday afternoon at 2:30."

Guy: "I don't want to come in. I just want to know if I need an MRI, and if so, to get one."

Mary: "I can't answer that, sir, and the doctor would need to evaluate you before deciding what's needed."

Guy: "You people are just in it for the money."

Leaves and slams door.

Sleep deprivation

I couldn't sleep, so finally gave up and went to the hospital to see a consult that had come in during the night.

I sat at the nurses station and called up the CT scan on a computer. It looked like a stroke, but the dictation wasn't transcribed yet. So I dialed the radiologist covering nights.

Dr. Radar: "This is Dr. Radar."

Dr. Grumpy: "Hi, Mike. Can you look at the scan on Mrs. Platelet? It looks like she has a right frontal stroke."

Dr. Radar: "Hang on... No, that's not a stroke. That's volume averaging artifact."

Dr. Grumpy: "Really? It looks like a stroke."

Dr. Radar: "No, definitely volume averaging."

Dr. Grumpy: "Okay, thanks."

I hung up and was a bit surprised. I began writing a note, when a nurse came over to tell me Dr. Radar had just called back looking for me.

Dr. Grumpy: "This is Dr. Grumpy."

Dr. Radar: "Yeah, it's me again. Did you say right or left?"

Dr. Grumpy: "Right."

Dr. Radar: "Oh, sorry. The left is artifact. On the right, that's a stroke. Big one, too."

Prize giveaway!

Congratulations, sir! You've won a free clipboard!

Now, we at the Grumpy Neurological Emporium are pretty protective of our office supplies. It's been 4 years since drug reps were allowed to give us bountiful gifts of pens and post-it notes. But, in some cases, an exception should be made, and you, sir, are the lucky recipient of our benevolence.

Even in this digital age, every practice has paperwork. Usually it involves an info sheet with your contact information. You fill it out on a first visit, and maybe once a year after that. Mary hands you the clipboard and form when you come in.

Most people sit in the waiting room and fill them out while she copies their insurance card.

Why you decided to take it in the bathroom with you, I have no idea. But it was blank when you went in, and completely filled out when you exited 10 minutes later.

You can keep the pen, too.

Sunday reruns

One of my favorite patient quotes:

"I was on my way to my girlfriend's place and did some meth in the car because if I waited till I got there she and her roommate might use it all. But there was something wrong with it and I began shaking, and got real dizzy, and then began puking all over the steering wheel. Then my vision got blurry and I couldn't see the road very well, and I was afraid to pull over cause then a cop might come try to help me, and I'd be in deep shit, so to be safe I started driving as fast as I could to get to the nearest emergency room."

Theater

Mrs. Drama: "I apologize for being late. It's been an awful day. I lost my son this morning."

Dr. Grumpy: "Oh, that's terrible. I'm so sorry."

Mrs. Drama: "It's okay. We eventually found him playing games at the arcade."

Games and players

Recently, some of you may have seen ads for "Fresh & Sexy," a new product on the market with somewhat provocative ads. Basically, they're "intimate wipes," to be used for frantically wiping off your naughty bits in situations where you're filthy, and desperately need to clean up before getting laid.

Now, I personally have to question the need for this product, at least in civilized societies. The majority of us bathe regularly, and hopefully don't need such items. A friend of mine commented that if she were "in a situation where I was that disgustingly filthy, like a long camping trip away from water, I'm pretty sure I wouldn't have the wipes with me. Or be near a store where I could buy them." By the same token, societies where regular bathing is rare are unlikely to carry "Fresh & Sexy" in local stores.

There's also the point that people have been banging each other for roughly 2 million years, of which only the last 100 or so have seen regular washing. So filth, and the absence of "intimate wipes," has never stopped them for >99.9% of human history.

But this is modern marketing. Necessity is no longer the mother of invention. Nowadays, instead of making a product that people actually need, it's easier to make a product, then convince people they need it. It's how P. T. Barnum got rich.

The same trend is in pharmaceuticals. There are a lot of drugs that are legitimately useful, but some companies try to create drugs we don't need, then hope to convince us we do.

Let's take the fictitious drug Ophelicia, which is an overpriced knock-off of a cheap generic, polonicoxib.
 
R&G pharmaceuticals (the original manufacturer of both) knows their aging drug has been used off-label* for a boatload of stuff, and its profitable patent life is running out. So they're sinking research dollars into getting more indications for it, rather than, say, a new drug that might benefit people.
 
Sometimes you get a REALLY painful hangnail. It hurts more if you accidentally bang your finger on something, you can't pick your nose with it, and start screaming if Purell or salsa get on it.

There are MANY dirt-cheap generic drugs, such as polonicoxib, that can be used for a hangnail, all reasonably effective.

R&G, smelling a market opening, sinks a few hundred million bucks into getting Ophelicia OFFICIALLY FDA APPROVED for hangnail pain. Granted, their data didn't show it was any more effective than the 20 cheap generics out there, but now their sales reps can proudly say "We are the ONLY drug with an FDA approval for this debilitating condition."

Unfortunately, there aren't enough people with painful hangnails to make this indication financially worthwhile. Besides, any insurance company will force you to try 5 cheap generics before they'll let you think about prescribing Ophelicia and it's $20/day price tag (I agree with them).

BUT it adds to the razzle-dazzle. Your average doctor will figure it has so many indications for pain, it must be good for anything, and grab it off the shelf without trying a generic. It's much easier to hand someone a bottle of samples than it is to write a script (R&G knows this. Why do you think the companies give away all those samples?). If the patient is hooked, maybe they'll pay for it. Or the doctor will find it easier to have her staff fill out a pre-authorization form than call in for some cheap polonicoxib. After all, it's not her problem.

This gets back to the need for intimate wipes: Is it really there in modern societies? Probably not. But there isn't a need for a drug that's specifically indicated for hangnail pain, either. It's the game, and R&G and their competitors are simply players looking for an edge.

The key to selling is marketing, and the gold standard of marketing is making people think they need something that they don't.


*Prescribing it for something other than what the official FDA rules say you should use it for. This is very common. Odds are that you've taken something off-label.

Dear Kids,

As the weather warms up, I think it's great the 3 of you want to walk home together after school. It's about 2 miles, certainly nothing awful, and gets you home sooner than riding the bus, or waiting for me to finish at work, would.

I also think it's good you guys want to get some exercise now that the snow has gone.

BUT

Stopping about 1/3 of the way home at Kwik-E-Mart to get "snacks" of chili-dogs, candy, and slushees, then hanging out with friends there and calling me to come get you, is sort of defeating the whole idea.