The Doctor Will See You Now

by Cory Franklin

  43

  HOW MOVIES AND PHARMACEUTICALS ARE ALIKE

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  Everything I learned I learned from the movies.

  —AUDREY HEPBURN

  WHILE YOU’RE BUSY filling your tank with $2.50 a gallon gasoline, you may not have noticed the price of some other commodities—movies (average ticket $8–$10) and medicine (50 percent rise in the past fifteen years)—has risen far faster than that of gasoline in the past four decades. The honchos running Hollywood and the pharmaceutical companies must marvel at their good fortune when the public expends its venom at big oil. Cruising under the radar, hands in our wallets, the studio and pharmaceutical executives could lunch together and exchange tips on business strategies and problems their industries share:

  1. Both industries count on blockbusters. Movie studios constantly seek the next Titanic (total gross—$2 billion), while drug companies look for the next Humira (2014 sales—$11.8 billion). The phenomenal success of early blockbusters decades ago—Jaws in the theater, Zantac in the drug store—reconfigured both industries. Blockbusters reduced the pressure to turn out a steady number of good products with modest sales. By the same token, art house films and orphan drugs produced by smaller independents, which show meager returns on investment, are tolerated grudgingly, if at all.

  2. The safest financial bets are sequels. By barraging the public with countless sequels and remakes, Hollywood displays its lack of creativity—consider Pirates of the Caribbean and The Fast and the Furious. Likewise, a pharmaceutical industry staple are “me-too” drugs; witness the profusion of cholesterol-lowering medicines. If drugs were movies, Crestor would be Mevacor II. As with sequels, the “me-too” drug strategy replaces an emphasis on creativity with reaping profits from known commodities. Good science becomes less important than good marketing.

  3. Costs and uncertainties of movie and drug development mean both industries must realize large returns quickly to offset expected failures along the way. Movie revenue occurs primarily in the first year of release. The most desirable movie, the one most likely to recoup costs, is one that can be franchised and incorporated into toys, games, and theme parks. Drugs take a long time to develop and generate revenue for a longer period, but the motivation is similar—when the patent expires, the generic pill sells for twenty-five cents. (Patents extend out twenty years and are necessary to protect investment but essentially act as a short-term monopoly.) The pharmaceutical equivalent of the theme park is the nongeneric drug you must take for the rest of your life.

  4. Success is tied to marketing and distribution costs. Technology, including computers and genomics, has brought down the cost of producing movies and drugs, respectively. But the costs of advertising and distribution (and in the case of drugs, Food and Drug Administration approval) continue to increase. Consequently, in both industries, small independent producers (and for pharmaceuticals, universities and the government) now do much of the exciting new work. Industry giants sometimes function as distribution companies, buying their new products from small producers by promising the necessary promotion in exchange for a share of profits.

  5. Companies can get too big and too cautious. They lose their tolerance for risk while their size allows them to accept costly failures. Occasionally, mergers or acquisitions of smaller companies with good products can lead to an unhealthy concentration of power in a small number of major studios and drug firms in the United States. The new, larger conglomerate is often less responsive to the public, and product innovation suffers. As past mergers in both sectors demonstrate, sometimes 1 + 1 = 1.5.

  6. Both industries confront serious threats in the courtroom. Hollywood fights desperately to control online piracy and new technologies that facilitate copying and sharing films. The pharmaceutical giants, always mindful of patent infringement, always face the danger of mass tort litigation. Companies forced to “lawyer up” pass on their legal fees as an increasing part of the cost of that movie ticket or bottle of medicine.

  7. Accounting practices remain mysterious. When the late columnist Art Buchwald successfully sued Paramount for stealing his idea for the movie Coming to America, Paramount claimed, straight-faced, they lost money on one of the highest-grossing movies of all time (a settlement was later reached). Meanwhile, court rulings that most pricing information is proprietary and companies shouldn’t have to open their books have protected the pharmaceutical industry for years.

  Today both industries thrive because the public loves movies and depends on medicine. They may pick our pockets, but we need them. The final similarity? Some of what they sell us is a waste of time and money. The really good stuff can change or save our lives, but the really bad stuff is sometimes deadly or just deadly dull.

  44

  UNPROFESSIONAL PROFESSIONALS

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  A good reputation is more valuable than money.

  —PUBLILIUS SYRUS

  MANY PHYSICIANS THESE DAYS are seeing their incomes squeezed as hospitals buy their practices and insurance companies and the government come down hard on reimbursements. One recourse for this loss of income is for physicians to augment their incomes through expert testimony in the courtroom. By itself there is nothing wrong with this; the system certainly needs more independent experts willing to explain medical science to the lay public. The key word is independent.

  Unfortunately, the money to be made can prompt some physicians to advocate too strongly for one side or the other by offering opinions that stretch the limits of advocacy. From there it is only a short journey to junk science. And even courts have trouble identifying junk science; there are different standards in different jurisdictions.

  Throw in to this mix the fact that both plaintiff and defense lawyers are always on the lookout for doctors with favorable bias toward their sides. To build their legal cases, this is often much more important to the lawyers than the search for “the truth.” In medical litigation it is a common practice for lawyers to keep rolodexes of expert physicians categorized as “pro-defense” or “pro-plaintiff.” This is a tacit dismissal of the possibility of the unbiased expert. One of the first questions physicians are always asked at an expert deposition is how often they work for the defense versus how often they work for plaintiffs. This standard question is done to establish that “pro-defense” versus “pro-plaintiff” classification. Time was when if a physician testified for only one side, it was tacitly assumed he or she was biased. Lawyers have countered that assumption with the argument that if someone is a renowned expert in a specific area, say blood clots in the lung, who better to testify that the diagnosis was missed than this expert? Hence 95 percent of the time that expert testifies the blood clot was missed. No bias, just expertise.

  There is no simple solution to this problem of the search for the unbiased expert. Most experienced attorneys understand this and adapt appropriately. The amount of money tied up in medical litigation is so great that conflicts of interest and unscrupulous advocacy will always be a point of contention. The answer does not lie, as some physicians propose, in eliminating lay juries from the equation. Whatever the flaws in how it judges cases, the lay public must remain a part of the system even if it means an occasional outrageous settlement or unjust jury verdict.

  Years ago I served as an expert witness in several cases. I split my time almost equally between plaintiff and defense, and I accepted only cases I thought had merit, one way or another. I faced a number of formidable experts on the other side, some of whom I felt were scrupulously honest, others who I felt were not. Doing this, I learned a valuable lesson. The primary purpose of medical litigation (and much other litigation) is not to establish “the truth”; to assure good medicine is practiced; or even to dispense justice, whatever your concept of justice is. The purpose of medical litigation is to resolve disputes, when one party says X and another party says Y. (Consider it a civilized advance from the time our long-ago ancestors settled disputes by means of violence.) This doesn’t mean that better me
dicine doesn’t result from medical litigation—it often does. And in many cases, the truth is established and justice is realized. But those are the by-products of a dispute resolution system that is admittedly imperfect but may be the best we can do.

  The best approach to minimizing outrageous advocacy and junk science is greater scrutiny by the professional societies, medical and legal, that oversee their members’ behavior. But unless and until the professional societies are willing to publicly condemn unscrupulous and avaricious behavior, the rest of us will be at the mercy of the occasional unprofessional professional.

  45

  ASSISTED SUICIDE: HOW CAN WE BE SURE WHEN IT IS RIGHT?

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  When life and death are at stake, rules and obligations go by the board.

  —ALBERT EINSTEIN

  BEFORE HIS DEATH IN 2011, Dr. Jack Kevorkian was released from prison after serving seven years of a ten- to twenty-five-year sentence for the 1998 second-degree murder/mercy killing of Thomas Youk, who suffered from Lou Gehrig’s disease. Kevorkian looked none the worse for wear as he relentlessly made the talk show rounds on the Today Show, Good Morning, America, Larry King, and on 60 Minutes with Mike Wallace. The 60 Minutes appearance represented a comeback of sorts since it was the 60 Minutes story on the administration of lethal drugs to Youk that led to Kevorkian’s original conviction.

  According to his lawyer, Kevorkian was offered speaking fees of $50–$100,000 to discuss his experience and advocacy for assisted suicide. But while Kevorkian became a media celebrity and brought renewed attention to the subject, an ominous development on assisted suicide in Europe has escaped notice in the United States.

  In Switzerland an inconspicuous medical clinic known as Dignitas is located among a block of studio apartments in a modest suburb of Zurich. Founded in 1998 by a Swiss human rights lawyer, Dignitas was created to take advantage of Switzerland’s liberal assisted suicide laws. A patient can become a member of Dignitas and apply in writing for assisted suicide with a doctor’s note certifying illness, prognosis, and pain. The clinic’s volunteer staff certifies the information and provides the patient with a lethal cocktail of barbiturates, which the patient then self-administers. Dignitas has helped over two thousand patients die in Switzerland.

  Dignitas has become the focal point of a “death tourism” industry for citizens of other European Union countries who travel to Switzerland to end their lives discreetly in one of the suburban studio flats. Germans and Britons are the main travelers, and over three hundred patients from Great Britain have died in the Swiss clinic. But now questions are emerging as to whether some foreign clients who were helped to die were simply depressed rather than terminally ill or in incurable pain. It appears some of these clients may have been given lethal cocktails without appropriate investigation into their medical conditions.

  The London Daily Telegraph reported that a German woman who died in the Dignitas clinic presented the staff with phony papers stating she was suffering from terminal liver cirrhosis. It was later discovered she was suffering from depression and alcoholism. Other death tourists may have also provided spurious medical and psychiatric records, which the staff failed to verify. A member of the Swiss regulatory agency on biomedical ethics admitted, “We suspect there could have been cases where people who suffered from a temporary depression have been helped to their deaths.”

  Here in the United States, observers relooked at the 130 patients Dr. Kevorkian admitted to helping commit suicide, some of whom traveled great distances to avail themselves of his services. Several of these patients did not have terminal illnesses, and although many suffered from chronic conditions such as multiple sclerosis, at least a few did not have any life-threatening condition at autopsy, a fact lost in the media attention at the time.

  If his interviews were any indication, Jack Kevorkian did not mellow after his prison stint. He was a well-read, clever man who lacked introspection. He readily stated that physicians who engage in assisted suicide must be free of conflicts of interest, and he admitted that he never accepted money for his services. But he never acknowledged a different form of conflict of interest. Before his first assisted suicide, he was an obscure retired pathologist. Then his exploits brought him unimaginable fame—media attention and national celebrity that he enjoyed again after his release from prison. In his defense the lure of all those television cameras would be hard for anyone to resist. But that level of fame, a conflict of interest no different than taking money, may have caused him to cut corners even by his own iconoclastic standards.

  In his 1991 book, Prescription Medicide: The Goodness of Planned Death, Kevorkian extolled the virtues of assisted suicide while never acknowledging its limitations. He wrote, “Reverence for the traditional Hippocratic basis of medical practice is vacuous nostalgia, childish daydreaming.”

  The question of physician-assisted suicide has never been as cut and dried as Kevorkian portrayed it. When rules and obligations go by the board, as they may have in Switzerland, doctors are left with the moral dilemma Kevorkian seemed oblivious to: When we take another’s life, how can we ever be sure what we are doing is right?

  V

  THE BRAVE NEW WORLD OF NEUROLOGY

  46

  BETTER USE OF OUR NEW TOOLS FOR PATIENTS IN COMA

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  And men should know that from nothing else but from the brain came joys, delights, laughter and jests, and sorrows, griefs, despondency and lamentations. And by this, in an especial manner, we acquire wisdom and knowledge, and see and hear and know what are foul, and what are fair, what sweet and what unsavory.

  —HIPPOCRATES

  I TREATED PATIENTS IN INTENSIVE CARE UNITS all over the country for forty years, and patients in coma were unquestionably the most emotionally wrenching group to care for. Often the reason for coma was tragic, sudden, and unexpected. A family would come to the hospital in stunned silence and see their loved one, who had been alert and awake hours before, now lying in a hospital bed, unresponsive from trauma, stroke, cardiac arrest, or drug overdose.

  Eventually all families asked the same two questions: first, what happened to their loved one, then invariably, “Will he (or she) wake up?” And because some uncertainty was always present, I usually answered, “I’m not sure.” Depending on the cause, some patients ultimately woke up and others didn’t, but in some cases, the uncertainty over whether the patient would recover might last days, weeks, or even months.

  In patients with brain injuries from various causes, the extent of damage and the level of consciousness (“Doctor, can my father hear us talking?”) has always been difficult to judge. Hence the ability to predict which patients would recover from coma has, of necessity, been imprecise. This is primarily because most physician judgment has traditionally been based on bedside clinical examination of the patient. Although clinical examination is essential to a good evaluation, it is limited in the ability to ascertain which patients will wake up. A significant fraction of patients are misdiagnosed when clinical examination is used without other tests.

  In the 1980s, the CT scan became a widespread adjunct to physical examination and has helped immeasurably, primarily when the cause of coma is not obvious. But the CT scan is essentially an anatomic tool—that is, it shows normal and abnormal brain structures but does not tell us about brain function and is not an especially good predictive tool for patients in coma.

  Likewise, the MRI, introduced two decades after the CT, represented an advance in the care of coma patients. The MRI is often more precise than the CT scan, and it can show blood flow to the brain and how the brain uses oxygen. But even with the MRI, the uncertainty associated with recovery from coma is substantial. We still do not know exactly who will wake up and who will remain comatose.

  A study by Belgian researchers in the journal Current Biology suggests that a newer brain-imaging technique known as positron emission tomography (the PET scan) provides a strong suggestion of which comatose patients are likely to
recover consciousness. Unlike CT, the PET scan is an indicator of brain metabolism and shows how the brain uses glucose. While not perfect, the PET scan appears to be better in quantifying brain activity and predicting recovery in comatose patients than clinical examination. Future studies are likely to show that a combination of imaging tests, combined with good examination of the patient, will be superior to any one of them alone.

  Only recently has the PET scan been used to test diagnostic accuracy in actual patients. Until now it has been primarily a research tool, and doctors have been reluctant, perhaps too reluctant, to use it in everyday patient care because of the expense and unfamiliarity with the new technology.

  Commenting on a 2014 study in the Lancet, two prominent neuroscientists suggested the use of PET scans in brain-injured patients should become common. They predicted that the PET scan will revolutionize neurology: “Functional brain imaging is expensive and technically challenging, but it will almost certainly become cheaper and easier. In the future, we will probably look back in amazement at how we were ever able to practice without it.”

  The brain is a remarkable organ; over twenty-five hundred years ago, Greek physicians understood it to be the seat of consciousness. And yet today, centuries later, our understanding of the brain remains in its infancy. The incidence of brain injury continues to increase, and at a cost of billions of dollars annually, we remain challenged to predict which patients will recover. These amazing new tools may help us successfully confront the challenge of patients in coma.