Sunday, December 31, 2006

What not to put on a CV

I received an e-mail today from someone applying for a sleep fellowship at the local university (I briefly held the position of sleep fellowship program director before I left the university in 2005). The following was included in the applicant's cv:


2006- Selected in
Strathmore’s Who’s Who
Strathmore’s Who’s Who publishes annual registry of outstanding professionals based on one’s position and accomplishments. Inclusion is limited to individuals who have demonstrated leadership and achievement in their occupation, industry or profession.

2006- Selected in
Marquis Who’s Who in the world
Marquis Who’s Who publishes annual directory of leading citizens from all over the world in different professions.

Lucky for him I am no longer program director, I would have just deleted his application. I forwarded his application to the current program director.

Some foreign medical graduates do not realize that these Who's Who books are just scams in which your brief biography is published in hopes that you will spend a lot of money on the book. Do not put it on your cv.

Welcome to Mississippi

This Marshall Ramsey cartoon was reprinted in today's Clarion Ledger.

Obesity is not good for the health status of Mississippi, but it does make it a good place to practice sleep medicine (which from a financial standpoint is the treatment of sleep apnea). The population of Mississippi is less than 3 million, yet there are over 40 sleep labs in the state.

Saturday, December 30, 2006

Thanks to my Readers

Rebel Doctor and sleepdoctor blogs got click # 50,000 today. Still a while to go before I catch up to blogs with 1 million clicks. I am going to try to increase the frequency of posting over the upcoming year. It wouldn't hurt if Kevin MD linked to at least one of the blogs. And I need to get back into submitting to grand rounds on a regular basis.
Thanks to those who have read Rebel Doctor and sleepdoctor, and to those who have linked to the blogs. I especially want to thank those who patronize my advertisers, and allow me to earn 50 cents a day from Google adsense.

Michael Rack, MD

Tuesday, December 26, 2006

Not Everyone Benefits from Health Insurance

USA Today has a feature in their financial section in which they present a person's financial problems and then have an expert devise a financial plan for that person. I think USA Today got it wrong this time.
The financial problem:
Dana Dwyer, 24, had just quit her first job after college as a manager at a Ralph Lauren store in Miami and hadn't started her second yet when, wham!
She was in a car wreck. Her front teeth were knocked out, and her palate was broken. In between jobs, she had no health insurance.

Worse, though, was the $16,000 bill. Dwyer was forced to use her savings and work out a deal with the hospital to pay $200 a month.
"I paid $2,000 upfront to have my teeth fixed," she says. "You have to have teeth."

Their Solution:
Davis recommends that Dwyer buy an individual health insurance policy — she could get coverage for about $300 a month in Florida — before she focuses on paying down credit card debt. "She's one more bad drive down the street from being right back where she was" when she had a wreck, the planner says.
I think Dana Dwyer is currently getting a good deal. Instead of paying $300 per month for bare bones health insurance coverage, she is paying $200 per month to the hospital- a savings of $100 per month.
Even if she did have health insurance at the time of the accident, she would probably still owe the hospital- many health insurance plans exclude injuries that are the result of motor vehicle accidents. What she really needs is a good automobile insurance policy.
I was recently in an auto accident with some minor injuries. Luckily I have good auto insurance.

Monday, December 18, 2006

The New York Times Slams Eli Lilly (again)

Earlier I posted about Eli Lilly withholding information from the public and physicians about some of the dangerous side effects of Zyprexa, an antipsychotic used for the treatment of schizophrenia and bipolar disorder. Today the New York Times reports that Eli Lilly has been promoting off label uses for Zyprexa:
Eli Lilly encouraged primary care physicians to use Zyprexa, a powerful drug for schizophrenia and bipolar disorder, in patients who did not have either condition, according to internal Lilly marketing materials.
The marketing documents, given to The New York Times by a lawyer representing mentally ill patients, detail a multiyear promotional campaign that Lilly began in Orlando, Fla., in late 2000. In the campaign, called Viva Zyprexa, Lilly told its sales representatives to suggest that doctors prescribe Zyprexa to older patients with symptoms of dementia.

Zyprexa is not approved to treat dementia or dementia-related psychosis, and in fact carries a prominent warning from the F.D.A. that it increases the risk of death in older patients with dementia-related psychosis. Federal laws bar drug makers from promoting prescription drugs for conditions for which they have not been approved — a practice known as off-label prescription — although doctors can prescribe drugs to any patient they wish.
Yet in 1999 and 2000 Lilly considered ways to convince primary care doctors that they should use Zyprexa on their patients. In one document, an unnamed Lilly marketing executive wrote that these doctors “do treat dementia” but “do not treat bipolar; schizophrenia is handled by psychiatrists.”
As a result, “dementia should be first message,” of a campaign to primary doctors, according to the document, which appears to be part of a larger marketing presentation but is not marked more specifically.

The issue of off-label marketing is controversial in the drug industry. Nearly every company is under either civil or criminal investigation for alleged efforts to expand the use of its drugs beyond the specific illness or condition for which they are approved.
At the 2001 meeting in Dallas with Zyprexa sales representatives, Mr. Bandick praised 16 representatives by name for the number of prescriptions they had convinced doctors to write, according to a script prepared in advance of the meeting. More than 100 other representatives had convinced doctors to write at least 16 extra prescriptions and thus “maxed out on a pretty sweet incentive,” he said.
“Olanzapine is the molecule that keeps on giving,” Mr. Bandick said.

Sunday, December 17, 2006

Polycystic Ovarian Syndrome, an introduction for psychiatrists

Polycystic ovarian syndrome (PCOS), also known as Stein-Leventhal syndrome, affects 6-10 % of women of reproductive age. Characteristic features of PCOS include menstrual cycle abnormalities and hyperandrogenism. Menstrual cycle abnormalities range from a decreased frequency of menses to complete amenorrhea, though some patients have normal menstrual cycles. Abnormal uterine bleeding can occur. Fertility is decreased. Manifestations of hyperandrogenism include acne, alopecia, and hirsutism. Recently hyperinsulinemia and insulin resistance have been recognized as features of PCOS (hyperandrogenism can lead to insulin resistance, and vice versa), and women with PCOS are at increased risk of type II diabetes mellitus. Obesity is common. The pathophysiology of PCOS is incompletely understood and the components of PCOS interact with each other in a complex manner. For example, obesity can lead to insulin resistance which can lead to hyperandrogenism.

Diagnosis of PCOS requires the exclusion of other causes of hyperandrogenism and anovulation/oligo-ovulation. Since pituitary or thyroid disease can cause ovulatory dysfunction, a prolactin level and TSH should be checked. Although the luteinizing hormone (LH)/ follicle stimulating hormone (FSH) ratio is usually greater than 2.5 to 3, a normal ratio does not exclude the diagnosis. A pregnancy test should also be checked. Androgen-producing neoplasms can be excluded by checking total testosterone and dehydroepiandrosterone sulfate (DHEAS) levels. Total testosterone levels are often mildly elevated in PCOS, but a level greater than 200 ng/dl suggests a virilizing neoplasm. 17-hydroxyprogesterone should be checked to screen for late-onset congenital adrenal hyperplasia. Sometimes a dexamethasone suppression test is performed to rule out Cushing’s syndrome. Non-obese patients should be screened for anorexia nervosa.

A transvaginal ultrasound is sometimes obtained in patients with PCOS; this test can identify most virilizing tumors. However, patients with PCOS do not always have radiographically demonstrated polycystic ovaries. In addition, approximately 25% of women with normal ovulation have polycystic-appearing ovaries.

Patients with PCOS are at increased risk for cardiovascular disease due to hyperandrogenism. Therefore fasting lipids should be checked. The patient should be assessed for other cardiac risk factors, such as smoking and hypertension. Due to the association between PCOS and insulin resistance, a fasting glucose level should be checked. Some also recommend checking insulin levels or glucose tolerance testing.

One of the primary treatments for PCOS is oral contraceptives, which suppress androgens. Sometimes spironolactone, which suppresses enzymes in the androgen biosynthetic pathway, is combined with oral contraceptives. Fertility can be increased by clomiphene citrate. Metformin, an insulin-sensitizing agent, has been shown to restore menstrual regularity. Weight loss is also helpful.

Several studies suggest that PCOS is more common in women with bipolar disorder or epilepsy than in the general population. Valproate probably increases the risk of PCOS. However, since the disorders that valproate is used to treat are also associated with PCOS, valproate has not been conclusively proven to be a causative factor for PCOS.

Psychiatrists should take a detailed menstrual history in female patients with bipolar disorder. It is also important to ask about hirsutism. Patients with baseline abnormalities should be referred to a primary care doctor for further evaluation. The development of PCOS symptoms during treatment also warrants referral to a primary care doctor. Symptoms of PCOS often remit or improve after the discontinuation of valproate. Prolactin-elevating antipsychotics can also cause menstrual abnormalities, and occasionally hirsutism.
the above is for a psychiatry newsletter article I am writing

Saturday, December 16, 2006

Eli Lilly Minimizes Zyprexa Risk

The New York Times reports that Eli Lilly has been minimizing Zyprexa's risk for years:
Lilly’s own published data, which it told its sales representatives to play down in conversations with doctors, has shown that 30 percent of patients taking Zyprexa gain 22 pounds or more after a year on the drug, and some patients have reported gaining 100 pounds or more. But Lilly was concerned that Zyprexa’s sales would be hurt if the company was more forthright about the fact that the drug might cause unmanageable weight gain or diabetes, according to the documents, which cover the period 1995 to 2004.
Critics, including the American Diabetes Association, have argued that Zyprexa, introduced in 1996, is more likely to cause diabetes than other widely used schizophrenia drugs. Lilly has consistently denied such a link, and did so again on Friday in a written response to questions about the documents.
However, psychiatrists became well aware that Zyprexa was much more likely to cause weight gain, diabetes, and high cholesterol than other 2nd generation antipsychotics. So what did Eli Lilly do?
Lilly did expand its marketing to primary care physicians, who its internal studies showed were less aware of Zyprexa’s side effects. Lilly sales material encouraged representatives to promote Zyprexa as a “safe, gentle psychotropic” suitable for people with mild mental illness.
Eli Lilly repeatedly lied to or withheld information from doctors:
To reassure doctors, Lilly also publicly said that when it followed up with patients who had taken Zyprexa in a clinical trial for three years, it found that weight gain appeared to plateau after about nine months. But the company did not discuss a far less reassuring finding in early 1999, disclosed in the documents, that blood sugar levels in the patients increased steadily for three years.
In 2000 and 2001, more warning signs emerged, the documents show. In four surveys conducted by Lilly’s marketing department, the company found that 70 percent of psychiatrists polled had seen at least one of their patients develop high blood sugar or diabetes while taking Zyprexa, compared with about 20 percent for Risperdal or Seroquel. Lilly never disclosed those findings.

(Risperidone and Seroquel are antipsychotics that have a moderate risk of causing diabetes. The risk with these 2 drugs is less than that of Zyprexa, but greater than that of Abilify or Geodon)
I hope that Eli Lilly loses its lawsuits:
Last year, Lilly agreed to pay $750 million to settle suits by 8,000 people who claimed they developed diabetes or other medical problems after taking Zyprexa. Thousands more suits against the company are pending.
Because of the efforts of Eli Lilly, guidelines now force psychiatrists to monitor patients taking Geodon or Abilify for diabetes and other metabolic side effects. These drugs rarely cause metabolic side effects. All of the 2nd generation antipsychotics have been tarred with the FDA diabetes warning because Eli Lilly refused to own up to the problems with Zyprexa.

Thursday, December 14, 2006

Malpractice Immunity for Academic Physicians

Kevin MD linked to this article regarding immunity for physicians working for the state (in this case Ohio):
The Ohio Supreme Court issued its opinion this week in Theobald .v University of Cincinnati, granting blanket immunity from liability to physicians for their negligent acts when the medical malpractice occurs while the physician is teaching medical students or residents of a state medical school. It makes no difference whether the doctor is being paid privately or whether the doctor is acting outside of his official teaching capacity when the malpractice is committed. The bottom line is that the doctor may now be immune from suit and from accountability whenever a student is present during a medical procedure.
The lawyer writing this article just doesn't get it. In most states, full-time physician state employees are working for the state all the time, whether they are with students/residents or not. The usual university contract forbids full-time employees from practicing medicine except as part of their state employment. Billing is often done through a group practice plan (the university usually can't bill insurance companies directly). The income from this group practice plan is often controlled/distributed by the department chairman and is not the same as "being paid privately."
Here is how it works in Mississippi.
The actual court decision is interesting reading.