Drugs that Cost a Lot

New drugs for Hepatitis C, leukemia, and several rare diseases can cost $50,000 per month. Companies that sell them stress that developing a new drug is expensive and that these are superior to previous drugs. This is true although it’s hard to judge if their profits are excessive. They might be.

Old drugs once cost slightly more than nothing. A single Lomotil, the leading diarrhea remedy once cost a few cents. It’s now thirty cents for the generic (that’s wholesale; you’d pay more). Colchicine, an excellent gout remedy that doctors have used for several thousand years, cost a nickel a pill. A few years ago it jumped to $5.00. Everyone expressed outrage, including our elected representatives. But it’s still $5.00

How do you explain that?

You may be surprised to learn that Medicare Part D, launched in 2006, which pays for prescription drugs, was a Republican program. Anxious to protect the free market, Republicans included language forbidding Medicare from negotiating drug costs. Doctors and hospitals must accept what Medicare pays but drug companies set their own prices. The Veteran’s Administration (which has the power to negotiate) pays much less. Drug companies are not required to sell to the V.A., but they do, so they’re not losing money. They’re not required to sell in foreign countries where the government regulates drug prices. But they do.   

Unquestionably, hanky-panky is going on. I would not be surprised if a bottle of aspirin jumps to fifty dollars in the near future. You can expect our elected representatives to express outrage.

Being Sick, and French

If you are French, in Los Angeles, and want a housecall, you call a French lady, Veronique Mastey. How she acquired this business is a mystery, but it is not trivial because I’ve made dozens of visits for her.

This year I returned to a mansion in Pacific Palisades to care for a member of Johnny Hallyday’s entourage. I doubt if the name rings a bell, so I must add that Johnny Hallyday is the greatest rock star you have never heard of. He’s been an idol in France since the 1960s, selling over 100 million records, 18 platinum.

We Work Miracles But Not All the Time

Practitioners of complementary medicine (alternative medicine, herbal medicine, homeopathy, naturopathy, acupuncture, etc.) always know what to do. That’s because all follow a theory that explains (1) what causes illness and (2) the proper treatment. This is very satisfying.

Doctors like me don’t have a theory of disease. I hate to say we use science because many people – some with college degrees – believe “scientists” are like “Episcopalians” or “Republicans.” They hold certain opinions, but it’s OK to have other opinions. It’s a free country.

Rather than say doctors are scientific I like to say we search for the truth. We try to find out what makes people sick and then what works to help. This is hard. Throughout history everyone assumed that the best doctors were wise, but this isn’t so. Wise doctors throughout history answered big questions, but they were usually wrong. Hippocrates came up with a few gems that everyone quotes, but most of his advice is garbage or the usual platitudes doctors deliver when they don’t understand what’s going on (avoid stress, eat nutritious food,…).

By searching for the truth (remember that’s another word for science) doctors have turned up miracles. An appendectomy or a kidney transplant is a miracle. The same is true for antibiotics, vitamin B12, immunization, anesthesia, even the discovery of germs (no wise man in any other culture came up with the idea that tiny bugs cause disease).

Doctors work miracles but not all the time; surgeons do better than medical doctors. I help most patients, but I don’t save lives often. When I do, I write about it here.

A Useful Technique

“It sounds like a stomach virus. These usually don’t last long. You’re healthy, so vomiting for a while isn’t life-threatening, but it’s definitely miserable. I make housecalls, so if you’d like me to come….”

“It sounds like a stomach virus. These usually don’t last long. Here’s what I want you to do. Don’t eat anything. Don’t drink anything. Get some ice from the ice machine. Lay quietly with a piece of ice in your mouth. Don’t chew. Keep sucking on the ice. I promise to call back in two hours. If you want a housecall, I can come.”

I’ve given these two pieces of advice thousands of times. If, after hearing the first piece, a stoic vomiter decides to wait, I deliver the second, but sometimes I go straight to number two.

“The fish tasted funny, and I’ve been throwing up since two. Can you give me something?”  The caller was at the Beverly Garland in Universal City. It’s an easy fifteen mile trip but not at 6 p.m. on a weekday. I try not to drive long distances when the freeways are jammed. To avoid this, I use a technique we in the medical profession call “stalling.”

At least half have improved when I call back, so I lose a good deal of money, but I wouldn’t have it any other way.

Medicine and Pornography

Twenty years ago my back began hurting. After a week of hobbling, I went to a doctor who ordered an X-ray that showed “arthritis.” He injected something into the area. I didn’t notice an improvement, but after a few weeks the pain disappeared. Almost all low back pain goes away.

I had received what medical experts calls a “low value service.” You would call it a “useless test.” Good studies show that if you have acute back pain alone (without another symptom such as fever or a neurological defect) X-rays rarely help, and that includes super-X-rays such as CT scans or MRIs.

For years the medical establishment has been waging a campaign called “Choosing Wisely.”  It’s an admirable effort to persuade doctors (tactfully, no pressure…..) to stop ordering worthless tests, performing procedures that don’t help, or prescribing useless antibiotics. You can Google it.

Is it working?... Maybe a little. For decades journals have published studies in which a medical group tries to encourage its doctors to practice better medicine. Sometimes these programs flop. Sometimes they succeed but never dramatically. Unless it’s unpleasant (like a colonoscopy) patients like doctors to do stuff. Doctors themselves like to take action even if they know (they usually know) that it probably won’t work.

It’s like watching pornography. Most doctors feel a twinge of shame after they do something that’s not likely to help. They don’t disagree with experts who disapprove. But when a patient walks in, and they feel the itch…..

Another Reason Doctor Oppenheim is not Rich

Plenty of patients have bad breath. They never tell me, and I never mention it because I have no solution better than mouthwash. If you want to know how to eliminate bad breath, google any media doctor. They all know. They’ve been delivering the same advice since I entered practiced forty years ago, and I haven’t noticed a decline in bad breath. On the other hand, they’re rich, and I’m not.

Perhaps a dozen times (mostly before I became a hotel doctor) patients announced that they had bad breath. I smelled. They never had it but were skeptical when I reassured them.

You have bad breath if someone else tells you. If you’re the only one who detects it, you have a delusion. Of course, since it’s a delusion, no one can change your mind.

The History of High Blood Pressure

For much of his presidency, Franklin Delano Roosevelt’s blood pressure was high. His doctors knew but didn’t do much.

Doctors had been measuring blood pressure since the 19^th century, but they considered it a vital sign – like pulse rate or respiration rate or temperature. They felt better if it was normal but didn’t believe that high pressure was a disease. Everyone knew (as everyone knows today) that stress makes your pressure go up, so avoiding stress was a good idea, but that’s hard for a president. His pressure was spectacularly high the day he died of a stroke in 1945 while relaxing in Georgia.

By the 1950s many doctors believed that high blood pressure was unhealthy. Doctors who act on their beliefs are no different from anyone else. They do a lot of dumb things. So not every doctor treated it.

Proving that high blood pressure kills requires observing thousands of people for years. By the 1960s it was proved. It seems a no-brainer that this means doctors should lower high blood pressure, but that doesn’t follow. After all, a rapid pulse or fever is often an ominous sign, but returning them to normal doesn’t accomplish much.

Proving that reducing high blood pressure saves lives requires observing thousands of people, treated and untreated, for years. By the time I entered medical school in 1968, this had been done, and we heard lectures urging us to treat high blood pressure vigorously.

This was not easy because the drugs available lowered many things beside blood pressure, so they made patients drowsy, dizzy, constipated, and impotent. But things have improved.  

A Japanese Guest

A check of Google Maps revealed an ominous red line from my on-ramp to downtown, so I left twenty minutes early for what is usually a half hour drive. It wasn’t enough, and I arrived ten minutes late at the Miyako in Los Angeles’s Little Tokyo.

It caters to Japanese, a big advantage when I see Japanese patients. Japanese businessmen sometimes speak English but Japanese tourists don’t, and these were tourists. I asked the desk clerk if she could provide an interpreter. Even in a Japanese-run hotel, most workers are Hispanic, and it may take half an hour to pry loose an employee, often a Japanese-American who speaks Japanese as well as I speak Hungarian, the language of my grandparents.

Luckily, as I waited, the tour leader appeared. His English was rudimentary but adequate. The guest had a fever but the major complaint was indigestion from strange American food.

I Need a Test

Asked how a doctor makes a diagnosis many would answer: “He does a test.”

This is actually uncommon. Experts agree that ninety percent of our diagnoses come from what you tell us.

Having spoken to the hotel guest over the phone, I’m certain of what’s going on when I drive off ninety percent of the time. Ten percent of the time, I’m not certain. Sometimes more talk or the exam gives me better information. Sometimes, almost always if the illness turns out to be worse than I thought, I send the guest off for a test, usually an X-ray.

I carry dipsticks that detect many substances in the urine. Once or twice in thirty years, I’ve discovered a new case of diabetes. I see guests with symptoms of a urine infection perhaps once a week. I always test their urine.

I then look thoughtfully at the test strip before announcing that the guest has a urine infection. In fact, 10-20 percent of the time the results are normal. No matter. If the guest describes symptoms of a urine infection, I make the diagnosis. Doctors often ignore tests, usually for a good reason.

Something Unforgivable

I sent a colleague to see a hotel guest perhaps thirty years ago. He didn’t carry a bag as well stocked as mine but took some drug samples from the office. He gave one out. Later the guest noticed that its expiration date was past. His anger, when he phoned me, remains a vivid memory.

Commercial prescription drugs are probably OK for years after they expire, but we don’t give them out. My bottle of nasal spray has an expiration date, and it’s pure salt water. When my aspirin expired, I kept it around.

My lawyer has tapped me on the shoulder and warned me to add that this is my personal opinion, that I have no special pharmaceutical expertise, and that you must never take an expired drug.