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Comment by jedrek | Hacker News Reader

It really bugs me when people talk about Big Pharma pushing pills, cause really, 8-9 times out of 10, it's patients begging for pills. Are pharmaceutical companies angels? Fuck no, neither are doctors, but if nobody was buying, they wouldn't be selling.

There's a great post on reddit from a doctor who wrote about a typical patient-doctor interaction (which I'm too lazy to find right now):

Patient comes in with elevated blood pressure, about 30 lb overweight, sedentary lifestyle. Doctors talks about blood pressure, possible future issues with it, recommends patient start getting some exercise, portion control, lose some weight, maybe a dietary consult.

Patient comes in a month or three later for a follow up visit. No weight loss, no drop in blood pressure. Doctor writes a script.

Hell, when I was checking out doctor review sites for a podiatrist, one of the negative opinions he had said, "He didn't even prescribe me anything!

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> It really bugs me when people talk about Big Pharma pushing pills, cause really, 8-9 times out of 10, it's patients begging for pills. Are pharmaceutical companies angels? Fuck no, neither are doctors, but if nobody was buying, they wouldn't be selling.

Pharmaceutical companies don't help their image when they behave as poorly as Roche has in the UK with avastin and lucentis.

Avastin and Lucentis are very similar compounds. A astin is older and much cheaper than Lucentis. Lucentis is licenced for use in macular degeneration - the leading cause of blindess outside poor countries. Avastin is not licenced for macular degeneration.

Despite numerous safety and efficiency trials Roche are refusing to allow Aventis to be licenced for macular degeneration, and they intend to use the law to its full extent to prevent aventis being used for macular degeneration. (Off label rules are stricter in England).

This is a scumbag move. Roche have chosen to let people go blind because they want the profit from lucentis.

Here's the US version: http://www.allaboutvision.com/conditions/lucentis-vs-avastin...

Here's the UK version: http://www.bbc.co.uk/news/health-30138097

Between the constant TV ads shouting "BUG YOUR DOCTOR FOR PILLS!" and the vacations, free samples, and outright cash bribes lavished on doctors, I can't see how you can characterize what's going on as anything but pill-pushing by Big Pharma.

There may have been things lavished on doctors in the past, but as of a few years ago docs effectively can't get anything free unless it is under $10 an instance and less than $100/year.

See: http://www.rxvantage.com/sunshine-act

$10/instance and $100/year are only the threshold for reporting, not the threshold for banning. Plenty of doctors are still getting lots of perks from the pharmaceutical industry.

In some circles, most notably in academia, doctors even consider it a mark of prestige to get expensive perks from multiple pharmaceutical companies. "Pfizer just asked me to speak at their conference in the Bahamas. Too bad I already agreed to attend Novartis's event in France!" The Sunshine Act does nothing to curb their corruption and only fuels their pride.

>It really bugs me when people talk about Big Pharma pushing pills, cause really, 8-9 times out of 10, it's patients begging for pills. Are pharmaceutical companies angels? Fuck no, neither are doctors, but if nobody was buying, they wouldn't be selling.

In the case of children it is the parents begging, but the real question is why do they beg. If you met large populations who begged for something dangerous or bad to be done to them that would benefit another, would you think they truly wanted it of their free will having made fully informed decisions, or would you suspect that for many, there had been some manipulation/misinformation/etc.?

That particular story seems like reasonable behavior on the doctor's part. But my personal experience has been that no doctor has ever brought up anything but pills to treat any condition I've had or my wife has had (and we've each had a condition that we later mitigated with a relatively small amount of experimentation, once we sort of realized it was up to us).

So to me the answer is "The doctor needs to start with non-pill solutions (if they make sense), then if the patient gets pushy or is uncooperative resort to pills, with fair warning that for the most part she's treating symptoms instead of the root cause." Does that sound like a reasonable compromise that we should all be able to agree on?

No, I can't agree.

The doctor should do what their training and experience leads them to believe will lead to the best outcome for the patient. Pills are not evil. Optimise for good outcomes.

Doctors are trained to use pills to treat conditions, so that's what their experience is in. Few have training in other treatment modalities; you can't get reimbursed for many other treatment modalities; you can't carry out an effective CBT session or really work on behavioral change in 12-15 minutes. Doctors are very well-trained in a very narrow area, which emphasizes pharmaceutical approaches.

That's why many good docs refer you (to a physical therapist or dietician or psychologist) if they are aware of other effective non-pharmaceutical treatments for your condition.

I'm assuming this is specific to the United States? My anecdotal experience in Canada has been that it is not unusual for doctors to misdiagnose, but pill pushing isn't particularly a problem.

Yeah, not much of a problem in the UK either. The US system is a bit unusual. I daresay they'll still prescribe the pills if you ask - there are an awful lot of people on antidepressants.

In the US I've been to 5 doctors over the past 10 years (lots of moving), and none have ever been pill pushing.

I'd say maybe it's region specific but I've been on the East coast, Midwest, and West Coast.

In this trio, I blame the doctors far more than anyone. Patients have no clue, they just want to be cured. It's the responsibility of the doctors to only prescribe what is necessary.

Every time I hear my father say he got antibiotics for his cold I cringe, and wonder WTF the Dr. he saw was thinking. I think the count is up to a dozen times he's received them in the last 10 years.

I agree with you in that it's the doctor's irresponsibility.

But you know they're human too, and the path of least resistance is still the path of least resistance. That and they're a product of their education.

Yep, that's really strange. Have you reported the doctor? Their name should be on the scripts.

That said, I don't see how your father's health is entirely the responsibility of the doctor. He has the majority of the responsibility for his own body. Yes, when you are sick and scared, a doctor has enormous discretion over you. They take these oaths for a reason and the legal system is very tough on them when they fail (as things should be). However, your father has much more responsibility for his health, especially for something as simple as a common cold. I mean, the excuses that you 'don't know' are gone these days. Google is literally in your pocket for most people.

That said, we have issues with filter bubbles and getting good information. There is a lot of chaff for the seed online.

> He has the majority of the responsibility for his own body.

The doctor has the responsibility to not inflict antibiotic resistance on the population at large just because he can't stand up to pushy patients.

> Google is literally in your pocket for most people.

Far more likely to result in "I hear this causes autism!" than "I hear I shouldn't take antibiotics for a cold".

No, the doctor has no such responsibility, they only have responsibility to their patients. They are bound to operate based on the standard of care in the profession and location (this varies widely between states, cities, and countries). The doctor, likely, can easily stand up to pushy patients and, likely, has been doing so for years. The alternative of censure is much more harming than some patient that knows exactly the opioid and dosage they want. if they are not doing so, then it is the responsibility of the patients and other staff to report the doctor to the appropriate medical boards such that the doctor continue to practice safely.(http://www.ehow.com/how_5106471_report-bad-doctors.html).

Also, yes, the issue with Google is that your filter bubble gets in the way and you make bad choices about what to listen to. Honestly, it's really bad. You point out the autism-vaccine controversy (...good God, what the hell has happened to us...Jesus...) and I'm sure there are a million other nutters out there with even more dangerous ideas. I.... I'm at a loss here. I can only say that you just have to research more, but I know that is beyond the reach of most people to do so. The excuses are gone, but not the stupid. We have all this information, but it's like a library with pages just thrown everywhere and there are no curators. I can't expect people to know what to do. My own father would say 'Well, life sucks, and it sucks a lot more if you're stupid'.

Man alive, is that a cop-out. It's true, but saying that life just sucks for stupid people is heartless and against all of medicine as an ethos. Still, the question remains, how do you get people to be responsible for their own damn asses?

Any ideas?

Yeah, tell them to ask a doctor while shutting up and listening. Telling stupid people to Google stuff is how we ended up in this mess to begin with. Maybe we could tell them to consult a medicine textbook, at which point they'll be begging for option 1.

> No, the doctor has no such responsibility, they only have responsibility to their patients.

Their patients, who soon will not be able to use antibiotics for a genuine bacterial infection because of resistance.

My father is 80 and 3,000 miles away. So, no, I haven't reported the doctor and it's pretty silly to think I would.

My father doesn't know any better. The doctor does. That makes it clear where the responsibility lies.

> In this trio, I blame the doctors far more than anyone. Patients have no clue, they just want to be cured. It's the responsibility of the doctors to only prescribe what is necessary.

That's a bit naive. Many patients practically demand pills, and if you displease them all you'll take a hit on your "patient satisfaction" metrics, which in turn displeases the hospital administration as things like Medicare funding are tied to these metrics. So unfortunately, doing what's best for the patient doesn't always correspond with what's best for the doctor keeping their job.[1]

Blaming the doctor for having to make an impossible choice is not entirely fair. I think the federal government (Medicare) and hospital administrators need to reevaluate the weight they put on patient satisfaction and the pressure it puts on physicians as well as patient outcomes.

[1]: http://www.medscape.com/viewarticle/821288

I completely agree with this, but also think that it's important for patients who are sick to leave their doctor experience somewhat soothed.

I think that if a patient listens to explanations about how antibiotics won't help with their viral infection, but still wants something to be done, that perhaps doctors should be allowed to prescribe cheap placebos of some sort. Though this is in some ways incredibly disrespectful to the patient, perhaps if it wasn't a sugar pill and something truly soothing, like bed rest and warm soup, it may pass ethical muster.

There's a reason that unsound treatments like homeopathy gain traction. Some people just want to be cared for and told that they are in good hands and will get better faster than if they were on their own.

I like this idea. Just have a can of ready-made soup - store-bought if necessary - and just add something somewhat odd-but-good-tasting. A patient with half a brain will understand they're being fooled, but whoever seeks homeopathy wants to be fooled anyway, so that won't be an issue.

And this is why there are prescription sugar pills available. Give the patient something, but don't give in to their stupidity.

Blaming the doctor for having to make an impossible choice is not entirely fair.

?? There's no "impossible choice" here. This conversation has taken an absurd turn.

So, the doctor is not to blame for writing the script. Last I heard, patients were not required to have medical degrees.

I don't care what I, as a patient, as for, I think the doctor should base his/her response on science and training and experience. Not what I want.

>That's a bit naive. Many patients practically demand pills, and if you displease them all you'll take a hit on your "patient satisfaction" metrics

So then the blame is back at big pharma for the views they are pushing.

Why can't we blame ordinary people for being so dumb?

The masses are what they are. Big phrama is the one taking advantage of the natural state of the masses. We could blame a child for being dumb, but instead we make laws protecting children from those who would take advantage of them (banning child labor, lots of rules to protect children concerning contracts, banning predatory lending, etc.).

Maybe if a patient demands pills, fine, the patient has already been brainwashed and lost and you have to give them what they want or you will get a bad score.

Yet whenever I visit a doctor for some minor issue, I have never asked for antibiotics, yet Doctors ALWAYS just straight away say I'm going to prescribe you such and such antibiotics.

I always push back and say is that really necessary? And they just get all glassy eyed and spout that this is the standard course they always do, as a preventative measure. (Despite that usually these interactions are over some issue that resolves without any difficulty when I don't take their prescription).

Would it be so hard for them to just stop the bullshit when it is clear the patient has a brain and is not going to be angry with them for not "givin them their pills"?

Why would you go to a doctor for a cold?

Because people don't know any better? The answer seems pretty obvious.

Or maybe you aren't a doctor and shouldn't be judging if your father needed abx based on a few google searches.

Get a second opinion from a professional if you think your dads doc is over prescribing.

While colds are not dangerous for the young -- they can be very dangerous for the elderly and easily progress to a pneumonia that can kill. Pneumonia used to be called 'old mans best friend' because it caused such a swift and painless death. So what is 'just a cold' for you isnt for others and that isn't even taking into account that the elderly often have baseline lung disease.

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