What's wrong with this picture? - XI (De-Sign)

This is a sharps container in the OR.



I definitely agree that we don't want to misplace pointy stuff with body fluids on them. But is this the best way to ensure safe disposal?





Here's a mobile computer monitor in the ER. It has 2 huge screens mounted at head height...



... and a tiny support stand that makes it necessary to...



... tape this handwritten note to the screen.



Who designs this stuff? Do they get any feedback from endusers? Would they be upset to see that the product they created has to be kludged with warning signs?

If you'll forgive me a little corny wordplay, doesn't the word "design" imply "de-sign", i.e. function is obvious and intuitive without ad hoc instructions? Even better, shouldn't the product somehow force us to use it safely and appropriately?

Recommended reading about design: Small Things Considered - Why there is no perfect design, by Henry Petroski.

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Free lunch with whine

Predictably, after the CMAJ's editorial about pharma influence over physician behavior, industry has fired back. In a letter to the Globe and Mail yesterday, Rx&D CEO Russell Williams sputters:

Canada's Research-Based Pharmaceutical Companies (Rx&D), an industry association that represents major drug firms, has had a code of conduct for many years that specifically bans offering gifts or other incentives to gain influence with health-care professionals.

Anyone who has evidence of a violation may lodge a formal complaint, the results of which are posted publicly on our website.

Well, Mr. Williams, no one accused your crew of being blatant about it. You may not be offering free vacations or rounds of golf (anymore), but there are still plenty of less extravagant freebies to be had. It reminds me of the old joke attributed to Winston Churchill. As I mentioned in my last post, the local reps are more than happy to buy us supper (and line up to do so.) Of course, this is in the context of supporting "legitimate" educational endeavours, such as Grand Rounds.

There are also the lavish lunches the reps buy for our office staff. But those couldn't possibly be considered an influence on physicians, could they? Let's not be naive. A cozy relationship with my staff earns drug reps access to physicians' schedules and coveted appointment times.

A particularly devious technique is using office staff as go-betweens. Last month, one of my staff (knowing full well that I rarely see reps) stepped into my office and held out a business card asking, "Can you see him? He just bought us lunch." Wow, maybe next time, they'll start sending doe-eyed orphans with chronic diseases to plead their case. Or a fluffy kitty with a big satin ribbon around its neck. (FYI: I declined the offer to be educated.)

Mr. Williams, don't get so upset about about the CMAJ editorial. It was directed at physicians, not at your industry. Despite your letter to the contrary, we already know that your members' interactions with physicians are designed to influence behaviour and market your product. That's a given.

What's in question is how physicians should respond. What is our responsibility to our patients and society in general?

If your industry truly believes its stated objective -

To educate health professionals and consumers in the optimal use of medications

- then put your money where your pious protests are. Tally up everything you currently spend on marketing/promotion/education and give that amount to the proposed Institute of Continuing Health Education. No strings attached.

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Free lunch

This week's CMAJ editorial is a kick-in-the-pants for most practicing physicians. We get roasted for accepting perks from drug companies. And, mea culpa, this week, I had supper at Grand Rounds courtesy of one of our pharmaceutical reps.


The Globe and Mail commentary on how cozy some of us are with pharma reps quotes Prof. Arthur Schafer, "They (physicians) deny that they're influenced - all of them do deny that they're influenced."

Well, duh! Of course we deny we're influenced! If we admitted that we're influenced and yet continued to accept freebies, the cognitive dissonance would fry our brains. It's like those people who talk on cellphones while driving (you know who you are). Despite evidence to the contrary, those drivers have to deny that they are driving while concentration-impaired, otherwise they'd have to change their behavior.

(Quirks and Quarks podcast about cognitive dissonance here.)

(Star Trek fans only: Check out this classic, campy demonstration of the detrimental effects of cognitive dissonance.)

I rarely see drug reps in my office, but I admire their skill in getting the job done. They are universally intelligent, courteous and personable - essential behaviour to develop personal relationships with docs. That personal relationship is the key to exerting influence without burdening the poor doc with inconvenient thoughts of unethical behaviour. As the CMAJ piece points out, pharmas' business is to make money, not educate doctors.

Who am I to talk? This week, I sold my soul for some Greek ribs and a Caesar salad.

Let he who is without sin throw the first dinner roll.

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Has it been 10 years? It seems like only yesterday...

After I ranted about pharmaceutical companies direct-to-patient marketing on Friday, I was interested to read the Saturday Globe and Mail's piece on the 10th anniversary of Viagra. It's worth the read.

I was struck by sociologist Dr. Barbara Marshall's view on the marketing of Viagra:

"Men had to be retrained to understand occasional erectile failure as a disease, a disorder that needs to be treated rather than something that happens once in a while in the normal course of events."

The article mentions many of the celebrities who have "endorsed" Viagra (and cousins, Levitra and Cialis). At the 2002 Canadian Urological Association meeting, I remember the excitement in the conference hall when Viagra pitchman/hockey legend, Guy Lafleur, was introduced as a speaker. This was during the scientific session and Mr. Lafleur's speech had not been included in the morning's program. He gave a nondescript, rah-rah, glory days spiel that had nothing to do with urology.

Nonetheless, many of the good old boys were thrilled to see a sports hero in the flesh, and several dashed out of the conference centre, purchased hockey jerseys in a nearby sports memorabilia store, and hurried back to have them autographed. Some of the stick-in-the-mud, wet blanket types (yeah, me) were disgusted that the conference organizers had let this blatant pandering take place. Was Pfizer in some way $pon$oring that CUA meeting, you ask? Don't be so cynical!

(BTW and FYI, during his tenure as Viagra spokesjock, Mr. Lafleur insisted he did not have to use the product. Now you may be cynical.)

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Jay Parkinson redux

Remember Jay Parkinson? In his comments on that PBW post, he hinted at a new venture that would "seriously turn some heads". He's been a busy boy...

In his own blog, Jay outlines the features of hello health. This service is to be provided through Myca - a Quebec city-based company that intends to provide its services in the US. I can't wait to see Myca's EMR interface.

After reading Jay's ambitious goals for hello health, I can answer my own "cherry-picker or visionary" question.

Go, Jay!

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Cynic's corner

Maybe I'm too cynical.

I just watched a TV commercial about fibromyalgia. I don't watch a lot of TV, so maybe this commercial has been running for a while, but it's the first time I've seen it. It had high production values, so it didn't look like a public service announcement.

So my immediate (and very cynical) thought was: Some pharmaceutical company has a new drug targeted to people with a diagnosis of fibromyalgia.

The ad gave a website address for more information: www.myfibrorelief.com. I'm going to surf over there right now and see whether my cynicism is misplaced. Be right back...

... I'm back.

Bingo! Pfizer it is.


Pfizer's website has an interesting feature offering a free "My Fibro Relief Kit". Except that it's not free. Sure, you don't have to pay for it, but you do have to submit personal information and are asked to complete a questionnaire. After that, you'll receive information about the condition, tips on how to get relief, etc.

If Pfizer is so concerned about the well-being of fibromyalgia sufferers, why not just post this helpful information on the website without making them jump through hoops? Could they have a hidden, less-altruistic agenda?

I remember a similar phenomenon when Viagra was released. (Coincidentally, also a Pfizer product, but I'm confident I could tar all the pharmas with the same brush).

The company had never previously expressed an interest in men's sexual health. Yet, all of a sudden, it was running ads exhorting men to "talk to their doctor" about erectile dysfunction. Men were encouraged to take a questionnaire about their sexual function. That questionnaire set the bar pretty low, i.e. there would be very few men who wouldn't be candidates for Pfizer's drug.

Of course, I'm not naive about pharma's intent in direct-to-patient marketing. They're in the business of selling their product for a profit. I'm just suspicious when they insist that their primary goal is patient welfare. Isn't the primary goal of any corporation the same - shareholder value? I just hope the pharmas achieve that goal without stepping on patients' welfare.

I guess I am a little cynical.

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Help wanted? (What's wrong with this picture? - XI)

The Canadian Medical Association is running a Help Wanted campaign to convince politicians and the public that Canada needs more doctors.

Here's the eye-catching ad that ran in the Globe and Mail yesterday:




Earlier in the week, I received a CMA mail-out containing a postcard. There was an exhortation to mail the postcard to the Prime Minister to draw his attention to Canada's physician shortage.

I didn't mail it.

Some times I ignore similar calls for political action purely out of apathy. This time, it's a stand on principle. I reject the premise that having more doctors will solve problems of access and quality in Canadian healthcare.

It may be part of the answer, but this campaign (see "alarming facts") ignores some broader issues.

"Do it yourself?" over the picture of a man suturing his own wound is a dramatic demonstration that some medical care should be provided by trained professionals (pace Rambo). But, is there an opportunity to educate patients to manage aspects of their care that currently "require" a physician? Why not DIY?

Most diabetics manage their own insulin to control their blood sugar. We trust patients to self-administer their prescription meds. What other "medical" duties can we educate our patients to perform? Can other personnel free up physicians to do the tasks that truly require their expertise?

The "More doctors. More care." slogan suggests that we're doing a great job already; we just need to more of it. There's remarkably little nuance to this argument.

What if we're not operating at maximum efficacy? If we crank up the number of practitioners, we'll multiply waste and poor quality.

Please note that I ask about operating at maximum efficacy , not efficiency. Many physicians are already putting in long hours and would find it difficult to work harder/more efficiently. But what are the outcomes of those long hours? Are we making a positive impact on chronic disease? How often do we really need to review the stable hypertensive's blood pressure? Or, in my practice, the man with an undetectable PSA after he's had surgery for prostate cancer?

Are we even asking ourselves these questions, or are we completely occupied with the struggle to keep our heads above the ceaseless demand for medical services?

Over the last year in my office, we've reevaluated many of our practices/traditions/habits as part of our Advanced Access practice. Many of our procedures don't add value for our patients, and (by definition) are wasteful to the system. We're trying to change, but it's challenging, given the demands of a busy surgical practice. And (let's not ignore the 800 lb. gorilla in the room) the absence of fee-for-service remuneration for quality improvement efforts.

How much waste could be trimmed if the CMA put some of its "Help wanted" budget into quality improvement training, mentoring and support for physicians? How much physician time would this free up for additional patient care?

Dr. Day, show me some creativity beyond the sledgehammer approach of expanding the physician workforce.

Then, maybe I'll sign your postcard.

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