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Tuesday, April 11, 2006

More on Disease Mongering

Health Care Renewal recently referenced a symposium on Disease Mongering (DM) and the full text essays are now available on the PLOS website.

In recent months,I have written about certain aspects of the promotion of the diagnosis and treatment of two conditions,bipolar disorder and restless legs syndrome (RSL) as having features of the DM phenomenon.

Let me attempt to preempt one line of possible criticism by stipulating that Bipolar Disease is a very serious psychiatric disorder and warrants treatment by qualified physicians and that RLS can be in some patients a very disturbing disorder with definite morbidity relief from which could be very worthwhile.

However, I had questioned the drug company initiative to round up primary care doctors to seek out and take on the often daunting task of managing a bipolar patient,an enterprise in which psychiatrists really earn their fee.(I will admit that in No-trees Texas type locations the PCP may have to take on the job as the region may be bereft of psychiatrists).I also questioned the wisdom of screening for RLS with a drug company sponsored questionnaire with the objective of offering treatment with a dompamine agonist for positive screenees.

The PLOS symposium essay on RLS is worth reading as it takes up several aspects of this matter with much greater development of the issues than my gut feeling sense of it that I posted. Hats off to Doctors Steven Woloshin and Lisa M. Schwartz of Dartmouth Medical School .

Another article questions the evidence or lack of it underpinning the whole issue of diagnosis and treatment of bipolar disorder.

It can be argued that the marketers manipulate the motivations of physicians and various support groups . The physicians are obviously an essential element in the equation. It is their desire to foster the welfare of their patient and do the right thing that is necessary for the DM process to flourish. I believe the "shame of being ignorant" is branded into the limbic cortex of medical students .Hats off to the ever insightful author of the blog PURRY GUD (tomwaitsatemyaby.blogspot.com) who used that phrase recently.

Physicians-many at least-are haunted by the fear that we will harm someone or fail to help someone because of something we do not know (there are certainly other ways we can harm also). This motivation to know what we need to know allows marketers to direct our energies to detection of new illness and to accept wider definitions of disease . Medications are not prescribed because we like the free food or notepads or pens even if we like the free food. Free lunches are not really the problem. The marketers not only manipulate the physcians' hypertrophied sense of duty but the prestige of evidence based medicine as well with all the tricks and traps one can squeeze into a randomized trial to give the veneer of solid science to something that may be no more than a comparison of their drug with one no one would use anyway.

The good news here, if there is any, is that we are catching on. The DM symposium is evidence of that.

We are getting more skeptical about what we read.We are realizing there is more to a RCT than the fact is randomized and blinded. With Google and other search engines it is easier to more quickly confirm or deny material from various promotional efforts. (The bad news is who has time to check and analyze everything that appears in print)

But even as our duty pushes us to strive even harder to figure out what it is we should do to do the right thing we learn of still another tactic to thwart and divert our efforts.

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