Teaching and Thinking

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education. —Sir William Osler

Today’s New York Times (13 June 2007) carries an op-ed piece about a conflict of interest that those of us who practice medicine face daily, namely the overwhelming influence that the pharmaceutical industry brings to bear on our prescribing habits.

This comes on the heels of two other recent articles exposing the huge profit some oncologists make by routinely prescribing chemotherapy to some patients despite documented lack of effectiveness.

Much more than mere pillow talk these days, drug companies actually underwrite the cost of much of our continuing medical education. In the past they wined and dined doctors to influence prescribing habits. Nowadays, they underwrite the research that supports the use of their particular drugs, then buy contracted physicians to peddle their influence through continuing medical education materials and seminars.

If that were not egregious enough, the pharmaceutical industry has taken things one step further: they actually define illnesses or disease states to market their drugs more effectively. No where has this been more blatant lately than in the realm of psychotropic drugs. For example, what we used to call shyness is now labeled social phobia, in large part because there is a drug with an indication to treat it: Paxil.

It has come to the point that drug companies dictate so much of a physician’s education from the outset that they have doctors in their back pocket as loyal prescribers for the duration of their careers.

This flies in the face of Sir William Osler’s late 19th century admonition to physicians to be wary in dealing with powders and potions:

“Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs.…the desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures. It is really one of the most serious difficulties with which we have to contend. Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor’s visit is not thought to be complete without the prescription.…the temptation is to use medicine on every occasion, and I fear we may return to that state of polypharmacy, the emancipation from which has been the sole gift of Hahnemann and his followers to the race. As the public becomes more enlightened, as we get more sense, dosing will be recognized as a very minor function in the practice of medicine.…” (“Teaching and Thinking,” in Aequanimitas, p. 125)

Again Sir William admonishes us: “The battle against polypharmacy, or the use of a large number of drugs (of the action of which we know little, yet we put them into bodies of the action of which we know less), has not been fought to a finish.” (“Medicine in the 19th Century,” Ibid., p. 255) Indeed not—the fight continues. Our ranks have been infiltrated, and we have sold our license to practice medicine for a price.

Osler’s talks and essays eventually appeared in a single volume, Aequanimitas. In the early decades of the last century, this book was given as a gift to many graduates of medical schools in the United States by none other than—who would have guessed it?—the pharmaceutical giant, Eli Lilly.


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