March 2006

IIb. Proposal 2- How to Avoid Prescription Medicine Mistakes

     How many times have you received a prescription from your doctor and said to yourself, “I hope the pharmacist can read this because it looks like Chinese characters”? There is a standing joke about the poor penmanship of physicians. However, this is no joke when it recklessly endangers a patient’s health.

     According to an analysis by the Institute of Medicine’s Committee on Quality of Healthcare in America, medical errors, including prescription errors caused by poor handwriting, might be partly or wholly responsible for 98,000 deaths a year. These medical error costs are in the billions of dollars. An analysis by the Institute for Safe Medication Practices stated,  
     “Virtually all of the prescriptions issued each year in the United States are written by hand. Indecipherable or unclear prescriptions result in more than 150 million calls from pharmacists to physicians, asking for clarification, a time-consuming process that could cost the healthcare system billions of dollars in wasted time. At the very least, that process can delay the time until patients receive their medications. At worst, a misread order can lead to injury or even death.”

     A number of commentators have suggested that physicians use electronic ordering tools to electronically transmit the prescription to the pharmacy. This suggestion has a number of weaknesses. First, the cost to equip all doctors and pharmacists with digital prescription ordering machines may be prohibitive and the cost will be passed down as higher physician fees, higher medical insurance premiums and higher drug costs. Second, authentication of the digital prescription has to be secure to prevent hackers from causing harm to the patient through mischief. The most important weakness in the use of a digital ordering system that is directly between the physician and the pharmacist is that it leaves the patient out of the loop. What we need is a secure electronic ordering information tool that enables the patient to be part of the loop.

     As stated in Part One, Maximizing Your Medical Advice, the patient must be actively educated about his or her medical care to be a successful patient. The patient should see the prescription, be able to read the prescription and question the prescription before leaving the physicians office. For example, if a patient has been treated for high blood pressure or high cholesterol, he or she will be familiar with the medication. If the prior medication provided for 10mg per day and the prescription says 100mg per day, the patient should immediately question the physician before leaving the office. In a digital ordering process between the doctor and the pharmacist which excludes the patient until the medicine is in the patient’s hands, the above mistake may not have been caught. Always look at the prescription before you leave the doctor’s office to make sure you can read it and understand what it is for. Ask the doctor to explain what the prescription is for and to clarify illegible handwriting. If your doctor is unwilling to explain and clarify the prescription, then get another doctor.

     A second proposal for change to our broken medical system, is to require all physicians to print or have office staff type the paper prescription. A hand printed prescription of 3 or 4 words and 1 or 2 numbers is not an unreasonable burden on physicians. In fact less cost will be associated with a printed prescription than a script prescription. The mandate to require printed prescriptions will require either legislation or state regulation by the medical licensing authority in the state. Significant monetary fines and warnings should be imposed on doctor’s writing script prescriptions. Two warnings will result in fines only, while a third infraction will result in a one week suspension of the physician’s medical license.

     This is a simple, no cost fix for a large physical, emotional and financial problem. All we need is the political will to mandate the use of printed prescriptions either by hand or machine and the cooperation of physicians. Since physicians take an oath to do no harm to their patients, this rule change should be readily accepted by physicians. 


     Last Tuesday I attended a lecture at a premier medical school given by two eminent microbiologists. The focus of the lecture was to educate the attendees about the flu and the risks of a possible worldwide infection (pandemic).

     Viruses cannot live outside the host. If human beings become immune to the virus, the virus will become extinct in humans. The smallpox virus killed over 300 million people in the 20th century. Through worldwide innoculations, the smallpox virus could no longer infect humans. Therefore, the smallpox virus is now extinct because there are no longer any human hosts it could infect.

     Viruses cause illness in humans by invading cells and replicating within the cells. The virus then spreads to other cells. Unless the immune system can control the virus, the virus will infect every cell and overrun the body. In some cases, death can result. Viruses are fought with the body’s natural immune systems or through vaccines. Vaccines stimulate the body’s immune system to produce antibodies to fight the disease. The viruses are isolated and then killed (inactivated) or weakened but live (attenuated). These killed or weakened viruses trick the immune system into an immune response namely the production of antibodies. The immune system does not distinguish between harmless dead or weakened viruses and a fully functioning virus. The immune response produces antibodies from the vaccine so when the fully functioning virus hits, it is met with antibodies which kills the virus before it can replicate throughout the body. Without the vaccine, the body cannot produce antibodies fast enough to stop the spread in the body of the virus.  

     The flu is a virus. A virus is smaller than bacteria or parasites. In fact, viruses are so small that if it were the size of a 3×5 index card, the cell would be the size of the old World Trade Center. The flu is classified as “A” type and “B” type. “A” types are subject to antigenic shifts. This means the virus has the ability to jump from animals to humans. A “B” type flu virus is a human virus that cannot jump from animals to humans. “A” type flu viruses can reside in birds, horses, pigs, whales, reindeer, seals and camels before jumping to humans.

     The 1918 Spanish flu killed 675,000 people in the US and 50 million worldwide. The high death toll could be attributed to the lack of knowledge about the flu. Health authorities believed the flu was a bacterial infection. Even if antibiotics existed in 1918, they would have been useless against the flu virus. Antibiotics are effective only against bacterial infections but are ineffective against viruses. The flu virus was not isolated until 1933. It is hard to believe how far medical science has come in the 90 years since the 1918 flu.

     The “A” flu virus has 16 different subtypes. There are currently 3 types of flu viruses circulating in the human population. These are H1, H2 and H3. The H1 and H3 strains were included in this year’s flu shots.

     The worry in public health circles is the H5 bird flu. There is currently no vaccine for humans for this flu virus. Various antiviral drugs may help if there is an outbreak. Currently, microbiologists report there has been no jump of the bird flu to humans. Of the 175 cases reported in humans worldwide, all had close contact with chickens or other birds. The bird flu has not yet appeared in the US. The scientific thinking is that the infection of the 175 people was caused by ingestion of infected birds without proper cooking. This released massive amounts of the bird flu virus into the bodies of the victims. Heat through proper cooking will kill the virus.

     The 1918 flu virus although extinct contained certain genetic proteins that made it lethal in humans. If that genetic protein combined with other flu viruses, a health problem could result. The best current scientific evidence is that the bird flu will not jump to humans but constant mutations in the virus requires significant monitoring.

     To summarize, 1) get your flu shot every year, 2) the bird flu is not currently a significant risk of jumping to humans from human contact and 3) chicken is safe to eat as long as it is cooked thoroughly. Chicken should be cooked thoroughly to avoid a bacterial disease called salmonella poisoning.    

      In my opening remarks, I tried to bring patients to the realization that medical services are dispensed in an inefficient manner. This inefficiency is largely due to the fact that the US medical system is broken and sorely in need of reform. Reform of the medical system will not happen soon. Therefore, we patients must adapt to the current medical system by maximizing the benefits of the medical advice given. Only then can we be successful patients.

     Some of my friends who are medical doctors tell me that many patients are uneducated or unwilling to learn basic principles of the science of good health. These doctors have told me that many of their patients know more about their car than they know about their bodies. Anecdotal conversations with one physician revealed that some patients service their cars every 6 months but do not get physical exams at least once a year.

     The first step toward being a successful patient is to be proactive with your health. This requires patient preparation. As with every profession, the medical profession has its own vocabulary with which patients need some familiarity. This does not mean for the patient to run out and buy the latest edition of Gray’s Anatomy. It does mean however, a frequent use of the internet. For example, my dad thought he may have a hernia. He made an appointment with his primary care physician for the doctor to evaluate his discomfort. Before he went to the doctor, I went on the internet to learn: a) what is a hernia? ,b) what are the different types of hernias? ,c) what are the treatments for hernias? and d) this is important, what are the risks if I have a hernia but fail to correct it? Armed with this information, the doctor’s diagnosis and treatment made sense to my dad and our family. Remember, there is a waiting room full of patients that the doctor has to see. He or she has 15 minutes to explain the diagnosis, treatment and answer any questions you may have. Without proactive preparation as a patient, the doctor’s 15 minutes is merely a directive not a dialog.

     Just as car owners buy magazines and manuals for their cars to better understand what is under the hood, the successful patient needs to continue or begin their education so as to better understand “what is under his or her hood.” This does not require the successful patient to go back to school or to spend a lot of money. How can this be done? The modern hospitals have recognized that patient education is not only good business but increases satisfied patient outcomes and reduces malpractice litigation. One noted NYC hospital has introduced a no cost mini-medical school for anyone wanting to learn more about medical sciences. Lectures are given by medical school professors with materials given to medical school students. The focus of these lectures, however, is not to diagnose ailments but rather to educate patients about medical ailments and the medical jargon associated with the discussion. The author of this blog will be attending a 2 hour lecture next week on the possible pandemic associated with the bird flu.

     To reiterate, these lectures are not intended to preempt a doctor’s diagnosis or treatment of the flu. It is however, intended to educate the patient about: a) What is the bird flu? b) How is it transmitted? c) What are the treatments? and d) know what is fact and what is rumor. I will report next week on this blog about what is fact and what is fiction about the bird flu. Finally these lectures give the patient the vocabulary needed to comprehend the news, avoid the flu if possible and if necessary, seek and understand medical advice. This is the beginning prototype of the successful patient.

     Contolling the cost of medical care in the US is the touchstone to repairing the broken US medical system. By broken, I mean the delivery of care is inefficent and too expensive. This post will discuss some of the cost issues facing the US healthcare system. Make no mistake, I believe the healthcare in the US is the best in the world. However, outcomes are equally favorable in Europe and yet the per capita heathcare bill is significantly less than the US.  Healthcare in the US is big business. Roughly 16% of the US GDP is spent on delivering healthcare. By the year 2015, that figure is expected to reach 20% of US GDP. Controlling the cost is an imperative.

     Recently I attended a party with a number of doctors of Indian descent who practice in the US. One doctor in particular cornered me to tell me of his experiences in returning to India to practice medicine. He told me that the cost of dissolving kidney stones in India is 75% less than the cost in the US. The procedure which costs $40,000 in the US costs $10,000 in India. The equipment is manufactured in Germany  and used in the US and India. He stated to me that the doctor’s fees for the procedure are unreasonable compared with India. He then smiled and said “But I am not complaining. It goes in my pocket.” It is true that US laws and patient malpractice suits increase the cost of medical services as compared to India. The real reason for the higher cost in the US verses any other industrialized country is that medical costs are not controlled in the US where such costs are controlled everywhere else.

     If we assume a free market in the US, then the laws of supply and demand apply. However, even Adam Smith would recognize that medical costs must go up if demand is inelastic. Stated differently, patients have no choice to consume if they are ill. Basic economics teaches us that if prices go too high consumption will decrease thereby reducing the price. This only works in a scenario where demand is elastic, that is, moves downward when prices are high and up when prices are low. Medical services are consumed when needed regardless of the price. Some form of price controls are required to affect the inelastic demand for medical services, and in the case of prescription drugs, a free market exists only in the US.

     Advocates for the free market of prescription drugs point to the US as the leader of a free market policy. I absolutely believe in a free market if there is a level playing field. Let me give you a simple example. Pfizer, a leading drug company develops a drug for a cost of $1billion. The board of Pfizer authorized the development based on the assumption of a 10% return each year for 15 years. In the first year, Pfizer must earn $100 million. Sales in all parts of the world except the US are running at a $30 million rate for the year. Since the US is the only free market for the drug, Pfizer must price it to earn $70 million in the US to reach $100 million for the year. Thus, because of foreign price controls, US prescription drug consumers pay more than double the amount paid by foreign consumers. In short, the US public is subsidizing the cheaper drug costs for the rest of the world. Two possible approaches are apparent: 1) enact a law that US drug costs cannot exceed 110% of the average cost for the rest of the world, or  2) foreign markets will not be supplied unless the price is at least 90% of the average cost in the US market.

     Prescription drug costs in the US will continue to outpace inflation unless the US goverment recognizes that demand for prescription medicines is inelastic and the pricing mechanism is distorted by foreign price controls. The US people can no longer subsidize the rest of the world by turning a blind eye to the fact that a free market for prescription drugs exists only in the US. Legislation to require drug companies to price in the US based upon worldwide pricing is needed to stem the spiraling costs of presciption drugs.