Undermining my Teetotalism

I am not much of a drinker and it is pretty rare for me to have a drink at home.  However, for the last couple of nights I have been kicking back with a relaxing gin and tonic.

I grew up in a tea-totaling church.  This branch of the church (Assemblies of God if you're interested) gradually came to accept a bit of "sensible" imbibing over the years.  And so I got to graduate from Lemon, Lime and Bitters, to occasionally having something a little more potent.

I have spent a lot of my 4th decade unraveling the knots I acquired in this environment but I still have not acquired the knack of drinking very much.

I have found it interesting to observe how others relate to alcohol after deconverting from the same, or similar, religious upbringings.  Some continue to avoid it: "I have lived perfectly well for this long without drinking why start now?"  Others suddenly embrace alcohol, and by embrace I mean at every possibly opportunity as they try to rapidly make up for missing out on teenage hangovers and embarrassing lapses of dignity at parties.

I have tended more towards the conservative side.  Partly because I have a voracious sweet tooth and most alcohol still tastes crappy to me (though I don't leave your bottle of butterscotch schnapps lying around).  But probably it is mostly because I am a control freak and the thought of being drunk is scary.

I watched Paul last night (while nibbling on dips and bread and sipping my G&T) and had a good laugh.  I loved Kristin Wiigs character who undergoes an instantaneous deconversion.  She makes it look so simple.  All you need to do is find an accommodating alien to lay hands on you and impart his knowledge and experiences.

Below is a little promo youtube thingy.  I have included it here because it shows some of her post-deconversion antics.  It is a pretty predictable movie so I don't think it will spoil it too much if you have not already seen it.

I love the character's reaction to her suddenly altered world view and new found freedom.  Pretty different to how I have reacted.   There is a lot for me to think about right there.

Jessi Arrington: Wearing nothing new

Wow.  This is so simple and yet so inspiring.  I love it!

Whether you want to save some pennies, save the environment or are just plain anti-consumerism, this might just be the idea you are looking for.

I have two questions:
1. Can you do this as successfully as Jessi Arrington if your personal style (or lack there of) is a little less flamboyant?  She rocks those outfits! But I just don't have the confidence to pull off gold glittery skirt especially with knee-hi white socks.
2. Doesn't $50 seem a little expensive for a second hand outfit?

Either Thrift shops in the US are way more expensive than here in Australia, or Arrington is shopping at fancier second hand stores than me.  Most items of clothing in the charity "op shops" I like to visit are under $5.

My favorite piece of clothing is from just such a shop.  A Salvation Army store to be precise.  I have worn it and worn it.  Almost every time I wear it someone tells me how much they like it.  To think I almost didn't buy it because it seemed to expensive at $15!

My favorite skirt.

Unfortunately I got the bottom of it caught in the wheel of my chair at work one day and it tore.  I was devastated.  But a very kind friend sewed it for me and did such a wonderful job you cannot even see the repair.  Now I don't wear it to work too often and if I do I am very careful not to roll around on my chair as much!

Perfect for twirling!

When I set myself a similar challenge to "Buy nothing new" in February 2009 it was surprisingly easy to stick to.  In fact, it was so easy that I found it quite challenging to go back to buying clothes after that.

My mum told me about a similar concept: "Buy nothing with a bar code".  It is intimidating to think of how that principle would apply to buying food!  I am certainly not ready for that.  No where near ready for that!

Disclaimer & The Importance of Laughing in Earnest.

I forgot to mention - my daily blog for September will be happening on The Vegan Apprentice.

I have a few posts in mind for this blog this month, but daily?  No, not going to happen.  Not this month anyway.

Although, come to think of it, I could just about do a post a day with patient bloopers collected over my years in general practice.  Lately some of my patients have, inadvertently I am sure, upped the ante in the bloopers stakes.  Hmmm, or maybe its a plot.  Something along the lines of "Try and make Mandy laugh in a patients face".  If that is the case, so far I am winning.  I always manage to keep a straight face.  Well, at least until the consultation is over.  I do have some decorum!

It's probably not a devious plot.


In fact maybe it is a good plot.  One designed to bring me more laughter.  And I do love to laugh.  And then I get to laugh about it again when I come home and tell my husband.


(It's not a plot at all is it?)

Anyway, here is an example from this week:

After examining a reasonably well 9 year old boy:
Me: He has a head cold and does not need any antibiotics.  (This is the abbreviated version).
Mother: Do you have time for one more question?
Me: Sure
Mother: I have been trying to teach him how to breathe. Do you have any tips on teaching children how to breathe?

I would love to hear your bloopers.   Opportunities for laughter should be shared.  

PS. No patients where harmed in the writing of this blog post.  Confidentiality upheld at all times.  :)

Matt Cutts: Try something new for 30 days

Over the last few days I have been umming and ahhing about whether to commit to 30 Day Blog September.   If you don't know what I am referring to then check Good Reason Blog.

There will always be excuses for taking on any challenge in life and I was manufacturing a few for myself.  Then I stumbled across this neat TED talk by Matt Cutts (never heard of him before either?) and realised I had nothing to lose.  Except of course pride if I didn't complete it - but I will complete it!  So win-win!!

Here are some examples he gave of 30 day challenges.

The interesting thing for me is that it was a 30 day challenge that gave me the inspiration to kick off this blog.  It all started with November 2008: Supermarket Free Zone.  Then there was December 2009: Non-fiction read-a-thon.  Followed by January 2009: Regular Exercise and February 2009: Consumer Detox, which I actually carried on past the end of the short month for the next 18 months.

I guess my vegan apprenticeship is a kind of challenge but it is bigger deal than a monthly challenge for me.  Though I think a vegan 30 day challenge would be a pretty cool experiment for those who have never tried it.  Or, for those a little less keen, maybe a "Vegan day once a week for a month", or even a "Vegan dinner one day a week for a month" would be a great challenge to set yourself! 

I really enjoyed setting myself those challenges and the motivation it gave me to do something different.  Unfortunately I did not get around to setting myself any more monthly challenges after those first four months.  So here is just the push I needed to get started again.  Not saying I will set a challenge every month (2012: monthly challenge every month year???) but I am going to do it more regularly than I have for the last couple of years.

Cutts says that when he started setting himself monthly challenges "instead of the months flying by, forgotten, the time was much more memorable."  That sounds good to me! 

Decision Fatigue - A Pervasive Malaise

Have you ever looked back on a decision and wondered: "What on earth was I thinking?"  I certainly have.

My husband came across a very interesting article this week in The New York Times Magazine which might help explain some of these lapses in judgement:  Do you suffer from decision fatigue?

Image from the NYT Magazine

I found it very interesting and it is well worth a read.  I plan to keep this in mind when in situations that demand decisions.  Hopefully it will result in less retrospectascope regret.

It reminds me how important it is to take a 5 minute break and have a snack at work.  I now have a name for that sluggish, frustrated feeling I can get mid afternoon on a busy day!  I will tell the receptionists at work: "No more squeeze-ins please.  I am suffering from decision fatigue."

I learned early on in my career that it is good medical practice for me to keep a piece of fruit, muesli bar or sandwich handy (or even chocolate!).  But I sometimes feel guilty snatching a quick cup of tea between patients.   This article reminds me how important this really is.  Keeping a patient waiting for another 5 minutes may inconvenience them.  But trying to provide a consultation when suffering from decision fatigue will result in me not being able to give that person a good quality consultation and may result in much more than inconvenience.

Next time you are faced with a situation where you are required to make a lot of decisions - beware decision fatigue!  Allow yourself to take a break, fix your blood glucose levels if necessary, and avoid making a decision you will later regret.

No More Drug Lunches for Me.

It has been two months since my last Drug Lunch.

That statement may require some explaining. By "Drug" I mean Pharmaceutical Company, and by "Lunch" I mean any gift (edible or otherwise).

What is a Drug Lunch?

Pharmaceutical sales reps regularly visit doctors and they generally bring food.  Over lunch they chat about the products of their company.  They offer sample boxes of medications (to give to patients of course) and "trinkets" such as measuring tapes, boxes of tongue depressors and patient education booklets, all blazoned with the company's logo and feature products.

Pharmaceutical companies also run "educational" events such as dinner meetings with a local specialist as the speaker, and more elaborate weekend conferences with international guest speakers covering a range of medical topics.  For example a company promoting a new antidepressant medication may organise for a local psychiatrist to give a talk on the treatment of depression to up-skill GPs.

This is pretty tame compared to the all expenses paid weekends away to golf resorts for doctors and their partners that used to be on offer.  In Australia the marketing strategies of pharmaceutical companies have come under scrutiny and regulation since the 1960's and now any perks offered have to be directly related to educational content.  Pharmaceutical companies also have to be able to justify how much they spend on meals - so the fine wining and dining has mostly been replaced by more modest meals.

In practice, for me, that meant free sandwiches or sushi for lunch on a pretty regular basis, with cake for dessert on a good day, and a bunch of stuff in my office with pharmaceutical company logos and products on it.

For more info on the current regulations/guidelines click here: Medicines Australia - Code of Conduct 

The Challenge:

I had a little about the potential conflict of interest but had been procrastinating on doing anything about it.  The kick that I needed to finally do some thing about this came from a facebook discussion of all places!  Someone posted a response on a friend's status update, their comment included the following:

"It is time to remove the title of doctor from people because the Medical profession is all about money. Research is not for cures, only repetitive medications for ongoing profit. Disband the AMA then we can fund health appropriately. " 

Silly me waded into the discussion - defending doctors and our prescribing patterns.  Here is a snippet:

"I also won't dispute with you that big pharma is about profit, I would go further and say that big pharma is corrupt to it's core, but pardon me if I still chose to judiciously prescribe their products in the best interests of my patients."

The person responded politely and then posed the following question:

"Do any Doctor's receive any benefits from prescribing particular brands/products including business trips etc.? "

The simplistic answer is no.  Doctors' do not receive incentives for prescribing particular products.  But the question got me thinking.  And reading.  And the more I thought and the more I read the more it became obvious that my interactions with pharmaceutical companies were probably compromising my professional integrity and ability to practice unbiased medicine.

It is insidious, not innocuous:

Nearly all doctors I know interact with pharmaceutical companies sometimes.  And most of the doctors that I have talked to feel that they do not allow pharmaceutical company information to affect their prescribing habits.  This is what I used to think too.  But the research disagrees.  You can find links to articles dealing with this topic on the No Free Lunch site.  Here is one example:

"These alterations in prescribing patterns occurred even though the majority of physicians who attended the symposia believed that such enticements would not alter their prescribing patterns."  - Wateska L, Orlowski JP "The effects of pharmaceutical firm enticements on physician prescribing patterns.  There's no such thing as a free lunch."  Published in Chest, 1992 Jul;102 (1):270-3.  Abstract available here.

It must seem pretty arrogant (of just stupid) of me to have thought that I was not affected.  But to be honest, most of the time I just did not think about the implications of these interactions.  Which I am sure is just how the pharmaceutical companies want it.
 The bottom line is that pharmaceutical companies wouldn't bother if it didn't work!

Once I started to actually think about the issue the ethical decision became crystal clear.

My pledge:

I will accept no gift, however large or small, edible or inedible, from a pharmaceutical company.  I will accept no information, education or training from a pharmaceutical company, no matter how reliable or prestigious the invited speakers may seem.

The Response:

I wondered how my decision would be received at work.  I suspected that my colleagues would think I was strange, or being over the top.  (Hmm, maybe they already think that!)  But actually my decision has been received very positively. 

More Info:

If you would like more information on this issue you could check out the following organizations:

No Free Lunch

I came across this web site pretty quickly when I started googling info on doctors and pharmaceutical companies.  The organisation was started in America by health professionals concerned about the influence that pharmaceutical companies have over the health industry.

No Free Lunch encourages doctors to take the pledge reproduced below, and to let their patients know about it.   The organization maintains a list of health professionals in the US who have signed on.

"I, __________________, am committed to practicing medicine in the best interest of my patients and on the basis of the best available evidence, rather than on the basis of advertising or promotion.   

I therefore pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my practice, teaching, and/or research." 

 - copied from No Free Lunch.

Healthy Skepticism

I asked a friend if there was a similar organisation in Australia and he pointed me in the direction of Healthy Skepticism.  (He is doing some research into this area and must have wondered why it took me so long to reach the decision to boycott drug lunches.)

Healthy Skepticism was started in 1983 in Adelaide Australia, but has members from around the world.  From the web site:

"Healthy Skepticism is an independent, international, not for profit organisation for people with an interest in improving health. We aim to improve health by reducing harm from misleading drug promotion.

 - from The Identity Statement of Healthy Skepticism

Healthy Skepticism is in the process of merging with No Free Lunch.  Strength in numbers!

Doctors Reform Society

The DRS was formed in 1973 in Australia, specifically to support the introduction of Medicare, which was opposed by the Australian Medical Association at the time.  The DRS has much broader interests than just the issue of pharmaceutical marketing but I think it is relevant to this discussion. 

From the DRS website:

The DRS functions as a medico-political think tank, a lobby group and a public resource centre.
It is not affiliated to any political party, receives no corporate funding, and relies financially on subscriptions and donations.
The DRS will speak out against any political party, organisation or individual that threatens public health care.

- copied from the About Us section of the DRS website.

So, where am I at now?

• I have not attended a "Drug Lunch" in the last 2 months
• I have become a member of Healthy Skepticism.  
• I plan to attend the August meeting of the Perth branch of the DRS.  
• I have not finished removing all the Pharmaceutical paraphernalia from my consulting room but I am getting there. 
• I am looking at educational events that are not sponsored by any pharmaceutical companies.  This means I will have to pay to attend them but at least my conscience, and hopefully my clinical judgement, will be clearer.