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companies also have to be able to justify how much they spend on meals - so the fine wining and dining has mostly been replaced by more modest meals.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.

Swiss Suffrage Shock

I was sitting in my politics lecture this week busily taking notes and being impressed by Swiss style democracy.  Switzerland is the closest example we have of direct democracy in modern society.

On average there are 7 referendums per year in Switzerland.  Major policy decisions and all changes to the constitution are decided via referendums.   The reliance on referendums dates back to 1848.  It has led to a very stable government and, contrary to what you might initially think, is a very efficient and progressive system.  For example the referendums have led to approving legislation regarding carbon taxation and recognition of same-sex partnerships .  Voting in referendums is not compulsory and voters tend to be well informed.  As opposed to what we see in modern representative democracies - politicians are part-timers without huge media prestige. 

However, just as I was thinking yay

for the Swiss, the lecture said:

"Switzerland did not grant women the vote until 1971"

I said:  "Gasp"

I mean I actually, literally, audibly gasped. 

And a number of swivel necked and primarily female students turned to look at me.  They seemed nonplussed by the information and but apparently surprised by my shock.  It's not that these students are mute.  They can raise a decent "murmur" when something piques their interest.

Why did these other students seem unsurprised by what the lecture had said but so shocked by my gasp? I have a few theories:

1. They already knew about this appalling example of the abuse of women's rights and were surprised that I did not already know this.  How could any self respecting female politics student not know this?

2. They were not actually listening to the lecture as they were too busy robotically taking notes.  Of course when they read over these notes as part of their exam preparation their shocked gasp will bring their parents or other house mates running to see what the matter is.

3. They are all so terribly young that 1971 sounds like such a long time ago.  Any time in history that predates the internet and Twilight must have been so horribly primitive that they are surprised anyone had the vote, let alone women.  Of course for someone born just 3 years after 1971 it seems unspeakably outrageous that the women's suffrage movement in Switzerland had to fight so long for this basic sign of respect.

4. They just didn't care.  They have been born into a time and place where their rights as women to vote, get an education and pursue any career of their choice are unquestioned.  Unfortunately these rights are now taken for granted, and consequently are undervalued.

I find it quite astounding and disturbing that Switzerland took so long to grant women the vote.  And I wonder long would it have taken for women to achieve the right to vote in Australia if the issue was decided by a referendum amongst male voters? 

For a time line of women's suffrage in Switzerland:

Women's Right to Vote In Switzerland

As a comparison, here is a link to the a time line of when the vote was granted to women by country:

Time Line of International Women's Suffrage

I have picked out a few examples from the timeline in case you can't be bothered perusing the whole list:

1893 - New Zealand

1902 - Australia

1906 - Finland

1917 - Canada

1918 - UK, Germany, Russia, Ireland,

1920 - US

1924 - Mongolia

1930 - South Africa - Whites only of course

1944 - France

1945 - Italy, Japan, Indonesia

1948 - Israel

1949 - China

1963 - Afganistan, Iran,

1971 - Switzerland

1994 - South Africa - blacks

There is more to me than what I eat.

My vegan apprenticeship is going well.  I am enjoying reading, learning, experimenting, tasting.  I am doing one strict day per week of a vegan diet and for the other 6 days per week I am working on excluding animal products without being fanatical.

But this is not all there is to me!  No-one likes to be pigeon-holed and I have already experienced this during my years of being a vegetarian:
 -  "Oh you're a vegetarian" (You are obviously some kind of animal-loving, tree-hugging nut.)
And I experienced it for years when I was a Christian:
 -  "Oh you're a christian"  (You are obviously a weird, judgemental and anti-fun nut).

I guess that is part of human nature.  We all (yes me too) judge a book by it's label.
But there is more to me than what I eat.

I also recognise that this vegan apprenticeship is just another development in my "I need something to focus on" quest.  I am a crusader.  It hurts to admit that.  But I do recognise a need in me to have something outside myself that I am "living for".  I am not an apathetic person.  And I am not satisfied with life being mundane.  But since (gradually) leaving the church I have struggled at times to know where to direct my crusading energies.  I get interested in an issue, (whether environmental, social or political) but soon realise that the "problems" of the world are bigger and more complicated that just that issue.  I want to keep things in perspective but this is very hard to achieve.

Maybe I just need to relax a bit more.
Not in the sense of frittering away my time on a-muse-ments.  A tendency in western society that really concerns me!
But in the sense of relaxing into my life as it is right now, with a bigger measure of acceptance, and taking time to smell the proverbial roses.

Or maybe I am just making things overly complicated and being too hard on myself.   I think I will just enjoy the day and enjoy my new found interest in veganism without worrying so much about the bigger picture today.

So what yummy new vegan recipe shall I try today.
:)

The Apprenticeship Begins.

Today is the first day in my quest to change to a vegan diet.

I have been a vegetarian for nearly 5 years.  And honestly, changing to a vegetarian diet was so easy!  I have occasionally missed gelatine (oh marshmallows how I used to love your squishy sweetness).  But I really have not missed other products that animals have had to die to produce.

For quite some time now my conscience has been nudging me towards veganism.  But convenience and taste buds have been bitterly opposing.

Last night I watched the "Farm to Fridge"  - thanks to my meat eating mum posting it on facebook.  And teary eyed and feeling terribly guilty about the cows who have been suffering to feed my dairy addition, I decided it was time to make real commitment.  And so my vegan apprenticeship starts today!

Certainly I am against animal suffering.  But my main reason for wanting to go Vegan is environmental.  The dairy industry has an enormous ecological footprint.  More on that in future blogs.

So my challenge is to cut out dairy.   One day at a time.  And I do mean 1 day at a time because right now more than one day dairy free seems daunting.  I know - I am a wuss!


Step 1 - one dairy free day per week.  If you knew how much I loved my cups of white tea you would know how hard this is going to be for me.  No, soy milk is just not the same.

And I will start to try out new vegan recipes, both sweet and savory.  I will aim to try at least one new vegan recipe per week.  I also plan to post recipes, nutritional info and my veganification experiences on my new blog: The Vegan Apprentice.   I will continue to post non-vegan blog posts here from time to time.

Well, now I am off to the supermarket now to buy some soya milk.

A 10% decrease in weight is associated with...

Looking for a New Years Resolution that is worth making? Maybe the following my provide some inspiration.

A 10% decrease in weight is associated with .....
(obviously this only applies if you are currently overweight)

↓ >20% total mortality
↓ >30% diabetes-related deaths
↓ >40% obesity related cancer deaths
↓ 10 mmHg systolic BP
↓ 20 mmHg diastolic BP... See More
↓ 50% in fasting blood glucose in newly diagnosed DM
↓ 10% total cholesterol
↓ 15% LDL cholesterol
↓ 30% triglycerides
↑ 8% HDL cholesterol
↓ frequency of sleep apnoea
↓ breathlessness and improves lung function
Improves back and joint pain
Improves ovarian function

And for all you folks out there who have been thinking about breast cancer (thanks to that sophisticated "what colour bra are you wearing?" status updates), did you know that increasing your physical activity can decrease your risk of breast cancer. In fact exercise is astoundingly good at increasing your health, well being and longevity.

Health benefits of physical activity:
(30 minutes of moderate intensity exercise on most, or preferably all, days of the week.)

• All-cause mortality risk reduced by 50%
• Cardiovascular disease risk reduced by up to 50%
• Hypertension prevention and management
• Stroke risk reduced by up to 30%
• Type 2 diabetes prevention (risk reduced by 30–50%) and management
• Cancer risk (colon, breast) reduced
• Osteoarthritis management (pain control, maintenance of muscle strength, joint structure and function)
• Osteoporosis risk reduction
• Falls risk in the elderly reduced by resistance exercises
• Weight management and reduction (when combined with dietary changes)
• Mental illness (anxiety, depression and subjective feelings of stress) prevention and management

Now turn off your computer and go for brisk walk!

(PS the stats are shamelessly cut and pasted from a RACGP online education module I am doing today.)

Worth Watching

I talked to someone on the telephone yesterday at length about how can we possibly account for the tragedy and evil in the world. Where is the meaning in our lives? Is there something beyond random chance at work?

As humans, we have a rich heritage of mythology, which has persisted through the ages and across diverse cultures. What are the lessons that we, as individuals and as the human race, can learn from this wisdom passed down in story form, and from the breadth of our history?

The person I was talking to has started on the process of discovering and asking their own questions quite recently. I could identify very strongly with their dismay in realising that the more they thought about "things" all it did was reveal more questions, rather than resulting in answers.

I find this talk by Jordan Peterson very helpful.
>> Jordan Peterson: The Nature of Evil
He is a Professor of Psychology at the University of Toronto (formerly a professor at Harvard). He has obviously been thinking about these issues for much longer, and much more in depth, than I have.

I highly recommended watching this presentation. It is well worth taking the time to watch and think about some of the ideas he presents.