Overdosed America: The Broken Promise of American Medicine

DEDICATION

To Charlotte, who gave me the courage to go forward with this project.

And in memory of Bruce Spitz, my trusted colleague and friend.

EPIGRAPH

It is no limitation upon property rights or freedom of contract to require that when men receive from government the privilege of doing business under corporate form . . . they shall do so upon absolutely truthful representations.. . . Great corporations exist only because they are created and safeguarded by our institutions; and it is therefore our right and duty to see that they work in harmony with these institutions.

Theodore Roosevelt

CONTENTS

DEDICATION

EPIGRAPH

PREFACE TO THE PAPERBACK EDITION

INTRODUCTION

PART I: A FAMILY DOCTOR’S JOURNEY OF DISCOVERY

CHAPTER 1: Medicine in Transition: Caring for Patients at the Crossroads

CHAPTER 2: Spinning the Evidence: Even the Most Respected Medical Journals Are Not Immune

CHAPTER 3: False and Misleading: The Misrepresentation of Celebrex and Vioxx

CHAPTER 4: The Myth of Excellence

CHAPTER 5: A Case in Point: The Saga of Hormone Replacement Therapy

PART II: THE COMMERCIALIZATION OF AMERICAN MEDICINE

CHAPTER 6: American Medicine’s Perfect Storm: A Brief History

CHAPTER 7: The Commercial Takeover of Medical Knowledge

CHAPTER 8: The Snake and the Staff: Duping the Doctors

CHAPTER 9: A Smoking Gun: The 2001 Cholesterol Guidelines

CHAPTER 10: Direct-to-Consumer: Advertising, Public Relations, and the Medical News

CHAPTER 11: Follow the Money: Supply-Side Medical Care

PART III: TAKING BACK OUR HEALTH

CHAPTER 12: The Knee in Room 8: Beyond the Limits of Biomedicine

CHAPTER 13: From Osteoporosis to Heart Disease: What the Research Really Shows About Staying Healthy

CHAPTER 14: Healing Our Ailing Health Care System, or How to Save $500 Billion a Year While Improving Americans’ Health

BIBLIOGRAPHY

INDEX

ACKNOWLEDGMENTS

P.S.

ABOUT THE AUTHOR

ABOUT THE BOOK

READ ON

NOTES

PRAISE

COPYRIGHT

ABOUT THE PUBLISHER

PREFACE TO THE PAPERBACK EDITION

When Overdo$ed America was first published, I expected the book to generate immediate excitement. After all, the book exposes many of the drug companies’ well-kept secrets, such as the misrepresentation of their own research on Vioxx and Celebrex in our most respected medical journals and the pushing of cholesterol-lowering drugs on millions of Americans, unsupported by the scientific evidence. I had spent nearly three years documenting the undue influence of the drug and other medical industries on American health care and was sure that the response to my findings would be explosive.

During the first week after publication the silence was deafening. Maybe doctors were not ready to accept that much of the scientific evidence upon which they base their medical decisions is more like infomercials than disciplined science. Maybe the American public was not ready to swallow this bitter, but critically important, pill.

Then, just one week after the book hit the stores, Merck stunned the medical world with its announcement that it was withdrawing its $2.5 billion a year arthritis remedy Vioxx from the market. This was the biggest drug recall ever(about one out of ten American adults had taken Vioxx in the previous five years.

Initially Merck was credited with acting responsibly and decisively when it learned that its blockbuster drug doubled the risk of serious cardiovascular problems in a study designed to determine whether Vioxx reduces the recurrence of non-cancerous polyps of the colon. But the real news was not that Merck had done the right thing in September 2004 (which it had). Rather it was that American doctors had prescribed $7 billion worth of Vioxx, causing an estimated tens of thousands of heart attacks and deaths, after both Merck and the FDA had become aware (in 2000) that Vioxx was significantly more dangerous and no more effective than an older and far less costly anti-inflammatory drug, naproxen (Aleve).

Suddenly it was as if the waters had parted or the code of silence lifted. Americans wanted to know how a non-essential drug that turned out to be so dangerous had become so widely used. The media responded. Instead of being ignored, I was invited to explain to millions of Americans how this had happened on NBC’s Today show, CNN’s American Morning, Lou Dobbs Tonight, and on all the other major networks.

In the following three months an unprecedented string of drug company failures and embarrassments came to light. Just one week after the Vioxx recall, Americans learned that half of our supply of flu vaccine, 46 million doses, would not be arriving as planned from a manufacturing plant in Liverpool, England. The plant, which sends 90 percent of the flu vaccine it makes to the United States, had been abruptly shut down. Bacterial contamination of four million doses of flu vaccine was the initial sign of trouble, but the underlying problem was the inadequacy of the manufacturing safety systems. With most of the flu vaccine being produced in this plant headed for the United States, one might assume that the FDA had been actively monitoring the safety of these imported medicines-especially given its oft-expressed concern about the potential danger to individual citizens of importing drugs from abroad. But it wasn’t the FDA that shut down the plant in England. In fact, FDA officials were taken by surprise when they were informed that the British drug authorities had shut the plant down to protect Americans from unsafe flu vaccine being produced by an American company’s plant in the United Kingdom. This debacle was an accident that had been waiting to happen, at least in part the result of having transferred more than one thousand FDA employees into the department that approves new drugs (like Vioxx) and out of the department that oversees drug safety (like inspecting manufacturing plants).

This was not all. The following week the FDA issued a strong warning about the use of antidepressants in young patients: Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents. British drug authorities had mandated a similar warning a year and a half earlier, based upon the same information that had been available to the FDA. Eight months before the warning was issued in the United States, an FDA Advisory Committee met to discuss the potential danger of these drugs. But the FDA’s own epidemiologist, who had been heading up this investigation, was removed from the agenda and not allowed to present his report.

Although the six studies involving young patients that had been published in medical journals showed that antidepressants are safe and effective, nine studies showing just the opposite had not been published. Doctors, trusting their medical journals, were being misled. Instead of taking protective action based on a clear and present danger, the FDA asked an independent panel of researchers to review the data. When the outside experts agreed with its own, the FDA belatedly mandated the highest level of caution: a black box warning on the drug label and a patient information sheet to accompany the medication. In other words, the drug companies had maintained sales of largely ineffective drugs by not publishing results from their own studies showing that the new antidepressants increase suicidal behavior in youngsters, thus leaving doctors uninformed about these negative studies. When confronted with this situation, the FDA’s reaction was first to protect the drug companies rather than our children. (This brings to mind the maxim that the best measure of a society is how it treats its most vulnerable members.)

This rapid-fire series of events may have brought us to a watershed in American medicine, dispelling the illusion that what’s good for the drug companies is good for Americans and helping us to understand that we are not getting commensurate value for the enormous cost of our health care. Probably the greatest cause for optimism is the Senate Finance Committee hearing called by Sen. Grassley (R-Iowa) to investigate whether the FDA and Merck had adequately monitored the safety of Vioxx. Americans were given the opportunity to witness academic researchers and public employees describing how drug companies wield influence and suppress information. Most of the senators on the committee appeared to care deeply about protecting Americans from the unnecessary dangers of potentially harmful drugs and seemed to understand that the FDA is not now providing adequate monitoring of drug safety.

As the litany of previously undisclosed risks of some of our most widely used drugs grows ever longer, most of the attention is being focused on the FDA. Certainly reform at the FDA is necessary to improve the safety and effectiveness of our medical care, but this is in no way sufficient to achieve all our goals. Like a dentist not drilling all the way to the bottom of a cavity, we are still not getting to the bottom of the problem, and anything less is going to squander this extraordinary opportunity.

The over-use of Vioxx, Celebrex, and cholesterol-lowering drugs in adults, and antidepressants in children and adolescents all show that at the heart of the crisis in American medicine is a crisis in the quality of our medical knowledge. As you will learn in the pages to follow, the corruption of that knowledge extends far beyond the reach of the FDA. Overdo$ed America tells this story without protecting any of the vested interests, which is how we need to approach the crisis in American medicine if we truly want to restore its broken promise.

INTRODUCTION

For more than 20 years I practiced family medicine in a small town about 45 minutes north of Boston. During those years I often marveled at how lucky I was to have found my calling, balancing the science of medicine with the art of caring for people. I got enormous satisfaction out of watching children grow and families mature, assisting them through daily worries and occasional tragedies. I treasure the lessons I learned from my older patients as they met the challenges of their senior years with dignity and humor. I have had no greater sense of accomplishment than helping people preserve their health, recover from illness, and, when recovery was not possible, provide comfort.

Just before I left my practice to write this book, one of my longtime patients, Mrs. Francis, came in for a last visit. I always enjoyed seeing Mrs. Francis, a widow then in her in mid-eighties. Her greeting was warm and her presence made the exam room feel comfortable—an oasis in the midst of daily time pressures, multiple tasks, and complex patient challenges. During this visit, Mrs. Francis asked why I was leaving. This wasn’t just a casual question, nor did I feel that she was prying. Over the years, we had enjoyed many conversations, and I felt as if she genuinely wanted to understand what had gone into my decision. I did my best to explain.

I told her that over the last few years a profound shift had been taking place in the culture of American medicine. I explained that tests unlikely to improve patient care were being routinely ordered and expensive drugs that had not been shown to be any more effective or safer than the older drugs they were replacing were being routinely prescribed. I told her that the research I had been doing at night and on weekends was confirming my sense that much of the scientific evidence on which we doctors must rely to guide our clinical decisions was being commercially spun, or worse; and that many of the articles published in even the most respected medical journals seemed more like infomercials whose purpose was to promote their sponsors’ products rather than to search for the best ways to improve people’s health.

I told her that many of my patients were being drawn in by the growing number of drug ads and medical news stories; that patients were increasingly arriving for their visits with a firm (if not fixed) idea of the outcome they wanted instead of the expectation that the best medical care would emerge from open discussion of their symptoms, concerns, and exam, and then mutual consideration of the options. I told her that when I tried to refocus patients on interventions proved to be safe and effective, many were reacting as if I were purposely trying to withhold the best treatment, making me choose between providing the best care and yielding to their demands in order to maintain the healing potential of our relationship. Finally, I told her that I had come to the conclusion that the best way I could help people to achieve better health was to find out what the scientific evidence really shows and explain this to the public—in much the same way that she and I had talked over the years—and to other medical professionals.

That was the best answer I could give Mrs. Francis at the time. I wasn’t sure what I was going to find when I turned my full attention to these issues. But it was becoming clear that American medicine was like a runaway train picking up speed, fueled by the commercially generated belief that ever-increasing medical spending is necessary to achieve good health. It was also becoming clear that the train’s brakes were failing. It seemed to me that, despite a few clear and brave voices, there was no effective counterbalance to the influence of commercially sponsored research. Nor was there even a way to determine whether all this expensive new care actually led to better health. And it was also clear that this crisis would soon come to a head when the burden of relentlessly increasing medical costs became more than many Americans could bear.

What I found over the next two and a half years of researching the research is a scandal in medical science that is at least the equivalent of any of the recent corporate scandals that have shaken Americans’ confidence in the integrity of the corporate and financial worlds. Rigging medical studies, misrepresenting research results published in even the most influential medical journals, and withholding the findings of whole studies that don’t come out in a sponsor’s favor have all become the accepted norm in commercially sponsored medical research. To keep the lid sealed on this corruption of medical science—and to ensure its translation into medical practice—there is a complex web of corporate influence that includes disempowered regulatory agencies, commercially sponsored medical education, brilliant advertising, expensive public relations campaigns, and manipulation of free media coverage. And last, but not least, are the financial ties between many of the most trusted medical experts and the medical industry. These relationships bear a remarkable resemblance to the conflicts of interest the Securities and Exchange Commission recently brought to a halt after learning that securities analysts were receiving bonuses for writing reports that drove up stock prices with the intent of bringing in more investment banking business.

As a result of all this, the pharmaceutical industry is raking in unheard-of profits—more than three times the average of the other Fortune 500 industries, even after accounting for all its research and development costs. At the same time, the average yearly out-of-pocket health care costs for employees of large corporations (including payroll deductions for health insurance, co-pays, and non-covered drugs and services) increased by more than $1000 between 1998 and 2003. To put the magnitude of this growing health tax in perspective, the much ballyhooed middle-class tax cut amounts to $469 for the average American family. In 2004, out-of-pocket health care costs for that same family are projected to increase by another 22 percent, coincidentally costing exactly an additional $469 per year. While the drug and medical-device industries are enjoying their enormous profits, hardworking Americans are struggling to keep up with their health insurance premiums and medical bills, 44 million Americans are without any health insurance at all, and half of all personal bankruptcies in the United States are caused by medical expenses.

Worse, many of the mechanisms that Americans trust to protect their health and resources have been dismantled by political pressure from doctors and medical industry lobbyists, while others have become absurdly dominated by people with financial ties to the pharmaceutical companies—a situation that no impartial observer would ever conclude was designed to represent anything other than corporate interests. The shocking news is that this is now commonplace at even the most trusted of American health institutions, the National Institutes of Health and the Food and Drug Administration.

The bottom line is this: There has been a virtual takeover of medical knowledge in the United States, leaving doctors and patients little opportunity to know the truth about good medical care and no safe alternative but to pay up and go along. The ugliest truth of all is that these enormous costs do not come close to producing commensurate improvements in our health—the health of Americans is actually losing ground to that of the citizens of the other industrialized countries, which are spending far less and at the same time providing health care to all of their citizens.

Over the past 28 years as a physician I have had the privilege of observing the transformation of American medicine from a number of vantage points. My first experience as a primary care doctor was in Appalachia, with the National Health Service Corps (then a part of the U.S. Public Health Service). There I worked in a rural health clinic where I got an excellent introduction to the basics of clinical medicine—including working alongside an exceptional nurse practitioner, who showed me the importance of a team approach to patient care. Later, as a Robert Wood Johnson Fellow, I spent two years studying research design, statistics, epidemiology, and health policy and then researching the consequences of providing medical care to low-income inner-city residents through an innovative health maintenance organization (HMO). I was able to continue my academic interest in health policy at Brandeis University’s Heller School of Social Policy, participating in a project designed to tailor local health care expenditures to local health needs. I witnessed the evolution of HMO coverage from the inside during my seven years as a part-time associate medical director in an early HMO in Massachusetts. In the mid-1990s, I merged my practice into Lahey Clinic, a large, doctor-run multispecialty group practice. Lahey Clinic showed its commitment to primary care by setting up a department of family practice, in which I served as chair for seven years.

Teaching has also been an important lens through which I have observed the changes in medicine. I began teaching Harvard Medical School students in my office after I had been in practice for about 10 years and enjoyed supporting and supervising them as they progressed during these clerkships through the stages of becoming doctors. My first task was to help the students learn to apply the medical science they were learning to the patients they were seeing in my office. As they became comfortable with the nuts and bolts of disciplined primary care, I especially enjoyed helping them develop their skills in the art of medicine—understanding that the person-to-person connection they were making with their patients was not just a pleasant amenity but an integral part of medical care. I hoped to help them add this essential dimension of good doctoring to the technically oriented medicine they were learning while caring for very sick patients in university hospitals, where they spent most of their time.

As an outgrowth of this focus on the fundamental importance of healing relationships in good medical practice, I taught a course for several years at Harvard Medical School with Dr. Herbert Benson of the Mind/Body Medical Institute. My goal was to provide medical students with an intellectual framework to support (protect may be a better word) their humanistic ideals while they struggled to learn the scientific basis of medicine.

But by far the most important vantage point from which I observed the changes taking place in American medicine was caring for my patients. I enjoyed keeping up to date on the latest developments by reading the medical journals and occasionally using my research skills to check analyses and conclusions. I took great pleasure in working with specialist colleagues on patients who required more care than I could provide alone.

As I think back on my practice and patients over the years, I recall with particular clarity the moment before each visit when I would lift the patient’s chart out of the holder on the exam room door, pause for a moment to think about the person I was about to see, and refresh my memory with a quick look at the chart. As I entered the exam room, I would make a mental note of anything that might help me better tune in to my patient and then would begin the visit with either an open-ended question or a continuation of a conversation from the last visit (a recent change in medication, grandchildren, a job change, a sporting event, a marital problem, a school report, and so on). Visits of this kind gradually build the healing relationships that establish the foundation of good medical care. In the final analysis, it was both the loss of trust in medical science and the weakening of doctor-patient relationships that led me to write this book.

Mrs. Francis listened carefully to my explanation, but she had a hard time understanding what I was saying—not because she didn’t believe me but because the changes in American medicine that I was telling her about were so vastly different from the world of medicine and the values that she had grown up with and that had served her so well. Nonetheless, she sincerely wished me well, and we ended the visit making clear to each other that we would miss our relationship.

This book approaches the crisis in American medicine from the radical center—the simple ideal that unbiased medical science and strong doctor-patient relationships ought to define optimal medical care and serve as the basis of medical practice.

My research has shown me how easily this could be achieved simply by restoring the integrity of medical science and refocusing its mission on improving health. I have come to understand that the system we now have is far from the best way to advance medical knowledge and pay for health care, but is probably the best of all possible ways to transfer massive amounts of wealth from the American people to the drug industry and other medical industries.

Popular wisdom, even among health policy experts, is that there is no good solution to this crisis of rising health care costs. As long as the validity of our medical science and method of translating it into medical practice remain unquestioned, this is true. But our medical science has become deeply flawed, manipulated to serve corporate interests. What appears to be a crisis in the cost of medical care is really a crisis in the quality of American health care. Fixing the distortions in our medical knowledge will not only lead to far better health and health care, but at the same time save hundreds of billions of dollars a year.

Obviously, one person and one book cannot present an exhaustive discussion of all the issues that need to be considered to resolve this crisis. But by beginning to lift the veil of scientific authority, commercial spin, and outright deception, I hope I can improve public understanding about the contribution of commercial distortion to the crisis in American medicine.

This book is presented in three parts. The first, A Family Doctor’s Journey of Discovery, describes the changes that were taking place in my own practice and the commercial influence that was starting to appear in respected medical journals that made me want to delve deeper. Discovering the hidden truth about Celebrex and Vioxx and, later, understanding the debacle of hormone replacement therapy showed me how profoundly disordered American medical research and practice had become.

The second part, The Commercialization of American Medicine, presents a brief history of the commercial takeover of medical knowledge and the techniques used to manipulate doctors’ and the public’s understanding of new developments in medical science and health care. One example of the depth of the problem was presented in a 2002 article in the Journal of the American Medical Association, which showed that 59 percent of the experts who write the clinical guidelines that define good medical care (the standard to which doctors are often held in malpractice suits) have direct financial ties to the companies whose products are being evaluated. The exaggerations and distortions of the 2001 cholesterol guidelines that are responsible for millions of Americans’ being treated with cholesterol-lowering statin drugs (despite the lack of scientific evidence of benefit for such widespread use) is presented as a case in point.

The final part, Taking Back Our Health, proposes a broader paradigm of medical care than the one learned by doctors during their medical training and reinforced by the medical industry’s commercial interests. Part III examines what the research really shows about the most common chronic diseases—from osteoporosis to heart disease—explaining that much of what is called scientific evidence is really disease mongering designed to sell more drugs. The final chapter shows that restoring the integrity of medical science is the best way to finance universal health care and still save hundreds of billions of dollars a year.

This book tells the hidden story of American medicine. If you or your doctor ignore its findings, it could be hazardous to your health.

PART I

A FAMILY DOCTOR’S JOURNEY OF DISCOVERY

CHAPTER 1

MEDICINE IN TRANSITION

CARING FOR PATIENTS AT THE CROSSROADS

The air was hot and muggy even by Amazon standards. It was the end of an exhausting but very satisfying day of doctoring indigenous people of all ages in a two-room school building temporarily transformed into a clinic for this small medical mission. We were putting the medical equipment and records away, and I was thinking about how nice a cool shower was going to feel, when our interpreter approached me with a look of concern and asked if I would make a house call to a woman who was too sick to come to our makeshift clinic.

Several villagers led me across an open field and down a narrow dirt path to the sick woman’s open cabin. As we approached, I could see her lying still in a hammock. Her husband was sitting nervously by her side, and her four young children were darting playfully in and out of the cabin, pausing for just a moment to check on their sick mother. As I sat down next to her, I could tell from her detached, pained, and frightened look that she was seriously ill. Even the subtle facial expression she mustered to greet me seemed to cause her pain.

I was introduced to the sick woman and her husband by our interpreter, and learned that she had had a spontaneous miscarriage several days before. The pain in her belly and vomiting had been getting worse for the past two days. I asked if I could examine her. She responded with a minimal nod and looked over to her husband to make sure that he agreed. Her temperature was now 103 degrees. Her abdomen was stiff and exquisitely tender to even the slightest touch. Most likely she had developed a uterine infection as a consequence of an incomplete miscarriage, and the infection had spread throughout her abdominal cavity, causing peritonitis. She needed to be hospitalized for intravenous antibiotics and fluids, and she needed dilatation and curettage of her uterus—a D and C—to remove the infected tissue.

Her husband and several other villagers listened attentively as I explained my diagnosis. But their expressions changed from hope to despair when I told them that she needed to be treated in a hospital. They said that she couldn’t go to the hospital because they did not have any money. I suggested that they take her there anyway and that someone would care for her. They said that wouldn’t work, that she would be ignored, left to die on the hospital steps. I asked how much it would cost for her to get hospital care. They said $160. The two other Americans present and I glanced at one another and agreed, without a word being spoken, that we would get the money together. Fortunately, a boat soon came by, headed in the right direction, and off she went, accompanied by our capable interpreter, who could help her with travel and hospital arrangements. The woman returned to the village three days later, weak but much improved. Her look of fear was gone. Her husband and children stared in happy disbelief when they first saw her and realized she would recover.

When I got back home, I went to my office the Sunday before resuming my normal schedule to go through the paperwork that had accumulated while I was away. Among the several 3-foot-high stacks of patients’ charts, test results, consultants’ notes, medical journals, and junk mail was the latest issue of the Journal of the American Medical Association (JAMA), from November 24, 1999. I noticed an article about Celebrex and one about Vioxx, the latest drugs for arthritis pain. Each article presented the results of a study sponsored by the drug’s manufacturer claiming that the drug was significantly safer than older anti-inflammatory medication, which was available in much less costly generic form.

The accompanying editorial—these are typically included in medical journals to provide expert perspective on the most noteworthy articles published in each issue—reported with unusual candor (especially since both authors had financial ties to at least one of the manufacturers of the new drugs) that neither of the new anti-inflammatory drugs provided better relief of symptoms than the older alternatives. The editorial also explained that the highly touted safety benefits of the new drugs appeared minimal in people who were not at high risk of developing serious gastrointestinal side effects. So minimal, the editorial said, that 500 such people would have to be treated for one full year with the new drugs instead of the older anti-inflammatory drugs to prevent just one serious but nonfatal stomach ulcer. Based on the difference in price between the new and older anti-inflammatory drugs, the editorial calculated that the cost of each serious ulcer thus prevented was $400,000.

Still moved by my experience in the Amazon, I wondered how many lives like that of the woman to whom I had made the house call might be saved for the cost of preventing a single nonfatal stomach ulcer by using Celebrex or Vioxx. I took out my calculator to see how many times $160 goes into $400,000. I could feel myself change when I saw the figure 2500 on the display and realized the injustice of that equation. Though I didn’t realize it at the time, this book was conceived in that moment.

This incident sensitized me to the intense marketing of these two drugs. Advertisements for them suddenly popped up everywhere. At first the ads seemed inappropriate, but quickly they claimed their place as normal fixtures of the American cultural landscape. The implication of the ads was that the (unspecified) superiority of the new drugs allowed people to enjoy activities that they had previously been unable to enjoy because of arthritic pain—though no such superiority had been found in any of the major research.

The marketing campaigns were certainly successful. In the year following the JAMA editorial, Celebrex and Vioxx were two of the four drugs with the greatest increase in sales. Many, if not most, of the orthopedists and rheumatologists in my community began prescribing them enthusiastically, despite the reservations expressed in the JAMA editorial. My patients were not immune to the effect of all this advertising. They increasingly requested and occasionally demanded these expensive new drugs for their arthritis symptoms and various other aches and pains, and many interpreted my reluctance to prescribe the new drugs as simply a primary care doctor’s lack of expertise or inability to keep up with the latest medical therapies. Even after I carefully explained the details of the best available scientific evidence about these drugs, not all of my patients could be convinced otherwise.

THE NEW MEDICAL CONSUMERISM

Mr. Black’s visit provides a typical example. A successful small-business owner in his mid-forties and an avid intermediate tennis player, Mr. Black came to see me because of nagging pain in his right elbow. A brief exam revealed tenderness on the outside of his elbow at the point where the tendon that extends the wrist into a backhand tennis shot attaches to the bone. I explained that the problem was epicondylar tendonitis, more commonly known as tennis elbow, which is caused by the repetitive impact of the tennis racquet hitting the ball. I made a series of recommendations that would allow the tendon to heal: use a forearm band when playing tennis to partially protect the point of insertion of the tendon into the bone from the impact of the tennis ball hitting the racquet; ice the area after playing tennis to prevent the inflammatory reaction from progressing; decrease the tension in the racquet strings and perhaps change to a more flexible racquet frame to lessen the impact of its hitting the ball; and talk to his tennis pro about possible grip or swing changes that might improve his tennis elbow (and perhaps his tennis game at the same time). Finally, if there was still no improvement after doing all of these things, I warned Mr. Black that he might have to temporarily decrease the amount of tennis he was playing to give his arm time to heal.

Mr. Black listened patiently to all my suggestions. When I was done, he said, My friends are getting good relief from Celebrex. Would you write me a prescription for that? I explained that, despite what the ads implied, Celebrex would not provide him with any better relief than the other anti-inflammatory drugs (commonly referred to as nonsteroidal anti-inflammatory drugs, or NSAIDs for short) and was a lot more expensive. He replied that the additional cost was not a problem, because my insurance covers it. Mr. Black’s belief that Celebrex would solve his problem made him unwilling, or perhaps unable, even to consider my suggestions. And he made it very clear that if I would not prescribe Celebrex, he would find a doctor who would.

I quickly thought through the possible responses to Mr. Black’s ultimatum. I didn’t want to permanently weaken our relationship of many years over a single prescription for a drug that was unnecessarily expensive but unlikely to do him harm. I wrote the prescription.

A couple of weeks later Mr. Black called my office to report that his elbow pain had not improved and to request a referral to an orthopedic surgeon. I was frustrated that he was still unwilling to do the simple things necessary to protect his elbow from the consequences of more stress than it had been designed to withstand, but I did not want to put either of us through a repeat of the last visit. If I wanted to preserve the potential of our relationship’s being helpful in the future, my only option was to acquiesce, once again. The orthopedist confirmed the obvious diagnosis of tendonitis with an MRI and sent Mr. Black for physical therapy. His elbow pain improved slowly.

AN OLD-FASHIONED DOCTOR-PATIENT RELATIONSHIP

In stark contrast, my relationship with Sister Marguerite is an example of the potential of doctor and patient working together toward the same goals. I first met Sister Marguerite after she had been brought to the emergency room by ambulance, desperately short of breath. She could barely talk as she struggled to get enough air into her lungs. Her heart was beating irregularly, at about 170 times per minute. She was in atrial fibrillation—chaotic electrical activity in the upper chambers of her heart was overriding her heart’s own natural pacemaker. Her chest x-ray showed pulmonary edema, fluid in her lungs, as a result of her heart not being able to pump blood effectively when beating so fast. All I knew about Sister Marguerite was from her chart: she was in her mid-eighties and had recently retired to the local convent after teaching school for 55 years.

At first I thought she would not survive this episode without intubation and mechanical ventilation. Fortunately, she responded quickly to intravenous medications that slowed down her heart and made her kidneys excrete much of the excess fluid in her body. Within 24 hours her breathing