The Show Must Go On! The Authentic Practioner and Discipline versus Deception

When does it become inappropriate to feign one's emotions?

At the end of a very long clinic day I suspect few physicians can say candidly that they look forward to working through another patient's complaints. And yet, the patient is there in the late afternoon, expecting quality and personalized service. So I ask: Is it OK for a doctor to smile on the outside when they are thinking secretly to themselves "God I just want this person to be gone from my sight"? Is it acceptable to force a few jokes, feign interest in a kid's extracurricular sports activities, and smile charmingly (Proverbs 31:30) to the mother?

Where does discipline end and deception begin?

How traumatizing for a child might it be to have a pediatrician act the way he really feels all the time? But then again, how traumatizing for an adult might it be to recollect those smiles from his childhood pediatrician and realize that they were a superficial mask covering his pressing desire to be gone from the clinic, at home with his family, drinking a cold beer?

Obviously there are times when we are called upon to act in ways contrary to our desires of the moment. The noble term for this is discipline. The ignoble term, deception. In my short time in medicine thus far, I feel I have seen it in both forms, and struggle with an answer.

Perhaps that is the hidden appeal of a doctor like House -- we don't have to second-guess his smiles and wonder whether he only likes us because we are paying him. Surely this conundrum is not limited to the medical profession. And I suppose that is why we call it the medical profession. 

America's Most Common Prescription Drug

Well, I began by searching the most commonly prescribed drug in America. It is a painkiller. In 2011, according to Time, the most common prescription was the combination of hydrocodone and acetaminophen marketed under different names including Lortab or Vicodin.

 

Hydrocodone is a synthetic version of a compound discovered originally in opiates. Acetaminophen is the compound found in Tylenol, discovered through drug compound research in the nineteenth century. When administered together in a single tablet, these duo create a powerful pain killer. We don't understand exactly how either one functions. Loosely, hydrocodon works on the central nervous system, and acetaminophen works on the periphery. Acetaminophen is absorbed from the gut, has a half life of 1.5 - 3 hours, is metabolized by the liver, and excreted by the kidneys into urine. Hydrocodone has a half life of about 4 hours and a more complex metabolism. These drugs get rid of pain and are used widely, except in cases where breathing is too slow or where there may be rising pressure in the brain.

 

So, where does it come from?

 

I begin by reviewing drugs@FDA to find an application approval in 1996 to a company called UCB Inc for the combination drug Lortab: 500mg acetaminophen, 10mg hydrocodone bitartrate in oral tablet form. Apparently, Lortab is the "Reference Listed Drug" (RLD) for its class. This means it is the approved drug product to which new generic versions are compared to show that they are bioequivalent. The site lists five other companies make drugs considered bioequivalent to Lortab: Amneal, Mallinckrodt, Sun, Vintage, and Watson. Lortab, it turns out, has another incarnation listed in 1982 as a drug in the class of Vicodin (which was the RLD itself). The difference with the 1996 Lortab is one of dosing: previously, Lortab contained only 5mg of hydrocodone, not the 10mg in its newest listing.
 

What, then, is "UCB"?

 

It's website tells us that it is "aspiring to be the patient-centric biopharma leader", and lots of happy images corroborate that image. Yay! It does business in 40 countries with annual revenue of 3.2 billion euros in 2011. The company was founded in 1928 in Brussels. 49% of sales is from Europe, 33% from North America. Its US headquarters happens to be located just outside of Atlanta in Smyrna. Interestingly, it is quite difficult to discover that Lortab is one of its drugs. For it lists Lortab as the last drug under the category of "Immunology" drugs...somewhat of a stretch! The drugs most touted are some rarely-used ones for compelling conditions like Crohn's and Parkinson's, not the habit-forming pain-killer reminiscent from House.

 

The "Products" site neglects to list Lortab, but does say  "For additional information on other products not listed here, contact UCB Medical Information at +1.877.822.9493." We'll pick up the trail here another day!

Is one egg the same as another egg? The people who sell us organic farm-raised eggs would certainly beg to differ. Is a cow the same as another cow? Michael Pollen disagrees. Now, why is it that we don't ask the question of whether one pill is the same as another?

 

Just how different is one aspirin produced by one company from another aspirin produced by another company? Perhaps they are identical, but in this world, it hardly seems possible. And yet everyday millions of Americans subconsciously assume that one pill is as good (or as bad) as another. That a walmart heart pill will do the same thing as a Canadian mail-order heart pill. It occurs to me, as a medical student, that we scrupulize neither the pills we take nor the pills we prescribe. One pill is just the same as another, our actions suggest. Yet how odd that we are willing to pay so much more for an organic blueberry versus an industrial one.

 

Perhaps the world is a refreshing place where we can indeed take certain facts for granted -- for example, that the drugs we prescribe/consume are 100% pure products formed of the chemical compound illustrated in the textbooks. On the other hand, could there be a whole tangled web of "better" and "worse" within the category of things we wishingly lumped together into "pharmaceutical"? 

 

Either we are being deceived by the Whole Foods of the world that tout quality, health, and sustainability differences or we have been very naive about a class of products that most Americans consume everyday without a pang of questioning. This is a topic I intend to explore piecemeal over the coming months. Obviously, there will have to be a discussion of the placebo effect.

Mothers Behave

You white trash mothers better behave.
Don’t you go blaming that school
for your third grader’s neuroses, which are
really your own.

Nobody says you’ve had a crystal stair.
Yes your daughter’s father is an alcoholic
and your aging parents are separated
and poor. Those contradictory counselors.

I suppose it really does seem that the world is out to get you.

But your beautiful asthmatic mulatto daughter wasn't supposed
to inherit that.

Pediatrics

With authority he swept round the midnight ward in a preppy papillon:
“Where’s that nightshift Indian doctor?
Tell him what’s needed: a brain MRI with venous angiogram!”

His consult had found her reflexes intact, pupils symmetric,
navel pierced. The nubile child, that is, with the Innocent smile
and recalcitrant headache.

Did you know that he trained under the best? He told me so.
With two hospitals yet to visit,
two doses more of hope and purpose for the old doctor.

Dear World,

I am a medical student questioning my place in the world. This is my newest blog.

Yours Faithfully,

Hanfei

“This life therefore is not righteousness, but growth in righteousness, not health, but healing, not being but becoming, not rest but exercise. We are not yet what we shall be, but we are growing toward it, the process is not yet finished, but it is going on, this is not the end, but it is the road. All does not yet gleam in glory, but all is being purified.” 
― Martin Luther