Index Home About Blog
From: "Steve Harris" <>
Subject: Re: iatrogenic pains
Date: Sat, 18 May 2002 14:16:37 -0700
Message-ID: <ac6gsc$o0d$>

Nicolas Martin wrote in message ...
>In article <weXE8.16931$

>I said what I said, that they profit mightily. In many cases people are
>forced to have office visits for medications that couldn't possibly hurt
>them (used as labeled). I used to use Nizoral shampoo. No doctor EVER
>gave me unlimited refills for that shampoo.

Federal law prohibits unlimited refills for any Rx drug-- the most you can
get is a year's worth. And I routinely give patients a year's worth of
things like Claritin, Nizoral shampoo, antihypertensives they've been on for
more than a year, etc,etc.

> What harm could have
>befallen me from using Nizoral? Well, now that it has been made OTC we
>know not much.

Its costs companies money to switch from Rx to OTC. Until then, all Rx drugs
are subject to the same Federal prescribing laws.  If you don't like that, I
invite you to write your congressman. For example, you can write your
senator-- since there is exactly one physician in a senate of 100 people and
about 50 lawyers, do be sure and include you suspicion that federal laws are
written by lawyers to make doctors more money, since lawyers love doctors so
much, and vice versa.  Let me know what answer your senator gives. Yuck,

>Why do you think a doctor would not give unlimited refills for a
>medication that is both harmless (used as labeled) and effective?

No medication is harmless-- used as labeled or not.  And risks vary, but
there's only a binary set of laws-- OTC or Rx. Perhaps a four-tier system if
you count the separate laws and hassles for DEA scheduled stuff, and four if
you separate C-II from C-III to V DEA controlled stuff.  But at max that's 4
categories in an infinite range of dangerous stuff. So it will never really
fit very well.

> What
>other motivation besides money could require an office visit for this
>refill? You think docs yearn for my company?

Perhaps they don't want you using stuff for  for months or years when it
will cause damage if used for that long--- but is fine when used for weeks.

>What would have been the
>liability issue resulting for unlimited Nizoral refills?

None, since you can't get unlimited refills for anything.

> In many
>countries where people have less money (and no insurance) to waste on
>unnecessary office visits, most drugs are OTC. We are blessed with the
>obligation of perpetually returning for expensive drug renewals and
>negative test results.

Correct. But those countries steal our drug study results.  Information
costs money to produce, and the question is: who should pay?

>Are these revisits to protect patients? Evidence please?

The irony. You provide the evidence yourself below, and you don't even know

>I once got a prescription for a Texas doc for a drug for a face rash.
>When I went to fill it the pharmacist (God love him) said, "You don't
>want to use this, it will permanently change the shape of your face."

That should have been a high potency steroid creme. And it will only change
your face skin permanently if you use it for too long. This doesn't happen
in weeks-- it takes months or years.  It would happen an unlimited
prescription of the sort you're pining after, but doubtless you'd have been
fine if you'd used the drug as directed, and had a pharmacist who wasn't an

> On top of that it was not indicated for my condition.

I doubt that.  Supply details and I'll tell you. Dermatologists use medium
and even high potency steroids on the face all the time-- but they know when
to stop.

>When I called the doc
>to ask her why she recommended a drug with such a serious side effect
>and which was not indicated, she literally screamed at the phone: "It is
>not my job to tell you about the side effects of the drugs I prescribe."

A likely story.  The point is that the side effect you mention is
time-dependent, and is *exactly* the kind of thing that prescription
limitations work best to keep from happening. Your own illustrative story
illustrates only what an ignoramus you were being (and your pharmacist
doesn't get off very well, either).

>I called the clinic management where she worked. It was arranged that I
>see another doc at that clinic. When I explained things to him and
>showed him the drug, he asked that I give him the drug so that I
>wouldn't be enticed to use it. I declined and kept it as a momento. He
>agreed that it was totally inappropriate for my mild skin rash.

Not a dermatologist, was he?  Non-dermatologists have a horrid (and not
well-justified) fear of high potency steroid cremes. But they are not very
dangerous if used correctly. You were telling us that your original doc gave
you a year of refills for this stuff?  No, you weren't.

>What would have been my fate if I hadn't lucked upon an attentive

A hysterical  pharmacist, you mean?

>What penalty was levied against the doctor? None, she still
>works at the same clinic. (Oh, and my insurance company and I got to pay
>for the improper medication.)

I want to know what penalty got levied against the pharmacist?

>My wife recently went to a Knoxville clinic, primarily for a referral.
>She also had some persistent coughing and respiratory distress. The doc
>came to the door of the office my wife was in, he did not enter the
>room. She told him of her problem breathing and coughing and he said,
>"There's nothing I can do about that, I'll prescribe an antihistamine."
>He never got within 8 feet of her, so how did he know she didn't have
>something serious and contagious?

Like tuberculosis? There aren't many persistant contageous things. You say
it was for a referral? So how much information did you bring with you?

>When I complained to that clinic's management they said he had been
>"talked to" before about diagnosing without examening patients. But he
>suffered no penalty and the clinic still billed our insurance $70
>despite agreeing that the doc had provided no competent medical service.

I won't make excuses for a doctor who didn't examine the patient personally.
However, there are some referrals where it doesn't add much.

>These are not horror stories, these are normal medical practice, and
>I've experienced much worse.

Perhaps (from reading stuff such as your "steroid nightmare" above), your
experience is not as bad as you think it is.

I'd be the last to say that the practice of medicine doesn't have a lot of
problems. But a good many of them would be fixed by 45 min office visits.
Alas, the system (which means the patients) are only willing to pay for 15.
A lot of the money that used be paid to doctors to spent 45 has gone into
regulatory overhead and expensive tests. There's an interesting article in
the NEJM this money about luxury medical care-- patients spend an extra
$1000-10,000 a year to get the longer office visits, house calls, doctor's
pager number, 24 hour access, etc. This allows doctors to have 300 patient
practices instead of 5000 patient practices.  It's a lot like the HMO or
insurance plan, except we eliminate the middle man (the HMO or insurance
company). Everybody who had afford it is very happy with it. People who want
something for nothing, naturally, aren't.

>One of the more laughable was when I went
>to be told of a test result (which was negative and could have been told
>to me over the phone gratis), the doc spent the majority of our time
>together dictating a thank-you letter into a tape recorder to the doc
>who had referred me to him.)

If you don't show up in person, your insurance doesn't pay the doc.  That's
not his problem-- that's YOUR problem. Tests have to be ordered and
interpreted, and letters have to be dictated, and almost none of it is
billable without a patient sitting in an exam room (this courtesy of
medicare, which has de facto now set the standards for non-medicare care
also). It's conceivable that third parties will eventually figure out how to
pay doctors for thinking about particular patients when the patients are not
there in front of them. But save for the unique case of radiologists and
pathologists, it mostly hasn't happened. Medicare in a serious of moves over
the last 15 years has decided that "face to face" time is the gold standard
in billing. That means your federal government (remember that senate full of
doctors? ;) ) has decided that you therefore must waste a lot of your time
going to the doctor's office.  Do be sure and write to tell them how much
you appreciate this.

Don't write to the doctors. If you think they make the rules, please follow
Harris' law for deciding who has the power in societies. Go to your nearest
large city.  Look at the big buildings.  Why owns those buildings?  There
might be hospital, but do the doctors in it, own it?  No.

The owners of the buildings are who run your society. They, plus, the
voters, make the rules.  We doctors are outvoted, and we're outspent, and we
don't own those buildings.

>the medical party line is "we're here to help," but the reality is often
>much different. You can see just by the example of the Texas doc that
>she didn't give a damn whether she permanently disfigured me, and in my
>experience she is not unusual.

You wouldn't have been disfigured unless you'd had the power to buy drugs of
any kind of an unlimited time, and then proceeded to use them against all

>Let's see, there was the doc who gave me a pain med to which I had a
>nasty reaction. I called his office and he didn't call back for several
>days. When I finally got him he said, that is not unusual and you can
>just quit taking it if you want. No, it is not unusual, my side effect
>was potentially serious and listed among reasons to quit taking the drug
>immediately, which I had. But suppose I hadn't quit taking it and had
>waited the several days for him to call back? What might the
>consequences have been? Liver damage was certainly a possibility.

Ummm, you weren't smart enough to know you could stop taking a pain pill any
time?  Hello?

How unusual it was or wasn't, and interpretation of rest of your story, can
only be told if you provide the details. Otherwise, we'll file it under
urban myth.

>Before you are three instances of medical incompetence that could have
>led to serious medical errors. Not one of the doctors showed the
>slightest concern or sustained any penalty.

We haven't been given enough information to tell how much concern was
warranted- just vague stories. And that goes double for penalties.

>Either iatrogenic disease will be drastically reduced or there will be a
>popular uprising.

A popular uprising?  ROFL. That would be the populace that spends more on
pet food than medical research?

>People like the guy I ran into recently at Circuit
>City, whose leg was amputated after he went in with a sprained ankle and
>ended up with 17 surgeries during which his bone was infected, are
>getting plenty steamed.

I'm getting plenty steamed at these ridiculous stories.  Nobody gets bone
infection from a sprained ankle. Nobody gets operated on for a sprained

I welcome email from any being clever enough to fix my address. It's open
book.  A prize to the first spambot that passes my Turing test.

From: "Howard McCollister" <>
Subject: Re: inguinal hernia repair & vasectomy
Date: 18 May 2005 16:14:03 -0500
Message-ID: <428bafd1$0$50238$>

<> wrote in message
>I read somewhere that some surgeons slot the mesh for the sperm cord
> during inguinal hernia repair surgery, which I'll be undergoing
> shortly.
> Would it be reasonble to inquire about having a vasectomy procedure at
> the same time as the hernia surgery? Any reason to believe it's not
> feasible?

Sure, it's feasible - in fact it's a great way to go if you have a hernia
and want a vasectomy. The vas deferens can be sectioned on the hernia side
easily at the time of the operation. The other side will require the usual
small incision in the scrotum.

This assumes that your surgeon has no religious compunctions against
vasectomy and knows how to do one transscrotally (for the non-hernia side).
It also assumes that your insurance company is willing to pay for it and you
can be pre-certified for it by them, and that the surgeon considers the
reimbursement that they offer for it to be reasonable. When done as a
concomitant procedure, insurance companies will often deny the vasectomy fee
after-the-fact, or will only pay 25% or less of the actual fee. I personally
wouldn't do it for that.


From: "Howard McCollister" <>
Subject: Re: Study: Cancerous Prostate Removal Pointless If Over 65
Date: 19 May 2005 12:33:03 -0500
Message-ID: <428ccd69$0$16234$>

"Steve U" <> wrote in message

>  Anybody with a doctor more interested in money
> than in the patient's best interests is a fool who will soon be parted
> from his money.

Sorry, but that's just unrealistic. While I agree that that no doctor should
jeopardize a patient's life because of financial issues, the financial
reality is that the patient's best interests *frequently* take a back seat
to reimbursement.

An example...a patient needs both a colonoscopy and an EGD. Obviously, the
most convenient and comfortable thing for the patient is to do them both at
the same visit, under the same anesthetic. That way they only need to take
one day off work, they don't have to come in early, get an IV started etc
etc. Unfortunately, most insurance companies won't pay for the second
procedure done at the same time, or at most will reimburse 50% of the usual

Likewise, another poster recently asked about getting a vasectomy at the
same time as a hernia repair. That would be a great idea, and more
comfortable for the patient, but again, many or most insurance companies
won't pay for that kind of concomitant operation.

So is the surgeon supposed to do it for free?


From: "Howard McCollister" <>
Subject: Re: Study: Cancerous Prostate Removal Pointless If Over 65
Date: 19 May 2005 20:43:02 -0500
Message-ID: <428d3ff6$0$50234$>

"Jim Chinnis" <> wrote in message
> As a patient and a non-MD, I would hope that you would discuss the
> alternatives with me. Then I could decide if I wanted to have a
> dual procedure anyway and pay you what you say my insurance
> company would not.

Insurance programs vary state by state and company by company. Contracted
fee-for-service is the norm in this state and many others and
balance-billing for covered services is not allowed by the contract. If you
want a colonoscopy and EGD at the same time, and your insurance carrier
won't pay for the second procedure, and it's not an emergency or assuming
there's not an overriding health reason to do both, then they'll be
scheduled separately. You wouldn't have the option of paying for the
additional procedure.


Index Home About Blog