And Then, What Happened?


In these virtual pages I have written about medical mysteries, the frustrations of today’s healthcare, and the human dramas we encounter in the practice of medicine.

Below are updates to three previous posts, one from each of these three categories: “The Great Imposter”, “Calling Mrs. Kafka”, and “Invisible Ties”. Readers who don't remember these posts may want to follow the links to catch up on the beginning of each story.



The Great Imposter” ended in clinical uncertainty:

“And so I leave Norman Sprague in the competent hands of Dr. Brown, who returns from his vacation tomorrow. Norman’s lung nodules and lymphadenopathy still remain to be diagnosed, and he still may have gallbladder disease, but he also, again, has the original working diagnosis of herpes zoster, the great imposter.”

The other day I saw Dr. Brown walk Norman Sprague down the hall. Afterward, I asked whatever happened with his possible shingles, gallbladder pain, lung nodules and mediastinal lymph nodes.

“The PET CT looked pretty benign”, said my octogenarian colleague, “and nothing came of that pimple you saw on his back. He still has his gallbladder and Roger White is pretty sure it's sarcoidosis. Interesting, though, that the Lyrica samples you gave him when you thought it was shingles cut his pain at least in half, but the pain is on both sides of the midline…”

“I don't know why it's working, then”, I said.

“Neither do I, but I kept him on it. He's meeting with Roger next week to discuss treatment options, probably steroids.”

“Pretty sure, huh”, I muttered to myself.



In “Calling Mrs. Kafka”, I went to bat against the insurance company for Harriet Black. She really did have a terrible case of shingles, and Lyrica was the only thing that really helped her pain; the gabapentin and her regular pain medication had not been enough.

After my call to the surreal Mrs. Kafka in the Prior Authorization department, I asked Autumn to call Harriet and tell her the drug was approved. She was very grateful on the phone. Some time later she came in for her follow-up appointment.

“How’s your shingles pain”, I asked.

“Still pretty bad”, she answered.

“I thought the Lyrica was working pretty well”, I said, confused.

“I can't afford it. The copay is too high”, Harriet said, her voice trailing.

So much for getting a medication approved by the insurance company…



Four years ago, in “Invisible Ties”, I described how Kirk Donner, adopted at birth, went to the State Capital to look for his birth mother after he turned eighteen. He knew she had an unusual name, Suann:

“Kirk took the elevator to the fourth floor. He was alone. As the door slid open, he stepped forward and almost collided with a tall, dark-haired woman with designer jeans and a plain, white blouse. Her eyes met his as he stopped and apologized. They were large and kind. She flashed a smile as he swerved around her, embarrassed and eager to get to the registry.

He walked up to the receptionist and stated his errand with words he had practiced in his mind the whole trip.The clerk handed him a form and as he reached for a pen he saw a stack of similar forms in front of her. Reading the top one upside-down he saw the name: Suann Walker.”

Mother and child made contact soon after that day, and each found peace in knowing what had become of the other. Kirk met his half-sister, also raised by an adoptive family.

Suann and her fiancé attended Kirk’s college graduation in May, and this summer Kirk spent a lot of time at their house while he took a summer course in the southern part of the state.

“Finding her and learning what she is like has helped me understand myself better, it makes me feel more whole”, Kirk has told me.


Many of my vignettes on this blog end with unanswered questions or unstated uncertainties, just like any typical physician’s patient encounters. These updates moved the plot forward in just three cases, but even these are not the final installments in the history of each patient’s own journey. Medicine, even practiced over many years of physician-patient continuity, is but a glimpse into the lives of a few fellow humans.


A Rash of Rashes

This week I suddenly felt transported back to my earliest years in medicine back in Sweden. In the last few days I have seen almost a dozen children with rashes. We have a Hand, Foot and Mouth epidemic in our little town, hitting the second and fourth grade children hardest.

One eleven year old boy had looked like an early strep throat a few days ago, but he came back today with subtle red spots on the palms of his hands. He was in the room across the hall from his two-year old cousin, who had a full blown case of HFMD, the worst I have seen all week. His aunt had sore, itchy palms with no rash. I don’t know if it’s a sympathy reaction or if she is next to come down with it.

Mixed in with the rest of them was a two year old from out of town with a sketchy immunization history and a bad case of chickenpox, and a handful of children with colds and worried parents. One little boy with a runny nose had one single macular lesion on his thumb – too soon to tell whether he is coming down with Hand, Foot and Mouth disease or not.

Working acute care in Sweden, I saw a lot of rashes, and in those days we did not have all the immunizations we have now. I remember feeling pretty confident with my differential diagnosis of rashes – measles, German Measels, scarlet fever, things we don’t see much of anymore. Scarlet fever, associated with streptococcus infections, was common then but is rare these days. We also saw enough post-streptococcal nephritis that I routinely brought strep patients back for a urinalysis after their sore throat had resolved.

I remember the varied reactions among parents during the small epidemics I witnessed in those early days. Most parents took things in stride, expressing gratitude that their children got their “normal childhood diseases” over and done with. Some parents even sought out chickenpox cases in their neighborhoods and had chicken pox parties in order to have some control over when their children got the disease. I just read somewhere that the Swedes still aren’t immunizing children against chickenpox, apparently for cost reasons.

When I worked in student health here in the U.S. in the late 1980’s, we had a measles epidemic at the university. Because the students had been immunized as children, they tended to get milder and atypical forms of the disease. I remember being called in to see my colleagues’ cases all the time as the local expert on the rashes of “childhood diseases”.

Hand, Foot and Mouth disease was first described in New Zealand (or Australia by some accounts) in the 1950’s. I don’t remember running into it often back when I used to see measles and German measles. I remember just calling it a coxsackie virus rash. Recently I have read that the Swedes call the disease “höstblåsor”, or “autumn blisters”. I do remember seeing more “herpangina”, which looks the same and is also caused by a coxsackie virus, but is limited to the mouth.

There is no widely available vaccine against Hand, Foot and Mouth disease, and antiviral drugs are ineffective against it, but it tends to be a very benign illness. Some of the eleven viruses that can cause the disease are more aggressive, and in other parts of the world, for example Vietnam, the disease can more often be associated with neurological complications, from minor twitching to convulsions.

The way our society reacts to the mild form of the disease that we usually see is interesting. People worry about second graders missing a week of school – something I have a little trouble with. The economic burden of working parents missing work is a valid concern, but with so few “childhood diseases” left to contend with, a week of reading, watching movies or playing games at home isn’t the end of the world.

Our few remaining “childhood diseases” take the time they take to get through, and we have no shortcuts. They offer us an opportunity to understand that we can’t control everything in our lives.

Hand, Foot and Mouth disease usually only strikes once, so unlike the common cold, it has not become big business for purveyors of useless remedies, and unlike influenza, we have no big-ticket disease modifying drugs, so we are left to practice good home care, humility and the ancient art of just “being sick”.

America’s favorite mid-century pediatrician, Dr. Benjamin Spock, wrote the following about the “childhood diseases”:

“There are only two things a child will share willingly — communicable diseases and his mother’s age.”

Where is the Mind?

When I was a little boy, I had a tendency to walk around on tiptoes. People said I had my head in the clouds. Over the years, I have heard different theories on the pathological significance of my early ambulation habits, from language delays to autism to cerebral palsy and also theories of the spiritual qualities of toe-walkers.

I have long since stopped walking on tiptoes, and I never did have any language delays or serious motor difficulties, but I admit I have always had a tendency to keep my head in the clouds. Since reaching middle age, a few years ago now, I have done a fair amount of reading and thinking about the difference between spirit and soul, and I have worked hard on changing my center of gravity from my head to my heart.

Jungian psychology has resonated with my own intuition and perception of the deep-seated causes of my thoughts and my actions. I have come to believe in the power of archetypes in our way of relating to the people and the world around us, and I have started to challenge my intellect and my powers of reasoning as drivers of what has happened and continues to happen to me.

Just lately, I stumbled onto some writings about the Bön tradition, which predates Buddhism, and which pointed the way toward that belief system or understanding of the nature of man.

According to the Bön tradition, man has three parts: Body, located in the head; Speech, located in the throat; and Mind, located in the heart area.

This struck me as a typographical error at first; body in the head and mind in the heart – how could that be? But, the more I thought about it, the more direct the connection seemed; it is in the brain that any and all of my awareness of my body exists, and therefore, it is there that my body “exists” to me. Without my brain registering it, my feet can’t be cold, my stomach can’t feel empty and my knees could never ache.

Equating the body with the mind offers a new perspective on what we in Western medicine have been calling the mind-body connection. It could, even should, be called the brain-body connection. Because our own computing power is inseparable from the nerve impulses it registers and transmits from and to every organ of the body. And if the brain and body aren’t just connected, but actually one and the same, many disease paradigms suddenly must change – some just a little, and others quite fundamentally. Pain becomes the same as suffering, fibromyalgia could become depression in the body, colitis might become anxiety of the gut and psoriasis could become self-hatred.

What, then, is the mind, and what is it doing in the heart area? The heart is the location to which many cultures ascribe our deepest emotions, whatever selfless love we are capable of, and whatever connection we have with our Higher Power or with the Universe.

Before going any further, let me recapitulate what is known today about the heart’s abilities beyond pumping blood around:

There are 40,000 neurons in the heart; the heart not only receives neural stimulation from the brain (for example via the vagus nerve), but also transmits afferent impulses to the medulla oblongata and to the cortex; a transplanted heart, lacking a functioning vagus nerve, still has adequate independent pulse regulation; the heart creates a measurable electromagnetic power field that extends outside the body; the heart produces several hormones – atrial natriuretic factor (similar to Brain Natriuretic Peptide, a commonly tested marker of heart failure), noradrenaline (found in the brain and adrenal glands), dopamine (also found in the brain), oxytocin (released by the brain during childbirth, bonding with infants or lovers and during orgasm), afferent nerve fibers from the heart to the amygdala of the brain can stimulate autonomic responses to stress before any impulses reach the neocortex. Finally, healthy heart rhythm patterns have been linked to emotional well being, heightened intellectual abilities and better judgement.

The heart-mind is not an organ we use to design airplanes, do math or figure out how to get coconuts down from the trees; those are simple brain exercises.

The heart-mind may just be what connects us to what is infinite and eternal, our connection to everything that is not our body. Sometimes, our words, actions or our physical creations can seem to be what we call divinely inspired; then our minds control our bodies and our speech, but we are not the ultimate originators of our music, our poetry or our art. Something bigger is.

If the heart-mind, and thereby our connection to the collective mind of the Universe, is disrupted during heart surgery when the heart is chilled or bypassed by a heart-lung machine, we would suddenly understand the claims that 40% of patients experience significant depression even after relatively simple coronary bypass surgery.

The fact that we can measure the electromagnetic field of the heart beyond the physical boundaries of our bodies and the observation that people in close proximity can experience synchronization of their heart rhythms gives the heart more than symbolic significance in how we relate to our loved ones, mankind and the Universe.

All this is certainly something to ponder, even if it is just with my human brain, or what some Buddhists call the monkey-mind.

After I stopped walking on my tiptoes, I attended a Methodist Sunday School and I was later confirmed in the Lutheran state church of Sweden. In my studies of religion, I have learned that Buddhism isn’t an actual religion, but it does represent an ancient view of the Universe that science is now rediscovering.

A quote by Albert Einstein sums all this up:

“Science without religion is lame. Religion without science is blind.”

Cave! Ultracrepidarianism

“Sutor, ne ultra crepidam judicaret.”
(Shoemaker, not above the sandal judge – “stick to your last”.)

“Doctor, what do you think of alternative medicine”, a patient with Chronic Fatigue Syndrome asked me the other day. She was interested in doing something more for her severe fatigue. “Would acupuncture help me?”

I paused and, as I have done many times before, answered that my training and most of my clinical experience has been in Western, allopathic medicine. (Ironically, the word “allopathic” was first used as a derogatory term by the classically trained physician Samuel Hahnemann, who founded homeopathy after becoming disillusioned by medicine as it was practiced in his era.)

I don’t believe we allopaths have all the answers, and I have a personal interest and fascination with many other forms of healing, but I have set a standard for myself to only promote and recommend treatments that are consistent with my training, because I don’t have anywhere near the same expertise in the other forms of healing. Even within allopathic medicine I try to be really clear about what we know and what makes sense but still remains to be proven. For example, some cholesterol and blood pressure medications have been shown to decrease heart attack rates while others have not, so I make this distinction very clear to my patients.

I support every patient’s quest for health and health care that fits their belief system and temperament, and I can sometimes be a resource in understanding some of the claims made by practitioners of “alternative medicine”. But I don’t point patients in that direction unsolicited. In that sense, I very much live by the words of Hippocrates of Kos, the father of medicine, who set strict limits for physicians’ scope of practice. In the Hippocratic Oath he wrote:

“I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.”

The cobbler analogy in the old adage “Shoemaker, stick by your last” has an interesting history and is of roughly the same vintage as the Hippocratic Oath:

The painter Apelles, also of Kos, who also lived in the 4th century B.C., liked to stand back and watch spectators’ reactions to his paintings. One day a shoemaker commented on the way Apelles had painted a sandal incorrectly. Hearing this, the famous painter introduced himself and thanked the shoemaker for pointing out his mistake. Emboldened by this, the shoemaker offered further suggestions for “improving” Apelles’ work. Legend has it that the artist, angry and annoyed, cut the shoemaker off with the words “Shoemaker, don’t judge above the sandal”, or “Sutor, ne ultra crepidam judicaret.”

This quote has given rise to the word ultracrepidarianism, which is something rampant in medicine and in today’s Western societies. Doctors often feel tempted to opine in matters beyond their formal training and experience, both in their exam rooms and in national media.

I have colleagues who prescribe red rice yeast, a “natural” statin instead of Lipitor or Crestor, and almost every doctor I know screens patients for vitamin D deficiency, which is a chemical abnormality that is still in search of clinical significance beyond that seen in osteoporosis. The hypotheses for this potential elixir of youth are tempting, but still not rigorously proven. For now, I cannot in good conscience recommend vitamin D with the same emphasis as blood pressure or diabetes control.

There should be only one standard in medicine when it comes to actively recommending treatments for our patients. But doctors are often tempted to stray from good, solid science because of personal hunches, a desire to be cutting edge, or from the temptation of creating “profit centers” in medical offices, selling supplements or delivering nontraditional services for cash.

But this is where I see my job as supporting my patients’ own desire to find ways to health they can believe in. My wife once had a very spunky elderly patient, Gloria, who for forty years had taken a special B vitamin she ordered from the AARP. As the woman aged she always swore by this vitamin as one of the things that preserved her vitality.

One day during a housecall, Emma noticed that Gloria wasn’t her usual, witty and vivacious self. Going through the woman’s medication bottles, Emma noticed that the bottle of vitamins was empty. Gloria confessed she had been too tired to order another bottle, even though she knew how the vitamins always helped her. Emma encouraged Gloria to order some more, and at the next housecall, Gloria was her old self again

There is a world of difference between physicians promoting unproven, “alternative” treatments and being intrigued by or simply supportive of our patients’ pursuit of them. And, strictly speaking, I feel even most vitamins fall into the latter category, short of taking in enough vitamin C to prevent scurvy.

P.S. Cave is a fairly universally (except in the USA) known word for caution, including but not limited to drug allergies. For example, pseudocholinesterase deficient patients, who cannot metabolize the muscle relaxant succinylcholine, may have the warning “Cave! Succinylcholine” in their charts.

“Cave! Ultracrepidarianism” is a warning to all health care professionals.

There may be future postings about medical pitfalls under the new category “Cave!”

Doctors Speaking Accountanese

You have to think fast in medicine. Not that most doctors handle life and death emergencies all day long, but even seemingly mundane clinical situations require a lot of rapid gathering of data, processing of applicable information and attention to detail in formulating a plan.

I have always been bemused by the so called E&M (evaluation and management) coding that dictates payment by requiring documentation of how doctors think. Ironically, the AMA defines this work and thereby has been a major contributor to physicians now spending more time on documentation than on doctoring. The documentation, even with EMR templates, takes infinitely more time to complete than the thought processes that go into clinical work. Even our preliminary observation of a patient, before any history taking occurs, is something instant, that in a novel might fill a whole first chapter, or in a homeowners’ insurance inventory might go on for pages. We can take in details of a new face or a new place in the blink of an eye; this is something all of us experience. Doctors, by nature of their profession, hone this ability in Sherlock Holmes-like fashion.

Not that I follow sports, but I can imagine a pro golfer or star soccer player could go on for quite a long time describing all the millisecond judgments that go into every aspect of their game. But the difference is they don’t have to. It seems they get paid according to their results, and not by their stated mental work behind those results. In fact, most fans’ appetite for hearing all the details behind the action shots is probably rather limited.

In medicine today, unlike the worlds of Sir Arthur Conan Doyle or Sherlock Holmes, we don’t quite have the option of using the richness and nuances of our language to document our observations. Our words must be chosen from a dictionary of “findings” that correspond to numerical codes used as underpinnings of our EMRs. Our patients can’t be “uncomfortable”, “squirming”, “braced”, “forced”, “pensive” or even “vague”; we must choose between “in acute distress” or “not in acute distress”.

Our language is no longer ours; we must speak like accountants. But when we do, will accountants understand us any better than when we speak like doctors? I suspect that by speaking their language, we risk having our powers of observation, ability of analysis and skill of formulating a clinical plan reduced to something with less depth than what it is, regardless of the number of details we provide.

When we encounter patients we have seen a long time ago, our own notes can fail to give us the instant familiarity of past medical records, and when we see our colleagues’ patients, we struggle more to get to the essence of the clinical notes.

By accepting to describe our work in this foreign language, Accountanese, we have deprived ourselves of some of the tools of our trade, the shorthand that soccer teams might use to synchronize their game. We have lost the nuances of language we need to describe complex processes and multidimensional clinical scenarios involving patients of flesh and blood. So we fumble around, choosing more and more words from our pick lists, none of them quite the right one, while our notes get continually bigger and less and less precise.

We are more or less trusted to care for the lives of our patients, but we are not trusted to bill honestly for whether we just did an easy visit or a complex one.

Maybe I should ask my tax accountant for an itemized bill for his preparation of my income tax filing; all he sent me was a note, stating:

“Preparation of 2013 form 1040. $180″

I would never get away with anything that brief.

Angry Docs

“Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else; you are the one getting burned.”

“I came to realize that if people could make me angry they could control me. Why should I give someone else such power over my life?”
Ben Carson, M.D.

“Depression is rage spread thin.”

“Depression is the inability to construct a future.”
Rollo May

The other night I got an email with a survey from the AMA. I don’t recall ever getting one from them before. Not that I have been all that involved with the politics of healthcare; I joined the AMA when I was a senior resident, a newcomer to American medicine, and bought life and disability insurance through them.

In all the years of change and upheaval in American medicine, I have never been asked my opinion on what I need in order to do my job well or how I feel about my chosen profession. Until now, that is. And now, they skipped over any questions they might have had about what I need; they went straight to the more ultimate questions:

The AMA wanted to know if I’m burned out or depressed and if I hate my EMR. They also wanted to know if I am contemplating changing practice location, dropping out of medicine, retiring or committing suicide.

And I had somehow gotten the impression that the AMA was one of the drivers of change for the last thirty years. But maybe I was misinformed.

Clearly, the questionnaire indicates that the medical establishment is quite worried about its constituency.

In “Bitter Medicine” I wrote about how outside forces have distorted the traditional doctor-patient relationship. I also wrote about how doctors need to see their patients as suffering kinfolk and doctoring as having a higher purpose.

The four years that have passed since that piece have been years of increasing physician dehumanization through “Meaningful Use” and other bureaucratic mandates. I have seen more signs of anger and bitterness in doctors and there has been a great deal written about physician depression and suicide.

But what is this anger really, what is the nature of this depression, what are their consequences, and is there a way out?

In psychodynamic theory, Abraham postulated in 1911 that depression can be self-directed anger in people with narcissistic vulnerability. Freud linked depression to anger at oneself after a perceived or actual loss of a person one felt ambivalent toward.

Brenner, while I was in medical school, saw depression as resulting from symbolic castration or more or less actual disempowerment. Aggression towards the person who causes the feelings becomes self-directed instead out of fear of the other person.

Physicians, or rather, people who choose to become physicians, often think of themselves as more dedicated and perhaps even smarter than other people. We carry the world on our shoulders and sometimes feel we are different from other people. These are essentially what psychologists describe as narcissistic personality traits. I believe many of us are vulnerable to and apt to react with strong emotions to real or perceived rejection or loss of power, such as what has happened in our profession in the last 30 years.

The reality of today’s patient encounter is that some of the preciously short time we have allotted is spent fulfilling the requirements of the healthcare system that may or may not directly benefit each patient. That leaves little time for diagnosis and treatment, and even less for relief of suffering. And, of course, if we are trapped in our own suffering, we cannot help relieve that of our patient.

Physician anger and depression may, ironically, be as great an obstacle to good patient care as the Government mandates, insurance company obstacles and Health Information Technology shortcomings we doctors are so upset with.

Venting our frustration with the system is a waste of our patients’ appointment time. At most, we may need to briefly explain what can and cannot be done in the minutes we have together. And harboring feelings of depression or helplessness distracts us from the necessary engagement with each patient.

There may be ways for physicians to effect change of the system, but the place for that is not the exam room. There is also the possibility of opting out of the system. But for all of us who choose to stay, every patient encounter with a fellow human being deserves our full attention and genuine compassion.

Thinkers from all different religions and schools of thought have all said the same thing: We have a choice whether to cultivate our anger or not. Most tell us we can’t suppress it, because it has a way of expressing itself in other ways, even as illness.

Physician anger or depression that stems from powerlessness, like all anger, has an antidote. Borrowing from Buddhist thought, the antidote is love and the path is mindfulness.

Thich Nhat Hanh writes:

“When we embrace anger and take good care of
our anger, we obtain relief. We can look deeply into
it and gain many insights. One of the first insights
may be that the seed of anger in us has grown too
big, and is the main cause of our misery.”

“In a time of anger or despair, even if we feel
overwhelmed, our love is still there. Our capacity to
communicate, to forgive, to be compassionate is
still there. You have to believe this. We are more
than our anger, we are more than our suffering.
We must recognize that we do have within
us the capacity to love, to understand,
to be compassionate, always.”

He also says something that points out Westerners’, including Western doctors’, emphasis on formal education compared with cultivating our well-being. Hearing about divorce rates and alienation of other family relationships among physicians, these words should make us stop and think. Not that we should have forgone our education, but why do we think our life, well-being, and our relationships don’t also require effort and time?

“Getting a university degree may take you six or even eight years, and that is quite a long period of time. You may believe that this degree is important for your happiness. It might be, but perhaps there are other elements that are more important to your well-being, and to your happiness. You can work on improving the relationship between you and your father, your mother, or your partner. Do you have time for this? …You are willing to put aside six years for a diploma; do you have the wisdom to use just as much time to work out a relationship? To deal with your anger?”

Our anger demands attention, but not encouragement. Like Buddha’s hot coal, it hurts the one who carries it. When we are angry, like many of us are with the system, we need to examine our anger. Are we angry more or less because we can’t have our way? Are we angry because we think health care politics need to change? In the first case, our anger is only hurting us; in the second, it needs to be turned into political action.

We need to stop banging our heads against the wall. Yes, our tools aren’t as good as we would like, those who pay us don’t know enough about what we do, and the Government is fixated on form without function.

But did Hippocrates have top-notch equipment, did Albert Schweitzer have all the resources he needed, and did Michelangelo always have the right paints and brushes? Sure, we could all do better if only….but we’re just wasting our breath, using up valuable time and watering the seeds of anger and depression if we harbor such thoughts in the exam room or at home. We can take them to the political arena, but we must not let them poison our patient care, our home life or our souls.

Suddenly Expensive Generics

Fran Barker called today. She was in a panic because the cost of her monthly prescription of 150 mg amitriptyline tablets had gone up to $130 from $13 the month before.

Amitriptyline has been available in this country since 1961, and the 100 mg strength was on Walmart’s list of $4/month drugs the last time I looked at it a few months ago.

I called Fran’s pharmacy. Two of the 75 mg tablets would be less expensive, about $75 for a one month supply, but this would still be a hardship for Fran, who is disabled and lacks prescription coverage.

A few months ago I read that the older, generic statin drugs for cholesterol were suddenly not on Walmart’s $4 list due to sudden price increases by the manufacturers.

Something similar happened to insulin a few years ago – it went from a few dollars to $80 per vial without any explanation that I was aware of.

I have Googled around a few times to try to find out what is happening, or what people think is happening, but the dramatic price increases I have run into don’t seem to be getting much press.

It appears to me that the pharmaceutical companies have stopped their price competition, possibly by secretly dividing up the market and definitely by limiting supplies. If that is true, antitrust laws are likely being broken. Meanwhile, people with chronic illnesses are being squeezed financially even more than they already have been.

Generic drugs used to be a low margin product for manufacturers, but a major profit for drug stores. With newer generics, whose brand name competitors are still on the market, pharmacies may buy them for 10% of what they pay for the brand and sell them for 70% of the brand name price. Now, with their purchase prices going up on one generic after another, their markup is likely shrinking to the levels of brand name drugs. This will likely drive independent pharmacies out of business.

We already had a great deal of mystery and intrigue around pharmaceutical pricing and actual insurance payments for prescription drugs. Just like doctors and patients have trouble figuring out how much MRIs and artificial knee joints cost, the real cost of pharmaceuticals is often unobtainable. I can try to choose lower cost medications by looking up the average retail cost on Epocrates, but insurance companies and drug manufacturers often negotiate deals that make favored otherwise expensive drugs cost less than non-favored drugs with lower published prices.

This whole drug price situation is really the stuff of mobster movies. Or imagine a sitcom about what happens when gasoline (petrol) prices increase by 900% overnight. That wouldn’t be funny for very long. People would complain loudly about being held hostage or extorted.

But is anybody complaining about what is happening now with drug prices? Am I just not hearing about it because I gave up watching TV? Or am I an early voice in the wilderness? You tell me…

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