RX for Health Policy and Practice, Part II

GUEST: Dr. Jessie Gruman
VTR: 10/22/04

I’m Richard Heffner, your host on The Open Mind.

And this is the second of our programs with Dr. Jessie C. Gruman, the President and Executive Director of the Center for the Advancement of Health, a Washington-based policy institute funded by the John D. and Catherine T. MacArthur Foundation and other foundations to translate health research into effective public policy and private practice. So let’s pick up from last time and I wanted to ask you about something you said at the very beginning of the program that I think … of our last program that relates to something you said at the very end that I want to pick up, too.

You talked about the difference in the practice of medicine now that science has … not intruded, but made itself available. What do you, what do you mean? How has it affected medical practice and don’t doctors today make use of all of the science at their disposal?

GRUMAN: Well I think we need to start with the notion that, that medicine is very much a mixture of science and art … or art or experience … science and judgment. If you remember … if you think that … science always talks about risk and it talks about risk in groups of people and the job of a physician in understanding science, relative to the patient sitting in front of him or her … it’s to say, “Okay, given this data about the population of people who have this disease, what does that mean about the patient who’s sitting in front of me, who may have a whole different family history and may have other diseases at the same time.

So that’s a … you know, that’s in, in some ways that’s the complicated part of being a physician. Now, it’s very often the case, especially when physicians are, are busy and overextended, that the balance of where evidence … scientific evidence influences decisions and especially if it’s unfamiliar science and where pure experience influences decisions … the balance gets uneasy and it may be that people take shortcuts or they don’t … they don’t … can’t keep up on … with the science, or that science … the scientific evidence indicates something different.

I mean I’m giving a very sympathetic portrait that something many of my physician colleagues’ say I shouldn’t give a sympathetic ear to …

HEFFNER: What do you mean?

GRUMAN: Well …

HEFFNER: … What do you mean “sympathetic”?

GRUMAN: Sympathetic in that I guess I can understand how physicians would ignore evidence. And many of my physician colleagues would say that “You’re cutting too much slack … evidence is evidence and that should drive all of physician practice.”

And, you know, fundamentally, that’s a belief that I have, that science is the rudder that’s going to help us achieve better health. Whether those are health decisions that I personally make or whether those are health decisions that a physician makes in collaboration with me about what treatments I’m going to get.

But, as it happens right now, physicians don’t use evidence a lot of the time.

HEFFNER: But …

GRUMAN: … they don’t use science to guide their practice very frequently.

HEFFNER: But, of course, you made the point that sometimes that science is difficult to access.

GRUMAN: Well, sometimes the science is difficult to access and to, to go back to something that we talked about the last time … or earlier … just in the very notion that an electronic medical record is available. One of the things that goes along with an electronic medical record is this idea of decision support and, and you get the patient’s electronic medical record and ideally, along with that medical record, should be a check list of all of the tests and vaccines and shots and … that you need to follow up on as a physician in order to make sure that the evidence is kind of making its way into your practice with that patient.

HEFFNER: That would make it much easier to avoid the application of treatments or the use of drugs that are contra-indicated.

GRUMAN: That’s one of the … that’s one of the things that’s behind the drive to increase the use of … the development and use of electronic medical records. That not only does it keep all of the patient’s information together, but it also provides the physician with decision support and information about drug interactions and so on. So that, so that a lot of the medical errors, which is another big problem, in addition to not following the evidence of … for various treatments … is that there simply are errors. And electronic medical records will hopefully cut down a lot on both of those. Assuming that they’re operating well. And that people are making use of them.

HEFFNER: Now, there have been reports … certainly a year or so ago … two years ago of the magnitude of medical errors … was quite shocking.

GRUMAN: Quite shocking.

HEFFNER: Is that … do you think … do you suspect … as true today?

GRUMAN: Yes. I do. I think that there are a lot of efforts being made to address the medical error problem. Some of them having to do with how hospitals operate. Some of them having to do with electronic medical records. And various other electronic systems that kind of … keep information systems that, that make doing the right thing the default option kind of … you know, so that it’s more difficult to, to prescribe a drug with a bad interaction than it is to prescribe the one that doesn’t have the interaction.

HEFFNER: Now talking about doing the right thing, it seemed to me that in our first program together you were talking about something that was, to my ear, doing the wrong thing and that had to do with legislation relating to the comparison of drug effectiveness. Did I understand correctly?

GRUMAN: Right. One of the ways that we can … there are many drugs in a similar drug class that it’s unclear how they’re different from one another. So, for example, there are all these cholesterol drugs, and there haven’t been in the past any incentives for the pharmaceutical industry to test the various drugs head to head and say “Is this new drug different from this old drug? Is it more effective? Or less effective?”

Every once in a while you see a study like that come out and, and usually it makes a big wave because sometimes one drug will be very much more effective than the other, or one drug will create problems in another. We just saw that recently with the risk of suicide in kids … that you know, when drugs were put up side by side, there was a real difference in the outcomes.

In the Medicare Modernization Act there’s an explicit prohibition from using Federal funds to do those kinds of studies.

HEFFNER: Prohibition? Against?

GRUMAN: Yes.

HEFFNER: Rather than encouragement for?

GRUMAN: Yes.

HEFFNER: Why is that?

GRUMAN: Well, I …

HEFFNER: Or how did that come about?

GRUMAN: How did … well I think it’s the influence of the pharmaceutical industry, which has very little interest in actually having that kind of work done. Because there are economic consequences. I should note that there’s a … almost directly in response to that, there’s, there’s a coalition of large employers and state governments who pay for drugs under Medicare, who are very interested in these comparisons being done, and they’ve joined together in a coalition and they’re paying for those comparisons.

And that will influence their drug buying and, and hopefully will provide information for insurers around the country, so that they … the drugs that appear in their formulary are ones that actually work and are the … that the cost/benefit relationship of the drugs that are chosen to offer people are, are beneficial.

HEFFNER: Do you feel that we have benefited in terms of our, our national health by the, the extraordinary number of … amount of … and extent of drug/pharmaceutical commercials?

GRUMAN: Commercials.

HEFFNER: The advertising …

GRUMAN: The advertising …

HEFFNER: … on the air … in print … everywhere you turn.

GRUMAN: Yes. Well, you know, I believe in … I believe that people should be educated. And if you ask the pharmaceutical industry, they will tell you that drug advertising educates consumers. But I have yet to see an advertisement for a drug that says that “this drug has an effect that’s 11% greater than a placebo.” Or that “this drug is three times as expensive as a drug that has a, a comparable impact on the disease”. Those are … that’s … to my mind … or, even, even worse … “this drug has this kind of side of effects, under these kinds of conditions and this drug doesn’t have those kinds of side effects”.

To my mind, that’s education. And the kind of thing, the kind of promises that you see … I was just flashing through what examples … which example, could I give and I really don’t want to pick one out …but the kind of promises that you see portrayed in television ads and print ads for drugs are … I think alarming. And I don’t think that they’re helpful to people in actually making decisions.

HEFFNER: It was the Federal Drug Administration … wasn’t it, that finally permitted that kind of general public advertising of drugs?

GRUMAN: Yes, they did. There’s only … I think only two other countries permit that kind of advertising.

HEFFNER: Do you think we should go back to the situation before?

GRUMAN: Gosh. I … yes. But, but, not having any sense that that’s a possibility, I think it’s far more important that we fund a Federal Drug Administration … the FDA to enforce truth in advertising, which is simply not done now. The level of enforcement of advertisements and truth in advertising is, is, is vastly underfunded and one, one would think willfully so on the part of legislators who really don’t want to see, have been influenced by the pharmaceutical industry … and who really don’t want to see this constrained.

HEFFNER: Was the assumption made when we entered the age of advertising for what had been not over the counter, but prescription drugs … was the assumption that there would be truth in advertising follow-up?

GRUMAN: Oh, I think certainly. There was that, that assumption. I’m sure that there was that assumption. And, you know, many people … I think it’s very interesting, I think many people believe that the pharmaceutical industry couldn’t advertise like that unless it was truth because the government is watching over. There’s a …

HEFFNER: You have a person like that sitting right in front of you. That was my assumption.

GRUMAN: Oh. It was? Well, you think that assumption is bad, listen to this assumption. Another one where people believe that the government is watching over you is in the area of food supplements and vitamins. Now, the interesting thing about food supplements and vitamins is that they don’t have to show that they … they don’t have to do any research in order to make a certain kind of claim. And they … so they put out vitamins … they make vitamins and food supplements and, and claim … you know, they’re not drugs, so they can’t make drug claims, they can’t say that this is going to, you know, that this is going to cure cancer … they can’t say that this is going to specifically lower your cholesterol, but they do say that this is going to … this can help reduce risk factors for cardiovascular disease. That’s general enough. And they can make those claims and they’re not regulated.

Every once in a while you see someone who stepped so egregiously over the line that they get slapped down for advertising problems. But for the most part food supplements, which as I said include vitamins, include all of … kind of the things in the GNC store that are claiming to be energy and vitamin in strength and preventive, you know, those things are, are not regulated. They’re very loosely regulated even in terms of their ingredients.

HEFFNER: If you had to … and I’m going to ask you to do so … think about now and then …put whatever framework you want around this … do you have a sense of optimism about Americans health behavior, practices. Are we entering a Golden Age or do you have a sense that we’re not doing so well and that our practices, our customs, what we do to ourselves, the discipline that we exercise or do not exercise … pointed in the wrong direction?

GRUMAN: I … we’ve never … we’ve never been so healthy. I think that bio-medicine and bio-technology offer us wonderful possibilities for living long and healthy lives. I think that … you never step into the same river twice, so it’s difficult to go back with this … the epidemic of obesity, for example, is something new. We’ve never had that in the world, we’ve never had it here … solving this is going to require a different kind of creativity, a different way of thinking about what health is and the place that it has in both … with regard to medicine, but also with regard to our daily lives.

You know, the closest parallel to the obesity problem is the smoking problem that we had in … that was a huge problem particularly starting after, after the war and then got bigger and bigger and bigger until the 1964 Surgeon General’s report which said that smoking caused cancer and then there was a big drop off in smoking that’s continued on and the drop off has continued on in large part because many activists around the country and around the world have worked hard from every, every possible angle to help people understand that in this country smoking is something that we don’t do because it hurts us.

HEFFNER: We do it though, don’t we?

GRUMAN: Well, some of us still do it. But relatively few, in comparison to before the 1964 Surgeon General’s report. I mean about 22%, 23% of the people still smoke. And that’s very different from in the forties, you know, very different. And, and the health impact is very different. When you see that …what’s happened to lung cancer and cardiovascular disease in the cohort that stopped smoking … it’s really dramatic and it’s wonderful.

But that was a health problem that was not solved primarily within the medical care system. It’s not like people went to their doctors and their doctors said to them “stop smoking” and then they stopped smoking. It was solved because there were changes in the excise tax; it was solved because there were changes in environmental tobacco smoking restrictions, you couldn’t smoke at work, you couldn’t smoke in the hospital, you couldn’t smoke at church. You know, there are all of these different … kids learned in school about smoking causing lung cancer. And there were all of these different interventions that didn’t take place in the health care system; they took place out in the world where the problem existed, that made a huge difference.

And I think that obesity, while it’s very different in terms of both its causes and its consequences, will require a similar kind of creativity in terms of understanding what are the drivers behind people exercising so little and eating so much and eating so much of things that make them fat. And, and how can we shift those around so that the incentives are different and so that, so that people will have choices that are better in terms of not actually …

HEFFNER: Isn’t this going to be more difficult one because in terms of smoking you had a very distinct group of companies that had, as an interest of theirs, their … sometimes their only interest … to get people to smoke more, not less …

GRUMAN: Right.

HEFFNER: … here you have an American economy, it seems to me, that to a very considerable extent is based upon our stuffing ourselves with the unhealthy foods. I mean, am I exaggerating?

GRUMAN: No. I think not. I think, I think you’re exactly right. I think this is far, far more complicated. I mean with smoking, you either smoke or you don’t smoke. You know, with eating … we’re all going to continue eating. So it’s a matter of choices and it’s a matter of habits and it’s a matter of, of what influences are, are acting on us. And what feels good and what habits do we have. You know, I mean one of the things that has come up again and again … the Institute of Medicine just released a report on childhood obesity … talking about how … you know in some ways … if we’re going to, if we’re going to really invest in addressing the obesity problem we’ve got to right off the older people (laughter) who are obese and we really have to focus on kids who don’t have resources … who don’t have recess in school, who don’t have gym classes in school … did you have gym when you were in, in …

HEFFNER: Sure.

GRUMAN: Sure. I had gym when I was in school. You know kids haven’t had gym for years, you know. Kids are not walking to school. Kids are not riding their bikes around neighborhoods because it’s not safe. There are vending machines in schools because schools get a lot of money in order to keep those vending machines and they need that for the school bank program or the after school program to subsidize it. I mean … so, so the idea of focusing a lot of energy and creativity on helping kids to feel comfortable being active, outside playing kids, who, who like physical activity and for whom that’s a part of their life … and who don’t have always to make a choice between potato chips and, you know, an apple is, I think a really important contribution. And I think it’s going to take a tremendous amount of creativity beyond even that kind of intervention to actually change the social norm of eating and exercising and weight in the same way that we were able to fundamentally, with tobacco, change the social norm from “sure, we can smoke, it’s cool to smoke” as it was in the forties and fifties and early sixties … to what it is now, which is that for the most part, you know, “we don’t smoke here”.

HEFFNER: Mmmmph. You don’t know the same people I do. But I grant that there’s less, less smoking. What sign do you see that the public health concerns about obesity are having an impact on our patterns?

GRUMAN: Oh, I see no signs that they’re having … (laughter). I, I think that the recognition of obesity as a problem is fairly recent. There was a Surgeon General’s report I think in 2000 that, that identified the obesity epidemic and that kind of set off this cascade of interest in this topic and since then there’s been an obesity summit … from some professional group about every week or so.

But the important thing is that, you know, it’s taken us a couple of generations to get to this point and it’s going to take us a while to un-do it. Right now we’re still trying to figure out what the landscape is? What are the things that feed into it and where is … where’s the political and personal will to influence those things to actually make a change? And you know, social change is chaotic and it doesn’t happen at one time. I think that the recognition that obesity is a problem is, is a step in the right direction.

But I do want to caution you about one thing that I think is, was very interesting and this that I, I believe that one of the reasons that obesity has become, has been able to be talked about as a problem of late is because the pharmaceutical industry believes that they have a very important role in solving the obesity problem in this country. And one of the ways you see that is the recent change in designation of overweight to being a pre-disease condition. So what does that mean? That obesity starts at a certain body mass and that has been pretty well accepted as a medical condition and you can get drugs prescribed for that and you can have physician visits related to that. But overweight as a pre-disease condition and having it officially designated as a pre-disease condition opens up a whole new audience of people who are potential drug users and intervention receivers to … it basically opens up a new market.

HEFFNER: You mean like the drugs that would keep you from smoking or enable you not to smoke? Drugs that will enable you not to eat in the same fashion?

GRUMAN: Yes, sir. So there’s a good …

HEFFNER: You scare me.

GRUMAN: Well, I’m sorry. But this is … to, to come back to a theme that we’ve kind of been edging around for this entire discussion … that this is another place where you see commercial interests having a … in some ways a very positive role in, in that they have … that commercial interests have a lot to gain from addressing this very important public health problem, but it’s very important that the public health problem be addressed and it be thought of it and it be considered and that money go towards it and that people care about it and we re-organize our selves so that little kids don’t have to grow up with this sense of … that their, that their bodies don’t fit them.

HEFFNER: Because they’re taking drugs?

GRUMAN: Don’t do the drug thing here. I mean the important thing …

HEFFNER: But you just did it.

GRUMAN: Well, it’s not because they’re taking drugs, it’s because …this is a really important public health problem. And the pharmaceutical industry on one hand stands to benefit tremendously. On the other hand, the pharmaceutical industry is contributing to the notion that this is a problem we have to solve. And, indeed, this is a problem that we have to address because people are suffering unnecessarily because of it.

And you know, I … obesity is not a matter of, you know, just saying, “Oh, God, I’m just going to eat”. Obesity is highly over-determined … that means that there are a variety of forces that impinge on individuals as they’re making decisions about how they spend their days. Many of them are within an individual’s control. “I’m gonna eat this, I’m not going to eat that. I’m gonna go for a walk, I’m not gonna go for a walk.”

But many of them are not … “It’s not safe outside, I don’t have access to good food, good food is too expensive for me” … it’s a very complicated thing. And, you know, to come back to an idea that we really … we talked about a really long time ago in this discussion and that is the idea of behavior and kind of what role does behavior have in making use of what we know.

Well, this is a perfect example of … behavior is absolutely central to the notion of obesity, but behavior is influenced by a variety of things … not only drugs and not only genes, but by advertising and access and availability and what kind of place you are and who your parents were. And this is one of the reasons, I think, that behavior is so often overlooked in our discussions and our thinking about health. We just think, “Oh, well, you know, let’s, let’s get a pill for it. Let’s just get a pill because then you don’t have to deal with this complexity and the expense and how are we going mobilize all of these forces in order to improve the health of the population”.

HEFFNER: Dr. Gruman you’ve come to the point at which I have to say, this program’s over but we, by gosh and by golly have to do still another … if not this day, then another on this very theme that you’ve just expressed. Thank you for joining me on The Open Mind.

GRUMAN: Thank you.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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