Tamiflu: an expensive lesson in panic stockpiling

Swine flu

Oseltamivir (Tamiflu, Roche) has been downgraded by the World Health Organization (WHO) in the biennial review of its list of essential medicines.

A WHO expert committee removed Tamiflu from its list of “core” medicines, relegating it to the “complementary” list, a category used for drugs with consistently higher costs or less attractive cost-effectiveness.

This represents the latest blow to a drug whose sales hit $4 billion in 2009, riding on the back of worldwide stockpiling during the swine flu pandemic.

The spectacular rise and slow fall of Tamiflu is a cautionary tale worth remembering, if only to protect us from ourselves, the next time the public stampedes to pour money into the coffers of private industry.

Don’t forget; among the newspaper headlines screaming at politicians to stockpile Tamiflu in 2009, there was no shortage of doctors’ voices criticising any delay in access to the drug. Plenty of public health advocates—nearly all those with any influence—got it wrong, and we front-line clinicians were swept along.

The Tamiflu provided free to my Aboriginal health clinic provided the only opportunity in my entire career to stride out into my waiting room, spectacularly arrayed in gown, gloves and mask, to administer a drug to people who were mildly unwell with a fever. For two months I felt like I was on the set of the film, Contagion.

As it turns out, for my patients who did indeed have swine flu, the drug I so dramatically administered would have shortened their symptoms by just half a day, and not done a thing to prevent either complications or hospitalisation.

We only know of the extent of our mistake thanks to the dogged persistence of a few Cochrane reviewers, and the support of The BMJ. These folk noticed an anomaly that had eluded governments all around the globe, whose advisers were allowed to divert hundreds of millions of dollars from other public programs. Continue reading

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GP Sceptics podcast 10: GPs at the Deep End

pod10_mice Kat Ritchie small

Mice-level research, by Kat Ritchie

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We invite Dr Tim Senior to reflect on being a GP for disadvantaged groups. He discusses General Practitioners at the Deep End, an initiative involving 100 general practices serving the most socio-economically deprived populations in Scotland.

Tim works at Tharawal, an Aboriginal and Torres Strait Islander health service in Western Sydney, and is also a prolific writer and thought-leader in Australian general practice. Although Tim has never advertised the fact, @TimSenior plus @realDonaldTrump together have almost as many twitter followers as @KimKardashian.

Justin calls out a couple of Australian researchers who overplayed a ‘breakthrough’ anti-ageing pill that has only been tested in mice.  In doing so, Justin happily overplays his own role in the subsequent Media Watch TV episode where he was (very briefly) shown raising an eyebrow about the miracle pill.

And we introduce the new segment ‘Liz’s special source’.

This segment is a chance for Liz to showcase a reliable, independent source of medical information. First up is the Trip Database, which Liz actually uses mid-consultation.

Tim is wise, Liz is sharp, and Justin can only admire them both from the shallow end.


General Practitioners at the Deep End, University of Glasgow website

Tim Senior on twitter

Media love a miracle, Media Watch episode 3 April 2017, ABC television.

Trip database, which describes itself as “a smart, fast tool for you to find high-quality clinical research evidence”. And we agree.

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Pain clinics: how did such a fresh idea turn sour?

EnDONE by Ben Frost

EnDONE by Ben Frost

A report from the NT coroner this week about an opioid-related death raises a question I started asking after my very first referral to a pain clinic: what is the point of referral if the patient comes back on the same — or an even higher — dose of opioids?

The coroner’s case involved a Darwin mother with chronic pain and an opioid addiction. Every doctor involved found the interaction difficult, and the patient’s use of the system repeatedly thwarted attempts at reduction.

Each time there was a plan to reduce her dose, a new acute pain event or crisis occurred.

Other medications started creeping in — a sleeping tablet, and pregabalin (Lyrica), which seems to have somehow marketed itself as the high-dose alternative for desperate situations.

One of the frustrated GPs referred the patient to a pain specialist.

If I was designing my ideal pain clinic, it would consist of a specialist doctor (a physician or GP), a psychologist, an exercise physiologist and perhaps a social worker. I could refer patients who had a fixed belief that high-dose medication was helping their chronic pain, even though I observed the exact opposite.

The psychologist would help reframe the meaning of chronic pain. The physiologist would get them moving again, shifting the focus back to function. The specialist would oversee the safe but very strict reduction of their inappropriate analgesia. Contracts would be signed, prescriptions monitored, and we might actually get somewhere.

This coroner’s case typifies why I have almost given up on pain clinics for patients with opioid problems. Continue reading

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Not just a GP – I’m your specialist in uncertainty

uncertaintyAs a GP I’m your ‘specialist in life’. Yet life, as we know, is a tumultuous, unpredictable creature.

What I actually specialise in is managing chaos.

It’s no exaggeration to boast that, after 25 years of constant practice, I have mastered the art of uncertainty.

Mastery is not an end point, of course — the day an expert stops learning is the day expertise wanes. But I, along with thousands of my GP colleagues, am about as good as it gets.

Collectively, we experienced GPs constitute the A-team of sorting out the whims and vagaries of all of life’s assaults upon health.

Give me a thousand people with a fever (or just hang around my office for a year) and I’ll sift through them more accurately, safely, swiftly and cost effectively than any other health profession in Australia.

It’s what I do.

I’ll do it cheaper than a paediatrician, safer than a nurse practitioner, with fewer tests than an emergency physician, and with better outcomes than a whole host of alternative therapists.

Ditto for a thousand folk with tiredness, pain, worry, dizziness or nausea. Or indeed, a thousand well people who want to stay well.

All these grand claims are based upon one underlying precondition: uncertainty. Continue reading

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GP Sceptics podcast 9: The Environment

Justin in lycra, small, Kat Ritchie

Justin’s lycra legs, by Kat Ritchie

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Justin dons his finest lycra and tackles Dr George Crisp, WA chair of Doctors for the Environment Australia.

How do health gains in the doctor’s surgery stack up against environmental and population-based interventions? Could the nanny state be good for our grandchildren, and does Liz actually believe in wind farm health conspiracies?

Liz wonders if her recent public health-screening day with medical students did anyone any good, while Justin suspects that ego is, at least in his case, a dirty word.

We encourage listeners to join Doctors for the Environment Australia 


The Cost-Effectiveness of Environmental Approaches to Disease Prevention Chokshi D, Farle T. N Engl J Med 367;4 July 2012

Upstream or downstream? By medical student Victoria Smith Med J Aust 2015; 203 (10): 412-413

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Let’s celebrate the bolt-cutter surgeon

bolt cutters

When orthopaedic surgeon Chris Phoon sent someone to a local hardware store in Bega, NSW, to buy bolt cutters mid-operation, his admin bosses weren’t impressed.

But I was.

Dr Phoon’s hospital-supplied bolt cutters snapped mid-operation and his attempt to source a pair from Canberra Hospital failed. Time for plan C.

Staring at a stubborn steel pin needing urgent removal means only one thing to a red-blooded Aussie male…Bunnings!

Quite unreasonably, in my view, the surgeon’s heroic attempt at pulling the pin was frowned upon by the hospital administrators, whose lawyers pulled the pin instead. The plan was abandoned mid-operation and the patient may be still, for all we know, languishing somewhere on the hospital’s 247-day-average surgical waiting list.

Now, I’m as guilty of poking fun at my orthopaedic friends as the next bloke—guiltier, because I put it in writing. Like when the orthopod took six days to solve a simple jigsaw puzzle and was proud, because it said “From 4-6 years” on the box.

But these bone grinders aren’t hired to lead group discussions around whether psychological therapy helps healing after a fall out of bed.

If I have a thick metal shaft poking out of my leg and the fella with big hands tells me I’m better off without it, I want to wake up with it cleaved in twain and in the bin. Keep subtlety for the soft tissues. Continue reading

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Greater transparency on specialist fees: a no-brainer

$7 and a Medicare card

The question as to whether medical specialists should make their fees more transparent has long ruffled a few feathers.

The debate is raging afresh this week, sparked by a new study of billing data that reveals wide variations in specialist fees. The study, published in the Medical Journal of Australia, finds fees can vary up to five-fold within a single specialty.

As with any service, of course, some providers are of higher quality. But this is unpredictable. And as the study authors note, the rationale for fee variations is opaque without data on quality of care in private outpatient services.

An accompanying commentary cites unpublished research by the Royal Australasian College of Surgeons which finds “no correlation between the size of the fee charged and the quality of the surgery”.

Commenters have been quick to react, noting that the cost variation may reflect differences in office rental costs, the time spent per appointment, and the experience of the practitioner.

While these may be valid arguments for the existence of cost variation, they do little to counter the contention that costs should be made more transparent for consumers.

As a rule, transparency is the grease that keeps supply-and-demand systems running smoothly, and the confusion of the specialist fee system should be no exception. Continue reading

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Four Corners Big Vitamins exposé: cuts both ways

Vitamins, by Steven Depolo

Photo: Steven Depolo

Last night’s Four Corners exposé of Big Vitamins marketing their supplementary pills via community pharmacists would have had doctors throughout the nation nodding their heads.

We only have to walk past a pharmacy shopfront to see how rife the problem is. Clearly most pharmacist-owners see it as a profitable—some would argue, a critical—part of their business plan.

As for pharmacist-employees, most are presumably resigned to selling these supplements by the kilo, and some would perhaps believe the industry’s own hype that ‘pick me up’ vitamins really do pick people up. Even well people, with clean livers.

The issue is not so much the selling of products in a free market, but the dubious veneer of scientific credibility, beginning with exaggerated or false advertising claims and ending with a highly trained, trusted professional. As a pharmacist said on the show, “If they’re after complementary medicines, then I’m happy to provide them”.

After such media reports featuring sceptical doctors, inevitably some commenters retort by questioning why they pick on pharmacists, when the medical profession itself is so influenced by Big Pharma. Something about sinners casting the first stone.

And, you know what? They have a point. So, let’s lob a few stones in every direction, even if a wall of my own glass house cracks. Continue reading

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Five reasons why I’d still encourage my child to do medicine

Back Camera

If you read the wrong kind of comments in the online medical media – as I do, religiously – you might conclude that retiring doctors are glad to be leaving the sinking ship. These disembarking medicos  proclaim they would discourage their child from ever boarding the leaky vessel. Why commit to years of study, long hours, frustrating paperwork, little respect and crappy pay?

After all, being a doctor is a tough gig these days. Especially if you stretch ‘these days’ to include one million days ago. Hippocrates noted in his opening line of the first ever book about the burden of being a doctor, “Life is short, and art long, opportunity fleeting, experimentations perilous, and judgement difficult”.

Life is less short since Hippocrates’ day, but the rest still rings true. Today’s graduates will face increasing bureaucracy and regulation. Recent reports highlight the threats of bullying from within the profession and of litigation from without—although I’d argue neither is escalating.

Would I encourage my child to do medicine? You bet I would, and here are five reasons why. Continue reading

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GP Sceptics podcast 8: Marketing


‘Carrots & Sticks’ by Kat Ritchie

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Doctors try to ‘sell’ behaviour change to patients, who are often reluctant to ‘buy’ the message. What tricks can we learn from the modern experts at selling?

Justin and Liz bite the bitter bullet and enter the strange world of marketing.

We grill Dr Ninya Maubach, whose former life involved a PhD in marketing, but who has now seen the light and is studying medicine at ANU. That’s a powerful combo when it comes to teaching doctors how to sell a message.

Our starting point is a paper ‘Carrots, Sticks and Promises’, and it turns out that most of our attempts at behaviour change involve the least effective selling method: “I promise that if you stop this pleasurable thing today (e.g. smoking, lying on your couch), you will reap rewards in the future.”

That message is pretty easy to trump (are we still allowed to use that word?), and plenty of full-time tobacco and food industry marketers know just how to trump it.

Turns out the ‘stages of change’ model  we all learned (precontemplation, contemplation)may not be so useful after all. Continue reading

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