Pharmacy business model: consumers at risk

conflict of interestAustralia’s first comprehensive pharmacy review in two decades, released this week, asks the important question:

“Is it confusing for patients if non-evidence based therapies are sold alongside prescription medicines?”

Let me save the reviewers some trouble: the answer is “yes”.

The harder question, of course, is “What, if anything, should be done about it at a regulatory level?” I don’t pretend to have an answer, but doing nothing at all will be a poor outcome for consumers.

The Review of Pharmacy Remuneration and Regulation (the ‘King review’) can be found here (pdf).

I spend a lot of effort highlighting potential conflicts of interest when it comes to doctors’ prescription decisions being swayed by marketing rather than evidence. But this is merely fine-tuning within a system already ensuring most doctors gain no direct financial reward.

The community pharmacy model is, necessarily, far more prone to financial conflicts of interest. Arguably, this could loosely apply to any business with a cash register, but the health industry requires particularly careful oversight. Continue reading

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Does high antibiotic use prevent serious complications?

pill bottle

BMJ article yesterday provided strong evidence that doctors who prescribe antibiotics at high rates for respiratory tract infections are not, in fact, protecting their patients from serious bacterial complications such as meningitis.

This finding negates the ‘patient safety’ claim repeatedly pulled out by some high-prescribers to justify their practice of using antibiotics for colds. They typically recall an awful case of mastoiditis (ear-bone infection) they once treated, then suggest that the researchers must be heartless not to want to prevent it.

I have always resisted the urge to point out that, logically, the more anecdotes these high-prescribers produce, the less it would appear that their prescribing practices actually prevent these bacterial complications!

I resist that urge because, of course, fighting anecdote with anecdote is not how good evidence works. Happily, this study now provides the missing evidence.

Please note: the antibiotic problem certainly doesn’t lie with GPs alone – quite rightly, we need to look at antibiotic use in hospitals, specialists’ rooms, the agricultural industry, and third-world countries with minimal regulation etc. And of course, thousands of GPs do the right thing, and our profession deserves credit for talking about the issue openly.

But who am I to hold back when writing for a GP audience?

Article published in Medical Observer today:

Every medical media article highlighting antibiotic over-prescription of for respiratory tract infections (RTIs) seems to attract at least one doctor’s comment about Continue reading

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World’s best video animation about pharmacists in GP-land

Disclaimer; my claim of ‘world’s best’ relies heavily on the supposition that this is also the ‘world’s only’ such video animation.

It introduces the novel concept of embedding a pharmacist within a general practice (in addition to the pharmacy business owner down the road). This in-house pharmacist would consult from the GP’s rooms, and would not sell or dispense medications.

Besides the obvious benefits to patients in terms of fewer medication errors and misadventures, the appeal to me is that the in-house pharmacist has no conflict of interest.

Because they are non-dispensing, there is no gain or loss to them whether a patient takes one more pill or one less. If a vitamin is of no use to you, they’ll say so. These pharmacists don’t have anything to sell – their role is to advise, educate and oversee.

My video was commissioned by academic pharmacists Debbie Rigby and Chris Freeman, and launched at their AACP Consultant Pharmacy annual conference last weekend.

They tell me that around 25 Australian general practices currently have in-house pharmacists.

Let’s get more.

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We doctors must lift our game on antibiotics

ab'c prescribing report

Today’s major report on Australia’s antibiotic prescribing makes fairly grim reading. The Antimicrobial Use and Resistance in Australia (AURA) report reveals the following:

  1. Almost half (46%) the population was prescribed an antibiotic in 2014.
  2. More than half of patients with colds, flu and respiratory illness who received antibiotics did not need one.
  3. Acute upper respiratory tract infections (colds) resulted in antibiotic prescription 47% of the time (data taken from a sample of 180 GPs).
  4. Prescribing rates for sinusitis, bronchitis and middle ear infection massively exceed evidence-based recommendations.
  5. A fifth of nursing home residents who receive antibiotics have no signs of infection.
  6. Of the 38% of hospitalised patients who receive antibiotics on any given day, a quarter of prescriptions were inappropriate.
  7. Of those receiving antibiotics as a preventative measure around the time of their surgery, 40% of prescriptions were inappropriate.

When this sort of stuff hits the medical media, the response of a few doctors is to dig in, defend our position, and blame the messenger.

I pre-empted this with my own response below, which I have just sent out to GPs via my Medical Observer column. The main message is that we must do something to change.

Antibiotic overprescribing

It’s not hard to feel that GPs are under the pump, with rebate freezes and various reports suggesting we are using medical interventions too much or too little. Continue reading

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Weight-loss surgery: really the most radical treatment in a century?


I spend a lot of time highlighting the commercial forces that promote expensive medical interventions. So yesterday, when I read a lead author describe his new guidelines as “the most radical change in the treatment of type 2 diabetes for almost a century,” my first thought was, “why the hype?”

Francesco Rubino, who made this extraordinary claim in Nature, was describing not a new type of intervention, but a new consensus statement which argued we should be funding bariatric (weight-loss) surgery for more people, and at lower degrees of obesity. Yesterday’s Sydney Morning Herald article gives further background.

Now, we all agree that bariatric surgery has its place, but what are we to make of this statement which potentially expands that place from a niche into a town square?

First, we can dismiss the hype: a bunch of experts recommending surgery does not constitute a radical change in treatment, much less the biggest in a century. Continue reading

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My last laugh


This column marks the end of four years of my writing for the Medical Observer column Humerus. The GP magazine is undergoing a major revamp and there just ain’t no more room for the funny bits.

That’s okay; publication is a fickle business, and I’ll be writing elsewhere…but until I find another willing publisher, I’ll have to stick to serious stuff rather than these enjoyable frivolities.

Herewith: my final humorous musing.


Goodbye, dear fans. I salute both of you (see you Sunday, mum), and also congratulate any others who stumbled upon this Humerus column believing it would deliver a refresher on shoulder anatomy.

After 45 monthly columns from me, and countless more from others, this is the last you will ever read. That’s if you bother finishing it at all—the last paragraph notably runs out of steam. They may say at my eulogy, “He was a funny fellow until quite near the end.”

Vale Humerus, 2003-16. When I look at my fellow columnists over the years—Ron, Pam, Simon and Sarah—I may not have the most columns to my name, but I notice I do have the most letters to my name. A six-letter moniker is an encumbrance in this cutthroat world of column inches. If the Medical Observer bean counters look offshore to replace us, they’ll head-hunt a Bo, Li or Vy.

The last laugh. The brevity of levity. Closure. Continue reading

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Do you know what you don’t know? Want to find out?

Here’s a fantastic new list of things doctors should consider avoiding. The list is the brainchild of GP Rob Park, who borrowed the brains of hundreds of doctors on the GPs Down Under facebook group.
Plenty of food for thought.


How can we know what we don’t know?


I asked an amazingly brilliant GP, who has been one of my long time mentors, why he had had a few patients with a TSH <0.05 for many years. He replied that he titrated to T3/T4 levels as he always does. He was horrified when I showed him that best practice is to titrate to TSH not to T3/T4 and that his patients were possibly at increased health risks. He couldn’t believe it! How could he have been practicing for such a long time and never come across this!! In reality, his patients felt fine, and therefore there was no opportunity for feedback. And this doctor is brilliant! It is SO easy to keep doing what we have always done and not know if it is best practice!

“Makes you think – what might you be doing in not the best way?…

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Calling all hospitals: reduce Pharma marketing

MJA pharma

My 2014 No Advertising Please campaign, while aimed at all doctors, ended up impacting mainly on GPs. The pledge not to see drug reps is more easily fulfilled when one is in autonomous, private medical practice.

However, it is equally important that prescribers working in hospitals choose their medications on the basis of best evidence rather than marketing.

In today’s Medical Journal of Australia (MJA), I co-author a paper with Monash doctors Dr Jessica Dean and Prof Erwin Loh.

We call for a severing of ties between pharmaceutical sponsorship and hospital-based medical education. Continue reading

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I could have been a logician

Dr 'Grand Master' Only 10,000 hours away?

Dr ‘Grand Master’
Only 10,000 hours away?

With medical jobs so commonplace, I sometimes fantasise about alternative career choices.

Three logicians walk into a bar. Says the bartender, “Would all three of you like a cider?” The first logician replies “I don’t know,” the second also says “I don’t know,” so the third one says “Yes.”

I got that joke immediately, which suggests I might have made a good career logician. Except I doubt such a career exists. Ergo, I’d currently be an unemployed wannabe and unable to afford cider.

Incidentally, my answer to the bartender would still have been correct; not my fault his question conflated the desire to drink with the ability to pay. Never lend money to a logician.

The thing about doctors is, in different circumstances most of us could have chosen other careers. Even interesting ones. I might have chosen music if I hadn’t jammed my left hand in Mrs Bell’s patio door-rail while attempting to escape a piano lesson early. In retrospect, it was my sliding door moment. Continue reading

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Cochrane 2015 – writing for a non-expert audience

Cochrane15Apologies to anyone reading this who is not currently listening to me live at my Cochrane Symposium writing workshop (Melbourne, Wed 25 Nov); I’m teaching clever researchers how to write for ordinary folk. I have just dumped a few exercises and links for workshop participants.

If you’ve been falsely lured here via automated social media alerts, and have read this far (second paragraph means you’re a bit curious) please feel free to browse around my other posts. If nothing else, the tedious nature of this one makes the others look brilliant in comparison.

Given the Cochrane theme, I humbly suggest starting with, How Archie Cochrane flipped the medical world on its head

The workshop content starts below: Continue reading

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