Authors: Jerome Groopman
Machines cannot replace the doctor's mind, his thinking about what he sees and what he does not see. Attention to language—the words of a referring clinician and the report of the radiologist—can make perception and analysis better. Laymen should understand the inherent limits and potential biases in the beholder's eye, so that when there are important decisions to make, they can ask for another set of expert eyes.
Chapter 9
Marketing, Money, and Medical Decisions
I
FIRST ENCOUNTERED
Karen Delgado in the early 1980s and have followed her career ever since. She carries great sway in her specialty of internal medicine and endocrinology. She sits on national committees that review practice guidelines and set out curricula in physician education. Colleagues look to her for counsel on complicated cases.
She is a typically busy clinician with a typically heavy load of patients. One day not long ago, she had ten minutes to grab lunch before her clinic began, with three new patients and six follow-ups. Two residents would be working with her, but, if anything, these trainees would extend her hours.
As Delgado gathered a sheaf of lab reports to take to the clinic, she saw a face out of the corner of her eye and froze. Rick Duggan filled the doorway of her office. There was no escaping him.
"I don't know what more I can do, Dr. Delgado," Duggan said. He was a sales representative for a pharmaceutical company that made a testosterone product. "You haven't written a single prescription for my drug. Not one." He was dressed in a bright blue shirt, gold tie, and sharply cut suit. "Dr. Delgado," he said, his voice taking on a forceful tone. "I want you to write three prescriptions a week for the next month."
She was dumbstruck. Duggan had been shadowing her for nearly a year, trying to promote his product. He brought boxes of candy to her office three times, and when this ploy failed (the candy wasn't very good, Delgado noted), he left invitations to "educational dinners" at the most expensive restaurants in town. Delgado ignored the invitations, telling herself that if she wanted a good meal, she would have it with her husband on her own tab. What astonished her was that the salesman knew which prescriptions she was writing.
"I need you to do this," Duggan pressed. "Three a week for the next month."
She stared icily at him, said "No," put the lab reports in the pocket of her white coat, and walked out of her office.
The first patient Delgado saw in clinic was Nick Mancini. Mancini was a solidly built handyman in his early fifties whom she'd first met in the ICU. He had come to the ER complaining of blurred vision and the worst headache of his life. He had hemorrhaged into his brain. Brain scans failed to reveal why he bled, but showed that his pituitary gland was enlarged, so Delgado, an endocrinologist, was one of the specialists called to the ICU on his case. She approached the bedside. She couldn't see his face clearly; the lights had been dimmed because of his blistering headache. But as she shook Mancini's hand and pressed his palm, she made the diagnosis that had eluded all the other doctors. Each had presumably shaken his hand as well, but the thick, doughy flesh signified to Delgado more than the mitt of a handyman.
Mancini had acromegaly. This disorder occurs when a tumor causes the pituitary gland to produce too much growth hormone, so the hands and feet grow larger and the facial features become coarser. Located at the base of the brain, the pituitary is called the master gland because it signals other glands in the body, like the thyroid and the adrenal, to make essential hormones. As a pituitary tumor grows, it can rupture its feeding blood vessels, resulting in a cerebral hemorrhage. This is called pituitary apoplexy. The nerves to the eyes run near the pituitary, which accounted for Mancini's blurry vision. If the hemorrhage destroys the pituitary gland, it no longer sends signals to the body, so production of essential hormones stops. The adrenal glands make cortisol, one of the most critical of these hormones. Without it, people are prone to shock, especially under stress—as in surgery, for example.
Delgado gave Mancini protective doses of corticosteroids, and he was taken to the OR. The surgery to drain the blood succeeded. He no longer had a functioning pituitary gland, so Delgado prescribed replacement therapy for the missing hormones; in addition to daily doses of thyroxine and corticosteroids, she gave him testosterone, which the pituitary also controls.
"Everything okay at home with the kids?" Delgado asked.
"Great. My daughter is starting high school next week." Mancini smiled.
Delgado nodded. The testosterone preparation she wrote on the prescription pad was not the one made by Duggan's company.
The next afternoon, Delgado attended the weekly clinical conference where trainees present cases and the senior endocrinologists comment on them. At the end of the hour, Dr. Bert Foyer approached Delgado. Foyer was in his late sixties, also a prominent member of the staff, active in both clinical care and research. His specialty was testosterone replacement for men with various endocrine disorders.
"Good cases today," Foyer said.
Delgado agreed.
"I ran into Rick Duggan yesterday," Foyer said. "Couldn't you take a few moments with him?"
"Bert, I'm really busy." The silence that hung between them finished Delgado's reply.
That night at home, over dinner, Delgado's husband, a surgeon at her hospital, surprised her by bringing up Duggan's name. "I don't know if he was looking for me," Delgado's husband said, "but he was in the corridor when I was leaving the OR." She raised her eyebrow. "He introduced himself and said, 'Why doesn't your wife like me?'" Delgado's husband grinned. "I had a few one-liners, but I just shrugged. What's this about?"
The answer to his question is that some pharmaceutical companies are striving to change the way doctors think about health and disease. In this case, they are medicalizing normal change in aging men. These companies make testosterone products; they want not only to have their drug prescribed instead of the competition's, but to expand the market beyond what medical science dictates. When I spoke with Delgado, she acknowledged that Duggan had targeted her because she was, in marketing parlance, an "opinion leader." Working at a prominent teaching hospital, widely recognized as one of the top clinicians in her specialty, supervising the education of the next generation of doctors, readily given the floor at conferences, and having a steady flow of patients, she influenced clinical decision-making in her city and beyond.
Duggan had used several classic marketing strategies to get her, in essence, to endorse his brand. The first was gift-giving. Besides the candy and the dinner invitations, he had brought other small gifts, including a calculator, a desk clock, and pens. Delgado left these unopened on her secretary's desk. Duggan—well dressed, and with a practiced seductive manner—then chatted up Delgado's secretary. He knew that without her assent he stood no chance of pitching Delgado face to face. Delgado politely ignored her secretary's enthusiasm for the sales representative. Once Delgado rejected these approaches, Duggan switched from honey to vinegar.
"I was really offended by him," Delgado told me. "He was trying to bully me. It may work with some doctors, but not with me."
At dinner, Delgado told her husband how surprised she was that Duggan knew which products she prescribed. Her husband recently had read in a business magazine that pharmaceutical companies contract with drugstores to learn physicians' prescribing patterns. Of course, the companies did not know whom she prescribed the drugs for, but they could obtain a complete list of how many prescriptions she wrote for which products over a designated time period. "It's perfectly legal," Delgado's husband said.
"But I don't like it," she replied.
She noted that Duggan's company seemed to be using a strategy of escalation, from gifts to confrontation and then the intervention of her colleague Dr. Foyer.
"I don't really think it's about money for Bert," she said, although Duggan's company had given him grants for some of his clinical trials of testosterone products. "I think it's simply that he's a believer."
For many years, the market for testosterone replacement therapy was relatively small. Doctors treated patients like Nick Mancini, who lacked a functioning pituitary gland, or men born with an extra X chromosome, who have what is called Klinefelter syndrome; their shrunken testicles don't produce enough of the hormone. Androgen pills were originally used in replacement therapy, but they often caused liver damage. Then intramuscular injections were tried; these produced a sharp spike of testosterone and a sharp fall, often accompanied by parallel swings in mood, sex drive, and energy. In the late 1980s, a transdermal patch was developed. This allowed safer and steadier dosing, but sometimes the skin became irritated or the patch fell off during exercise. Finally the hormone was prepared in a form almost any man could conveniently use: a colorless gel that could easily be rubbed on a part of the body, like the shoulders, once a day. This would simplify treatment and expand the potential market—if a group of men could be shown to benefit.
A few months before Rick Duggan confronted Dr. Delgado, a two-page ad in
Time
magazine showed a car's gas gauge and beside it the words "Fatigued? Depressed mood? Low sex drive? Could be your testosterone is running on empty." The ad went on to explain that "as some men grow old, their testosterone levels decline," and recommended that they consult their doctors about testosterone replacement therapy. At the bottom of the ad, the gas gauge pointed to "Full."
Delgado had seen the ad in
Time;
it was just one of many. There had been a flurry of similar advertisements in medical journals over the preceding year. One of them called on doctors to "identify the men in your practice with low testosterone who may benefit from clinical performance in a packet." The ad featured photographs of robust and happy men placed beside the words "improved sexual function," "improved mood," and "increased bone mineral density." Doctors were told to "screen for symptoms of low testosterone" and "restore normal testosterone levels."
One pharmaceutical company, a competitor of Rick Duggan's employer, developed a questionnaire physicians could use to identify aging patients with testosterone levels below "normal." These men were said to be experiencing the equivalent of female menopause. "Male menopause" may be the popular term, but physicians call it andropause or
PADAM
, for partial androgen deficiency in aging men. Some of the questions were quite specific: an experience of decreased libido, for example, could be related to a decline in the male hormone. Other questions were more vague. A sense of lowered energy or endurance might also indicate a testosterone deficiency, but could also result from many other disorders. And some questions cast an even wider net. Was the man enjoying life less? Was he irritable, less efficient at work, falling asleep after the evening meal? I discussed the ad with Delgado. "Who doesn't sometimes doze off after dinner?" she pointed out. The question, she felt, was simply a way to get doctors to measure an aging man's testosterone levels. With that result in hand, the physician would be obliged to tell the patient, who might then expect the doctor to prescribe the hormone. But was this medicine or marketing?
As men age, the response of their testes to signals from the pituitary gland becomes muted. After the age of forty, testosterone levels in a man's bloodstream decline, on average, about 1.2 percent a year. "Normal" testosterone levels refer to what is normal for men in their twenties. But even the definition of "normal" for younger men can mislead a doctor who is not expert in endocrinology. Among younger men, testosterone levels can vary markedly over the course of a day. Dr. William Crowley, chief of the reproductive endocrinology unit at the Massachusetts General Hospital, and his associate, Dr. Frances Hayes, are studying the consequences of testosterone deficiency in men. To do so, Crowley told me, they needed a clear definition of normal testosterone levels. So he sampled the blood of healthy men in their twenties every ten minutes for twenty-four hours. He also evaluated testicle size, body hair, erectile function, sperm count, muscle mass, bone density, and pituitary function. The men were completely normal by every measure, yet at some time during the day, 15 percent of them had testosterone levels well below the presumed lower limit of normal—more than 50 percent below it, in fact.
Many men sixty and older often test below this normal range. Does this decline impair their health and functioning to the extent that they need testosterone replacement therapy? In short, does male menopause exist?
Karen Delgado and many other internists and endocrinologists worry about what they see as a concerted effort to change how doctors think—to create a clinical disorder by medicalizing normal changes and challenges in life. In this instance, some drug companies were meaning to turn the natural aging process into such a disorder. In other settings, aspects of personality and temperament that deviate from a narrow norm are being labeled as psychological illnesses requiring medication. Of course, there are children and adults with disabling anxiety that cripples their ability to form friendships, but some people who are simply very shy are labeled with social affective disorder and given powerful psychotropic drugs. Others, who work with extraordinary intensity and precision, reluctant to unhinge from a task and worried that they are overlooking an error, are too quickly given the diagnosis of obsessive-compulsive disorder and medicated.
In Delgado's field, testosterone is only the latest hormonal elixir in the medicalizing of aging. The growth in prescriptions of estrogen for postmenopausal women can be traced to a bestseller published in the 1960s,
Feminine Forever,
by Dr. Robert A. Wilson. It turned out that a drug company that made estrogen had paid Dr. Wilson to write the book. Some came to see a supposedly well-reasoned analysis of the biology of female menopause, and how its consequences could be remedied with hormone replacement therapy, as a marketing manifesto, not an objective clinical treatise.