What Big Pharma Gets Right (13 mins)

Big Pharma spends billions of dollars on advertising that teaches the public how to say the names of their products. While millions of people live with hypertension, many of them cannot remember the name of their diagnosis or what it means. This episode discusses healthcare communication and shares helpful models for improvement.
Key Points:
-Big Pharma ads get it right
-Idiopathic Explanations
-Louis Braille and medical coding

References:
-Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy press.
-Hughes, RG, Ed (April 2008). “Handoffs: Implications for Nurses.”  Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ. https://www.ncbi.nlm.nih.gov/books/NBK2649/.
-Mole, B (Jan. 11, 2019). Big Pharma shells out $20B each year to schmooze docs, $6B on drug ads. Ars Technica. https://arstechnica.com/science/2019/01/healthcare-industry-spends-30b-on-marketing-most-of-it-goes-to-doctors/.
-Etymonline (Sept. 18, 2024). “Idiot.”  https://www.etymonline.com/word/idiot/.
-Petzold, C (2023). Braille and Binary Codes. Code: The Hidden Language of Computer Hardware and Software, 2nd Ed. Pearson Education.

Transcript

There is a story in the Bible about people in ancient times building a tower, but God wanted people to spread out and fill the earth, so He confuses their language so that they will not understand each other. The work on the tower is halted because when the people talk to each other, they only hear babel. So they leave the project, spread out on their own, and fulfill God’s plan. The story of the Tower of Babel shows how language can be confusing, highlight differences and cause us to drift apart.

This is the story I think of every time I walk into a healthcare environment. A lot of professions use their own language, so to speak, to maintain the integrity of the professional and separate them from the do-it-yourself hack. But when I enter the healthcare environment – even as a professional – I feel like I trip on the Tower of Babel just to get in the door.

The reason this is worth talking came to life for me when I was still in nursing school. One of my professors gave us a template for giving an SBAR handoff report. SBAR stand for Situation, Background, Assessment, Recommendation. We practiced giving handoff with each other over and over again as she handed out case study patients, one after another. Someone asked why she was making such a big deal about handing off a patient that we were no longer caring for. Why write a PowerPoint presentation when your job is done?

In “Crossing the Quality Chasm: A New Health System for the 21st Century” the Institute of Medicine (US)[1]stated that “it is in inadequate handoffs that safety often fails first” because that is when caregivers have the opportunity to ask questions, clarify, and confirm critical information, as well as take official responsibility for the care of the patient.[2]

Handoff is when you learn to pronounce the patient’s name, find out why they are here, and get a list of work tasks that are pending for their care. Whether in an SBAR handoff between nurses, or a physician history and physical, starting with the history of present illness, small changes in the report of these details can make the difference between life and death for patients. What if I shared in handoff that the patient has transfusions pending, but I didn’t mention that they have an anaphylactic, life-threatening reaction, to cold blood products? Or what if the previous patient left their dentures in the room and, without any report on the matter, the nurse tried to put someone else’s teeth in the new patient’s mouth? Problems that come from poor communication range from gross to dangerous – but all of it matters to the patient.

So communication is a big deal. Which is why it is so confusing that our medical terminology, our computer systems, and our medical coding are so incredibly obscure that the experts working in the field are often confused by them.

Did you know that pharmaceutical companies spend $6 billion on drug advertising in the U.S.?[3] Why do you think they spend so much money advertising products that Americans are already seeking? Language. Think about it. How many times does a drug ad repeat the name of the drug? “Lollipopsicle requires a prescription. Lollipopsicle should not be used while driving. Lollipopsicle is not for everyone. Some people experience blind rage while using Lollipopsicle. Talk to you doctor about whether Lollipopsicle is right for you. Lollipopsicle. Lollipopsicle.” Get the idea? It’s like pharmaceutical companies speak some sort of pidgin creole that requires language lessons for any normal person to actually discuss their products.

Literally, I think that half the battle of marketing pharmaceuticals is that most people don’t want to ask for or prescribe a drug they cannot pronounce. Which makes the secret language of healthcare all the more concerning. If it costs $6 billion dollars just to help people pronounce the name of a drug, how much time and money do you think it will take to explain words like “nocturia”?

Yet we send patients surveys asking them if they experience Nocturia, and I don’t even know if I’m pronouncing it right. Sometimes there is a helpful hint in parenthesis where the meaning is rephrased to something like, “do you get up at night to void?” No, doctor, I’ve never voided a check in the middle of the night. After all that trouble, we still don’t have an answer to the simple question, “do you need to get up frequently at night to use the bathroom?” This is a question that everyone over 60 discusses with their friends and family, yet we have obscured it into something that professionals are not confident reading aloud.

I’m suspicious that there is a pronunciation club somewhere in the world where they sit and talk about whether to call it SIMvastatin or simVASTatin, and whether teLANgiECtasia or telangiecTAsia is correct. I’ve never been invited to this club, so I have to ask how to pronounce things when I have fancy guests on my show, or even look it up online before I start talking about nocturia. Noct – yer -EEa. Noct UR ia. Noc-cher-EEah. You get the picture.

But if I could pick a word and banish it from healthcare forever, there is one in particular that bothers me more than any other. No, it has nothing to do with blood or bile. The word is less assuming than that. My least favorite word in medical terminology is “Idiopathic.”

Idiopathic something is a diagnosis with an unknown cause. When the doc runs tests and finds nothing, they tell the patient, “You have idiopathic headaches,” for example, and the patient thinks they have reached a diagnosis. They go home and look up idiopathic headaches to see if there is anyone else in their club, or a support group or forum to join. But there isn’t really, because it’s not a real diagnosis. It’s a fancy term that means “I don’t know, but I’ll try treat your symptoms.” The problem is that the patient THINKS they have an answer, and they stop their own search for answers. What if a different specialist could shed some light on the problem? What if they have a relative with wicked food allergies and they’ve never explored that possibility? What if bought a home blood pressure cuff and started finding that their pressure actually is really high at work, but it levels out when they check at the doctor’s office? If we don’t kill the search by telling them we have a diagnosis, the patient can continue the search for answers. I think it’s quite wrong to slap a fancy term on something when we should have an honest conversation about what we do and do not know about their condition.

The other reason I hate this word – yes, hate – is because it has the same Greek root for the word idiot. “Idios” was a Greek word for someone who is uneducated, lacking professional skill, and unfit for public service.[4] So an idiot is someone who shouldn’t talk in public, but should be kept locked up at home, on their own, apart from society. Not a great connotation for a diagnostic decision. “Well, Mrs. Smith, I’m afraid your diagnosis is only for private use. We don’t think the cause should be made public. It’s kind of your own thing and it might come across as unprofessional if we really dug in and still found nothing.” 

At the very least, if we are going to use the word “idiopathic” in a diagnosis, we’ve got to come clean with the patient and explain what it means: that we ruled-out the obvious culprits but we still don’t know what’s causing their symptoms. Then we are empowering them to make a decision about how far they want to go for answers. And that really is their decision, not ours. If they are done with testing, then we are all fine. If they will not rest until they have answers, then write another referral, explore another avenue, and let the patient share ideas based on family history and genetic predispositions, etc. That choice is really important for patients, and I hate to see it taken from them. But I also feel awkward explaining the diagnosis to patients after the doc walks out. It makes us all look foolish if I have to explain what idiopathic really means, and it is far better if we all just ‘fess up and admit what we don’t know.

So I think some of our medical terms need to get tossed out as archaic and – shall I say, “idiotic”? It’s dangerous to speak a language our patients can’t understand, and it’s expensive to the tune of $6B to explain it. In something as important as a final diagnosis, we really need to emphasize honesty over grandiose circumlocution. Such snobbish verbosity is supercilious, snooty, and contemptuous of the veracity of philological meaning. So yeah. Just say, “we don’t know, but it’s your choice what we do next.”

In fact, there is another option than the Tower of Babel approach. At the age of 12, Louis Braille heard about something called “night writing,” which used a pattern of raised dots to send military messages after dark. These messages could be quickly written with a stylus and paper, and it was a dramatic improvement from the raised, wax-embossed alphabet used in schools for the blind at the time. So this young man, who was not even a teenager yet, discovered that this system was not just touch-able (and therefore readable) but it was a system that could also be quickly written: The barrier for a blind man to communicate in writing was about to come down as braille text was tested and refined into a language we still use today.[5]

Understandably, the language of medicine is complex. While a gardener may not need to announce the Latin name for every weed they pull, an herbalist might actually need that much detail to ensure they are helping, and not poisoning, their patient. So it makes sense that the goal of most medical terminology is to be highly specific – because the consequences of generalized statements could be toxic. But codes and languages break down when they divide into too many variables – it becomes too much to memorize and track. Our ICD codes have subdivided over and over again to be so highly specific that they are hardly useful. Somehow there must be a balance between so-general-it-could-be-poisonous, and so-specific-it-can’t-be-used.

Intent is a major player in these decisions. The goal of Louis Braille’s innovation was to communicate. He felt the loss of not being able to take notes, keep a diary, or read the same books that his peers enjoyed. The beginning of improved communication in medicine will most likely begin when we feel the loss of not being understood by our own patients.

Have you ever gone to the doctor and had them ask how you tolerated stopping or starting a medication, only to realize you totally missed that they told you to make the change? I have, and it was AFTER I acquired a nursing license. We were both upset. I realized that I needed to repeat back the orders in my personal visits just as much as in the professional setting. I started bringing paper to write things down at my appointments. I found ways to keep things clear because I felt the loss. There was a major breach in communication, and it added weeks to my treatment plan. 

When we long to clearly communicate with our patients as much as a blind 12-year old wishes to read and write, I’m certain we will make progress.

[1] Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy press.
[2] Hughes, RG, Ed (April 2008). “Handoffs: Implications for Nurses.”  Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ. https://www.ncbi.nlm.nih.gov/books/NBK2649/.
[3] Mole, B (Jan. 11, 2019). Big Pharma shells out $20B each year to schmooze docs, $6B on drug ads. Ars Technica. https://arstechnica.com/science/2019/01/healthcare-industry-spends-30b-on-marketing-most-of-it-goes-to-doctors/.
[4] Etymonline (Sept. 18, 2024). “Idiot.”  https://www.etymonline.com/word/idiot/.
[5] Petzold, C (2023). Braille and Binary Codes. Code: The Hidden Language of Computer Hardware and Software, 2nd Ed. Pearson Education.