Changing the Leopard's Spots

Big Pharma at Work

Drugs come and drugs go.  Pharmaceutical companies tend to spend a lot
of money advertising their latest creations.  However, a new drug or the
newest form of an old drug may not be exactly what I need.

I have a standing request of the nurses to call me if any of my patients
have a fever of over 100.5 F, indicating infection that needs
attention.  Depending upon the symptoms, I often order cefoxitin because
it is effective against all eight varieties of bacteriodes fragilis, a
common infectious agent with women who have delivered babies.

When I got the call from the nurse at 5:00 a.m. indicating one of my
patients had a temperature of 102.7 F, I asked that the nurse order
cefoxitin.  As I made my rounds that morning at 7:00 a.m., I stopped to
check on my patient.  To my surprise, she had received no medication at all.

I checked with the nurse to see what had happened.

 I was told that the hospital pharmacy no longer stocked cefoxitin, but
instead had replaced it with cefotetan, a newer drug which could be used
for similar situations as cefoxitin.  The pharmacy had no cefoxitin, so
no medication was given my patient.  More importantly, I was not
informed of the problem.  In the end, even though I had no say in the
decision to no longer stock cefoxitin in the hospital pharmacy, and
indeed was not even informed of this, someone in the hospital made the
decision to not treat my patient because the medication I requested was
unavailable.  What is more, someone in the hospital failed to inform me
of the decision to leave my patient untreated.  I am the one who bears
the entire responsibility—the liability—for my patient's not getting the medication she needed, even though other people made decisions beyond my control which substantially lessened the quality of care my patient received. 

The next day, when I questioned the nurse about why my patient was not
given the medication I requested, she explained that those responsible
for operating the pharmacy had decided that cefotetan was easier to
administer to patients, so would be substituted for cefoxitin.
Cefoxitin must be given twice a day or more, sometimes up to four times
a day.  Cefotetan can be given only once a day, saving bags, tubing, and
nurse's time.  The cost of the drug per dose, I was told, is about the
same.

Drugs, like computers, may not be 100 percent interchangeable.  A
computer billed as "IBM-compatible" may well be very much like an IBM.
But the IBM compatible machine is not an IBM, and there will be times
when this can cause problems because the IBM-compatible will not
function exactly like an IBM 100 percent of the time.  This means that
there may be certain procedures,  depending upon what the consumer is
trying to do with the machine, where the IBM-compatible machine will not
do what an IBM machine will do. 

I knew from experience that my patients recovered better with cefoxitin
than cefotetan.  If you read the advertising literature about cefotetan,
you will find it is effective against bacteroides fragilis.  However,
there are several varieties of this bacteria and cefotetan is not
effective against all of them.  If you check the literature on
cefoxitin, you will find that it is effective against all eight
varieties of the bacteria. 

In its description of the effectiveness of cefotetan, the drug company
was telling the truth, but not all of the truth.  Sometimes a
substitution such as this one might make no difference.  However, in
this particular situation I had seen the drug I specified make a
difference in a number of cases, and now, without my knowledge or input
in the decision, a drug I considered important to providing quality care
to my patients had disappeared from the pharmacy shelves and I was not
told about it.  What's worse, my patient simply went untreated and I was
not told.

Those running the hospital had decided to no longer stock one drug and
substitute another for it because it required less of a nurse's time to
administer.  A decision was made, driven by the desire to keep labor
costs down, which would in many cases result in a poorer quality care
for my patients.  I had no say in this decision, but bear all the legal
responsibility for its consequences. 

This is a relatively small incident, but a very good example of the
kinds of decisions made for business reasons that are not necessarily in
the best interest of the patients.