ANSWER THE CALL

WOLF CALL

Since tax season is upon us, and you may be feeling the wolf at your door, I thought it useful to take a look at the importance of RETURN ON INVESTMENT…

Balance-Scale

Value. 

There is value when benefit outweighs cost. 

I was hoping to sell you on the value of belonging to the Greater Louisville Medical Society, the Kentucky Medical Association, and the American Medical Association. I thought about listing the savings from members-only programs. Or maybe the marketing, career development, and educational benefits might have impressed you. Charity, advocacy, and research could have been extolled.

I thought about asking you to go online to the Texas Medical Association’s “ROI Calculator” and input your specifics.  I even thought about the It’s a Wonderful Life angle – depicting a world where these physician organizations never existed.

potter

But how can there be a list of each valued benefit if one does not know which benefits are most valued by each individual?

Then I realized something.  I know you.  I can see through your eyes, because I am like you.  At some branch in our medical family tree we are blood kin.

I know you do not want to be forced to follow cookbook recipes for efficiency or some computer software’s definition of quality. You want the freedom to relate to your patients as individuals – not as record numbers and diagnosis codes. You want to be compensated adequately and fairly. You want to answer to a higher calling than a checklist of outcome measures.  You want to practice the art and science of medicine.

You want to be what you studied all those years to be, what you risked your health to be, gave up your precious time with family to be, went into debt to be, lost countless hours of sleep to be, worked endless hours on-call to be, got bloody to be, risked getting sued to be, what the core of your being demands you to be.

Physician.

white coat standing

By the time you see this article, I will have had the honor of addressing the University of Louisville Medical School incoming freshman class. It is a tradition called the White Coat Ceremony.   To don the gleaming garment symbolizes to the world, “I am called to a noble and trusted order of healers.” Years later their journey will culminate with acceptance into our family.

But will our family have a home in which to welcome them?  Or will we be living in cookie-cutter communes – designed for us but not by us?

Your Greater Louisville Medical Society is a home built by physicians, for physicians – regardless of who pays the salaries, the benefits, or the dues.  It is a home where you can find comfort, support, and refuge.  It is a place to focus, strengthen, coordinate, collaborate, and advocate.  It gets to the heart of why we went into medicine – to use our gifts, through dedication and hard work, to improve the human condition. And the KMA and AMA are extensions of this home.

Think back to when you were happiest as a physician. It was probably when you did something that was completely selfless, without any concern that the benefit outweighed the cost, without consideration of a return on investment.

op smile

You delivered the breech baby, clamped the bleeding artery, discovered the tumor in time, followed up on the lab test that saved a life, comforted the dying patient or the grieving family.  In moments like these, when cost is irrelevant, you become the quintessence of your calling.

In The Call of the Wild, Jack London wrote:

There is an ecstasy that marks the summit of life, and beyond which life cannot rise. And such is the paradox of living, this ecstasy comes when one is most alive, and it comes as a complete forgetfulness that one is alive.

For us, this ecstasy comes when we invest in our calling, and it comes as a complete forgetfulness that there be a return on that investment.

doctor-whitecoat-615x311

We are physicians.

This is our core value.

Cost is irrelevant.

Answer the call.

eVoice pic

Note: This article was first published as the Greater Louisville Medical Society President’s eVoice, August 2013.

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James Patrick Murphy, MD, MMM is President of the Greater Louisville Medical Society 2013-14.  Dr. Murphy’s blog is The Painful Truth. He can be found on TWITTER  @jamespmurphymd.  His President’s eVoice and other communications & videos can be accessed at the Greater Louisville Medical Society website.

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IS THERE METHOD TO THIS MARCH MADNESS?

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To prescribe or not to prescribe Zohydro ER…

In March 2014, Zohydro ER (hydrocodone extended-release) was introduced to the market. Never in my medical lifetime do I recall a medication stirring such angst. Worries of mass overdoses, backdoor FDA conspiracies, and blatant disregard for the public wellbeing abound. Is there method to this March madness?

620px-hydrocodone-svg

Some background…

Zohydro ER is a pain pill that, when taken by mouth, is released slowly over twelve hours. The active ingredient, hydrocodone, is an opioid (i.e. narcotic) that’s been around for decades in a short-acting pill form (e.g. Lortab, Vicodin, Norco) and has historically been combined with APAP (a.k.a. acetaminophen, Tylenol).  The FDA considers hydrocodone-APAP combination pills to be relatively less addictive and designates them as a schedule-three drug. Physicians can prescribe schedule-three drugs over the phone, with up to six refills. By contrast, schedule-two drugs (e.g. morphine, oxycodone, oxymorphone), even when combined with APAP, are considered more addictive, can’t be called in, and can’t be refilled without a new hard-copy prescription.

Because it is effective for pain, relatively well tolerated, and convenient to prescribe, hydrocodone-APAP pills have become the most commonly prescribed opioid in the United States.  It’s therefore not surprising that, since there’s so much in circulation, hydrocodone-APAP pills are frequently the most available opioid for abusers to abuse.  Add to this the legitimate worry about acetaminophen (APAP) overuse causing liver failure, and you can understand our leaders’ concerns surrounding this pain medication.

Enter Zohydro ER, the first extended-release hydrocodone pill without APAP. It’s easy on the liver and lasts twelve hours; so people with around-the-clock pain may need fewer pills per day. Additionally, it’s a schedule-two drug. In summary, Zohydro ER is a long-lasting version of a widely used and effective opioid, which until now had only been available in combination with acetaminophen.  So why the controversy?

Aye, here’s the rub…

Zohydro ER does not have any of the new and popular tamper-resistant technologies; e.g. a matrix that won’t dissolve easily, or a coating that is difficult to crush.  Instead, the makers took advantage of a delivery system (SODAS) already used successfully in a number other of extended-release drugs such as: Ritalin LA, Focalin XR, Luvox CR, and Avinza.

OxyContin and Opana ER are two examples of opioids that manufacturers took off the market briefly for reformulation as tamper-resistant.  However, while the changes have made them more difficult to snort or inject, many addicts still find ways to abuse these drugs or have just moved on to heroin. Tamper-resistant does not mean tamper-proof.

By the way, the generic form of Opana ER (oxymorphone extended-release) was not reformulated and is still available without tamper-resistant technology. Also, consider that Avinza (morphine extended-release), which employs the same sustained-release system (SODAS) as Zohydro ER, has neither been recalled nor been required to undergo reformulation.  In reality, probably 90% of the opioids in circulation do not have tamper-resistant formulations.

That’s why I have difficulty understanding the uproar over Zohydro ER. As a pain specialist, I welcome another effective treatment to offer chronic pain sufferers. Sure, I’d be happier if it had a hard coating or some other “deterrent” to abuse. But in reality, Zohydro ER is, for all practical purposes, neither safer nor more dangerous than many of the drugs I already prescribe with success. So far, tamper-resistant innovations have not been proven to be effective in the big scheme of things. All opioids, regardless of the formulation, must be prescribed with caution and careful monitoring.

According to the American Society of Addiction Medicine, there are four main factors that contribute to a drug being addictive:

  1. How much will it cost me?  All things considered equal, people will choose a drug that is cheaper.
  2. How fast does it get to my brain? Hydrocodone is water-soluble and actually diffuses into the brain slower than many other opioids.
  3. What kind of a buzz will I get? Opioids stimulate the brain’s “reward circuit.” There is no proof that hydrocodone is any worse in this regard than other opioids.
  4. How much of it can I get my hands on? People will abuse what is available to them. Since hydrocodone is the most prescribed opioid, expect it to be one of the most abused. It follows that if Zohydro ER floods the market it will be abused.

Therefore, my recommendations to physicians are:

  1. Prescribe Zohydro ER in the lowest dose possible, for the shortest duration of time, and only if the benefits outweigh the risks.
  2. Monitor regularly for effectiveness, side effects, and patient compliance.
  3. Educate yourself and your patient.
  4. Follow guidelines and regulations faithfully.

By the way, that’s my advice to physicians regardless of which opioid they prescribe.

Zohydro ER may not be tamper-resistant, but tamper-resistant drugs are not super heroes. Do not expect them to save us from the real villain.

The real villain is not the FDA, not the drug company, not the drug, and not the patient.

The villain is the disease of addiction.

Focus on the disease. Prevent the disease. Treat the disease.

This Zohydro hullabaloo is a prime opportunity to shine light on the problems surrounding prescription drug abuse and addiction. Let’s take advantage of it.

And stop the madness.

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me and c arm

James Patrick Murphy, MD, MMM

Board-certified in Pain Management, Addiction Medicine & Anesthesiology

Can We Make a Deep Run?

It’s March and that means basketball assumes center stage. So I decided to share my most basketball friendly eVoice.  A winning season requires a combination of passion, hard work and talent. But making a “deep run” in the tournament demands teamwork.

brackets

Do we have what it takes?

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LeBron, Trust, and the Power to Save our Profession

Recently my son and I made the trip to Indianapolis to see the Pacers play the Heat for a chance to go to the NBA finals.

pacers game

It was do or die for the Pacers, who were going up against the world’s best player, LeBron James. Even from the nosebleed section, it was clear that James was bigger, faster, and stronger.  He ran. He jumped. He rebounded. He dunked. He grabbed the spotlight.

lebron dunking on pacers

And he lost.

murphy speech at pres celeb

In my remarks at our Greater Louisville Medical Society’s Presidents’ Celebration on May 19th, I touched upon the concept that our team, a.k.a. our “tribe,” can reach our winning potential only if the pervasive attitude is “together we can be great.”

we are great

But is this possible?

It is hard to be together. There are so many barriers between physicians these days. We used to hang out in the doctors’ lounges, see each other on rounds, meet each other at seminars, and even pick up the phone and talk to one another. The GLMS roster, affectionately known as the “mug book,” included our picture, address, home phone number, and spouse’s name. A quick flip through its pages and you felt like you belonged to something special and could connect at a moment’s notice. But now we are partitioned into subgroups defined by things like specialty, locale, hospital affiliation, and employer.

It is critical that we reconnect, not just with colleagues but also with our passion. Deserve the privilege of our patient – physician bonds.  Be worthy of the immense trust gifted in this relationship. Trust is inherent to our profession and is born at the intersection of science and art. Trust is powerful yet fragile. Trust must be nurtured, honored, and protected.  By acting in our patients’ best interests, trust is sustained.

Are we powerful enough to save a profession?

Faced with so many dilemmas – where we will work, who we will work for, what we will earn, and how we will collaborate – our temptation is to cling to the status quo – protect our turf.  But the status quo will pit us against other professionals, third party payers, our patients, and even ourselves. If we do not solve these dilemmas, they will be solved for us. If we do not write the stories, they will be written without us. If we do not lead, we will be forced to follow.

I cannot keep from wondering what time will do…                                                                         and I wonder how far away from yourself you will go.

A very special teacher once conveyed these words to me. She understood that life’s living will weather anyone and would invariably change me. Even so, I can steer back toward my true self – the real me – by making a difference in the life of someone else.  No profession facilitates this journey more effectively than the healing arts. And there is no equivalent in the healing arts to the calling of physician.

Individuals we can be great. But together we can be greater.  We can positively affect people’s lives in a dramatic way and on a grand scale if we commit to our shared values, reconnect, and work together. It is not only possible. It is our inherent duty.

And we all win.

cards win ncaa

Note: This article was first published as the Greater Louisville Medical Society President’s eVoiceJuly 2013

eVoice pic

Patrick Murphy, MD, MMM is President of the Greater Louisville Medical Society 2013-14.  Dr. Murphy’s blog is The Painful Truth. He can be found on TWITTER  @jamespmurphymd.  His President’s eVoice and other communications & videos can be accessed at the Greater Louisville Medical Society website. 

View Dr. Murphy’s remarks at the Greater Louisville Medical Society’s Presidents’ Celebration May 19, 2013  http://vimeo.com/68703810

You Tweet Me! You Really Tweet Me!

sally-field-oscar

It’s Oscar season, so I thought it would be fun to take a look back at some of this year’s most memorable Twitter performances. The envelope please…

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Best Quote   http://goo.gl/jcHm5H

Confluential Truth ‏@jamespmurphymd  May 24

“…pay attention when your loved ones are speaking, as if it were the last time you might hear them.”

Mitch Albom, “Tuesdays with Morrie”

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Best Original Concept  pic.twitter.com/gzUs8hoOrx

Confluential Truth ‏@jamespmurphymd  Feb 15

our eyes met

how inspiring she is to me

we hugged

confluential truth http://goo.gl/jYzssi 

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Best Inspirational Tweet  pic.twitter.com/QElPmmk4Ef

Confluential Truth ‏@jamespmurphymd  Feb 10

I was a bit nervous much of the time. Now, dialing my cell phone, I was a bit nervous again. http://goo.gl/N235Ef 

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Best Supporting Tweet  pic.twitter.com/1lx2UyITx1

Confluential Truth ‏@jamespmurphymd  Feb 3

Tragedy, triumph, perseverance, and love @lauraungarcj chronicles Jill’s battle with cancer http://goo.gl/pxWopE 

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KEL ON SKI

Best Original Photo (tie) pic.twitter.com/Jzr4Bt0l8X

Confluential Truth ‏@jamespmurphymd  Dec 2

Interested in #pain? #Law? #Regulations? #Guidelines? I break down Indiana’s new pain rules at http://jamespmurphymd.com 

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journey for truth

Best Original Photo (tie) pic.twitter.com/poK2LTWHvQ

Confluential Truth ‏@jamespmurphymd  Jan 2

Searching for truth in 2014 https://jamespmurphymd.com/ 

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harmacy 2

Best Original Ironic Photo http://goo.gl/Vfp4Qt

Confluential Truth ‏@jamespmurphymd  Oct 6

National Substance Abuse Prevention Month 2013 http://wp.me/p3C62j-h 

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elf

Best Disturbing Photo pic.twitter.com/mxJoNI4jhN

Confluential Truth ‏@jamespmurphymd  Dec 20

You’ve ratted me out to Santa for the last time… the #shelf on the #elf

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Best Use of a Sports Metaphor  pic.twitter.com/fdGZaPU1Js

Confluential Truth ‏@jamespmurphymd  Jan 17

GLMS on a fast break to a healthier #Kentucky. But it’s not a slam dunk. We need your assist. http://goo.gl/2VBmJY 

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gravity small

Best Use of a Movie Reference  pic.twitter.com/6tyJNoprD4

Confluential Truth ‏@jamespmurphymd  Jan 18

Understand the #GRAVITY of the situation. Prescribers, take back your universe… with #OPIOID http://goo.gl/2dUZxI 

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ensemble

Best Ensemble Performance  pic.twitter.com/igkE0hia69

Confluential Truth ‏@jamespmurphymd  Feb 11

This #OPIOID thing didn’t just happen. Here’s to the people who gave us OPIOID… http://goo.gl/ABQdoM 

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Best Stunt in a Motion Picture http://goo.gl/RzvsNH

Confluential Truth ‏@jamespmurphymd  Oct 10

#NSAPM Day 10 How can you avoid being addicted to your pain meds? It helps if your doctor can juggle. I try it at: http://www.courier-journal.com/article/20120604/NEWS01/107100009 …

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Best Performance on a Local News Channel http://goo.gl/f8GEqn

Confluential Truth ‏@jamespmurphymd  Nov 26

Eric Flack’s #WAVE 3 Troubleshooter piece on #Concierge #Medicine was fair to both sides… and me. See for yourself: http://www.wave3.com/story/24064989/critics-fear-boutique-doctors …

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Best Performance on Public Television http://goo.gl/8m3L8X

Confluential Truth ‏@jamespmurphymd  Oct 15

Day 15 of #NationalSubstanceAbusePreventionMonth: Dr. Murphy talks pain and addiction with Dr. Wayne Tuckson on KET: http://www.ket.org/cgi-bin/cheetah/watch_video.pl?nola=KKHEA%20000902&altdir=&template= …

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Best Performance on Radio  http://goo.gl/w7D8vB

Confluential Truth ‏@jamespmurphymd  Jul 2

WED 7/3/13 @ 9 am – GLMS Pres Dr Murphy is on The Joe Elliott Show AM 970 WGTK  http://goo.gl/rNGHRx

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bleed red

Best Non-medical Tweet http://goo.gl/kBOE0q

Confluential Truth ‏@jamespmurphymd  Jun 16

Thanks Mike Rutherford for giving Louisville Medicine a spotlight. The Card Chronicle blog is witty & well written http://www.cardchronicle.com/2013/6/11/4420106/tuesday-evening-cardinal-news-and-notes …

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Best Patriotic Tweet  http://goo.gl/dBL3gW

Confluential Truth ‏@jamespmurphymd  Nov 11

Veterans Day With J.P. Murphy http://wp.me/p3C62j-2d 

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Best Advocacy Tweet  http://goo.gl/zUSpU8

Confluential Truth ‏@jamespmurphymd  Nov 26

Be a Good Samaritan http://wp.me/p3C62j-32 

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Best Commentary  http://goo.gl/5zZ3Nj

Confluential Truth ‏@jamespmurphymd  Dec 21

Dr Gupta, Seriously? http://wp.me/p3C62j-52 

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ghost

Best Original Musical Score  pic.twitter.com/4mZO4uCm9W

Confluential Truth ‏@jamespmurphymd  Oct 25

Dear fiends, I mean FRIENDS… a painful ghost story, sure to raise your Halloween spirits http://vimeo.com/77715467 

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you tube dr pat

Best Original Song  pic.twitter.com/jgUWQJib0u

Confluential Truth ‏@jamespmurphymd  Feb 21

Take advantage of my craziness before they come and get me http://goo.gl/IZ0LXR 

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karen neck

Best Original Poem (tie)  http://goo.gl/On3oi1

Confluential Truth ‏@jamespmurphymd  Jan 29

to interlope to offer hope through some relief tiny solace enough to cope – an excerpt from “The Algiatrist” http://goo.gl/IIkvkp 

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white coat standing

Best Original Poem (tie)  http://goo.gl/aoJrfI

Confluential Truth ‏@jamespmurphymd  Dec 27

a white coat http://wp.me/p3C62j-5w 

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Best Adaptation – Written Word  http://goo.gl/KI8BRk

Confluential Truth ‏@jamespmurphymd  Dec 24

HOLIDAY POEM FROM GLMS PRESIDENT http://conta.cc/19eakKk  via #constantcontact

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zohydro

Best Adaptation – Written Word (Hon. Mention) pic.twitter.com/mJ5ZhMSWy6

Confluential Truth ‏@jamespmurphymd  17h

No bologna! My #ZOHYDRO thoughts appear on page 4 http://goo.gl/yNzheP  of Sunday’s C-J http://www.youtube.com/watch?v=rmPRHJd3uHI …

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who you are

SPECIAL AWARD

Best Pre-Twitter Era “Thought For The Day” pic.twitter.com/c1uwmXnpfk

Confluential Truth ‏@jamespmurphymd  Feb 4

Feb 4, ’79 and 19 year old me was learning how to define himself. How do you define yourself? http://goo.gl/itw7YU 

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And the award for BEST MOTION PICTURE goes to…

pat and silvie

http://goo.gl/06JerG

Confluential Truth ‏@jamespmurphymd  Jun 9

watch me get heckled 🙂 it’s a call to take charge of our future! please share it with your friends! http://vimeo.com/67679697 

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dr m at kma

I want to thank the Academy.