September 29, 2009

Is More Regulation Needed?

I know disagreeing with Daniel Carlat is like disagreeing with Obama-- how can you?-- but someone has to.

The article is called, "Has the regulation of physician-industry relationships gone too far?"

Dr. Daniel Carlat starts with a rhetorical trick, conceding ground at the outset thus establishing himself as a practical centrist and not an ideologue, and then stealing the ground back.  Remind you of anyone?

I disagreed with many of the presenters but was in absolute agreement on one point: interaction between industry and physicians is a good thing.  It is crucial to scientific progress.
It's an election year trick.  Carlat followers already know exactly where he is coming from; so conceding this much isn't going to turn them off.  "It's politics.  He has to say that."  Those who don't know him can be soothed by what sounds like a reasonable voice.

But suppose I want to find out whether Drug A is better than Drug B.  Would I go to Company A for this find of advice?  Of course not-- this is the last place I would go.
I realize this seems unassailable, but it's not only theoretically wrong, it's actually false.

First, Company A can't actually say it has a better drug than Company B.  It's illegal.  They can't even tell you about a published study, even one they didn't do.  (Don't worry, I'm sure doctors will come across it on their own.)

Second, if it was allowed, why wouldn't you want Company A's answer?  It may be biased, but you already know the bias, and they're not allowed to lie.  Does Company A have nothing useful to say?  Then you can ask Company B what they think.  Isn't that how people pick their President?

But here's why it's actually false:

Likewise, I would not go to a physician paid to promote Drug A for this advice.  I would go to a source without that conflict.
He means a unicorn.  It does not exist.

In fact, he does go to Company A for the info, he just blinds himself to it.  The studies, academics, Departments, journals, reviewers-- all are eye deep in Pharma money.  "It's not Company A money."  Oh.  So when a Republican senator who does not get oil money votes for an oil project, you figure he conducted a dispassionate analysis of immediate energy needs vs. environmental/climate impact?


... I know about human nature.  When you have a financial incentive... you will respond to that incentive.
I know something about human nature, too: more powerful than money is the desire to maintain identity.  Narcissism.   When a politician "gives the money back" in order to keep his job, he's not doing it because the job will get him more money, he's doing it because the job is more important than the money-- it's his identity.

Your identity is so powerful that it actually biases other people more than money. Look back at my Republican/oil example.  It fit perfectly, it made sense to you.  But if I had made a Democrat/labor union analogy, it would have rubbed you the wrong way, even though they are equivalent.  You're biased, and for cheap.

That's why a man free of financial bias may be trustworthy, but he is not trustable.  Where's he coming from?  Is he pushing Depakote because he "believes" it?  Because his son, N=1, responded to it?    Because he works at a university where antiepileptics are the cause du jour?  Because his Depakote rep is hot?

I don't particularly want financial bias in my academics, but to single that out as the main source of trouble in our field is like singling out the elbow as the pivotal component of   matricide.


This is the same error people make about the need for government intervention, e.g. that the "free markets" have failed and more regulation is obviously needed.  Even if one were to agree on principle that people can't be trusted, the mistake is in forgetting that government is people.  These people are subject to the same biases, cognitive errors and general prejudices as the guys at Goldman Sachs, albeit currently it in the opposite direction.  We can argue that we prefer the government's biases, but one cannot argue that the government is less biased, self serving, or corruptible.

This may originally have been a country of laws, not men, but that's not the country most modern people want; they want to be able to alter the laws to suit the times.  Fine, it's your country.  But understand that if the laws are subordinate to men, then the enforcers of those laws will always have more power than you.  Has anyone tried to get an anti-Depakote study published in J Clin Psych in the past decade?

It's excellent that Daniel Carlat thinks doctors like himself cannot be trusted to read and interpret their own studies, and that some other group of-- doctors?  lawyers?  what?-- with special bias-immunity rings need to be assembled to protect us.  But those people are still people.  This is why the NIH, with their incestuous grant reviewers, crazy politics and flavors of the decade philosophies is so dangerous-- they're just as biased as Pfizer except you think they are objective.

In other words, before I agree to being regulated, I want the names of the people regulating me, so that I can at least laugh at the irony.

I am asked all the time, "where can I go for unbiased information on medicine?"  My God-- if the physicists don't have such a place, do you really think that medicine does?  And why does no one ever ask where they can go for unbiased political information?

People would do well to remember that at one point in our nation's history, "government" was George Bush.  When you argue that government needs to be more involved, you are arguing that George Bush needs to be more involved.  I do not trivialize this discussion by offering Barack Obama as an equivalent example of the government you want so desperately to supervise your lives.

also: The future of bias



Carlat seems to be an unexc... (Below threshold)

September 30, 2009 7:35 AM | Posted by acute_mania: | Reply

Carlat seems to be an unexceptional psychiatrist, who is trying to make a name for himself by mindlessly bashing the system (pharma sponsored symposia) by which other unexceptional doctors try to make names for themselves (also mindlessly). Which brings me to this:

At what point in a doctor's career does his brain fall out? Case in point: I was driven home by a cab driver who was listening to a CD. The lecturer was descrbing the structures of the face: the jaw, tongue, nose, orbit, etc, how and when they're formed during fetal development. Which crainial nerves control what muscles. I knew the level sophistication was much too great to be part of a Nursing or PA program. I also knew I've never remotely approached that level of sophistication in anything I've ever done in my life. Turns out he was studying for his USMLE Exam.

Fast forward ten years or so to CME exercises, which I'm sure you'll agree bear more resemblance to junior high school reading comprehension exercises than to anything you've ever encountered in medical school. It goes without saying they don't seem to require much medical knowledge. It's as if your're expected to have forgotten everything you learned in medical school by then.

Most doctors I've seen and spoken to have no idea as to how to interpret medical statistics and therefore rely on academic journals to tell them which practices are based on solid evidence. They are there making the dumb assumption that study authors' evidence supports their conclusions. For somebody with the brains to have made it through medical school, that is pathetic.

Is it the prestige of having the title "Doctor" that makes somebody think he is intellectually fulfilled and can turn his brain off? That he busted his ass so hard getting that title that he deserves to never have to bust it again? Is it the stress of medical practice that turns you into a mindless drone?

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cool story bro... (Below threshold)

September 30, 2009 11:54 AM | Posted by drugs are fun: | Reply

cool story bro

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How would you even determin... (Below threshold)

September 30, 2009 3:14 PM | Posted, in reply to acute_mania's comment, by Anonymous: | Reply

How would you even determine if someone was an exceptional psychiatirst?

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Great piece but there were ... (Below threshold)

September 30, 2009 5:55 PM | Posted by anonymous: | Reply

Great piece but there were more than your usual number of typos.

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You do a good job of provin... (Below threshold)

September 30, 2009 7:15 PM | Posted by Martin: | Reply

You do a good job of proving that government, or any similar bureaucracy, necessarily falls prey to special interest groups. Then you say the government "is" the people. Then you say it "was" George Bush. Think about the contradictions you have there. If everyone is self interested, whether for money or self aggrandisement (and, yes, they are, although people do also act from their conception of the greater good), well then it's important to make sure that the system is constructed so as to reward at least a reasonable degree of altruism.

That's why campaign donations need to be disclosed. That's why it's illegal for company A to say it has a better drug than company B. We can throw our hands up, as with your comment about wanting to savour the irony, or we can make an effort - in our self interest, and with the difficulty that we're swimming in a tank of sharks trying to build shark netting - to construct that balance of regulation which allows creativity but restricts naked avarice.

Anyway, that's the "liberal" project. That's why Obama is better for us than Bush however imperfect he is and however flawed his ideas. It's also the limits of that liberal project and the reason that if we want a better society we have to start by making it interesting to be better people rather than better served by the laws we make.

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It's a shame you feel compe... (Below threshold)

September 30, 2009 11:13 PM | Posted by David Johnson: | Reply

It's a shame you feel compelled to somehow bring the government into what would otherwise be a cogent post. I know ... it's hard letting biases lie, so here you go ...

I prefer to have a government biased towards serving the bottom 90% of America. Unfortunately, that hasn't happened yet. I do believe, however, that the ever-increasing gap between these two groups will not proceed at the pace it has over the last 10 years. The middle class is being hard hit in America while the upper 10% are enjoying record-setting increases.

The United States has the highest inequality and poverty in the OECD after Mexico and Turkey, and the gap has increased rapidly since 2000

Here's some nice reading matter ... Economic Gap Grows

Or this from the US Census Bureau (1999-2009):

The typical American household made less money last year than the typical household made a full decade ago. In the four decades that the Census Bureau has been tracking household income, there has never before been a full decade in which median income failed to rise.

Middle class loses

You stated

When you argue that government needs to be more involved, you are arguing that George Bush needs to be more involved.
Actually, what really happened was a significant majority voted against that corporate sock-puppet's policies. If anything, people voted for less sock-puppetry and more government. There is a distinction and it's not trivial-even to bloggers who concede
ground at the outset thus establishing himself as a practical centrist and not an ideologue, and then stealing the ground back. Remind you of anyone?

Oh yes. Yes indeed. And I'd bet I'm not Alone.

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Why stop at *just* money th... (Below threshold)

October 1, 2009 6:44 AM | Posted, in reply to Martin's comment, by caeia: | Reply

Why stop at *just* money though? There are as pointed out plenty of other ways to become biased. If your best firend is a psychiatrist, you'll have a different view of big pharma than if you're best buddy is a doctor. Other places like school (no college is unbiased in education, my school was so environmentalist that the Dems were too conservative for them), church, social clubs, books and magazines, etc.

I wouldn't mind disclosing the financial backers of politicians, but I'd also like to know other things about him. A Catholic who reads the Wall Street Journal is going to be more pro-free-market than someone who is a Pagan and reads the Huffington Post. Disclose everything on Myspace or something and get on with it.

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Excellent article, Alone!</... (Below threshold)

October 1, 2009 7:35 AM | Posted by John J. Coupal: | Reply

Excellent article, Alone!

Again, you've riled up those Progressives amongst us. Their heated defense of the indefensible always creates a chuckle for the rest.

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Cigarettes are still sold t... (Below threshold)

October 1, 2009 9:18 AM | Posted by Anonymous: | Reply

Cigarettes are still sold to suckers , but no longer for their helpful medicinal effects that used to go with their ads.
Everyone knows the nicoteen in cigarettes is a legal drug.
People like drugs.

Dr. Psychiatrist says "I like this gravy train" , exploiting the suffering of humans, controlling-selling-prescribing helpful medicines BUT not the UNGODLY harmful drugs. This is medicine I swear.

Carlat is good, because one has to start somewhere cleaning up a pile of shit, an adult doesn't just give up when faced with a problem.

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Amen, amen, amen, amen, ame... (Below threshold)

October 1, 2009 10:07 AM | Posted by reasonsformoving: | Reply

Amen, amen, amen, amen, amen!

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I thought it was funny when... (Below threshold)

October 1, 2009 10:11 AM | Posted by Anonymous: | Reply

I thought it was funny when Daniel Carlat defended the docs at Harvard last year (e.g., Biderman). I guess it all depends who's calf is getting gorged.

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I don't mind that the upper... (Below threshold)

October 1, 2009 12:58 PM | Posted by MH: | Reply

I don't mind that the upper 10% or 1% or whatever controls the majority of wealth. I have been on unemployment for 18 months, dirt poor, and I would still rather live in a country with as much economic freedom as I can get.

Bush flat out said you have to abandon free market principles to save it.


Obama barely pretends to believe in the free market (remember him talking about the equal rights movement, and how its too bad the courts didn't venture into the realm of wealth redistribution?)


I would rather be poor because I was a lousy wage earner then be "Nudge(d)."

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Yes, household income falls... (Below threshold)

October 1, 2009 1:39 PM | Posted, in reply to David Johnson's comment, by Anonymous: | Reply

Yes, household income falls because the SIZE of households is decreasing. Per capita, your argument makes no sense. Nice try, though.

Also, Democrats usually like to define "poverty" as the bottom "X" percentile, rather than some universal standard of living. 80% of Americans in "poverty" have a television. Not exactly third world.
According to this relative-only definition of "poverty", 10% of of Congressmen are living in poverty. Or 10% of NBA players. Or 10% of any group, relative to its other members.

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Alone's response: Perhap... (Below threshold)

October 1, 2009 2:24 PM | Posted by Alone: | Reply

Alone's response: Perhaps I am not clear. Think of it this way: whatever you want from your government, say, more/less financial regulation, universal healthcare, attack Iran, etc-- the government doesn't ask for those things, it asks for the power to affect those things. That power is what will last, not the institutions or maneuvers themselves. That power will be granted not just to your favored Administration, but also to the next one that you might not like. You guys have to start thinking longer than the 12 Presidential elections you all have left.

DJ's point that he prefers a government that supports 90% is fine by me, I'm with him. But what we are really talking about is not who your government favors-- you vote on this-- but how. That's why granting any government more power is almost always a bad idea. This is why when you want something from your government, you need to ask how they will be able to produce it. Just ask if you want that same power to be held by Bush or Obama, depending on your inclination.

There are many obvious examples, but I will give you one most haven't considered: taxes. When you ask the government to raise taxes on the top earners in the country, what you are really asking for is that the government be allowed to tax different people according to their logic. It is thus entirely possible that the next Administration says, "urban poor use up most of the city resources. We are imposing a 90% surtax on X, on them." AGAIN, I am not/not saying taxes shouldn't be raised, I'm pointing out the the primary function of government is to ensure its own survival. Public Choice Theory just poured itself an energy drink.

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Yawn. How much money are yo... (Below threshold)

October 1, 2009 4:48 PM | Posted by Anonymous: | Reply

Yawn. How much money are you getting TLP? Must be more than pens, clocks, note pads to spawn this sort of “WTF”esque blog post.
Kinda a strawman argument you’ve made there. Even if “narcissism”/ identity (whatever) is the primary driving force behind human behavior (this remains to be established), it doesn’t at all affect whether or not pharmaceutical funding is f*cking up medicine, SOCIETY, and that is the real issue here. I think you are biased by your own narcissism and goal-oriented nature. I really don’t think most people are as preoccupied with image/success as you seem to think. That’s a tangent.
You know what, this is really a moot point. Anyone without blinders on can see that this is obvious. Ask your prescriber if stating the god damned obvious is right for you. White trash moms with one story homes built on toxic waste dumps, zero education and bipolar IV, who get their 5 year old children on stimulants for ADHD and eventually antipsychotics for “pediatric bipolar” after the stims predictably cause unstable behavior… yea, that’s not a problem. Being rendered a freak for life from tics due to being drugged without consent in childhood is no big deal. “Bipolar kids” dying in their sleep from respiratory depression secondary to tranquilizers…that’s cool, freedom of choice is wonderful, no one is to blame for that. Pharmaceuticals and their puppet doctors pushing bogus diseases like pediatric bipolar have no influence over this madness. Hey, morality is overrated anyway. Sometimes people die, big deal. It’s not money, it’s…uh…narcissism (now please leave my money alone cuz I proved it isn’t money, I called it!)

Government is people, but government working properly is people who have their desire and impulses better in check by the systems set in place called government.
Just because government sometimes doesn’t work because the systems fail doesn’t mean government itself, all the time, is “just people”. That’s like saying “my old computer died; CPU overheated, power supply blew, hard drive lost all my data into illegible clusters, word forgot that I meant bare not bear, therefore computers don’t work any more systematically, fairly, reliably than people do”. People being forced to keep each other in check and hold accountability to the interests of the majority (so that long term society is maintained for all to enjoy) is indeed better than “people” just grabbing the things their animal brain tells them they need right this minute, which down the road cause unforeseeable problems for all.

Here’s the thing. Doctors, as practitioners, have a few goals in mind. Personal and professional goals, to profit, to be proficient, to give their patients good service… like any person, they just want to do good, generally, good for themselves and others. Doctors are neutral. The problem is when doctors are manipulated into thinking bad is good, or when their personal goals are so unfairly stimulated they outweigh their professional obligations.

You are also setting up another false argument: Most people want government “more involved”. I don’t think most reasonable people want that. Most people want pharmaceutical companies LESS INVOLVED which is not the logical equivalent to making government “more involved”. If a prison holds back a criminal, are prisons active participants in social interaction between people? I mean, in a sense they are (because they restrict certain people from being full participants in society), but in a more valid way, no prisons don't affect social behavior, other than to perhaps protect people from being afflicted more frequently by sociopathy.
Speaking personally, I would like to see more restrictions on the participating and nature of behavior of pharmaceutical companies in medicine… giving doctors trips and the extent of their advertising reach and stuff like that. In other countries it’s not permissible to advertise drugs on TV. People aren’t doctors, your average pharmaceutical company target is an old person who now knows vytorin targets both sources of cholesterol. Why does grandma or grandpa know that? It’s angering. Most people would prefer it if we didn’t have to see commercials where people swallow a pill and in the next clip, 3 seconds later, they are grinning like an idiot because life is a lot better. Drugs are DRUGS. They are not fashion. These are things that can seriously mess you up, and they should only be taken when NECESSARY. When did medicine become fashion? Drugs became fashion largely when they started being advertised on TV. They'll tell you that's incidental, but it sure as hell isn't.

The obesity problem started about the same time sugar and premade foods became very very cheap and available (when HFCS was invented and homemakers started entering the work force which increased the demand for and production of ready made meals and snacks).But, oh, this is incidental says the junkfood peeps. Sure.

Anyway, I don’t want government “regulating things” I just want them to hold back the ridiculous influence and behavior of pharmaceutical companies, that’s all. Just get them out of my face, I don't want to see adds for drugs, I don't want to see adds all over my doctors office. Come on. And maybe this way objective reality has more of a chance of being influential in the prescribing and diagnostic practices of doctors (rather than makers of miracle pills which cure everything at least until the patent expires, then it starts causing diabetes and sudden death. Woops.)

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If problems are unforseeabl... (Below threshold)

October 1, 2009 7:39 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

If problems are unforseeable, as you have written, how does government quide a population toward what is best, assuming that what is best is agreed upon? How can OTHER people determine what is in the best interest of OTHER people?

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Just get them out of my fac... (Below threshold)

October 1, 2009 7:45 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Just get them out of my face, I don't want to see adds for drugs, I don't want to see adds all over my doctors office.

1) Turn off your TV.
2) Put down the People magazine.
3) Choose another doctor.

The Freedom is there for you, long-winded one.

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anon 7:45pm, way to miss th... (Below threshold)

October 1, 2009 8:09 PM | Posted by Anonymous: | Reply

anon 7:45pm, way to miss the point.

I suppose you took the joke "it hurts when I do this; don't do that" literally eh.

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I agree. Money is a ... (Below threshold)

October 2, 2009 6:40 AM | Posted, in reply to caeia's comment, by Martin: | Reply

I agree. Money is a big source of bias, but as the original post points out there is pride, and as you point out there is religion. Some of these things are difficult to ever know, some are easy enough to find out, and some are more corrupting than others.

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Would you want to fly if th... (Below threshold)

October 5, 2009 9:14 PM | Posted by Mike T: | Reply

Would you want to fly if the airlines ran the NTSB and investigated plane crashes ? Would you believe car safety-data if Ford, Toyota, Honda etc. paid for all the crash research, and were allowed to throw out any data that didn't suit them ? The cozy relationship(s) between mainstream psychiatry researchers, the Pharma companies, the FDA, CME content providers and NIH compares pretty well to the above analogies. Keep fiddlin-- while Rome burns -Doc. India, Pakistan and China don't drug their kids the way the West does. I bet their psych CME isn't all paid for by Pharma either. Time, history and human evolution will decide if Dan Carlat has a better angle on the unbiased truth than you.

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MikeT that reply owned.<br ... (Below threshold)

October 6, 2009 12:43 AM | Posted by Anonymous: | Reply

MikeT that reply owned.

I shall glower like Mr Burns for a week after reading this blog entry. I expected more from alone... I am disappointed. I would sacrifice my first born kitty cat if it weren't true he were chin-deep in pharma gold.

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No, China drugs them for... (Below threshold)

October 6, 2009 5:15 PM | Posted, in reply to Mike T's comment, by Alone: | Reply

No, China drugs them for different reasons... again, again, again, my point isn't that money doesn't bias. My point is that there are other biases which are even stronger. Would you want people being medicated for social control? Etc. Here's a not great example: if the psychiatrist you go to takes no Pharma money, and gives you Seroquel, what does that mean? Anything? But if the psychiatrist you go to takes Pfizer money but prescribes tyou Seroquel (made by AZ), what does that mean?

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China doesn't drug its chil... (Below threshold)

October 7, 2009 5:05 PM | Posted by medsvstherapy: | Reply

China doesn't drug its children. It aborts them, as government policy.

Proof that more govt is better:
"Whoops, we over-shot the goal. Let's gear back a little on the abortions, comrade!"

Of course, here in USA, we would never do anything like that. Science Czar Holdren is on the case...

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Not surprisingly, Dan Carla... (Below threshold)

October 11, 2009 11:34 PM | Posted by Steven Reidbord MD: | Reply

Not surprisingly, Dan Carlat has anticipated the criticism that not all bias is financial (see point #3 in the link). Essentially, you're saying that our inability to eradicate all bias means we're unfairly (or misguidedly) singling out financial bias. This is like arguing against efforts to minimize preventable bias in research, because some bias surely remains. Or failing to prosecute criminals because some will evade justice.

In addition to avoiding financial bias, we should also be cognizant of, and make reasonable efforts to avoid, other sources of bias. The fact that we will never fully succeed does not make these efforts pointless. Nor does it relegate doctors to dull, ascetic lives: If you must date a drug rep, find one who doesn't sell what you prescribe.

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Oops, the link didn't appea... (Below threshold)

October 11, 2009 11:43 PM | Posted by Steven Reidbord MD: | Reply

Oops, the link didn't appear as expected. It's

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Dr. Reidbord,As a ... (Below threshold)

October 12, 2009 10:18 AM | Posted, in reply to Steven Reidbord MD's comment, by Jack Coupal: | Reply

Dr. Reidbord,

As a pharmacist, I notice that hotties seem to be assigned to visit the male physicians. The ones visiting female physicians seem to be of the "ordinary" variety.

Don't let the hotty or ordinary label lull you. Many new reps are clinical pharmacists who have done extensive clinical rotations in hospitals. Their knowledge of medications, complicated dosing regimens, etc., is awesome.

My graduation class had 10% female pharmacists. Today's much harder curriculum has graduating classes of 60% females. Females are much better at counseling patients about their many medications, in my opinion.

I'm feeling old.

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