NPF's National Medical Director, Michael S. Okun, and NPF's CIO, Peter Schmidt were co-authors on this article in the June issue of Parkinsonism & Related Disorders. See our consumer page for advice to share with your patients.
There is an ongoing debate about generic drug use for a multitude of conditions including epilepsy, psychosis, hypertension, post-organ transplantation, and several infectious diseases. Most of the concerns involve drugs with narrow therapeutic indices. There is a heightened attention to health care costs and macroeconomic policy as well as microeconomic business decisions that may impact the use of generic drugs. The issues surrounding generic substitution for chronic degenerative conditions such as in Parkinson’s disease (PD) continue to be controversial subjects for physicians, pharmacists, patients, Medicare/governmental insurance programs, and for private insurance companies. The United States Food and Drug Administration (FDA) requires that generic drugs meet a standard for bioequivalence prior to market approval, but this may not translate to therapeutic efficacy or to overall patient tolerance. In this review we will address issues related to the use of generics versus branded drugs in PD, and the potential impact substitution of generics may have on patients and on clinicians. Having proper documentation may help in deciding the appropriate usage of these drugs in PD. Medicare, governmental run health care systems, and third party insurance companies should in a complex disease such as PD, allow physicians and patients the chance to properly document the superiority of brand versus generic approaches. Currently, in the U.S, and in many countries around the world, there is no obligation for payers to respect these types of patient specific bedside trials, and there has been no standardization of the process.
By: Anthony Santiago, MD
Muhammad Ali Parkinson Center at Barrow Neurological Institute
“The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized…one of the essential qualities of a clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”
—Francis Peabody, MD
During my years as a Resident Physician in Neurology, I had the good fortune to spend that time with Dr. Mark Dentinger, Professor of Neurology and Neuropathology, Vice-Dean and Residency Director of Neurology at Albany Medical College. What modest standing I have in my field and in the eyes of my patients I owe considerably to him. Neither accommodating of arrogance nor ignorance, he was most severe when a patient was reduced to diagnostic jargon, or worse yet, a room number. He set a standard for having both a clear mind and a pure heart as regards the practice of medicine; he was overheard on more than one occasion during Hospital Rounds admonishing a medical student or Resident Physician that, “the first act of compassion is competence,” and simply being concerned for a patient’s wellbeing was insufficient.
And yet, we grew close despite his taciturn ways. He was quick to remind me of my faults and pressed me often for further effort and academic accomplishment. But it was in the practice of clinical care that we found a kinship. Prior to medicine, I worked as a Clinical Therapist with those unable to advocate for or assist in their own care. Whether staffing crisis hotlines, providing short-term supportive counseling to the homeless, most of whom had dual diagnoses of substance abuse and mood disorders, or working with adults with pervasive developmental disabilities and requiring behavioral management, I had spent time learning the art of listening – both to what was said and what couldn’t find a voice but was present just the same. I came to understand by personal experience, some familial, mostly professional, the subtleties of illness and its impact on a person’s life narrative. He and I had met years prior to my becoming a medical student and then Neurology Resident at AMC. It was on more than one occasion that we discussed patients in an Emergency Room that were ultimately determined to have a primary psychiatric diagnosis rather than neurologic, not often an easy assessment but one that seemed effortless to him as I reflect on those days. Although time has passed, I say with some certainty that it was more his manner than his acumen that struck me, and patients with considerable emotional duress seemed at ease with him; he seemed at ease as well.
Years later as a Resident Physician, it wasn’t infrequent that I was called upon to see patients in my outpatient clinic at the bequest of Dr. Dentinger, often overbooking my schedule at the last moment. At first glance, the cases were neither complex nor appeared to have a singular teaching point – often the criteria for a mentor to assign cases. As it continued unabated, I realized that my peers weren’t treated to the same attention, and as is often the case, I felt put upon and burdened. Most of the patients had chronic complaints that required considerable time in reflective listening and supportive care, often no curative course was available. In fact, loneliness and fear were the two most common features of most of the patients referred to me. I felt as if I was being taken advantage of because of my previous career and I wanted to spend my time in “neurology” not “psychology”. This went on for some time before we spoke about it. I was Chief Resident my senior year of Residency and it required weekly meetings with Dr. Dentinger. He broached the subject first, as was often the case with any topic. He was not verbose but had a quick wit and when he cut, he cut quickly and clean. “Feeling put upon, Anthony,” he asked. “Not more so than I can handle, Dr. Dentinger.” “You know, the shortest line in the world is made up of people who have earned our efforts. We take care of patients simply because they need us. But I should be preaching to the choir. I wouldn’t send patients to you if I felt you hadn’t yet realized this. The question is what have you learned about yourself. Remember, the first act of compassion is competence. But generosity and patience seals the deal. Patients want us to be able, affable and available. Probably in the reverse order when it comes right down to it. But it is in those moments when you are fully present that you realize that simply being there allows you to fully understand them. They don’t label their problems as neurological or psychological. All they know is that they are suffering. But it is when you truly care that you’re able to fully care for them.”
Dr. Mark Dentinger passed away recently, predeceased by his lovely and lively wife. He is greatly treasured by those of us privileged to have known and worked with him. He should also be greatly treasured by those who had never met him but have had the good fortune to meet those of us who try devoutly to live up to his measure.
Dr. Santiago received his medical degree from Albany Medical College in Albany, New York, where he also completed his Neurology Residency and Movement Disorders fellowship. He was a faculty member of the Department of Neurology of Albany Medical College, Medical Director of the Edward Ewell Parkinson's Disease and Movement Disorders Center in Washington State and Clinical Faculty of the College of Pharmacy. He is a nationally recognized clinician in Parkinson's disease and Movement Disorders and currently serves as the Medical Director of the NPF Center of Excellence at the Muhammad Ali Parkinson Center at Barrow Neurological Institute.