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Why Industry Largess Is A Necessary Part Of Good Healthcare

Largesse: (Form thefreedictionary.com):

1. a. Liberality in bestowing gifts, especially in a lofty or condescending manner.
b. Money or gifts bestowed.

2. Generosity of spirit or attitude.

Two days into last week’s Heart Rhythm Society meeting, Propublica, an independent online investigative journalism-in-the-public-interest endeavor published a series of high profile articles as part of their Dollars for Docs series. Their marquee piece, published prominently in the USA Today, chronicled the strong financial ties (the ‘largesse’) that bind medical societies to industry. Reporters Charlie Ornstein and Tracy Weber highlighted the meeting’s ‘mansion’-sized exhibits, intense advertising, and the fact that most of the opinion leaders, officers of medical societies and guideline writers, the experts, have financial ties with medical device companies. More than half of HRS’ revenues came from industry.

Well.

I’ll offer four simple thoughts about all this conflict:

1. Nothing about industry influence at medical meetings is new news. I have been attending medical meetings for nearly twenty years, and industry has always been there. And here’s something you don’t read much about: it was far worse then. That’s all I will say about that. I won’t tell you how cool it was seeing the Charlie Daniels Band play at a medical meeting for free.

You can quibble with the extent of these current-day “cozy” relationships, or the glitz of exhibits at our gatherings, but you should also know that there is progress. The show is now out in the open. There is infinitely more disclosure. Smart people are now watching, tweeting, and reporting. Any doctor who’s been around more than a few years will agree that things have grown increasing more transparent. Which I believe is an improvement.

2. Heart rhythm medicine and sophisticated expensive tools are inseparable. I fix your heart with high-tech gadgets. These tools come from innovative, competitive corporations who profit when their products help people. On this point, I strongly agree with incoming HRS-president, Dr Bruce Wilkoff, who said, “this is the business we are in.”

There are too many medical device company successes to list, but just take JNJ’s saline-irrigated ablation catheter as one shining example: though any catheter can make burns in the heart, this newer, and more expensive one burns with a reduced risk of clots, which translates to a lower risk of stroke. What’s not to like? But getting this catheter to market required partnering with experts. Does their industry relationship negate everything they say about the catheter? Does it negate my experience? Some would even go so far as to say that these relationships nullify the entire AF ablation literature base.

I realize, of course, there are blunders. As long as humans make these tools, they will be imperfect, and occasionally harm will come to people. Medical treatments carry benefits and risks. This point backs up one of my blog’s main points to patients: it is better to prevent heart disease in the first place.

3. Heart doctors are a lot of things, but naive and stupid they are not. Even regular guys like me know that most of the experts have relationships with industry. We also know that ACC president Jack Lewin is wrong: advertising, money, and the glamor of the stage do have influence.

But, and this is a big but, we learners consider these relationships in our synthesis of the information. Sure, you can fool us once, telling us a catheter or device is great, but when it doesn’t work, we will stop using it. You can come to town and tout a drug with company-sponsored slides, but, if the drug doesn’t work, we will stop using it. And then…and this is the best part: if you persist in touting crap, we stop listening to anything you say. Do you think anyone listens to those that reported 100% success rates in catheter ablation of AF?

4. The alternative to the current situation is worse. How can a specialty that depends on tools made by medical industry completely divest themselves?  How can a medical company innovate without consulting with doctors who use these devices?

There will have to be studies. Randomized controlled clinical trials do not come cheap, nor does pre-and post-market surveillance. While I listened to the oodles of data presented at the meeting, I thought to myself how much it must have cost to collect and organize all that information. If industry doesn’t contribute to these costs, who will? The government? You? Me? The hospitals?  If science does not pay, then who will do it?

And, can HRS really expect to extract more from its members through fees? Can you expect a young doctor with 200k in med-school loans to shell out thousands to get educated at meetings? Or to be re-certified?

So, for now…

…I accept the current largesse with an open mind and a critical eye. I don’t deny the influence, but at the moment, the good seems to far outweigh the bad. In this opinion, I speak as a doctor trying to do the best possible work, as a patient who has benefited from high-tech orthopedic tools, and as a person who enjoyed seven extra years of friendship with a man whose life was saved by an evidenced-based ICD. A device made and marketed by a human-powered company that occasionally makes mistakes.

*This blog post was originally published at Dr John M*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

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