January 4th, 2009 by Dr. Val Jones in Opinion
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I was a little surprised by a recent reader comment suggesting that pharmaceutical companies are no different than tobacco manufacturers. While I am strongly opposed to misleading pharmaceutical marketing tactics, the bottom line is that most drugs have a legitimate therapeutic value. Tobacco, on the other hand, is a known carcinogen with no medical value that I can think of. This comparison, however, brought into focus a common underlying assumption: that for-profit companies are inherently less ethical than non-profit and academic centers.
I’d like to question the tendency to absolve academic centers of any possible wrongdoing on the basis of their educational reputation or non-profit status. Of course, financial gain is not the only motivator behind endeavors, initiatives, and behaviors – though it may be the easiest to measure.
As a medical student I witnessed a sad example of academic misbehavior. Senior residents in the department of plastic surgery were performing liposuction procedures after hours for cash. When a patient experienced an infectious complication from a thigh liposuction procedure, an investigation ensued. The residents claimed to be putting the cash into the residency fund, to be used to support travel, lodging and participation in annual assemblies – therefore exonerating themselves of wrong-doing.
It is unclear if the department chair was fully aware of what the residents were up to, though he was reprimanded, terminated, and ended up teaching at another institution. The plastic surgery department lost its accreditation, and all of the residents had to finish their training elsewhere. As for me, I lost my mentor (the department chair) and ended up not pursuing a career in surgery. There certainly was a lot of fall out from that debacle on all sides.
A case of academic double standards was highlighted recently by Dr. George Lundberg in a Medscape editorial where journal editors claimed that continuing medical education (CME) courses should never be sponsored by for-profit companies. Meanwhile the journal accepted advertising from these same companies:
…The JAMA editors who wrote in 2008: “…providers of continuing medical education courses should not condone or tolerate for-profit companies…providing funding or sponsorship for medical education programs….” This is from a publication that, for more than 100 years, has been supported primarily by advertising revenue, mostly pharmaceutical. The editors will say “yes, but we follow rules to prevent bias or improper influence.” True. So do we, a for-profit company, follow rules that prevent bias and improper influence.
On the positive side, there are many examples of for-profit companies who cultivate a culture of environmental responsibility and charity – Ben & Jerry’s, SC Johnson, and Patagonia come to mind. And let’s not forget the foundations created by Bill and Melinda Gates, Warren Buffet and many others thanks to overflow from for-profit endeavors.
In the end, conflicts of interest, hidden agendas, and secret quid pro quos are a matter of individual character and corporate culture. The people who build a company (or a country) have more to do with its behaviors and processes than the simple label “for profit” or “non profit” or any assumptions made at such a superficial level.
We are all biased in many ways, both consciously and unconsciously. The best we can do is to strive for transparency. It may be best to judge each entity and/or individual by their degree of transparency rather than profit status, academic status, or subject matter expertise. For-profit companies can be highly ethical, and academic centers can be rife with undisclosed conflicts and questionable behaviors.
Healthcare organizations should not avoid or incur scrutiny based on their profit status alone. Bias comes in many forms – and the best we can do is work for the good of others in full knowledge of the influences around us.
January 3rd, 2009 by Dr. Val Jones in Patient Interviews
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Thanks to KevinMD for highlighting an interesting discussion about the ethics of disclosing another physician’s error. It reminded me of a case I witnessed many years ago.
A young man had been in a car accident and was transferred to the rehab unit after several orthopedic surgeries and a long inpatient stay. Prior to beginning physical therapy, he was sent for doppler ultrasounds of his deep leg veins to make sure that he didn’t have a thrombus (clot) that might break off and lodge in his lungs during exercise. The ultrasound was actually positive for a large DVT. Unfortunately, the radiology note listed all the large veins that were patent (had no clots) first, and then finished with a notation of (+) DVT in one of the veins. The patient was transferred back upstairs to the rehab unit, the physical therapist glanced at the radiology report (where the first several sentences indicated normal findings) and took the patient to group therapy.
The patient got up out of his wheelchair, stood for a few seconds, and immediately collapsed. His DVT broke off and traveled to his lungs, causing a massive occlusion of his vessels. The crash cart arrived as he coded, the vascular surgery team quickly took him to the OR to crack his chest and try to remove the clot, but he didn’t make it. It was shocking and terrible.
What happened afterwards was memorable. The rehabilitation medicine attending notified the family of the error, explained exactly what happened and apologized with tears. The hospital administration was notified, the physical therapist, radiologist, residents, and attending physicians got together for a meeting in which a new reporting protocol for positive doppler findings was created. To my knowledge, there has not been another case of pulmonary embolism on that rehab unit since.
The family members did not sue. They were deeply grieved, but grateful for the transparency. The dangers of DVTs were indellibly burned into the minds of all physicians and staff working in the rehabilitation unit – and I believe that our lifelong vigilance may save many other patients from a similar fate.
That’s what should be done when mistakes happen.
December 30th, 2008 by Dr. Val Jones in Announcements
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On January 31, 2009 The Medscape Journal will be discontinued. One can only assume that the journal’s parent company, WebMD, could no longer justify the cost associated with a free, open-access, peer-reviewed medical journal that receives no income from advertisers or sponsors. The Medscape Journal’s budget has been supported by revenue generated from Medscape (the website), and their robust Continuing Medical Education (CME) business.
In these challenging economic times, American companies are taking a cold, hard look at their P and L spreadsheets and nixing the least profitable parts of their businesses. The inevitable “non-profit” casualties present an ethical dilemma. What will become of the noble pursuits that are based upon “doing the right thing” rather than making a profit?
There is no such thing as completely unbiased publishing (humans all have personal agendas – whether conscious or unconscious), though The Medscape Journal came about as close to it as any medical journal ever has. The journal is free to authors and readers, and provides 24-hour online access to both professional and lay viewers from around the globe. There are no advertisements or outside sponsors, peer reviewers work without compensation or specific recognition, and editors are paid a minimal salary (full disclosure: I know this because I was an editor for The Medscape Journal several years ago). CME credit is offered for articles determined to be of special relevance, but no articles are commissioned specifically for the purpose of CME.
The Medscape Journal is a wonderful experiment in high ethics. It espouses, in my opinion, the gold standard principles of medical publishing. Tragically, market forces (or perhaps the lack of perceived value by its own parent company) killed it. So what does this mean for medical publishing? If there is no economic model for “pure science” then are medical journals doomed to go the way of health media – promoting sensational or biased science for profit?
The answer is no. But we must tread very carefully now. The Medscape Journal is our proverbial canary in a publishing coal mine. Its inability to survive on ethics alone speaks to a growing lack of value placed on purity over profitability. We must soberly consider the facts: 1) The Internet creates the illusion that information is “free” and therefore subscription-based publishing platforms will end as viewers simply refuse to pay. 2) Advertisers are becoming more aggressive in their requirements – dynamic microsites and multi-media advertorials have replaced the old billboard approach, often blurring the lines between content and advertisement. 3) Search engines like Google are changing the way that health messages reach the public and scientists alike. The “impact factor” of research often lies in its marketing campaign. Important negative trials are buried under case reports, anecdotes, and news stories with snappier headlines.
So what are scientists to do? I suggest that those of us committed to science-based medicine join together in a united effort to harness new media tools for the public’s benefit. Let’s use social networking applications (blogs, Twitter, Facebook, online communities, etc.) to educate others about science, research, health claims, and potential biases. Let’s not be afraid of marketing scientific integrity – decades have already shown us how effective marketing can be for snake oil. If we don’t raise our collective voices – how will people get good information on the Internet? How will Google searches return highly ranked, sound information rather than sensational headlines?
Farewell to The Medscape Journal – and thank you for nearly a decade of honorable medical publishing. May the rest of us continue the vision, if only on different platforms.
December 27th, 2008 by Dr. Val Jones in True Stories
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Fortunately for me, my recent brush with the healthcare system was not as frightening as Dr. Dappen’s (he blogs here every Wednesday and recently had a mild heart attack). However, it was provided me with some amusing blog fodder.
Last week I was minding my own business, planning to purchase a new batch of contact lenses from a local optometrist, when I was required (under threat of withholding my lenses) to undergo a vision exam. Much to my disappointment, my right eye was not behaving itself, and refused to correct to 20/20 despite a good deal of lens fiddling on the part of the doctor. A slit lamp retinal evaluation followed, and the optometrist concluded that my right eye’s macula “looked like an 85-year-old’s.”
Well, that was not the most welcome of observations. I asked for the differential diagnosis (being that I’m quite a few years away from 85) and wondered how I’d developed macular degernation. He suggested that it could also be a “central serous” which is (apparently) a stress-related swelling of the macula that requires no treatment and usually resolves on its own.
“So basically you’re saying that my eye could be ‘bugging out’ because of stress.” I said. “And you’d like me to see an ophthalmologist just in case it’s something worse and equally untreatable?”
“Right.”
So I made an appointment with a local ophthalmologist – one of the few working on Christmas Eve – and was sorry to have him confirm that there was indeed something wrong with my retina. He even ordered an eye angiogram (I didn’t know those existed, but it makes perfect sense) and I was injected with a vegetable dye. Photographs were taken through my dilated pupils at regular intervals as the dye wound its way through my retinal vasculature.
“It’s not a central serous.” He said with a serious tone. “And you can see the macular defect here on this photograph.”
“So my right eye is like an 85-year-old’s?” I asked, wondering how I’d been so fortunate to have one part of my body on the aging fast-track.
“Well, not exactly. I think it’s unlikely to be age-related macular degeneration. You probably have retinal thinning caused by your nearsightedness.”
“You mean all that straining to see the chalk board wore out my retina?”
“No. What I mean is that your eye is supposed to be shaped like a baseball, but yours is an egg shape. So your retina is stretched thin and is starting to wear in your macula area.”
“Well can you suck out some of the vitreous gel and shape my egg back into a baseball?”
“No. Unfortunately that doesn’t work.”
“How do you know?”
“The Russians tried it in the 1960s.”
“Ok, well how do I take some of the tension off my stretched out retina?”
“You can’t.”
“Well if I lose weight or eat carrots or exercise, or stop wearing contacts, or get lasik… would any of that help?”
“No.”
“So there’s nothing I can do to prevent further damage, and nothing to repair or treat it.”
“Right.”
Pause.
“I don’t like this condition.”
“Well, you’ll have to come and see me once a year so I can monitor the progression. Sometimes the body responds to the retinal damage by growing blood vessels in the area, and that can cause further visual deficits. But we can zap those new vessels with a laser and decrease the damage.”
“So my eye might overgrow with blood vessels like weeds in a garden.”
“It might. But it also may stay exactly the same for the rest of your life.”
“Well, the uncertainty is anxiety-provoking.”
“I’ll see you in a year. You’ll probably be fine. Don’t worry. Oh, and if you see any ‘floaters’ or flashes of light, come in to see me immediately.”
“What would that indicate?”
“A retinal tear that would need laser therapy right away. People with thin retinas can have spontaneous tears. Just keep that in mind.”
“Um… ok.” I said, smiling feebly.
So here I am, with one wonky eye, not knowing if it will get worse or remain the same indefinitely. There’s nothing I can do but watch the progression once a year with an ophthalmologist. Like so many patients, I’m in a gray zone where prognostication is a challenge and reversal of disease is not possible. I have one 85- year-old eye. May it bring me wisdom, courage, and more empathy for patients.
December 25th, 2008 by Dr. Val Jones in Announcements, Humor
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I’m visiting my husband’s family in Rochester, New York. If you don’t see any new blog posts in the next few days, you can assume that I’m actively digging my way out of their home to get back to DC.
Please check out this winter video to get a feel for life in snowy Rochester. It’s hilarious.
For more Christmas cheer, check out The Christmas Miracle story.
I wish you all a merry Christmas… and happy holidays!
See you on the flip side! (Don’t forget to sign up for my healthcare reform party on the 30th).
