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.
December 22nd, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Here’s my weekly round up of quotable quotes from my peers:
NHS Blog Doctor: Antibiotics do not cure snot. [Please go to the site for a fabulous illustrative photo.]
KevinMD: Since work-hours were restricted in 2003, there are no studies that have shown any marked improvements in patient safety or outcomes. Worse, errors have arisen from the so-called “patient hand-off,” the period of communication where rested doctors replaces those who are fatigued. Does increasing the frequency of patient hand-offs outweigh the benefit of better rested doctors?
Richard Reece, MD: The moral for doctors: Don’t expect as much leverage as in the past when negotiating with hospitals, even though you represent their main revenue stream.
Paul Levy: The medical community in Boston likes to boast about the medical care here, but we don’t do a very good job holding ourselves accountable.
Dr. Wes: Thanks to exorbitant costs of implementing EMRs in physician practices, the Medicare requirements for billing and prescribing electronically, and the prohibitive documentation requirements mandated by CMS in the name of “quality,” independent physician practices of all types will have no choice but capitulate to larger entities that have a fully integrated electronic medical record paired with collection software.
Heart found in a car wash (h/t Dr. Wes)
Ramona Bates, MD: I don’t think I would ever want to be part of doing a posthumous face lift or blepharoplasty or other cosmetic procedure, but I would be willing to debulk tumors if it would help families or individuals say “goodbye” more easily.
WhiteCoat Rants: For $79 you can blow into your iPod and it will play you a song if your blood alcohol is more than 0.08. You know this device wasn’t made for parents.
Just what we need. A bunch of drunk teenagers farting around with their iPods and getting into a “who can get the highest blood alcohol” contest.
The Happy Hospitalist: It frightens me to hear people say they want to work in medicine and work in a similar capacity as physicians, evaluating, diagnosing and managing disease, but not want to put in the time and sacrifice to be residency trained in depth and scope…
Science-Based Medicine: Our soldiers, grievously wounded in combat, deserve only the best science-based therapy available… If I were to propose treating our injured soldiers with bloodletting and toxic metals (both common methods in the 1700s and early 1800s) based on the concept that it would put the “imbalance of the four humors” back into balance, the Pentagon and the military medical establishment would toss me out on my ear as a dangerous quack–and rightly so. But introduce a method that claims “ancient Chinese wisdom” based on somehow magically redirecting the flow of a mysterious “life energy” by sticking small needles into parts of the body that correspond to no known anatomic structures through which “qi” flows, and suddenly the Air Force is funding a program to train medics and physicians treating our wounded soldiers how to do this method based on the same amount of convincing scientific evidence that qi exists as for the four humors (none) and in the face of no strong clinical evidence that it’s any better than a placebo.
Rural Doctoring: Hospitalists, take note: this is an example of why people go ape-sh*t crazy in the hospital:
• Her right arm is completely immobilized to protect the graft site.
• Her left arm has a heplocked IV in it.
• Half her head is shaved because the surgeon took the donor skin from the scalp.
• She’s vegetarian and the cafeteria sent her chicken for lunch.
• Dinner was vegetarian but she can’t really cut up a baked potato with only one hand.
• The hospital has double rooms and is running at capacity, so the staff is harried.
• Her roommate is an elderly, demented woman who keeps trying to get out of bed by herself and objects to the TV being on. So far, all she’s said to us is “Mind your own business!”
November 22nd, 2008 by Dr. Val Jones in Opinion
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I don’t subscribe to many newsletters, but the Galen Institute’s Health Policy Matters is always a provocative read. Here’s an excerpt from this week’s newsletter:
Incoming White House Chief of Staff Rahm Emanuel said this week that universal coverage will be an early, top priority of the Obama administration.
But where is the money going to come from to pay for these massive reform agendas, which were developed before the meltdown of Wall Street, the $700 billion rescue package, and a projected $1 trillion deficit?
The Obama plan is estimated to cost an additional $100 to $160 billion in the first year alone, yet the president-elect made fiscal responsibility a big part of his campaign platform. If the White House is going to extend the plan to mean universal coverage, the bill will be even more expensive.
Mr. Obama also will be facing the huge flood of red ink in Medicare, with the program starting to run out of money in 2017, about the time a second Obama term would end.
It’s impossible to make predictions in the current topsy-turvy political and economic climate, but these power political power centers, fiscal realities, and the urgency of other issues, including Detroit’s looming bankruptcy and an unstable geo-political climate, make these dreams of sweeping health reform a major challenge.
Mr. Obama will likely use the pending expiration on March 31 of the State Children’s Health Insurance Program (which will be renamed) as a vehicle to expand health coverage to all children and possibly even enact his mandate for children’s coverage. That probably means funneling more money to the states through Medicaid since they must pay part of the costs.
After SCHIP, Congress will take the lead on major health reform legislation from there.
We need to remember that 82% of the American people are happy with their own health care and only a minority is willing to pay higher taxes to get to universal coverage. Also, the employer mandate is a new tax, and it is going to be especially difficult to impose during the economic crisis. And can we really tell people who have lost their jobs that now, in addition to everything else, they are going to be forced to buy health insurance?
November 22nd, 2008 by Dr. Val Jones in True Stories
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I was traveling on an Amtrak train to a dinner meeting in Philadelphia. Two portly business men wedged in next to me and had an animated conversation about which companies do well despite a down economy. Here’s how the conversation went:
Businessman #1: You know, I’ve taken such a beating on the stock market, I just don’t know where to put my money to protect it and grow it. But I was thinking – one thing’s for sure – lots of people are going to continue dying despite the recession.
Businessman #2: So what kind of business insight is that?
Businessman #1: Funeral Homes, dummy. That’s where the action is. People still have to cremate or bury their loved ones, even in tough economic times.
Businessman #2: Nah, that’s not really scalable. I mean, you can’t save on costs with more volume. It’s fixed – a coffin costs what it costs. What you should really get into is Assisted Living facilities. Now THAT’s a growth market.
Businessman #1: No way, people can’t afford to pay for assisted living after the market crash. Their savings won’t last long enough to make it worth my while to take them in. Then when it runs out, what can I do? You can’t put them out on the street so you’re stuck with them till they die.
Businessman #2: You don’t have to be stuck with them, when their cash runs out you can transfer them to a lower quality facility. Then Medicare will pay for it.
