January 28th, 2009 by Dr. Val Jones in Opinion, Primary Care Wednesdays
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By Steve Simmons, M.D.
When I graduated from the University of Tennessee’s Medical School sixteen years ago, my last act as a student was to take the Oath of Hippocrates with my classmates and 98% of the other medical students graduating in the United States that year. This oath still resonates within me today and connects me to all physicians reaching back over 2,500 years to the time of Hippocrates.
Implicit in an oath is the understanding that the profession chosen will require more sacrifice than the average vocation, that the occupation’s rewards should be more than a paycheck, and that a paycheck would impart less value than the enrichment gained from nobly serving others. The high standard which society holds physicians to is still accurately described by the Hippocratic Oath. Regardless of what changes seep into our profession from outside influences, doctors will always be held to the ideals written in the Hippocratic Oath.
When I was a young medical student, the hope that becoming a physician would bring value and meaning to my life was more rewarding than thoughts of job security or financial stability. This helped propel me and my classmates through many long nights of study. One sentiment oft-heard in my medical school, and I suspect many medical schools today, was that no one would put up with ‘this’ just for money–usually stated prior to a re-doubling of the effort to get past a particularly challenging task. Painful physical effort often was required, such as waking at 3AM to make hospital rounds, or spending 24-hour long shifts stealing naps and bathroom breaks, sometimes even working over 100 hours a week during demanding rotations. Steven Miles, a physician bioethicist, wrote, “At some level, physicians recognize that a personal revelation of moral commitments is necessary to the practice of medicine.”
I would proffer that few students would endure the sacrifices necessary to graduate without understanding this point.
In Paul Starr’s 1982 book, The Social Transformation of American Medicine, he stated that in the future the goal of the health industry would not be better health, but rather the rate of return on investments. This unfortunately has come to pass. Arguably, medicine now is controlled by CEOs and other executives in the health industry — individuals who are not expected to take an oath. Physicians, remaining loyal to the Oath, are an unwitting weak and junior partner in today’s health care industry. Worse, doctors are now employees, often seen as interchangeable parts with one doctor considered no different than another. Third party providers in the health care industry fail to place any value on the personal interactions between doctor and patient. It may be better that the CEOs of health insurance companies are not required to take an oath, since many are on record, admitting loyalty to the share-holder alone with profits their first consideration.
Before the Great Depression, only 24% of the U.S. medical school graduates were given the Oath at graduation. Does this suggest they were less ethical? I don’t think so. I believe the increased use of the Oath demonstrates a growing awareness on the part of our educators that business has taken a controlling interest in the practice of medicine and that their graduates should be reminded that society still expects them to deliver on the noble promises of the past. Hippocrates’ Oath helped pry medicine away from superstition and the controlling interests of Greece’s priesthood in the fifth century B.C. Hippocrates plotted a course towards science using inductive reasoning while his Oath anchored his fledgling art on moral truths unassailable even today. I suspect he would see little difference between those profiting within the priesthood of his day and those monopolizing healthcare today. He would find familiarity in those putting forth their difficult-to-decode rules of reimbursement, recognizing these rules as intentionally confusing, pejorative, and detrimental to patients and physicians alike while profiting those few in control.
How would Hippocrates advise today’s students and physicians when shown how monetary realities have finally subsumed us all? He might remind us that money was not our motivation in pursuing this career and show us how a return to the reverence for our art, embodied by the Oath, could become a modern conveyance to the ideals of the past. By regaining our reverence for what motivated and guided us through medical school and residency we should find ample courage to do whatever is necessary. Much is needed to wrest control of today’s broken healthcare system from those making huge profits…. and an oath can remind us why it is important.
Until next time, I remain yours in primary care,
Steve Simmons, MD
January 14th, 2009 by Dr. Val Jones in Primary Care Wednesdays
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By Steve Simmons, M.D.
Gordian Knot: 1: an intricate problem ; especially : a problem insoluble in its own terms —often used in the phrase cut the Gordian knot 2: a knot tied by Gordius, king of Phrygia, held to be capable of being untied only by the future ruler of Asia, and cut by Alexander the Great with his sword
Generations ago, the American Medical Association’s (AMA) Code of Ethics stipulated that allowing a third party to profit from a physician’s labor was unethical. This tenet resides in a time when house calls were common place; when trust and respect helped forge an immutable bond between doctor and patient; and when it would have been unthinkable to allow anyone other than the doctor, family, or patient to have a role within the doctor-patient relationship.
The landscape of today’s healthcare system and its delivery methods make the authors of the AMA’s forgotten code look prescient. Insurance companies, controlling the purse strings, have become an unwelcome partner within the doctor-patient relationship, frequently dictating what can and can’t be done, and are reaping a healthy profit from their oversight. Obscene salaries and large bonuses are awarded to the CEOs of these companies for keeping as much money as they can from those providing health services, with the CEO United Healthcare being reported as receiving a $324 million paycheck during a five year period. Thus, short-term business strategies are given priority, often at the expense of patients’ long-term medical goals, creating a Gordian knot so entwined that no one – patients, doctors, insurance providers, or government regulators – can see a way to unravel it.
A result of so much money being skimmed off the top is that no one seems to be getting what they need, let alone want. Patients long for more time to discuss problems with their doctor and wish it were easier to get an appointment. Yet physicians are unable to receive adequate reimbursement from insurance companies for their services, and if they do get reimbursement, it’s after months of waiting and often at the high expense of having a posse of back office staff needed to negotiate these payments. These physicians therefore are forced to overload their schedule and rapidly move patients through their office if they are to earn their typical $150,000 per year, pay off medical school debt, and afford the salaries of their office employees. Finally, government agencies, looking for the elusive loop to tug on, ultimately burden physicians further with a myriad of onerous rules and regulations.
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January 12th, 2009 by Dr. Val Jones in Audio, Expert Interviews
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Well today was quite a role reversal for me – instead of interviewing someone for my blog, I was interviewed by another blogger. Dr. Philippa Kennealy of the Entrepreneurial MD, asked to speak to me about my new company, Better Health LLC. She summarized the interview here, calling me “The whole-brained physician who won’t ‘stay in the box.'” Quick, someone send for the men in white with butterfly nets!
You may listen to our podcast interview below (just click on the play button):
[Audio: http://blog.getbetterhealth.com/wp-content/uploads/2009/01/entrepreneurialmd.mp3]
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 2nd, 2008 by Dr. Val Jones in Book Reviews
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I just finished reading Dr. Ben Goldacre’s new book, Bad Science. It received a very favorable review by the British Medical Journal, and so I thought I’d take a look for myself. After all, I am passionate about patient empowerment and worry sincerely for their safety as healthcare is becoming more and more of a “do-it-yourself” proposition.
Ben is a talented writer – his style is straightforward, accessible, and witty. The premise of the book is to expose the underbelly of science – how it’s miscommunicated to the public (via media, PR, and representatives from the snake oil community) and how research is often poorly designed (by uneducated scientists and government agencies, for-profit pharmaceutical companies, and biased physicians).
The case studies presented in Bad Science are especially poignant. Ben has selected a few shining examples of self-promoting figures who have risen to the highest rank of “expert” in the eyes of the media – all the while referring to themselves as “doctor” and yet only having a Ph.D. from an online correspondence school. Their legal bully tactics, fabrication of data to support their proprietary health gimmick, and extreme narcicism – are excellent studies in poor character triumphing over common sense. It is painful to see how successful snake oil salesmen can be, even in these modern and “enlightened” times.
Bad Science carefully dismantles the pseudoscience that underlies many of the claims of alternative medicine. He clearly demonstrates how research can be manipulated to demonstrate a positive effect for any therapeutic intervention, and explains why cosmetic and nutrition research are particularly rife with false positive results.
Ben also explores the role of the human psyche in misunderstanding science. Our deep desire to find a 1:1 correlation between every cause and effect is difficult to overcome. We want 1) to bring artificial simplicity out of complexity, 2) a quick fix in a pill form, 3) to believe in “breakthrough therapies,”4) to read sensational or scintillating news headlines. Unfortunately, science is often coopted to pander to these wants, rather than illuminate the truth.
Finally, Bad Science explores the many ways that statistics can be manipulated to support any claim. In fact, human intuition about math in general is quite flawed, which works against us as we try to understand the data collected by researchers.
I finished the book feeling enlightened but somewhat despairing – yearning to read a sequel, “Good Science” if only to restore my hope in the idea that wise people will have the courage to seek truth over sensationalism, and value objectivity over subjectivity for the greater good of all.
What does Ben Goldacre think we can do to combat the tidal wave of bad science on the Internet? He suggests that people of sound mind blog about the subject as frequently as possible, so that those who are searching for a voice of reason may find one. I blog here and at sciencebasedmedicine.org for that very purpose.
In my next post, I’ll summarize some tips from Bad Science that will help you to recognize when a health message is likely to be inaccurate.
By Steve Simmons, M.D.
