Healthcare
conflicts of interest:
Industry
wants, Patient needs
Mitchell
R. Yoder
Senior
Seminar
11/12/07
Thesis:
In order to combat the
health care crisis faced by Americans today, licensed health care professionals
should seek independence from healthcare as an industry and commit to
serving patient needs at its core.
Outline:
Introduction:
As another generation of health care professionals enter the field of medicine within the next decade, personal and institutional questions will arise as well as decisions regarding the health system currently serving the nation. Many share the opinion that the current health system is in serious disarray and in need of much reform but few are actively involved in addressing the problems that plague this system. Indeed the problems faced by caregivers and patients alike are overwhelming, infecting those involved with powerlessness and fatigue. A large part of the healthcare crisis arises in the doctor-patient relationship, and the breakdown in how the patient is served versus what the patient needs. This breakdown in doctor-patient relationship can be directly attributed to the medicinal industrial complex that has arisen in the last seventy-five years in which organizations have aquired large amounts of money as a result of providing health care services to the American people. Fingers should not be pointed at these organizations without first pointing the finger at ourselves as we have directly placed demand for such structures in our unwillingness to accept a natural part of the life cycle.
"Almost all of us overestimate what modern medicine knows and can do, and few of us are prepared to face a fact that people in past generations simply could not ignore: all of us must die sometime, and if in the process we consume too many resources of those who will go on living, we may deny them the quality of life we ourselves have enjoyed." - Melvin Konner M.D. (1993)
Therefore, we are all responsible for playing our own part regarding needs and wants concerning our own health and the health of others. Although, we, the patient, rely on the vast knowledge that our healthcare professionals provide in order to make ethical informed decisions. This knowledge provided must be free of obligation or greed and must be focused on serving the patient shadowed by industry. Therefore, in order to combat the health care crisis faced by Americans today, licensed health care professionals should seek independence from healthcare as an industry and commit to serving patient needs at its core.
Healthcare Situation:
In taking a more in depth look at the crisis faced by the American public in regarding health care it is easy to become overwhelmed by the complex problem and all of the specific factors that contribute to this problem. Dr. Melvin Konner summarizes very well the current crisis in healthcare in his book Medicine at the Crossroads: The Crisis in Health Care. Dr. Konner describes three main problems in our current system. First, 1500 private businesses make up a industry of insurance companies that demoralize doctors and paralyze patients through policy churning. Second, our faulty malpractice system in which the vast majority of truly negligent acts by doctors are not detected and not punished and doctor/patient trust breaks down as a result of controlling physician error through litigation. Finally, A minority of greedy doctors and hospitals choose options for care on the basis of hoped-for income rather than medical necessity (Konner, 1993).
Doctor/Patient trust
With the breakdown of doctor/patient trust come immediate consequences such as defensive medicine in which technology and unnecessary treatments are administered for protection from litigation. With these unnecessary procedures and technology comes unnecessary expense. The United States exceeds all other developed countries in healthcare costs and yet is the only developed country that does not have a universal healthcare plan. The development of these technologies and treatments are important to the general health of the human race but continue to replace primary care with sub-specialized acute intervention. Solutions to these breakdowns in primary care exist and can be addressed directly by the primary caregiver. Yet the physician is faced with the knowledge that they are far from the heart of the problem and feel powerless, and this powerlessness prevents them from reforming the system. In addition, it is difficult for reform to occur when "Doctors who devote themselves to the simplest, most effective measures of primary care and prevention are looked down upon by their colleagues and by medical students as nonscientific second-class citizens" (Konner,1993).
Doctor/Patient Relationship:
Trust between a patient and a doctor is the most essential tool for progress in our healthcare system. Generations upon generations have come to the realization that care at the primary level is the essential part of caring for a fellow human being. Since physicians sit at a position to give this primary level of care, they are also in position to make changes necessary to the reformation of our healthcare system and should be held responsible for their role in changing the current system. Improved patient trust between patient and doctor can be accomplished by reforming the system in which physician error is controlled. Also, mandating policy that limits the ties doctors have to industry reduces conflicts of interests between physicians and patients (Konner, 1993).
Lawsuits:
In 1991 a study conducted in New York found that less than two percent of "actual negligent acts by doctors" came to the point of a lawsuit. The two percent that did come to lawsuit resulted in multi-million dollar settlements. The fear of lawsuit in the United States is such a reality that doctors practice defensively, basing the majority of tests and procedures administered on patients on the fear of litigation (Konner,1993). Judges that actively reward patients with overcompensating muti-million dollar settlements participate in driving a wedge between the doctor and patient. They also drive the cost of healthcare up by the necessity of the physician to actively participate in defensive medicine, which can include unnecessary tests and procedures. It is estimated that 20 billion dollars are spent annually on medical litigation including defensive medicine (Konner,1993).
Institutional academic-industry
relationships:
Before this year there was no statistical evidence that evaluated the degree of relationships between health care professionals and industry. In October, the Journal of the American Medical Association (JAMA) released a study quantifying the extent of "institutional academic-industry relationships" within medical school departments and department chairs. The selection of department chairs and their attitudes and experiences are important because they "manage the primary organizational structure of medical schools and teaching hospitals." In the study, department chairs of the one hundred twenty-five accredited allopathic medical schools were surveyed with a series of questions regarding their affiliations/relationships with industry. Sixty percent of department chairs reported some sort of connection to industry in the form of consultants, members of scientific advisory boards, paid speakers, officers, founders, or members of the board or directors. Seventy eight percent of Department chairs that reported having one industry relationship said that the relationships had no negative effect on the functioning of their department while fifty two percent reported that the relationships were positive (Campbell, 2007).
Department Chairs:
Department chairs were also questioned about discretionary funds towards food, bonuses, travel, journal subscriptions, software, and research/clinical equipment where sixty seven percent reported to have more than one of the above discretionary funds. Regardless of the positive or negative effect these relationships have on our health system, the study emphasizes that "the failure to address the existence and influence of industry relationships with academic institutions could endanger the trust of the public in US medical schools and teaching hospitals" (Campbell, 2007).
In another case study, released in February of this year by the Journal of General Internal Medicine, physicians were directly questioned about their attitudes and opinions regarding the conflict of interest between patient care and marketing through drug representatives. The study found that physicians had contradicting views of drug representative relationships in a few different ways. First, physicians generally approved of receiving gifts from drug representatives because they felt it was appropriate to receive these gifts because they learned about new products. At the same time, they disapproved of this gifting becoming known publicly because they understood that "gifts can compromise objectivity" (Chimonas, 2007).
Physicians:
Secondly, physicians understood the conflict of interest between patient needs and drug representatives and understood that these drug representatives have the potential to sway prescription of drugs. The surveyed group rationalized favorable views of the physician/drug representative relationships saying "I take a lot of it with a grain of salt. It presents information but its always going to be in their best interest. They try for education with a spin" (Chimonas, 2007). The study concluded that voluntary guidelines outlined by most medical societies aren't enough to battle this conflict of interest and suggest a permanent prohibition of these physician/drug representative relationships (Chimonas, 2007).
Pharmaceutical Industry:
It is alarming that the intelligent communities of our physicians would need policies prohibiting such interactions. But there are many reasons that physicians meet with representatives of drug companies. One main reason involves rationalizing their actions by finding out about new technologies in the drug field to benefit the patient. In actuality, the health care system needs to move in the direction of more affordable dependable drugs that have been on the market for quite some time (Konner, 1993). These old technologies have the capability of pulling the poor out of their immobilized class providing low cost, high quality health care. New expensive technologies do not have that power and physicians should look deeper when reasoning themselves into meeting with a drug representative.
Denying that drug representatives don't have an effect on prescription habits and conflict of interest is naive and close minded. First, the idea that public money from charitable trusts is given "without strings attached is a fiction" (Kent, 2007). The pharmaceutical industry spends the minimum of 25 billion dollars each year in direct marketing to physicians (Prescription, 2007). Taking gifts from representatives directly drives the cost of pharmaceuticals up increasing the cost of healthcare. Pharmaceutical companies allocate money out of their budgets to give doctors gifts because it increases sales and they continue to allocate money into these representatives because they continue to be affective. Ninety percent of all physicians have relationships with industry but fail to recognize that these relationships have the ability to influence their prescriptions (Roehr, 2007). These relationships directly contribute to more prescription of high cost medications and decreased usage of low cost dependable medications.
Ethical Decision Making:
Are our professionals not screened for ethical decision making abilities before entering academic medical institutions? Are these ethical questions not asked because senior leadership such as department chairs in academic institutions also have relations with industry? From personal experience it seems as thought doctors generally make ends meet financially regardless in their participation with drug representatives. It is therefore perplexing to hear that such relationships have the power to create conflicts of interest where the only real responsibility that doctors have is to serve their patients to the best of their abilities. Physicians with other objectives should be removed from their position of knowledge and power. These critical ethical decisions that cause conflict of interest are ones in which the patient's trust in a doctor begins to falter, leaving behind a major crisis in healthcare.
Prescription Project:
In the recent months, some solutions to these conflicts of interest have presented themselves as a result of the publication of studies like the ones outlined above. The solutions come from a project dedicated to the ensuring that physician relationships with industry don't influence decisions regarding prescription of medication and that physicians make decisions based on accurate and unbiased information (Prescription, 2007). The Prescription Project funded by Pew charitable trusts seeks to expand federal, state and other Academic medical center policies to actively address the problem at hand. Within the new state and federal policies they engage in efforts to control marketing in the following ways. First bans and/or limits on drug representatives marketing to physicians using tactics like samples and gifts should be enacted. Next, the use of evidence-based medicine and generic drugs should be expanded to lower costs while educating physicians regarding new, reliable drug releases that have been backed up by evidence and reliability testing. Finally, academic centers of medicine should be prohibited from being spokespeople for pharmaceutical companies. It is very important that these policies come into place but even more important that doctors become aware of every decision that they make and what effect that decision has on the patient that they serve.
Conclusion:
In
an ever-changing social context of business, industry and healthcare,
now is the time, more than ever, to reform our current system of medicine
and truly become dedicated to patient needs independent of industry.
The steps for changing our system are available and ready to be utilized
by those who have the power of reform. The economic gains in the medical
industry may be an important part of U.S. economy but cannot be put
before our own quality of life and physicians must not complicate patient
relationships with a conflict of interest with industry. The time
is always right to set the path straight and become aware and knowledgeable
of the downfalls of our own systems and to take responsibilities of
these downfalls. Reforming the system is a responsibility of the American
people and not just those in politics or medicine. We all have a part
to play in improving our own quality of life.
References: