Yes, these conflicts exist and we might as well acknowledge the fact. It's a first step to reducing their pervasive, if sometimes subtle, influence. Medicine makes a high moral claim on its affairs so it, and we, are doubly vulnerable to a charge of hypocrisy. And that threatens the high level of trust that we enjoy and need with the public to be effective in our mission of managing our patients' health.
At its heart, I am talking about the constant pressures from the marketplace to exchange a quid pro quo for doing something for or to your patient(s) that you might not do otherwise. These situations are often awkward, immoral by definition and sometimes illegal.
As far as illegal goes, we know about the 1%ers who are listed in the communiqués from our state disciplinary boards. We will all stipulate that dealing drugs without a good faith examination, insurance fraud and all the other gross irregularities that we human doctors are vulnerable to are reprehensible and worthy of regulation and discipline (both in licensing boards, hospital staff's purviews and the general society's wider jurisdictions).
At a less dramatic level, in recent years we have been brought to focus on how pervasive Big Pharma's influence is upon our pocketbooks and our prescribing. Gifts, trips and cash from consulting, speaking and advisory roles have been identified and trimmed back, resulting from the light-of-day exposure and actual legal and regulatory action.
Ask any doctor if all of this largesse has influenced his/her prescribing a bit and virtually all will deny it. Yet, some of us do not know that the reps and their companies who in the past have dispensed their samples, time and gifts get monthly reports from pharmacies about who prescribed what and how much in the last month. In other words, that corruptive influence we deny can be measured, and you can bet that Big Pharma hasn't spent major bucks on our profession without being able to prove the return on its investment. We have all been more vulnerable than we realize. And mea culpa.
Because of all the enhanced scrutiny and regulation, in recent years Big Pharma has shifted its billions to media advertising, pulling back from journal and conference support as well as gifting individual doctors. As I said, I am sure that it has documented proof of benefit of TV advertising as well, but oddly in my isolated personal experience, I have never had one patient request anything advertised on TV except when Viagra first came out. And I consciously avoid prescribing anything that I have seen advertised there. My own little protest. You know, it's better to light one candle than curse the darkness…
While we are at it, let's not ignore the medical ownership of labs, surgicenters and the like as a strong incentive to sometimes rationalize gray area utilization or the redirection of patient activity. Stricter scrutiny would tell us that we might not be strictly placing our patients' interests first in some situations, as we are pledged to do. Oh, I know it's occasionally more convenient for patients and doctors alike for doctors to do their lab/X-ray/etc. in-house, and/or doing so is cheaper, offers better control, etc., but you get the idea. It's always a lurking potential conflict of interest.
Remember when I cited a colleague a few columns ago who said his best financial decision was to install a lab and then put it in his children's names to pay their way through college? Legal, yes, but as we reflect on such things, maybe a bit tinged. Some congressional action has placed a limit and required disclosure to patients about physician ownership of these things, though our patients seem to rarely do or comment anything about it.
Big Pharma has also been outed as having undue influence on the Inner Temple of Academia and it's importantly influential studies. Now, in print, in journals and at conferences, these financial links at least have to be disclosed to other physicians.
The last element of potential economic conflict of interest to medicine is the most important, the most expensive, and the most pervasive; the fee-for-service system. We know this kind of payment dates back at least to Hippocrates when there was no alternative. But in the last few decades the entire character of the medical model has been upended and many more possibilities now exist for a more rational way of paying for health care, especially as it has gotten orders of magnitude more expensive and virtually unaffordable even for the insurance premiums for many folks.
Think about it; physicians have the sole responsibility to determine what we will do with, and to, our patients. And we directly financially benefit from our decisions. Does that sound like a perverse incentive to you? Yes, we are aware of our obligations — moral and otherwise — and most of us act with restraint, if not actually bend backwards at times thanks to the angel on our shoulder. But we are human and subject to the considerable economic pressures upon us, inner and outward.
There sometimes is the rationalization to do, and bill, more; "I have an obligation to do as much as possible for my patient," or "I have to do more to cover my behind," or "Being more thorough and putting in more time with the patient is all to the good," and on and on. There’s just enough truth to make it all palatable. And there is the imp representing debt, financial anxiety and, yes, consumer demands always there on the other shoulder, at the back of our conscious and consciences.
But we have enough reliable studies on best practices and outcomes now to have learned how often these statements break down. And our headlong plunge to do more simply because technology and scientific advances have allowed us to do more is sometimes, provably, actually causing harm. The list is getting longer. Remember "Primum non nocere?"
This concern may become moot as our fee-for-service system is going to self-destruct because all of these incentives are simply driving the country to bankruptcy and we will be forced to go to another, more rational and more cost-effective model. Big groups of salaried doctors with some kind of single-payor system like Medicare, or Kaiser, or some other such construct.
To the point, all of these factors, and more, have been pushing doctors in ways subtle and not-so-subtle ways to do things with and for our patients that, absent such forces, we would not do. And it's time to acknowledge them and remain mindful of them as we look to remodeling the structure of health care.