Thursday, May 21, 2009

Medical Corruption and Conflicts of Interest: Shades of Gray


There is a serious and expanding effort to address corruption in medicine. Regulators and lawmakers are addressing cozy relationships between physicians and industry to protect patients from financial conflicts of interests that may skew doctors’ medical advice. This is murky territory since not every potential conflict is corrupt. For example, is it acceptable for an orthopedist to benefit financially by using a particular artificial hip if the physician believes that this is the best product available for his patients? Does this practice become ethical if the physician discloses this financial arrangement? Are his patients entitled to know the actual dollar amount that the doctor receives? Is it proper for a gastroenterologist to receive a generous honorarium by a heartburn drug company to speak to primary care doctors about reflux treatment? Could this physician be trusted to offer truly objective information to his primary care colleagues with the company’s pharmaceutical representative sitting beside him? If medical researchers receive ‘consulting fees’ from drug companies or medical device companies, does this taint their scientific studies? Does a bland disclosure at the end of the study, such as Dr. Diamond is a paid speaker for Quartz Drugs, Inc, enough to sanitize the study?

Three Harvard researchers are being investigated for promoting certain medications after accepting millions of dollars from the drug companies that manufacture them. These fees were not properly disclosed. With every passing month, we learn that entangled financial relationships between physicians and industry are not aberrations. Currently, there are many similar allegations under review, and more will surely follow.

However, there is nothing intrinsically evil or unethical about physicians making money or even becoming rich. I make money every time I perform a colonoscopy. One could argue that I have a conflict of interest because my recommendations for colonoscopies are contaminated by my financial self-interest. Of course, this would also be true for attorneys, car mechanics, financial advisers, plumbers, retailers and anyone else who sells a product or a service. However, as long as the advice is pure, or the service is truly needed, then it is reasonable and proper that the professional or tradesman is paid for his effort.

Hidden financial relationships, however, that a reasonable patient would want to know about, are unethical. Disclosure should be sufficient so that patients or medical journal readers can consider their potential influence and impact.

Disclosed conflicts, however, can be proper and beneficial. For example, you consult a highly qualified heart surgeon to discuss replacing your aortic valve. He recommends a particular type of valve and discloses that he is an investor with the company and serves as a senior medical consultant. He has helped the company to improve the valve’s performance and longevity. He further states that he has been doing heart surgery for 20 years and truly believes that this is the best product on the market today. This is why he is affiliated with the company.

Do we want the anti-conflicts of interest brigades to end relationships between physicians and industry like the one described above? If such a doctor is compensated, does that imply that he is corrupt? Of course not, but it would be quite easy to tarnish his reputation with a few salacious headlines. Collaboration between physicians and industry has brought great benefits to the public. We need to be cautious before we erect too a high wall between them in the crusade against conflicts and corruption. Naturally, there are abuses, and they should be exposed, investigated and sanctioned. But let’s not rush to embrace a puritanical policy that will stifle medical advancements as it takes wild aim at every perceived conflict.

I hire lots of folks and pay them for their time and advice. Just because they make money on me, doesn’t mean that their advice is improper. We want a policy that handcuffs rogue individuals, not an entire profession.

Should every professional be paid a straight salary so that their income is not linked to their advice or performance? While the potential for corruption under such a system will be markedly diminished, the level of quality may sink even lower. Mediocrity is too high a price to pay for purity. Here’s a doctor’s advice for the regulators and lawmakers who are looking to sweep up my profession. Put down your chainsaws. I’ll loan you a scalpel instead.

13 comments:

Brad Lander said...

Very interesting post. I heard another physician speak about this in April at a conference. His name is Matthew Paul- an opthamologist in Danbury, CT. If you're interested, his talk was based on "Free pens influencing physicians prescriptions".

Michael Kirsch, M.D. said...

I'm a gastroenterologist. While we do have some Nexium pens, at least our toilet paper is pure white without any drug names or logos!

Anonymous said...

There is a basic problem at hospitals where docs are put in an environment where more more more is better. Its a COI of dramatic proportions that no one seems to ever talk about. At least when the FDA, CMS or NIH is involved there is at least a threat of enforcement along some sort of regulatory lines. In hospitals, there is none, and indeed there are many examples of whistleblowers being ruined.

Of course I have to post anonymously because as a whistleblower who was crushed, I am afraid.

Michael Kirsch, M.D. said...

You will note that this Whistleblower writes under his true byline.

Anonymous said...

Yes Michael, I did. I applaud you as well as fear for you.

Anonymous said...

Some pros and cons,

A while back I read that in France the doctors are happy with a nice income and a nice vacation, etc. There was actually a lengthy interview with a doctor and his wife. From what I could determine there is good healthcare in France. Possibly the article that I read did not cover enough territory in other areas to have much insight in comparison.

When I had this discussion with my son he said it is better to let the doctors compete. I don't know about that thinking it depends on what the doctors are competing for and how. If they are all competing to do a better job then there might not be this discussion.

The big problem is the inability, for whatever reason, to knock off the doctors who need knocking off.. No one knows better than the doctors themselves who those people are and why that doesn't happen. Considering the self regulation aspect there is room for much concern.

Yes, the above comment that different opinons are beneficial but give credit to the insurance companies who some years ago pointed out that need. I think people at one time knew there are rip offs in the world but just didn't consider that people will actually intentionally steal from a human body and possibly take a life in the process. That comes under some heading that seperates doctors from other "businesses" in such a way that helping people survive should not be a business but a gift. A person who intentionally steals from a human body is sick, something akin to cannabilism.

Who really wants the government and doesn't see a problem with that idea? If you read about the water contamination at Camp Lejeune for about 30 years and no one checking it all that time? you might question if the government can do a better job keeping all of us safe. Yet, the medical profession must benefit from that horror and it doesn't appear the government is paying the bill from what I have read.

At the same time, the fact is no one will argue and that is some people can disipline themselves and others can't. If there is no one disiplining the ones who can't people are in danger. For that reason, I appreciate this blog and the attempt for someone on the inside to confront the many issues.

True, there is nothing wrong about making money honestly. How many people can you run through an office in one day and take the time to inform and treat properly? That is one way to evaluate honest money.

With so many pros and cons to sort it is best for now to make the medical "business" as safe as possible for consumers and as quickly as possible. Exposure.

Just the number of people taking anti depressants is amazing to me. There are so many people taking anti depressants that you would think that circumstance is a conspiracy.

I think failure of regulation is what brings about talk of change. If people take care of their own problems they don't need anyone else to step in to clean up the mess, for lack of better words.

The notice that you are attempting to do your part is encouraging.

My2Cents said...

Great article. I talk to with physicians on a daily basis about this topic.

www.physiciandispensingsolutions.com

Kris Sergentakis said...

before u give anything

to The Leukemia & lymphoma Society

see http://www.leukemiascandal.com

Anonymous said...

NOT ONE CANCER ORGANIZATION HAS DIFFUSED THIS INNOVATION, WHICH THEY ARE ETHICALY OBLIGATED TO DO

THE REMARKABLE, BUT CORRUPTED, ANTICANCER PROPERTIES OF ANTIDEPRESSANTS

The idea that antidepressants might be effective for cancer was first explored fifty years ago, and ample proof has emerged. More than one hundred published studies show that antidepressants kill cancer cells, inhibit their proliferation, augment chemotherapy, protect nonmalignant cells from ionizing radiation and chemotherapy toxicity, and convert multidrug resistant cells to sensitive. Antidepressants can arrest cancer even in advanced stages, occasionally eradicate it, and significantly extend life. To verify, access Medline or Pubmed, and enter “antidepressants” and “cancer.”
Implementation of the innovation will remove a burden that society is unable to cope with.
A SMALL SELECTION OF MORE THAN A HUNDRED STUDIES, THE SCIENCE IMPECCABLE, THE SUPPRESSION BY VESTED INTERESTS HORRIFYING.
1.Hisaoka K, Nishida A, Koda T, et al: Antidepressant drug treatments induce glial cell line-derivative neurotrophic factor (GDNF) synthesis and release in rat C6 glioblastoma cells. J Neurochem 2001 Oct; 79(1): 25-34
2.Spanova A, Kovaru H, Lisa V, Lukasova E, Rittich B. Estimation of apoptosis in C6 glioma cells treated with antidepressants. Physiol Res. 1997; 46(2): 161-4
3.Xia Z, Bergstrand A, DePierre JW, Nassberger L. The antidepressants imipramine, clomipramine and citalopram induce apoptosis in human acute myeloid leukemia HL-60 cells via caspase–3 activation. I Biochem Mol Toxicol. 1999; 13(6): 338-47
4.Hsu SS, Huang CJ, Chen JS, et al. Effect of nortriptyline on intracellular Ca2+ handling and proliferation in human osteosarcoma cells. Basic Clin Pharmacol Toxicol. 2004 Sep; 95(3): 124-30
5.Chou CT, He S, Jan CR. Paroxetine–induced apoptosis in human osteosarcoma cells: activation of p38 MAP kinase and caspase-3 pathways without involvement of (Ca2+) elevation. Toxicol Appl Pharmacol 2007 Feb 1: Feb 1; 218(2): 265-73
6.Pan CC, Cheng HH, and Huang CJ et al. The antidepressant mirtazapine induced cytosolic Ca2+ elevation and cytotoxicity in human osteosarcoma cells. Chin J Physiol. 2006 Dec 31; 49(6): 290-7
7.Toki S, Donati RJ, Rasenick MM. Treatment of C6 glioma cells and rats with antidepressant drugs increases the detergent extraction of G (s alpha) from plasma membrane. J Neurochem . 1999 Sep; 73(3): 1114-20
8.Snyder SW, Egorin MJ, Zuhowski EG, Schimpff EC, Callery PS. Effects of the monoamine oxidase inhibitor, tranylcypromine, on induction of HL60 differentiation by hexamethylene bisacetamide and N-acetyl-1.6-diaminohexane. Cancer Commun.1990; 2(7): 231-6
9.Tang KY, Lu T, Chang CH et al. Effects of fluoxetine on intracellular Ca2+ levels in bladder female transitional carcinoma (BFTC) cells. Pharmacol. Res. 2001 May; 43(5); 503-8
10.Penninx BW, Guralnik JM, Pahor M, Ferrucci L, Cerhan JR, Wallace RB, Havlik RJ. Chronically depressed mood and cancer risk in older persons. J Natl Cancer Inst. 1998 Dec 16; 90(24):1888-93.

Brad Lander said...

Here's an article I think you'd find interesting:
http://www.cnn.com/2010/OPINION/11/30/elliott.doctors.drug.pay/index.html

Michael Kirsch, M.D. said...

Brad, great link! Hopefully, some other commenters reviewed it also. Regards, MK

Anonymous said...

First, I love your blog!

Next my question is;

Regarding Imaging pre-certifications, How do you feel about the "middle men" benefit management companies, who most health insurance providers utilize to "streamline" patient imaging tests, for example?

Thank you

Michael Kirsch, M.D. said...

Appreciate the inquiry re benefit management companies. These folks, like pharmacy benefit managers, are charged with managing money, not medical quality. Would you want someone with no medical training to make judgements on your doctor's advice and your medical care?

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