Medical Ethics Friday: Is your doctor on the payroll, and should you care?

I’m a medicine geek.  I love it.  I love going through cases in detail, developing a differential diagnosis, tossing around ideas with colleagues.  Medicine is great fun.   The professional organization for my specialty is the American College of Physicians, and we had our state chapter meeting recently.  One of the highlights was a session where experts were given difficult cases to solve.  These docs were sharp.  They are all respected clinicians and researchers, usually department or division chiefs.   Watching them work can be very humbling (well, not for them…).

There are no “grades” for doctors; your reputation is whatever your colleagues and patients say it is.  I like to think that these opinions will roughly track with ability.  What is certain, though, is that a real reputation can’t be bought.  But that doesn’t stop people from trying.

One of the big stories this week was ProPublica’s Dollars for Doctors, an investigation into the relationships between pharmaceutical companies and doctors hired to speak for them.  These docs are often touted as experts in their fields.   What ProPublica found (and what is unlikely to surprise many doctors) is that many speakers are not exactly experts, and many are not exactly at the top of their fields.

Speaking for drug companies can be very lucrative.  I’ve been approached a number of times, and given that even a few speaking engagements per year can significantly supplement the salary of a primary care doc, it’s not surprising that many say “yes”.

Having a financial relationship with a drug company is not prima facie unethical.   But there are all sorts of ethical pitfalls, some subtle, some not, that emerge from such a relationship.

So, here’s a case:

You’re sitting at dinner and start to feel some indigestion.  You burp a few times, but aren’t getting any better. In fact, you rapidly feel worse, and the “heartburn” starts to make your arm and neck ache.  You start feeling panicked, and are having a little trouble breathing.  Your spouse calls 911 and you’re brought to a tertiary care hospital where you are found to be having an “acute coronary syndrome”, but not an active heart attack.  The ED docs put you on medications and transfer you to the cardiac unit.  A cardiologist recommends going for an angiogram and possible stent placement in the morning.

Depending on the results of the angiogram, possible solutions to your problem may include coronary artery bypass graft surgery, angioplasty with stent placement (with either a bare metal or drug eluting stent) or medical therapy.  There may be further findings that suggest the need for an implantable device such as a defibrillator or pacemaker.

The cardiologists at the hospital have seen their (substantial) incomes decline significantly over the last couple of years due to a combination of better treatment of heart disease (not as many people need expensive interventions) and cutbacks in what they are paid for diagnostic tests and other procedures.  Some of the docs supplement their income by speaking for drug and device manufacturers.   The department has a national reputation, however, with the cardiologists actively involved in research and publication.

You don’t have a lot of time to shop around.

What sorts of ethical problems might be involved here?  Are the doctors’ judgments inherently invalid?

Remember some of the basic ethical principles: beneficence, non-maleficence, autonomy, justice.

There are a number of obvious questions here, but also a number of non-obvious problems.  I’d like to hear what you think.

18 Comments

  1. Dianne

     /  October 22, 2010

    Wow. Interesting problem. Can I add a question: Does it matter (to you in the acute setting) whether the doctors’ judgement is suspect or not? You don’t have time to shop around or evaluate the literature on each recommendation at this time. Do you have any real options besides hoping that they’re not pushing snake oil on you? Can anything be done about the meta-problem of lack of real choice in emergency situations?

  2. PalMD

     /  October 22, 2010

    Good questions. I intentionally made this not an acute MI but unstable angina so that being rushed to the cath lab wasn’t on the table. You don’t have time to shop around, but you do have time to think a little bit.

  3. I would judge my response according to how the cardiologist answers the question: “What do the most recent ACC/AHA guidelines for unstable angina recommend for cases like mine?” That ought to tell me what side his toast his buttered on.

  4. Stark’s law applies here right? The cardiologist can’t refer to his/her own practice for treatment? Doesn’t Stark II cover the stent/surgery issue too? i.e. Doc speaks/represents the company that manufactures the stent, so can’t advise, needs a third party referral…

    • it’s a separate issue, although i don’t claim to always understand all aspects of Stark. It’s basically an anti-kickback law, so i can use a cath lab that i own, but i can’t refer to yours for a fee.

  5. SurgPA

     /  October 23, 2010

    I as the patient don’t have any ethical conflict. The cardiologist does though, and it’s essentially that his/her role as a speaker for the drug/device companies influences his/her decision-making regarding this patient, specifically with regard to drug and device/procedure recommenations. It’s the “free” pens and golf junkets story all over again.

    I’m guessing you might have heard yesterday’s NPR piece?

    http://www.npr.org/templates/story/story.php?storyId=130598927

    • Dianne

       /  October 25, 2010

      Here’s my problem with the whole argument that doctors should be purer than Caesar’s wife and never take pens, cookies, or samples from pharma reps: We don’t know if forbidding these things makes any difference in prescribing practices*. Remember the big push to acknowledge all conflicts of interest? IRIC**, in the end people read articles with declared COI less critically because they assumed that the admission of COI meant complete honesty on the part of the writer.

      So here’s what concerns me about forbidding small gifts: The drug companies’ interests don’t change. They still want to sell their products. But now they’ve got a freed up budget and a mandate to be sneakier. What are they going to do instead? Well, remember scandal with the pseudo-peer reviewed Elsvier journals that orac wrote about recently? That’s the sort of thing they’ll be going to if the avenue of interacting directly with doctors is blocked. Personally, I’d rather know up front that I’m interacting with a drug rep than have to figure out whatever the newest deception is. But which will affect my prescribing practices*** more? That, I don’t really know. As far as I know, neither does anyone else.

      *At least last time I looked for literature there didn’t seem to be any. If anyone knows of any data to the contrary please correct me.

      **Again, I don’t have the data in front of me and could have it wrong. Data, anyone?

      ***In this case, “affect prescribing practices” should exclude changes made because of good data suggesting that a new pattern is needed, i.e. changing from zofran to kytril because the drug rep was nicer would “count”, changing from interferon to imatinib for CML because imatinib has a near 100% response rate doesn’t.

  6. I would start asking about things that I know are bogus, homeopathy, acupuncture, reiki, chelation and ask if I can “supplement” my treatment with them. If they say yes, then I move to a different place. If they say no, I move down the list of bogus treatments until they do say yes and gage the level of adherence to SBM based on that.

    I ask what fraction of the staff has been vaccinated for flu. If the doc doesn’t know, then it isn’t a priority. If he/she isn’t vaccinated I ask why. I ask the support staff if they have been vaccinated for flu and what reasons people have given for not being vaccinated.

    I ask about antibiotic resistant hospital acquired infections.

    I ask about how many of the different procedures they do, and how the ratios of those procedures have changed over the last few years. Are they a one trick pony, or do they have a broad spectrum of procedures that they apply? Did the frequency of procedure use change because of their personal experience, or because of whole industry experience?

    For most of these the details of the answer doesn’t matter, just that there are details, that these are things that are thought about and done for conscious reasons and those reasons can be articulated on the spur of the moment.

    • Jake

       /  October 23, 2010

      As a physician, I think everything you’re asking about after the first paragraph is valid (although you are assuming a relationship between the hospital and the doctor that frequently, maybe usually, doesn’t exist). I often, at least daily, get asked about treatments I know to be “bogus” (by bogus I suspect you mean are not supported by double blind, reproducible studies). I only discourage them if I know them to be dangerous. Placebo effects are both real and powerful. Why on earth would I to deny it to a patient who believes strongly enough in something that they will quite likely to experience real benefit?

      There’s also a distinct, even if infinitesimal, possibility that something we can’t recognize as beneficial today will be much better understood in the future. Imagine a 17th century doctor recommending you drink the excrement of a penicillin mold for your pneumonia instead of bleeding you on a daily basis. How absurd, right?

      So, “Doctor, did you get your flu vaccine this year?”

      Sure valid, and revealing.

      But, “Doctor, should I get acupuncture to help me recover from this operation?”

      I doubt that would give you any useful information about your doctors competence. I personally may be more suspect of a doctor who answers no. I would certainly question him or her more carefully about that answer to determine if she or he has a reasonable basis to be concerned about it.

    • Vicki

       /  October 25, 2010

      The problem with the first paragraph stuff is that some of it is just going to test for whether doctors are non-confrontational and/or worried that arguing with you on something minor will reduce your trust in them. I would avoid a doctor who suggested I use homeopathy or acupuncture, but “is it okay for me to use acupuncture in addition to your treatments?” might get something like “I don’t include it in my practice, but there’s no evidence that it will do you any harm.”

      Also, when you start throwing in a bunch of unrelated things like chelation for a heart problem, at some point the doctor is going to think–and maybe say–that you’re testing them and don’t trust their judgment. S/he is likely in a hurry, and “I’m going to keep probing until I get a yes on something” will probably get an “okay, if you want” because the doctor thinks that you’ll stop throwing these questions at them. You’re signaling that “no” is the wrong answer, even though you consider it the right answer: say “no” and you keep poking, say “yes” and you stop.

  7. “What sorts of ethical problems might be involved here? Are the doctors’ judgments inherently invalid?”

    Their judgments aren’t inherently invalid, there have clearly been real improvements in treatment (which is why the doctors are making less), presumably helped along by those same drug and device manufacturers. If they advocate for new treatments, it could be because the new treatments are ACTUALLY better.

    It would be good to know if the companies that the doctors are spokesmen for are able to obtain knowledge of what recommendations the doctors make – in other words, could the doctor implicitly or explicitly worry that recommending one treatment or another could have an effect on their future employment?

    • Drug companies can track doctors’ prescribing habits unless doctors know how to specifically opt out.

      • SurgPA

         /  October 24, 2010

        Exactly, and that’s how drug companies target potential speakers. They look for providers with high rates of (for example) statins, then recruit them to speak about a particular statin (say Lipitor). Because they have demonstrated consistently that the speaker’s statin prescriptions will subsequently shift preferentially toward Liptor.

  8. I am not sure how my pcp stays in business. Because she keeps trying to reduce my number of prescriptions and avoid adding any new ones. So does my mom’s. We are both doing well.
    I am not against prescription drugs – just the overloading of them.

  9. Zeebek

     /  October 26, 2010

    “Having a financial relationship with a drug company is not prima facie unethical.”

    Perhaps not, but as an ethical person I go out of my way to make sure that there are no “temptations” to be unethical. If I visit a doctor’s office and even see a pen or pad of paper with a pharma logo on it I am out of there and just assume they’ve been bought. Any self-respecting physician would be more than happy to spend the extra $1.50 on office supplies to make sure that there are no whiffs of unethical motives lingering in their office. If not, then I can likely expect the same carelessness when it comes to my care, as displayed in their choice of office supplies.

    • In my early 20s, I basically picked a physician at random because, hell, I was in my 20s, I hardly ever go to the doctor, what do I care? I noticed they had a lot of promotional material for a certain prescription drug. I ended up being prescribed that very drug. The connection didn’t occur to me until later, because the prescription was a reasonable (though, in retrospect, probably not optimal) choice for my condition, and in any case I was taking the generics anyway… but yeah. Kinda disturbing in retrospect.

      Regarding the issue at hand, I mostly agree with SurgPA. Particularly in this case, as a patient I would not be hugely concerned about the doctors’ choices — as I said, even in the disturbing case above, the prescription was still a perfectly reasonable choice — and given the short time frame in which to make a decision, I just wouldn’t bother to worry about it overmuch. But the docs have an ethical challenge, and I hope they would do their best.

      In regards to what we can do as a policy decision, I mostly agree with Dianne: Pharmaceutical companies are beholden to their stockholders to try and make a profit, and part of that will always be trying to influence doctors. We can’t in practice stop it (next step, ban alcohol!) but we can do everything possible to keep it above board. I part ways with Dianne in thinking that free pens are necessarily the best way to maintain transparency ;p but the general gist of her comment I agree with.

      • Dianne

         /  November 2, 2010

        I don’t think free pens are necessarily the best way of maintaining transparency. I just think that their effects on prescribing practices haven’t (as far as I know) been measured and therefore the effects of banning them are unknown. (Though any study is going to end with them going away: Either because they’re proven to be a corrupting influence and banned or because their proven ineffective and the drug companies give up on them.) It’s a complicated system and simple changes may have unexpected and undesired consequences.

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