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A closer look at commercial involvement in medicine
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“It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it” —William Osler, MD, one of founding professors of Johns Hopkins Hospital
“You are in this profession as a calling, not as a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed.” —William Osler, MD
Let’s talk money, always fun in an election year. But let’s center on medicine, not the White House. With all the talk of health care reform, and I’m not so naive to underestimate the role of moneyed interests in that debate, what will the future bring to our offices as we interface with corporate medicine industry and health care organizations including academia? Two areas of concern come to mind as we move forward — who will invest in pediatrics, and who will provide continuing medical education?
If we truly can envision a world where children’s well-being comes first, then we need to provide the support necessary for a vibrant pediatric medical community — and it cannot be done from the top down, it needs to grow up from our offices. There remain unresolved issues over who will partner and if this can be done without dimming our lights.
William T. Gerson
Commercial interests
Commercial involvement in the practice of medicine has a long tradition. Although we must be vigilant about the possible ethical quagmires, we also must be cognizant of the legacy of the better sides of these relationships. It doesn’t always have to be the dark side. And it can’t be all about money without any love.
Whether we are in private or academic practice, conflict of interest in how we practice is a constant presence. Every encounter is distilled to a billing code; every prescription a choice; every note generated an invitation to energy-sapping debates as to the adequacy of its compliance with arbitrary notions of quality of care; every referral, even laboratory test, open to question; in or out of network; in the best interest of self or institution or more hopefully of patient.
Those pediatric subspecialists with dedicated equipment, devices and procedures face an even more intense relationship with commercial interests. Because of limited pediatric numbers, these relationships differ from those of adult colleagues, often more complex because of a reliance on personal contacts and interests that lie beneath and compensate for a diminished marketplace. These are personal relationships that have often driven progress in pediatric care, and they have been dramatic. From ventilators and incubators to catheters, devices and treatments, individual entrepreneurs have made significant contributions to pediatric medicine. The melding of care, creativity, curiosity and philanthropy has often favorably tipped the balance away from just profit.
Wary of relationships
Unfortunately, the necessity of a personal relationship can be so individually dominated that the best interests of patients are abrogated. These situations are often the most profoundly disturbing. All of us owe it to our patients to be especially critical of situations where individual corporate entities or physicians exploit these relationships. Whereas journal editors have been critical to improving the scientific debate by ratcheting up the pressure on pharmaceutical companies, the oversight of individual physicians has been less intense. Left up to individual institutions, the oversight has been uneven, and the interest of subspecialty organizations highly conflicted. Pediatric psychopharmacology is a good example.
I feel confident in the success of office-based pediatricians in navigating these waters, but it remains a challenge. It helps that in pediatrics our professional organizations clearly advocate for the best interests of our patients. Despite this, pediatrics remains vulnerable to inadequate data and the transfer of responsibilities to anointed committees in our attempt to provide optimal care. The underlying reality of the difficulties with clinical trials involving children, the woeful lack of long-term follow-up studies and a reliance on adult models of disease and pharmacology intensify our frailties.
In our public health roles, we have a difficult job understanding the true costs and trade-offs of our suggestions: Should we advocate for two meningococcal vaccines or press for enriched preschool programs? Is universal screening for STDs and lipids really appropriate? Is it a zero-sum game?
In response to presumed conflicts, we have defaulted to assuming any involvement of “Big Pharma” equals manipulation rather than evaluating the data or product itself. Conversely, we accept the judgment of self-appointed committees of physicians to dictate practice with little scrutiny. This bias also affects CME, which is critical to fulfilling the imperative of life-long learning for physicians. Its future as we know it is under assault. At its best it is challenging, thoughtful and practice-changing. It also is expensive and inherently subject to manipulation. That leaves us to wonder how we going to deal with the cost and conflict conundrum of organized CME.
Determining what is appropriate
Outside of hospital-sponsored rounds, almost all of it is currently subsidized by commercial interests. Many question how to recognize appropriate from inappropriate and if it should be questioned at all. Who is responsible, and to whom? Remember, no one will do it for a loss and none of our organizations, including our professional organizations, have education as their prime mission. That leaves medical schools to fill this void. Unfortunately, they seem buttressed by the twin challenges of deficiencies of both mission and money. Can pediatrics establish a better model for medicine?
I think we can, and the answer comes from those of us in office practice — we need to do it ourselves. We can partner with others — AAP, ABP, medical schools, even commercial entities — but we should be the drivers, with high beams on.