Category Archives: Doctors

CME and Pharma: Doctors Want Support That They Can’t Trust

“Doctors want CMEs paid for them but can’t trust the people they want to help pay for their continuing medical education.” That’s how I sum up the below survey published by Archives of Internal Medicine.

Look at what the conclusion said: “Although the medical professionals responding to this survey were concerned about bias introduced from commercial funding of CME, many were not willing to pay higher fees to offset or eliminate such funding sources.”

If doctors are so concerned about ethics and bias, then they need to put up the money and pay for their own continuing education to stay current in their fields so that they can do their jobs. But based on “reality”, doctors are more concerned about their bottom-line and the survey suggests that their bottom-line trumps whatever concerns about bias they may have.

Clinician Attitudes About Commercial Support of Continuing Medical Education

Results of a Detailed Survey

Jeffrey A. Tabas, MD; Christy Boscardin, PhD; Donna M. Jacobsen, BS; Michael A. Steinman, MD; Paul A. Volberding, MD; Robert B. Baron, MD, MS

Arch Intern Med. 2011;171(9):840-846. doi:10.1001/archinternmed.2011.179

Background Pharmaceutical and medical device company funding supports up to 60% of accredited continuing medical education (CME) costs in the United States. Some have proposed measures to limit the size, scope, and potential influence of commercial support for CME activities. We sought to determine whether participants at CME activities perceive that commercial support introduces bias, whether this is affected by the amount or type of support, and whether they would be willing to accept higher fees or fewer amenities to decrease the need for such funding.

Methods We delivered a structured questionnaire to 1347 participants at a series of 5 live CME activities about the impact of commercial support on bias and their willingness to pay additional amounts to eliminate the need for commercial support.

Results Of the 770 respondents (a 57% response rate), most (88%) believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias. Only 15%, however, supported elimination of commercial support from CME activities, and less than half (42%) were willing to pay increased registration fees to decrease or eliminate commercial support. Participants who perceived bias from commercial support more frequently agreed to increase registration fees to decrease such support (2- to 3-fold odds ratio). Participants greatly underestimated the costs of ancillary activities, such as food, as well as the degree of support actually provided by commercial funding.

Conclusion Although the medical professionals responding to this survey were concerned about bias introduced from commercial funding of CME, many were not willing to pay higher fees to offset or eliminate such funding sources.

Would You Cancel a Surgery if Your Surgeon is Getting a Kick-Back?

The specific question is about getting kickbacks as a surgeon using a medical device, and was originally asked on Quora. The explanation to the question (posted by the asker) said,

“The department of justice has investigated conflicts of interest, and the Pittsburgh Post Gazette has published on the topic. To quote from the gazette:

Payments to other Pittsburgh area physicians include:
• The Orthopaedic Group of Pittsburgh received $75,000 to $100,000 this year from Smith & Nephew, and two of its doctors, Ari Pressman and Allan Tissenbaum, received individual fees. Smith & Nephew reported paying the same range of fees to Carnegie Mellon University, and to Carnegie Mellon professor Dr. Jeffrey O. Hollinger, a bone tissue regeneration expert.

• Biomet has a relationship with the University of Pittsburgh Medical Center’s Department of Orthopaedic Surgery, through Dr. Freddie H. Fu and Dr. Christopher Harner, paying $75,000 to $100,000.

• DePuy’s largest payment went to Dr. Lawrence Crossett, a UPMC surgeon who has received $250,000 to $275,000. On Dec. 6, he’s scheduled to perform two knee replacement surgeries, which will be broadcast over the Internet by DePuy and viewed by doctors.

• Zimmer, the largest of the joint manufacturers, paid out the most to Pittsburgh doctors, $1.16 million through Oct. 31.”

Regrettably, this is a relatively small fraction of the total physicians, giving the impression that most physicians have these conflicts of interest. Fortunately, the department of justice’s investigation has helped curtail these conflicts of interest. Having said that, if you discovered the night before your procedure that your surgeon has such a conflict, would you proceed with your surgical procedure or would you cancel it? Assume that the procedure is elective, not emergent.

I think there are various caveats to the question being asked, and perhaps, a different way of asking the question that can help the patient make better decisions about whether to stay with the surgeon or find another doctor:

Questions that came to my mind were:

  • Does the surgeon opt to cut when there is no clear benefit to surgery or when another therapy would give as good of a result?
  • Does the surgeon opt for one device over another device and is this decision based on a kickback or is it based on clinical data that suggests a benefit for the patient’s profile?
  • Is the surgeon an inventor or co-inventor of the device?*

Conflict of interest comes to light when surgeon has mostly a financial incentive to choose one device or another or to recommend surgery over nonsurgical alternative if there is no clear clinical benefit or if the recommendation introduces new side effects to the patient.

The last point that I marked with * warrants discussion because this is not so “clear cut” a conflict of interest as the first 2 bullets. In devices the physician may be an inventor or coinventor and then licenses the technology or device to a company.

Even though the physician may have a conflict of interest – by receiving royalty payments for example – the physician is also the best expert on the technology that s/he has invented, so the choice to go for one’s own device may have less to do with a kickback and more to do with the physician’s belief in the invention’s efficacy/benefit.

Here’s a link to an article a while back (and how I got the “mostly royalties” impression) from WSJ when device companies had to post what they’d paid to orthos – although the asker rightly pointed that that the medical device company engineers are probably the majority of inventors to the technology rather than the MDs themselves.

Yet there’s also the argument made by Andy Lemke on Quora (in the comments section) that a doctor who serves as consultants to several companies must know his/her stuff since s/he is so sought after by device companies, so it’s not necessarily going to hurt that physician’s integrity in the eyes of the patient.

Why I Chose NOT to be a Doctor

I was once a premed.

I chose not to become a doctor because I wasn’t truly interested in the profession, it was something I felt I “had” to do or “should” do because I happened to major in biology. And being a first generation Asian-American there was also pressure from being a “Tiger Cub”: we have limited career options: doctor, lawyer, engineer. I suck in math and was good in biology. Guess which option I had?

In my undergrad classes I was among other premeds; many of them went in for the Money, the Prestige, for their Parents. But they will all talk about how much they love helping people/patients on their applications.

I did consider taking the MCAT and even paid for one of those “prep courses”, in case I changed my mind. But I knew my grades weren’t good enough, I didn’t have “connections”, and I wasn’t going to throw good money after a bad risk, especially when that money was already borrowed money via student loans. I went to grad school instead.

Then I started working in the healthcare industry, first working for the pharma industry. Maybe the nature of my work in pharma predisposed me to witness the doctor-industry relationship in a way that brought out some of the unsavory traits of the medical profession.

I saw some of these doctors up close – their lives (and lack thereof), their values (and lack thereof), their character (and lack thereof), bedside manners (and lack thereof).

We are constantly reading about how “evil” the Pharmaceutical Industry is and how they corrupt doctors and so forth – that gets a lot of coverage in the presses. Well, I’ve seen it from the other side: there are doctors who have become savvier businessmen than they are savvy clinicians and they are perfectly capable of manipulating drug companies to fulfill their personal interests. I’ve had doctors asking me for favors that I knew had nothing to do with improving patient care. I’m not embarrassed to admit that my first year of working in industry had almost completely destroyed the trust I used to have in doctors.

I saw the state of Managed Care and the “healthcare business” that has made doctors more busy with administrative work than taking care of patients. A HMO doctor once explained to me that he goes through each day making sure he breaks even by seeing 50 patients. He knows how much $ he gets paid per patient from the HMO. So he has to see a certain # of patients to stay in business. Depending on the patient’s condition, say the patient has a cold, he’d spend a few seconds with the person, and knowing that the patient would expect “something” for the visit, the doctor would write a prescription for an antibiotic just to get that patient out of the office, so he could see the next patient.

The medical profession was not something I’d ever wanted for myself if I did not have a deep-rooted passion and conviction about going into the profession. In fact, the medical profession is one that I would not encourage my child to go into, unless again, he expresses a serious conviction about becoming a physician. I actually have to be careful about my own prejudices – that I do not vehemently discourage my child from considering this profession. That would be as bad as the Tiger Mothers who force their children into the medical profession.

I know this puts me in the “outlier” group of Asian mothers. But then again I’ve always been an outlier.

Which Side Are You Really On, Jane Chin?!

I received what is probably the most passionate email from a reader of this blog that I’ve ever gotten since creating NakedMedicine.com in 2006. The email concludes with this:

I can’t figure out what your agenda is Ms Chin. Are siding with the poor hard working physicians who are fighting a losing battle with their idiot patient’s lifestyles? Are you siding with the tirelessly industrious pharmaceutical scientists who are selflessly dedicating their efforts to cure our ills? Are you siding with the poor neglected suffering individuals who are bravely pushing onward in their lives, struggling with disease, possible disease, possible pandemics, or just plain plainness requiring cosmetic medicine? Doctors, business, persons, for whom are you advocating?

I was shocked by the email, because this reader “hit the nail on the head”! He can’t figure out what my agenda is, because my agenda is in NONE of those sides he described. In other words, if I were guilty of picking “a side”, it wasn’t part of the “usual suspects”.

Here’s my very long response to my reader, to whom I’m grateful, because he took the time and effort to share with me this question that obviously is frustrating him.

******

You wrote what you felt, and I don’t fault you for that. I can sense a real feeling of frustration from you, and I don’t blame you for feeling frustrated about the healthcare system that seems to be broken in many ways.

I want to address specific points you brought up – first one being ‘cures’. I genuinely don’t think that the drug industry is prevented from, or are resistant to, discovering cures for diseases. It’s not about ‘cure’ versus ‘not the cure’ that is the problem. It is often the economy of scale that is the problem, and a very understandable one when you consider that the drug industry is – and has to run like a business – in order to remain in business. I have no doubt that the drug industry would love to find a cure – because they can charge for the price of a ‘cure’ and be justified in charging such a price.

The problem on the one hand is that many times we simply cannot find ONE underlying factor of a disease, especially the chronic diseases like diabetes and heart disease (in fact, many diabetics die of a heart attack and don’t live long enough to die of diabetes complications, especially those consuming a western diet). It is not like a bacterial infection where we can pinpoint ONE origin of the disease and target that specifically, the way we can target an infecting bacteria with an antibiotic and ‘cure’ the patient.

The other problem is about the number of people with a certain disease. For example, there may be fewer companies willing to research rare diseases that may be ‘repaired’ let alone ‘cured’, simply because the companies need to get the money somehow to do all the experiments and clinical trials necessary to jump through regulatory hurdles to even get the drug approved. When i was a graduate student, doing what are pretty simple experiments (and not even in people – i worked off the petri dishes), i was often using reagents that cost my employer thousands of dollars to purchase from reagent companies. Each of my experiments has to cost at least a thousand bucks, and many of my experiments failed and produced no result.

These prices are nothing compared to the amount of money it costs to run a clinical trial at the scale required by the FDA. Now the drug companies have to pay for the drugs, the cost of mountains of paperwork needed to get the clinical trials started, the doctors who do the clinical trials (and some doctors get really snobby and brag to each other about how much $ they can muscle out of drug companies “per patient” to enroll in the drug companies’ trials), not to mention the “overhead” that the academic institutions charge the drug companies because their doctors work there (and these overhead costs can mean more than 50% of the total study budget).

And then most of the drugs end up not passing the FDA’s requirements and fail to get approved. So if you’re running a company, you will tend to want to go into areas where you will likely have more customers – heart disease for example – just so you stand a better chance of keeping your company operating should it succeed in getting a drug treating that disease approved. This is also why the government has to create incentives for companies that are willing to go into rare or “orphan” diseases – for example, Gaucher’s disease is a rare lysosomal storage disease affecting maybe 1 in 40,000 people. A drug company that competes in this market will be happy selling 1 prescription every 3 months.

I honestly do not view drug companies as entities that profit from the suffering of others, because of the logic of this assumption: If drug companies are creating diseases in people in order to make drugs for the very diseases they created, then that to me qualifies for the statement. However, drug companies happen to offer the tools to treat the disease, not unlike device companies making scalpels and surgical tools to allow doctors to cut us open should our illnesses demand it. It seems illogical to me to accuse device companies for profiting from people having tumors that require scalpels to operate and excise the tumors – unless we’re also implying that the scalpel companies are putting tumors in people that only their brand of scalpel can remove.

Additionally, I have observed that for the most part, people in our society today tend to prefer that we “have a pill to treat XYZ”, so that they do not have to do the hard work required to get their own health back on track. And then you add to the fire media agencies that charge pharma companies millions of dollars to come up with brainless gimmicky advertisements, and it is no wonder why many people feel like the drug companies are “profiteers of suffering.” Some years ago, there was a government funded study that shows that rigorous diet and exercise will help reduce diabetes risk at a very real level – in fact – the study patients who had diet and exercise regimen did as well in reducing their diabetes symptoms as study patients who took an anti-diabetic drug.

But why hasn’t the government or the doctors (not the drug companies – their responsibility is in making drugs) done anything about this amazing result? Because the of costs involved to the clinics in order to make “diet and exercise” possible in patients at a therapeutic level. Clinics would need to hire case workers and nurses whose job is to counsel and support and follow each and every single patient who opts for this “natural and effective” treatment. OK then, how about asking patients themselves to do this? Seriously, if you are a patient at risk for diabetes (i.e. risk factors are there, but patient is still “pre-diabetic” and not yet requiring drugs to control their blood sugars), you have everything you need at your disposal to go for the natural and effective (and less expensive than prescription drugs) cure! why aren’t patients doing this? because willpower and discipline are key – and you’re going to need both for a lifetime to prolong the onset of disease.

I can share this true experience – a relative had prediabetic blood work results some years ago when I urged him to see an endocrinologist, because his side of the family also suffers from diabetes. the endocrinologist told him that because he was so young (not yet 40 at the time), she preferred that he try the old fashioned diet and exercise, and see if he could get the risk factors down, before she put him on a drug. He happens to have a level of willpower and discipline that even I don’t have – and he altered his lifestyle dramatically – and it was enormously difficult. 6 weeks later he went back and the endocrinologist was so impressed with his results that she told him that most of his blood work results were approaching normal numbers. But she also told us that not every patient she sees can make this happen – and often she is forced to give the patient drugs to make sure that the patient doesn’t end up with uncontrolled diabetes symptoms (resulting in all sorts of nasty things including death).

I see drugs as exactly what you said you wished to see – repairs and cures. However, the reality is, few are truly cures because of the complexities of most diseases, and repairs don’t always “fix” things without creating new problems (called side effects) EXACTLY because of the complexities of most diseases.

The doctors’ hands are tied not (only) by pharma companies, but by insurance companies as well as malpractice lawsuit concerns. Your average primary care doctor has to track how many patients he sees everyday because he needs to make sure he breaks even. That’s not the drug companies doing, but the insurance companies that capitate how much doctors are paid for doing what. So you also have a system that don’t reward doctors for spending more time with patients – in fact – you’re making it very bad business for the doctor to spend too much time because then he’ll lose money that day – and this does not do well to cultivate trust with patients who then need to heed the doctors’ advice about doing the hard things they need to do to steer their health status back on track.

Perhaps I can’t take any sides because I don’t think there are any sides that I can reasonably take without acknowledging that there are other entities that also need to be held accountable. the healthcare ‘system” is truly a “system” and a staggering, complex one at that. the best I can do is to help the consumers – people like you and me – to think for ourselves about what is being “sold” to us whether it’s from the drug companies, insurance companies, the government, the doctors, even patient groups. If I am guilty of siding with anything, it will be on the side of “critical thinking” about the system of healthcare with all of its players.

Best wishes,
Jane Chin

Pharma Offering Lifestyle Drugs – Power will Shift to Patient Customers

You’ve probably seen it coming – smelled hints of it on TV – pharmaceutical companies are getting into what we call “lifestyle drugs”; products that focus on “enhancing” your life rather than “extending” it.

Yes, there is a big difference, and you may think that “extending” life pays big, “enhancing” life may pay even BIGGER. (just ask the Botox people.)

It’s only a matter of time before pharmaceutical companies shift their focus from “therapeutic intervention” to “lifestyle / recreation” because they now deal with a ready-and-willing customer base who are willing to pay.

This also creates a more dramatic shift: one of bargaining power from the physicians to the patients. Eventually, pharma’s customers will become the patients more directly than before, with doctors becoming more of a “broker” – the people who writes the drugs but apart from that having no real power. Doctors are already complaining about patients leaving them if they don’t do what they’re told by the patients – “if you don’t write me this drug, I’ll go to someone else who will!”

There’s a bit of theatrical irony if this happens, because doctors will get a taste of what pharma sales reps have dealt with for years: being punted to the position of a measly “order taker” or “human sample dropper”. How about doctors eventually becoming “order takers” and “human Rx writers”?