Physicians and US Health Care 2019

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Every undisclosed payment, free sample or all-expenses-paid trip is an attempt to manipulate. And whenever clinicians or researchers take the bait, it’s patients who are put at risk”. R Pearl Forbes Dec 10 2018

There is ample and well documented evidence of the way drug and medical equipment manufacturers co-opt and groom both physicians and the public. (1) For physicians the evidence is all around us. Physicians accept:

Gifts that influence medical decisions or practice.: :

Meals, and samples from attentive, attractive drug ‘reps’.

Subsidized Continuing Medical ‘ Education’ ( read grooming!)

Subsidized or free medical meetings

Free samples of costly drugs to promote later sales.

Physicians are not quite innocent in accepting such freebies; we know there is a payment due, but fail to make the obvious conclusion: Don’t accept the bribe!

ProPublica Dr B gave overly favorable reviews for Swiss drug company Roche but failed to disclose $3 million in direct payments from the company since 2014, claiming the lapses were “Unintentional”!

Brigham and Women’s Hospital in Boston revealed that Piero Anversa, a high-profile physician and cardiac stem-cell researcher, had falsified and/or fabricated data in at least 31 medical journal publications.

Tito Fojo, MD, PhD in The John Conley Lecture found that “the last 71 chemotherapy agents receiving FDA approval extend life by an average of only months—time often spent in pain, isolated from friends and family.” (2)

Misleading Direct To Consumer TV ads largely pay for ‘free’ TV. They are often so misleading as to be absurd; but they work! When an ad claims that a drug, “significantly increases the chance of living longer” What does that mean? Nothing! Another ad can state that a medication ‘can improve (symptoms) ‘ up to 75 %’ That must mean-75%-100 % may see no improvment! ( Step right up Ladies and Gentlemen! See the two headed woman grow another body!)

Medical trials funded by drug companies are 30% more likely to show their drugs are safe and effective compared to independently funded studies, according toa consortium of medical and statistical experts (the Cochrane Coalition.)

Is there something physicians could do? Various new Oaths have been written:

I swear to fulfill, to the best of my ability and judgment, this covenant:

Hippocratic Oath: Modern Version
Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University  (Good, but anachronistic in 2019)

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

“The original oath is redolent of a covenant, a solemn and binding treaty,” writes Dr. David Graham in JAMA, the Journal of the American Medical Association (12/13/00). “By contrast, many modern oaths have a bland, generalized air of ‘best wishes’ about them, being near-meaningless formalities devoid of any influence on how medicine is truly practiced” Probably modern oaths are written by a committee or by congress! (Sorry.My rant…Ed)

I agree the modern oaths are not much improvement in the 21st Century. We live in a new era, the equivalent of the time when the printing press and cheap paper appeared; what followed then was constructive chaos because information, and commuication only available to the few, became available to the many. Isn’t that what is happening today on a much wider scale? A world wide scale? It is as true of medical information as everything else. Therefore even if we physicians may refute or ignore the assertion that we are complicit in the prohibitive cost of US Health Care, we should realize that is irrelevant; we are no longer in charge. Who is? Our world with almost unlimited access to information formerly confined to the elite of medicine: to us. If we think we are in charge we could read Marcia Angel’s book; and if we still want to be the alpha wolf of medical care, simply going on line and looking up any disease, condition, medication or treatment option should abuse us of that illusion. Is there reason to reconsider the ethical practice of medicine? Even by drug companies? Yes!

If so, physicians should do that both individually, and collectively through professional organizations. We cannot absolve ourselves from being complicit by saying “ I myself wasn’t paid millions.” Rather, we could consider this: “I sold myself far more reasonably, like most of my colleagues! Still, I am not altogether innocent; I realized there would be some kind of payment due, but failed to make the obvious conclusion: Don’t!:”

I graduated under the old oath, from the University of Minnesota School of Medicine in 1954 and have been grateful every day of my life. There is no more privileged, challenging, joyous, or fulfilling work. Some things do not change! Not yet at least…

We should consider an Oath something like this which:Recognizes that patients have more access to information and therefore are more able to participate in medical decisions about their health and health care, and reads as follows:

I PromiseTo:

Conduct myself in the most rational and far sighted way I can, avoiding careless, thoughtless, or self serving prescription of medications or procedures that may harm the biosphere, or the health of my

patient or the bioshphere, or the wider community.

Honor traditional, rational and moral standards of medical ethics but willingly discuss and render my opinion about those I feel are unwise or harmful.

Refuse nominally free continuing medical education (grooming) through enticements.

Honor my patient as I do myself, being always willing to take time to explain the reasons for my opinions and always ready to listen and consider respectfully my patient’s ideas, concerns, objections and wishes.

Honor my patient’s right to choose among the various options for treatment or nontreatment.

Condemn  and Reject  Direct to Consumer Advertising by drug companies, manufacturers of medical hardware or devices; and by physicians or other healers.

Refuse payment for unmerited ‘research’ and speaker fees; where these may be justifiable, I may accept only after independent peer review and a commitment to total transparency.

Always take into consideration whatever effect my practice may have on the environmental, medical, biological, and economic aspects of medical care.

Alwaysbe ready discuss and to adjust my fees according to my patient’s request, regardless of any presumed ability to pay.

Respect the ethical guideline of medical care, Primum non nocere, First Do No Harm, while carefully taking into consideration my patient’s personal needs choices, and wishes.

Hold my patient’s medical history, diagnoses, and treatment to be privileged communications between us only, unless my patient directs me to act otherwise, or when consulting with a medical colleague about a difficult case, where the consultation is also a priveleged communicaion.

(1) Among the best reading on the subject are:

The Truth About Drug Companies by Marcia Angel, MD. For many years she was editor of the New England Journal Of Medicine. (ISBN 9780375760945)

Overtreated by Shannon Brownlee (ISBN: 9781596917293)

Selling Sickness Ray Moynihan, Alan Cassels (ISBN-13: 978-1560258568)

Mistreated: Why We Think We’re Getting Good Healthcare—And Why We’re Usually Wrong,”by Robert Pearl MD (ISBN-13: 9781610397650)

(2) JAMA Otolaryngol Head Neck Surg. 2014;140(12):1225-1236.

(3) No doubt freedom of speech could be claimed in defense, and yet Direct to Consumer Advertising is like shooting an automatic weapon into a crowd. Freedom to kill with an automatic weapon is the same sort of crime as killing through dishonest and deceptive advertising. One is killing for its own sake, the other is killing for profit. Neither is protected free speech!)

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