Doctors, Money, and Conflicts of Interest
ฝัง
- เผยแพร่เมื่อ 19 ต.ค. 2014
- I'm a doctor. My father is a doctor. My colleagues are doctors, the people I train are doctors, lots and lots of my friends are doctors. But that doesn't meant that doctors sometimes aren't blind to certain issues like their own financial conflicts of interest. Sometimes we have to poke doctors with a stick. That's how we show our love. Conflicts of interest are the topic of this week's Healthcare Triage.
This episode is adapted from Aaron's NYT piece on the topic. References can be found in the links there: www.nytimes.com/2014/09/09/ups...
John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics
/ aaronecarroll
/ crashcoursestan
/ realjohngreen
/ olsenvideo
Dear editors of healthcare triage: please add graphs/charts when lots of numbers are being listed. It would make these videos so much easier to understand for visual learners like myself.
show me a fake cartoon and I'll be satisfied with all the other unprovable information
I just took the annual [required] class in ethics at my government job. Nearly all - if not all - of the conflicts you described are illegal for those of us who work in the public sector. In fact, even the appearance of impropriety is enough to be punished. I'm not recommending that doctors have the same rules. But wouldn't it be nice if state medical boards, the AMA, and other boards and professional associations at least looked at the rules issued by the Office of Government Ethics and other agencies to try to learn why we have them?
Also, I am more than disappointed that the FDA has not been using those principles with the members of its advisory committees and panels.
Topics in this video are important far outside of the medical field.
Good job on this one guys.
Thanks for this. I used to work for a hospital that will remain unnamed and pharma reps would bring in lunch for the entire office staff at least once per week. That was nice and I get that it was a good opportunity to discuss their drugs, clinical trials, and things, but so many coworkers said I was missing out because the reps used to give away tickets to sporting events, theater, etc. The reps wouldn't even go with the doctors (or staff who got the doctors' tickets for events they weren't interested in); they were just straight up gifts. I'm glad they discontinued that practice.
Glad you are covering this topic, conflict of interest is a serious problem. Of course the flip side of the issue is that doctors who go to a conference on a drug know more about that drug, its uses and application, and that can make them more likely to use the drug than those who are less familiar with it. Same thing is true of doctors who have financial interest in a company, they may simply be better informed about the product. That doesn't mean there aren't very real influences on doctors from these conflicts of interest of course.
Also, I think you should do an episode about bias. All doctors hold biases that impact their practice of medicine. There are studies showing doctors are less likely to prescribe pain killers to black patients which is attributable to racial bias. This is just one example. There is also medical bias about gender, sexual orientation, weight, disability, economic status, age, and many others.
You yourself have demonstrated such biases in the past. It is worth talking about.
Your first paragraph exactly what I was thinking. The situation looks bad (admittedly is /can/ get bad) because the money only flows one way, but their is also a flow of information, and knowledge is critical in healthcare (and research, which also has conflicts of interest). I wonder whether this is such a big a problem as misreporting of drug efficacy & side effects by pharmas. I think that would make a good topic too (certainly something I'm keen to learn more on - my only lead into the subject are the TED videos by Ben Goldacre, which are worth checking).
I agree an episode on bias would be good too. That's pretty worrying.
Wonderful video about a very serious topic. Keep em coming, Aaron!
Best, most cogent observations ever to come from HCT. Thank you.
I'm glad you finally covered this, and your NYT article is very well written.
Also, weird seeing someone with my last name (haven't seen many people with it)
Ethics is a big problem everywhere. Glad to see you're covering in your industry.
Thank you for this video!!!!
I am glad that this issue is being addressed. I believe that these conflicts of interests will always be present in health care. As for the medication, drugs are going to change and new drugs are going to arise. By going to a seminar to learn about a certain provider, new drugs, or the like, it should not be surprising that they leave with that product or that provider. They were informed, and with a good presentation, it is likely they would want to support it. Doctor's are going to need to change because health care and medicine are constantly changing and improving. As we are seeing this it should not be something we are afraid of. We need to look at it in a positive light and see that doctor's are adapting as the medicine industry grows. However, I would have to agree that when learning that doctor's would go as far as to accept gifts from the providers, it could definitely alter perceptions of the health care field. Doctor's should adapt to these changes if they feel necessary, but they should not be persuaded by gifts given by the provider. Accepting gifts is what turns this ethical situation into an unethical situation.
This is a topic that can go in two different ways and I am glad that it is being brought to public attention. Even though doctors are supposed to look out for their patient's best interests they are still humans and can be swayed by a company's offers to personally benefit them. This does not mean that they are automatically going to endorse a company that is not safe but it can definitely make the company stand out and be remembered. However, this is not necessarily a bad thing, especially if the company has good resources. If the company has something useful to offer to the medical field and is on good terms with the doctor then the doctor is more likely to become more informed on their product, and then prescribe it to patients to help them. By which this will benefit everyone involved.
Very well done video! I wonder how long it's going to take for something like the sunshine act to be passed for Congress...
My Grandfather became a Physician in 1929 as a GP and Surgeon, at the time you could become both, well before specialization. He of course was alive at the very beginning of the buying of doctors by the drug companies. And died in 1976. So he wasn't corrupted to as great a degree as those currently practicing are likely to be. I seem to remember that he would go to conferences and seminars. Which I am sure were organized by the drug companies, not just professional organizations he belonged to.
A very nice video on an important subject in medicine. Ben Goldacres "Bad Pharma" is a good read on that as well.
Can you do a video on open enrollment and changes in various states?
Where would I find this medical database?
Does anyone have the location for the public database that he spoke of. The one where doctors are listed with their contributions?
Also interested on how this would be enforced, what is the law if they just decide not to.
Can you make a video about over supplementing? Like how much is too much and is it harmful? Can our bodies absorb it all or do we pee it all out? Is it toxic? i.e. Protein powder, vitamins, amino acids, etc... Thanks! Love all your videos!
Maybe it's because the field I work in takes financial conflicts of interest as par for the course in our operations (everyone has them and rather than put people in a quandary, we just remove them from the situation entirely) but I don't see how anyone could think that someone could be objective when they have a personal stake in the approval of a drug. I'm glad the FDA is taking the steps they do. Education on what's out there is one thing, being wined and dined is quite another.
I've encountered this first hand. I have mild psoriasis and my dermatologist wanted to go hardcore on prescribing me biologics (a fancy way of saying "injections") which would have cost me ~$150/month and that's with insurance; not to mention I'd be on restricted diet and mandatory blood tests. My current prescription of a topical lotion is $12/month and deals with my psoriasis fine with no restrictive diet nor blood tests. Not all doctors are money grubbers but they do exist and you have to spot them when they want you want to try "experimental" drugs.
Is there a breakdown of which doctors are most likely to be influenced, or most likely to be targetted with gifts?
scumbag salesmanship 101 right here
if you wanna get rich, this is a good video for you to digest.
Yeah when ever I've gone to a doctor I could tell what I'd be prescribed by the clock, pens, golf clubs and all the other gifts in the office. It never came as a great shock when they recommended starting with that medication. Not that office supplies are the greatest influence ever by any means but that's just what was available on the surface.
I'm not saying conflict of interest isn't a serious issue that needs to be monitored and regulated, but what if a doctor goes to a seminar on a drug, expenses paid, but is there to learn and truly decides that the drug is the best for their patients? The whole thing is just so muddy... I feel like those few people who actually aren't affected by the gifts are going to suffer from something like that. I still think the public record is a great idea, don't get me wrong, but as patients we need to also keep an open mind to our doctor's intentions. Talk to them about why they accepted a gift, and decide if they were influenced by money or by actual facts.
I can be fairly accurate about what would have an effect on my desicions. Basicly EVERYTHING, I would even be affected by just the offer of a gift, even if I didn't accept it
"poke doctors with a stick, show 'em our love"
.... giggity.
Following a lifetime of research into American medical practices through the medium of popular television, I firmly believed all doctors there queued up to be given free sets of golf clubs and medical drug seminars at exotic beach resorts by pharmaceutical providers.
This episode of Healthcare Triage does not come as a surprise to me in the least :)
So where can you find this database?
Some details are here: www.ama-assn.org/practice-management/physician-financial-transparency-reports-sunshine-act
I'm curious, is the use of the term "gift" rather than "bribe" a convoluted politeness thing in which one wants to avoid being accusatory? Is there a defined difference? Because these gifts sound an awful lot like bribes.
I agree with your breakdown. It would be good if there was an independent term to be used for implied bribes.
What he didn't bring up (since he's not a psychologist) is that, oftentimes, the subconscious mind is influenced by the "gift," and the conscious mind makes a rationalization to cover for it - something along the lines of, "Only after receiving this gift did I take a closer look, and see how great this drug is," or "It may be expensive, but that's just the cost of research."
The mind is a complicated thing. It's important to educate everyone in positions of power - including, of course, politicians - to make sure they understand they can be subconsciously manipulated without knowing it.
It's up to the physicians to regulate ethics since it will certainly not come from the corporate side.
just curiose: do you have to pay the author of the NYT article ? I don't have idea how the copyright thing works, just want to find out some practical advice
I am the author of the NYT article! :)
Aaron is the author of the NYT article. -stan
Aaron is the author of the NYT article! -Tim
Aaron is the author of the NYT article! - Exodah
Aaron is the author of the NYT article! -Othelbark
Something is wrong with the audio again
Healthcare Triage Dr. Carroll, how often are you offered these gifts, and what is your preferred response to them? Would you offer any particular advice to other medical professionals as to what may be a proper way to deal with sales reps from various drug developers/distributors?
Can you do one on Chiropractors?
God damn it he's a doctor? Now I'm going to have to look somewhere else for my medical news. After all his entire livelihood is tied to telling me that I'm sick or there's something wrong with me, and who can trust someone like that. I better hope there's someone on youtube who isn't part of "Big Medicine" that is ambivilent about patient health.
Pfft, Haha! Good one :)
I understand that you're being sarcastic and I definitely get your frustration, but you touched on a serious issue when you wrote "his entire livelihood is tied to telling me that I'm sick". The current paradigm of fee-for-service medicine is under debate. The healthcare system (specifically, the patients and physicians living by the physician's charter) might benefit more from an outcome-based reimbursement system.
To lend some ethos to my comment: I'm a med student, so my own livelihood is under the looking glass too.
There is an Healthcare Triage episode on pay for outcome.
To mitigate this, the hospital system my mom worked for (and where most of my doctors are) no longer allows doctor's offices to accept swag from pharmaceutical companies- at least what's visible to patients. I know dinners and other gifts still happen, but I'm glad at least some of it is controlled.
Replace the words "doctors" with "politicians" and "pharmaceutical companies" with "lobbyists."
To quote Molly Ivins, "You Got To Dance With Them What Brung You."
Totally unrelated topic: my maternal aunt has Rosai-Dorfman Disease, a rare debilitating disease that not a lot of people know about can you here on Healthcare Triage Please help me in educating others on what it is and why most people don't know about it?
The American Academy of Pediatrics' 2012 statement on newborn circumcision was the product of serious conflicts of interest. Nearly all of the committee members who wrote the statement either had a religious bias in favor of circumcision, or made money by performing circumcisions. Outrageous.
Nice use of equipoise.
you would think that with all that higher education (4 years undergraduate.. 4 years of medical.. and 4 to 7 years of residency) that physicians would know that conflict of interest can easily exist.. i think that no matter the level of education.. everyone KNOWS that conflict of interest could exist.. but not everyone is AWARE of that fact.. awareness is a different mental process than simply knowing.. we can simply know a fact.. but how many are aware how this fact can affect our lives? well.. i guess we have to reflect upon our lives.. become more mindful.. become more truthful of our decisions and behaviors.. or we can make a little bit more money on the side (which is easier to do than all that reflection and subconscious searching) so.. either we all have to work a little harder by think about our actions while at the same time foregoing extra income.. or pay for some kind of regulatory unbiased independent agency that will think about our actions for us.. either way.. both solutions require we give up a little extra money.. but what we gain is integrity in the professional and thus the public respects that profession.. the public has faith in doctors (or politicians or etc) it seems like the ideal game theory solution.. we just all have to agree that integrity respect faith (intangible wealth) is worth more than the extra cash thrown to us (tangible wealth)..
It gets hard, because many times a lot of this stuff is insidious. Like as an example, drug reps routinely buy small things like lunches and stuff. Can you get affected by that? Of course. We'd like to think we're above it all, but we really aren't.
I'm in my first year of medical school right now. Although there's already PLENTY to learn in my other classes, I wish we had an ongoing class dedicated to this subject and other prevalent ethical issues.
perhaps it is implicitly assumed that such ethical training ought to have been learned elsewhere.. yet.. i get the impression that when any person learns any new field.. their ethics can readily be shaped by their initial instructions
Yeah, DestinyQx, I think honest self-reflection would eventually resolve many ethical clinical issues.
That said, there are some unintuitive dilemmas. You might face challenges like this: a pharmaceutical company wants to give you free samples, but you know that having the free samples will bias your drug choice. However, you serve a low-income population with members who could really benefit from free (sample) drugs instead of paying out-of-pocket and/or drawing on their healthcare plans. That's just one example, but gray moral areas like that are everywhere in clinical practice.
On top of that, not many students or physicians have tons of free time to self-reflect on issues they encountered during the week, much less reflect on them at the time of making an ethical decision. I think a class dedicated to common ethical dilemmas would help physicians wrestle these issues preemptively (prophylactically? lol).
They're just not being honest with themselves when they say they wouldn't be influenced.
Okay, but what about the politicians who passed this bill who are probably being drowned in "gifts" by lobbyists etc.?
Plus, my dad's a doctor and all he ever got was some pens and sandwiches from visiting reps. I guess they can report that, but if people are REALLY abusing the system and bribing doctors, why would they start reporting things now? It seems like the sort of thing that's hard to regulate/ keep track of...
#DoctorGate
Stop adding "gate" to everything. Watergate was called watergate because of the Watergate hotel, not because of "gate" being a magical scandal suffix.
HAHAHA!
Diana Peña
Take a joke.
Diana Peña
It's a meme not a misunderstanding of grammar.
*****
Only because of repeated grammatical failures. Seriously, it's just silly to add "gate", like how it was ridiculous for Oxford English Dictionary to change the definition of "literally" to mean itself and its opposite because people were too stupid to get it right.
This happens in others fields as well. My friend writes articles and so hotels will give her a couple of free nights stay so she can write a few good words. Not as bad as this pharmaceutical bribery but one day hopefully people will realize that 99% of the "legal" drugs out there only mask the symptoms instead of remedying the illness
I want to be a doctor so bad. I know college is gonna put me in debt but I want to help people.
Become a social worker. There are areas and people that physicians can't touch due to local laws and culture. Social workers can get to those patients that regional "common sense" will not allow physicians near.
If you could hear how the talk about their patients when they don’t think anyone is listening freaked me out. A lot of them look at their paitents like prey.
You missed one of the most obvious conflicts of interest and it takes place daily. Pharma reps come into doctors offices all over the country. They are pushing a new drug to replace the old drug (which surprise is just getting read to go generic/off patent) but they don't compare the old and new drug and if the new one is better or not. They use the comparison against the placebo, unless the doctor investigates further, which is highly unlikely he won't know if the drug is better. Even then it will be tough to determine. Plus the will give out a bunch of freebies to start to encourage more scripts be written. Now if the doctor starts pushing the new drug, the patient is not getting the best quality of care. Even beyond that though it stops incentivizing the drug company to improve the product which over the longer term is less beneficial to us all. This happens in doctors office s every day. There is a TED talk about this as well called battling bad science.
So true. I think its funny congress passed legislation making gifting transparent when they themselves are lobbied the hardest to pass certain legislation.
As aslway, truely really intrest. Som construtktiv kridisisum, your audio is duse not sound 100%
If only that actually worked...
"Only, disclosure doesn’t seem to help. Several studies have shown that when professionals disclose their conflicts of interest, this only makes the problem worse. This is because two things happen after disclosure: first, those hearing the disclosure don’t entirely know what to make of it - we’re not good at weighing the various factors that influence complex situations - and second, the discloser feels morally liberated and free to act even more in his self-interest."
danariely.com/tag/medicine/
It is very unethical for doctors on committees of certain drug companies to vote in favor of drug products or promote drugs because of their financial interest. Some doctors who advocate for pharmaceutical companies prescribe their drug in great quantities because they are essentially being paid to do so. I feel doctors should be advocating for pharmaceuticals strictly because they believe them to be the best and most cost effective for their patients. Some argue drug makers paying doctors leads them to become more informed about different medications and the products they are advocating for. I would like to believe this is the case, but there are most likely generic brands that are much cheaper and work exactly the same that doctors could prescribe. Honestly, I am not against drug makers paying doctors to speak about their product positively but, only if the doctors prescribe their patient with the absolute best drug for them and erase all bias from their medical practice.
I tried poking my friends with a stick and they just got mad and bruised.
ohhh but drug companies give so much (and sweet) swag
Who watches over Congress, though? Excellent episode, by the way.
#Doctorgate End all conflicts of interests in FDA advisory committees!
Most MDs are great people but bias is a subtle thing.
This nation was founded by rich merchants. We are an economy of cartels and cronyism: industry buys off the legislature and industry professionals to essentially become their inside sales staff.
The consumer doesn't have free choice. The options are constrained for us intentionally to maximize profits instead of provide fair open competition.
Ohh, Pharma.
4:56 There must be a name for this cognitive bias. It sounds similar to how almost everyone considers themselves an above-average driver, but if it has a name, I've forgotten it.
Hold on, I think you are exaggerating one problem due to how the survey question was asked. Let me provide an analogy. 1. How likely is it that you will buy an apple today? 2. How likely is it that others will buy an apple today? Because there are many others it is more likely for them to buy an apple than you, even if you are more likely to than the average of them. Their survey question could have been phrased are others more or less likely on average to accepted bribes or gifts than you. It may still reveal that people think others are less moral than themselves; however, it will be a more accurate response for what you are looking for.
How about "What percentage of doctors do you think will be influenced by these gifts"?
'are the average other doctors' (as you said all other doctors) more or less likely to be above average...that's a broken question. The other doctors ARE the average.
Why do the doctors on these panels need to know the company producing the medicine in the first place? Why not keep the company anonymous. Then the doctors can't really be biased based on which companies they own stock in... Am I missing something?
You know what, it doesn't even bother me that much that they are accepting money or trips or gifts. Honestly that can be a part of marketing. We all receive incentives to listen to a presentation or consider a product.
However! I cannot condone the act of voting for a product that you have a personal intrust in such as ownership of the company. (I know that with normal companies this is a type of fraud and insider trading.) I shudder to think how our medical advancement has been impeded over the years by bias members on a council. This is the part that really upsets me. (Sure, maybe that meant that a new medicine came out about a year later or something small unto the like, however, if that medicine could have saved a few more people from dieing, or even just one; how could we ever justify this? How much money was made by the bias voting that caused the delay; and could it ever be worth how much was paid by the sick and afflicted?)
So if hes a doctor doesn't that make everything he talks about being healthy or not healthy have hold little water, as he has conflict of interest to say what all the doctors say or he will lose his job if he don't? Thus the truth will never be told.
Cronyism in a socialist bureaucracy.Who would have thought?
whole family of con artists