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November 14, 2017
Quarterly Article
Catherine D. DeAngelis
December 2024
Dec 19, 2024
Back to The Milbank Quarterly
Physicians have long been quick to point out the social contract they have with their patients and the community in which they live. Sadly, several baser trends have gathered steam that have the potential to diminish the nobler aspects of the medical profession.
For example, the ever-increasing commercialization of health care has resulted in the perception that medicine is now primarily a business rather than a vocation. Reports of annual salaries of a million dollars or more are common and, currently, the average salary for primary care doctors is about $200,000 and the average for specialists is about $300,000.1
Unfortunately, some doctors have either been enticed or forced to practice for the sake of the financial bottom line rather than for the greatest benefit to their patients. This has led to many doctors leaving private practice to work for institutions. In fact, more American doctors now work for institutions than are in private practice. These doctors are often faced with the same commercial interests as doctors in private practice when they report to administrators who care most, if not only, about the financial bottom line.
For example, many health care administrators admonish doctors for not ordering unnecessary, expensive tests or for spending too much time with each patient. The latter is especially exasperating for doctors who care for elderly, intellectually disabled, or mentally ill patients whose problems take much time to resolve. In addition, doctors who care for intellectually disabled patients have more trouble finding an ER or hospital to care for these patients as they do for “normal” patients. That can lead to these patients suffering unnecessary (and expensive) morbidity or mortality.
Today, doctors are spending too many hours a day completing electronic health records, which don’t help all that much with personalized patient care even if they are useful for billing.
Too many doctors work for the marketing section of pharmaceutical and medical device companies. That is, they serve on the companies’ speakers bureaus where they present at medical centers, meetings, or conferences, using power point slides provided by the company that accentuate the positive aspects and gloss over the negative aspects of an expensive drug or device. These doctors are paid well for these presentations, often scheduled by the companies.
Other doctors prescribe expensive drugs because patients come to them with coupons for a free first prescription that they found in a direct-to-consumer advertisement by a pharmaceutical company. According to the US Food and Drug Administration (FDA), the only other developed country that allows such advertising is New Zealand. Rather than spend precious time with the patient discussing why the expensive drug is unnecessary, some doctors simply comply with the patient’s request. Unfortunately, once the first prescription is written, those that follow usually are for the same expensive drug. Just like the old adage about lunches, there’s no such thing as a free drug.
Increasing numbers of doctors prescribe expensive drugs when less expensive generic drugs would work just as well or prescribe unnecessary drugs, such as opioids, having been enticed to do so by very persuasive drug representatives who bear gifts such as food and tickets to games or the theater. Any doctor who accepts a gift from a pharmaceutical or device company representative, when the motive is clearly to get the doctor to prescribe their drug or device, is working for the company and not the patient.
The 2010 Physician Payment Sunshine Act was designed to increase transparency about financial relationships between doctors and teaching hospitals and manufacturers of drugs, medical devices, and biologics. The Act requires all pharmaceutical and medical device companies to keep a record of all money given to doctors and teaching hospitals. In 2015, $8.09 billion was given to 1,118 teaching hospitals and to 632,000 doctors. Slightly more than half of the money given to doctors in 2015 was provided for research, but the rest was for honoraria and gifts. Some, but certainly not all, of the honoraria were legitimate reimbursements to doctors who provided sound medical and scientific advice to the companies. The amount of money given for honoraria in 2015 decreased by 50% and for gifts by 30% compared with 2014. Similar data for 2016 are essentially unchanged from 2015.
Pharmaceutical and medical device companies pay for clinical trials to test their new drugs or devices, a requirement before the FDA will approve their products. These clinical trials and other drug research are conducted by doctors and other scientists and are published in medical journals. This is a means of alerting doctors of new research, but it is also a means of advertising the drug or device. The problem is that too often many of these published studies are then retracted (withdrawn or disavowed) by the journal because of problems with the research.2 While some retractions are unavoidable, the exorbitant number of retractions reported makes one wonder about how carefully the studies are being scrutinized.
Publishing practice guidelines are meant to assist doctors in making decisions about treatments. However, many, or in some cases most, of the doctors who serve on the guideline committees are paid in some way by the pharmaceutical or device companies that manufacture the products in the guideline. This begs the question: How unbiased can these doctors be?
So, what must be done? The simple answer is for all doctors to remember why they chose medicine as a profession. As a medical educator for more than 40 years, I know that medical students’ stated reasons for entering medicine have not changed one bit. They, like the majority of doctors, want to have a noble profession of taking care of patients. It would be well for all doctors to read (again?) the excellent 1927 publication, The Care of the Patient, by Frances Peabody. He stated that, “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is caring for the patient.”3
If physicians are truly allowed to care for patients, they must refuse to take less time with patients than needed, to order unnecessary tests, to prescribe unnecessary drugs or expensive drugs when generic or other less expensive drugs would work as well, to accept gifts from pharmaceutical and device representatives, to publish articles that contain tainted data, and to complete forms that do little or nothing for patient care. Those doctors who already practice in this way need to encourage all of their colleagues to do the same. Those who deem this to be an impossible task should remember Nelson Mandala’s sage advice, “It always seems impossible until it’s done.”
References
Catherine D. DeAngelis is Johns Hopkins University Distinguished Service Professor Emerita and professor emerita at the Johns Hopkins University Schools of Medicine (Pediatrics) and Public Health (Health Policy and Management), and editor-in-chief emerita of JAMA, where she served as the first woman editor-in-chief from 2000 to 2011. She received her MD from the University of Pittsburgh’s School of Medicine, her MPH from the Harvard Graduate School of Public Health, and her pediatric specialty training at the Johns Hopkins Hospital. She has authored or edited 12 books on pediatrics, medical education, and patient care and professionalism and has published over 250 peer-reviewed articles, chapters, and editorials. Her recent publications have focused on professionalism and integrity in medicine, conflict of interest in medicine, women in medicine, and medical education. DeAngelis is a member of the Institute of Medicine and a fellow of the American Association for the Advancement of Science and the Royal College of Physicians (United Kingdom). She currently serves on the advisory board of the US Government Accountability Office, is a member of the board of Physicians for Human Rights, and serves on the board of trustees of the University of Pittsburgh.
