Friday, August 22, 2014

Just a Pen, Not a Payment

Medicine is a lot of things these days. It is a science and an art at the same time, but it's also a business and an opportunity. The latter two aspects of this profession, or as one elderly physician I know says it is a "calling," provide a dilemma for some and a bit of extra cash for others.

No doubt about it, ethics plays a big role here and some of the major forces in medicine have tried to address the touchy problem of ethics. Limits have been placed on just how expensive those nifty little gifts to newly minted physicians can be and what can be accepted in good conscience. But, as in any legal document, there's wiggle room for interpretation. How do you interpret not accepting cash gifts, but allow "funds are distributed to recipients without specific attribution to sponsors." So, giving away some money but don't say who gave it? But doesn't that still mean it came from some sponsors of such programs and doesn't that have a halo effect on every sponsor participating? 

In prior years, I was bemused as the young medical students who were about to graduate whooped and hollered when they saw the shiny stethoscopes, the textbooks, the pens, the tablets, even the software. It was like Christmas in late Spring for them and they delighted in it. Some, with rather grim countenances, announced that they were giving it all to the local healthcare clinic. They were in the minority of the group merriment. Others just delighted in all of it. So this was what medicine was about to give them. It was wonderful. Sure, that was years ago and, sure, things have changed.

I have worked at several hospitals and healthcare settings over the years and I've also sat in waiting rooms both as a patient and a member of a research team. The waiting room experiences are familiar to anyone who has watched the detail (aka sales persons) come and quickly be ushered into the office.

On some occasions, the person (used to be men, now it's shapely, well dressed young women) would be carrying expensive textbooks or small pieces of computer equipment. On others, the salesperson was followed by one or two men carrying large trays of steaming foods for a lunchtime presentation to the staff. Education, after all, is necessary in medicine and staff training is essential. But it's also nice to have someone pay for your lunch as you sit and quietly and watch them run through their slide presentations.

Some jobs I've had allowed me to see physicians sneaking out (yes, sneaking out) of the office to give presentations of prepared slides to physicians and other healthcare workers. Last time I questioned one, he got $1,500 for each of his efforts--all while he was receiving his salary as a full-time employee at an agency. I only know because I had to help him figure out how to use a USB drive on a computer. But is he any different from the psychiatrist who held five full-time jobs (all at the same time) at various facilities? Or the other psychiatrist who signed in at one job, went to another full-time job and then, at the end of the day, went to the other to sign out? Of course, he's retired now and left instructions that he was to have no forwarding address provided to anyone.

Now a physician who has also seen the underbelly in its unattractive presentation has provided another look at medicine from his perspective.  You can read it in "Doctored: The Disillusionment of an American Physician" if you wish.  It it, according to reviewers, an often unpalatable view of profiteering, cronyism, unnecessary testing and generally reprehensible behavior on the part of those who have sworn to do no harm.

Again, there's that tricky little word play. Doing "no harm" to whom or what? Do they harm the patient or society as a whole when they order unnecessary, very expensive testing that the rest of us will pay for? How about "no harm" if a patient is exposed time and time again to potentially harmful x-rays or other radiation? Well, I'll let one reviewer, from the Yale School of Medicine respond when they wrote that (the book) is "a fantastic tour through the seedy underworld of American medicine.” Enough said on that account.

A physician I respect once told me that he had breakfast each morning on a regular basis with peers at a major hospital. One of the peers is an orthopedic surgeon who, when he was leaving the table, would regularly joke, "Well, got to be off to do another unnecessary surgery." He was joking, surely. What's the standing joke in medicine about surgeons? Go to a surgeon and you get surgery. Do they imply that you get it whether you need it or not? Oh, no, can't be true.

What's the remedy for all of this? Tighter control by someone or some agency? Doesn't always work because of the lobbying that's involved and we consumer have no lobbyists to speak of. Hospitals should ride rough shod on fast-and-loose physicians? Not when they're the ones who bring in all the money and funds all those extensive building projects. Will the new trend of hiring physicians away from private practice and making them hospital employees help? Do you think so?

All it comes down to is caveat emptor as it does when you buy anything. You're buying or paying for a service and you have a right to negotiate, get a second opinion or begin a grassroots movement against anything you see needs fixing.  Yes, it's left on your already-burdened shoulders.