ProPublica Vital Signs

It has been a while since ProPublica came out with a list of physicians who receive money from the pharmaceutical or medical device industry.  They began posting their new list of physicians who get the greatest reimbursement to the outrage of some who saw their Twitter post.  They also posted their updated Vital Signs search engine that allows anyone to search for how much money a physician receives as payments from the pharmaceutical or medical device industry.  I was able to locate my profile (it is not always easy) and it is readable. I do it when they post an update just to make sure there are no errors.  I don't accept money from anybody and also don't attended sponsored free CME courses because that is also listed as a benefit from whoever is sponsoring the course.

Although they are using a practice address I have not had for over 9 years (it is blurred but available on the ProPublica site) - when I was at that site I saw many Medicare and Medicaid patients.  At one point those were the only patients I was treating.  The disclaimers written on this page need clarification.  I am currently working 4 days a week and for me that is at least a 45-50 hour week and seeing full schedules of patients. The reason ProPublica has no information on my medical practice is that I receive no payments from the medical device or pharmaceutical industry, but you don't know that for sure by reading this information and the disclaimers. The introduction to the new database update gives an example of the reporter searching on the names of his primary care MD and the consultants he has seen.  He looks at the report of payments in terms of royalty or licensing fees, promotional speaking, consulting, travel  and lodging reimbursement, and food and beverage reimbursement.  What he does not say is what these figures mean to him.

I have written about this database in the past in terms of what it does and does not mean.  Over the past decade these payments were used as an easy way to discredit physicians, in some cases entire specialties.  Psychiatry and psychiatrists were at the top of the list, despite the fact that according to ProPublica they were ranked well below most other specialties in terms of medical industry payments.  The furor seems to have diminished as physicians are now subject to more rigorous payment reporting than politicians. In modern society - it seems that the illusion of transparency is all that is required to satisfy the moral outrage of the public.  After all - we have politicians who are actively engaged is legislating issues that affect their top campaign contributors.  There could probably not be a more significant conflict of interest and nobody bats an eye.

Despite the unrealistic idea that physicians are easily influenced and are in lock step to treating their patients according to orders from the pharmaceutical and medical device industry - this database serves a symbolic purpose.  That is - personal treatment from your physician will somehow be better now that all of these payments are known. You might make value judgments about physicians on that basis, but it would probably be a mistake. Physicians should be paid for their work and their intellectual property.  As a group they end up giving far too much of it away. And the largest conflict of interest affecting personal medical care is not mentioned in this database.  That is how your insurance company, managed care organization, or pharmaceutical benefit manager rations your care and tells your physician what they must prescribe, what tests to order, and how they can treat you if they want to remain an employee or get reimbursed.  Don't expect to see those numbers anytime soon. And by the way - that rationed care adds at least a trillion dollars to the health care budget - just as a jobs program for administrators and it skims an unknown (but probably large) percentage off the treatment your physician really wants to provide.

In the meantime - remember that this blogger is beholden to no one.

George Dawson, MD, DFAPA



Supplementary 1:

I discussed some critical issues when a Presidential appointee stood to make massive profits while in the Executive Branch.  Although that deal fell through, the President himself has made an estimated $2.3 billion in profits while sitting in the Oval Office.  This is the same President that provided massive tax cuts to businesses and massive rollbacks in environmental regulations on businesses. In the meantime, physicians accepting $10 worth of pharmaceutical or medical device company pizza are reported to the payments database.

Should $10 worth of pizza be a red flag for anything?

Where Are All of the Pizza Shamers?

On the drive home tonight I was listening to a radio piece about the new White House Press Secretary.    Anthony Scaramucci, was apparently a banker and hedge fund manager before he accepted the new role.  He was the head of SkyBridge Capital LLC and sought approval in January to sell this fund to a group of Chinese investors.  He could make as much as $125 million off of the deal.  The deal requires approval of the Committee on Foreign Investment in the United States (CFIUS) since it potentially involves national security issues.  Another interesting aspect of this sale is that the President can apparently veto CFIUS decisions, although that has never happened in the past. Several commentators have discussed the role of White House Press Secretary as being a critical role in the administration.  From an ethical standpoint, the relevant question is - should anyone with a pending large sale to a foreign power that is under review by an agency of the federal government be placed in such a position?

Similar questions and others have been a constant consideration with President Trump and his administration.  He has refused to distance himself from his businesses by placing them in a blind trust like previous members of the executive branch.  That is the most glaring problem even though elected officials apparently get a pass relative to non-elected employees who have to adhere to Standards of Ethical Conduct for Employees of the Executive Branch.  Additional criticisms include the foreign and domestic Emoluments Clauses, prohibiting elected officials from accepting gifts or making a profit from their elected position.  Those criticisms have included hotel deals by foreign concerns in staying at the President's hotels or golf clubs and whether investments by government employee retirement funds in the President's businesses constitute violations of these clauses.  An encyclopedic look at these potential conflicts of interest are included in reference 3 below.  The only offsetting factor in terms of the potential to make money from some of these areas was an analysis in the Economist  - suggesting that the President's business is mediocre and not very dynamic.  That author thought that it would be several years before any profits could be realized due to these constraints.

The lack of transparency for the President and the Executive Branch is stunning, but I think consistent with what could be expected from placing a businessman in the White House.  Americans have general amnesia when it comes to the mistakes of history.  Despite a Hollywood movie, most people forgot that in the financial sector engineered financial crisis of 2008, only one top banker went to jail and that was for concealing hundreds of millions of dollars in mortgage backed securities losses at Credit Suisse (5).  The way around financial conflict of interest is to design a system where everyone's financial security is at risk all of the time and to let the investor know that absolutely nothing can be depended upon.  Pages and pages of boilerplate illustrate this concept.  Lose everything and it always comes down to your lack of due diligence, not the financial adviser who is selling you stock and shorting that stock at the same time.  What do Americans expect will happen when they elect a President from that ethos?        

The standards for physicians are much different.  Physicians can be reported to a database and listed on that database for accepting a meal worth as little as $10.  In the heyday of drug representatives trying to convince physician to use their products the common currency was pizza.  I used to see these reps dragging large boxes of pizza through the hospital where I worked usually to a Grand Rounds.  People would pick up a piece of pizza and eat it during the noon presentation and then go back to work.  Eventually arguments were made that even a single piece of pizza would bias a physician into prescribing a drug from the pharmaceutical representative who purchased that pizza.  Examining the database of physicians who accepted payments shows that the vast majority on on the list because they were pizza eaters or they were listed for attending a company sponsored continuing education event.  Research was presented to prove that pizza or an equivalent trivial reimbursement led to the expected pattern of prescribing.  Psychiatrists were criticized far more than other physicians.  I have posts on this blog that highlight the poor quality of these arguments and the associated research.  Those posts include clear data that refutes the basis for pizza shaming and suggesting that there was something unique about psychiatry.    

The Institute of Medicine argument is that since it is hard to tell the difference between an appearance of conflict of interest and true conflict of interest - in the case of physicians they must be considered the same thing.  The IOM rationalizes their opinion as necessary to maintain public trust because of the traditional role of the physician.  Coincidentally their opinion makes sanctioning bodies like the IOM and other organizations that purport to tell physicians what to do and how to behave even more important and central to the medical profession.  After all what would physicians possibly do without the IOM and other sanctioning bodies meting out these sacred opinions? The short answer of course is what they have been doing since sometime around the 4th or 5th century BCE and Hippocrates in Epidemics: "As to diseases, make a habit of two things—to help, or at least to do no harm."  The writings are considered the foundation of the main elements of modern medical ethics.

Rather than considering ancient history - ask the question - what is the the larger conflict of interest - a $5 piece of pizza provided by a pharmaceutical company or millions to hundreds of millions of dollars in trading profits? What is the appearance of conflict of interest versus actual conflict of interest in those two scenarios?  In other words, if the party questioned denied they were influenced by a piece of pizza or a million dollars - who is the most likely to be lying? Keep in mind - the pizza is gone after you eat it.  No matter how good it was the benefit is transient and overall trivial.  Most people would not say that about a million dollars.

Considering more realistic  numbers for Congress rather than the Executive Branch, the average donation to a member of Congress from the pharmaceutical industry is $46,579 (averaged across members of both houses).  What will have more impact, the money to a Congressman who is writing laws and regulations that govern the industry or a piece of pizza to a physician who may or may not write a prescription for that company's drug? That is assuming the Congressman is writing the law.  There is plenty of evidence that the lobbyists either write it or directly influence it. You can't get that kind of influence with a slice of pizza.

Taken at another level, the idea of physicians being so important in society that they must be held to a standard that few other citizens are makes sense in terms of individual health care.  It does not hold at the level of society in general.  It takes relatively few politicians to make decisions that affect the lives of tens of millions of people.  Those decisions can result in mass casualties and result in generations of people living in armed conflict and poverty.  Political decisions can result in large segments of society being actively discriminated against.  Economic decisions can transfer wealth from citizens to favored industries at a large cost to individuals and their families.  For all of these reasons - the idea that physicians should be reported for accepting pizza at a conference and members of the executive branch talking to potential business partners when they are supposed to be representing the best interests of the American people is more than absurd - it is an outrage.

Where are all of the pizza shamers when they can really make a difference?  Why aren't they focused where they should be?


George Dawson, MD, DFAPA                





References:


1.  Reuters.  Scaramucci Awaits U.S. Approval for China Deal.  July 21, 2017.

2.  Adrienne Hill.  Scaramucci's hedge fund sale to Chinese firm could pose a conflict of interest.  Marketplace.  July 27, 2017.

3.  Jeremy Venook.  Trump’s Interests vs. America’s, Pensions Edition.  The Atlantic.  July 27, 2017.

4.  The Economist.  Donald Trump’s conflicts of interest.  November 26, 2016. (Contains an infographic of the Trump organization's estimated value).

5.  Jesse Eisenger.  Why Only One Top banker Went to Jail for the Financial Crisis.  New York Times Magazine.  April 30, 2014.



Attribution:

Pizza slices are from Shutterstock per their standard licensing agreement for non-commercial use.
Stock photo ID: 122225896 Cheese Pizza with white background, close up - by Hong Vo.  Accessed on 7/28/2017.

Wait A Minute - Is Psychiatry Less Unhinged Than Most Other Specialties?

For the past decade psychiatry has taken far more than its share of hits on conflict of interest from both within and outside of the profession.  There are any number of bloggers that claim their reason for existence is to keep the profession honest.  Needless to say - a smug attitude like that rubs people like me and the majority of my colleagues the wrong way.  But I will go beyond that in terms of conflict of interest and have in many posts on this blog.  Unlike managed care administrators and US Senators, I believe that even physicians are entitled to be paid for the work that they do.  That includes providing CME presentations and doing consulting work - whether or not that includes payment by pharmaceutical companies or medical device manufacturers.  The only reason I do not do that, is to keep my name off the corruption list (implicit) that is currently compiled by an agency of the US government.  That list is episodically analyzed by consumer agencies who think that they are doing somebody a favor by naming any physician who gets reimbursed by industry.  My reasoning is simple - businesses and governments already have a painfully large amount of leverage against physicians -  why provide them with more?  Especially when it involves a good faith effort on your part and somebody is distorting  that effort and doing their best to make it seem like you have done something wrong. More importantly there is the frequent suggestion that a physician is aligned against the interests of their own patients.  I don't think that happens, even if a name is on that list.

This decade long campaign to compile the information has resulted in a difficult to decipher database with many errors.  It takes time to go through the data and sort it out.  It is impossible to try it on a casual basis.  It is a full time job.  The first of these disclosures came out in July of 2015 from ProPublica.   In the article, they looked at the number of days per year that a physician would receive industry payments.  They also looked at the top 20 MDs in each state in terms of payments received and in my home state there were no psychiatrists?  Wait a minute - weren't psychiatrists maligned in the press at the national level by a US Senator and also at state levels as being frequent recipients of pharmaceutical money?  In the most popular post on this blog - I point out that erroneous assumption used by a reporter to criticize the DSM-5 process at the peak of DSM-5 hysteria.  In an attempt to suggest that the DSM-5 may be swayed by the fact that the APA received money from the pharmaceutical industry the author fails to point out that the money received was less than half of what another specialty organization received.  I pointed out in a separate post that the theory that pharmaceutical company money to physicians is tied to pharmaceutical prices is equally flawed.  Taking physicians totally out of the loop results in the most expensive pharmaceuticals in the world in the USA.  That suggests that the monetary influence occurs at the level of Congress and not physicians.

The May 2, 2017 edition of JAMA has a conflict of interest theme.  Many of the articles are editorials with very predictable conclusions.  For the past decade conflict of interest in medicine has been simplified on the one hand in terms of definitions and solutions and politicized on the other.  I abstracted the table at the top of this post from one of the data driven articles (1).  They analyzed data from the CMS National Plan & Provider Enumeration System (NPPES), a database of all allopathic or osteopathic physicians with a national provider number (NPI).  The NPPES records input of all general payments, research payments, and ownership interests of these physicians.  General payments were described as all forms of payments (like speaking fees, food, beverages) other than research payments done under a written protocol.  The ownership interest was presumably in medical concerns but that was not really specified in the article.  The specific listing of specialties is available in the full text of the reference below.  My only focus here is on psychiatry.  I don't think the rankings or specific amounts have any particular meaning.

The abstracted table lists two of the end points in the article -  the percentage of physicians receiving some kind of general payment and the percentage of physicians receiving more that $10,000 per year.  The $10,000 amount was flagged by the the US Department of Health and Human Services as representing "significant conflicts of interest".  In fact, for most physicians who do consulting - it represents about 2 weeks of work.  The news for psychiatry reflected the reality that I am aware of.  Psychiatry was mentioned just twice in the article and both of those mentions were in the above highlighted table.  None of the headlines from the past decade that psychiatrists were getting more money from pharmaceutical companies than anybody else.  A little more than a third of psychiatrists got some kind of general payment with a median value of $171 (median interquartile range of $34 - 442.)  For perspective - I purchase 2 or 3 new textbooks a year that typically range $300-400 apiece.  I also subscribe to the standard online internal medicine text at a cost of $500/year.  I am not saying that the transaction involved textbooks but many do involve educational materials and I am not sure they are not added into this figure.

The second endpoint is the $10,000 figure and psychiatry is lower on this metric with 3.6 % of psychiatrists getting this level of payments.  For context, the upper end of the range for these payments is 11-12% for some specialists and the lower end is at about 1%.   Proceduralists (surgeons and interventionalists like cardiologists) tended to get the highest level of payments usually due to substantial licensing fees and ownership interests in the industry like medical imaging facilities and surgical facilities.

The authors do not draw many conclusions about the data.  They point out that there have been some concerns about accuracy.  In their conclusion section they point to other studies about connections between payments and prescribing patterns that suggest a "subconscious bias" in their decision-making.  In other words, accept a free lunch and start prescribing the medication of the pharmaceutical rep that bought the lunch.  One of the reasons I continue to read these articles is to see if the "subconscious bias" argument has any more evidence to back it up than speculation and rhetoric.  I continue to not see very much.  I have pointed out the flaws in one of their references in a previous post.  In other words there are a number of explanatory factors operating here other than "subconscious bias".  I have not seen any Manchurian candidates among my colleagues.  Physicians use a lot more discretion in prescribing medications than whether or not somebody bought them a piece of pizza.  The easiest way to avoid the brainwashing accusation is to not accept the pizza or payment for an educational presentation.  That is what I and two-thirds of my colleagues do.  When you are squeaky clean according to the US government/CMS, it is easy to develop an unrealistic idea about yourself - as if this hall of shame approach means anything.

The downside of course is that industry and medical education suffers unless there are incentives out there for physicians to do additional work.  If you happen to be a national expert in demand - will you fly back and forth across the country to educate your peers for nothing?  Maybe a time or two but not much beyond that.  If the pharmaceutical or medical device industry needs consultation from an expert - will you go to a multi-billion dollar a year business and provide your expertise for nothing?  There are no academics from any other department in any university that are expected to do that.  Another piece of the equation that is never mentioned is how physicians are reimbursed relative to the pharmaceutical industry.  An asthma specialist can see a patient once or twice a year and during that time prescribe $4,000 to $6,000 worth of inhalers.  That specialist might bill $200-300 for their professional time, but that will be discounted by insurance companies.  An argument can be made that physicians are seriously underpaid for managing expensive products and working for the industry is one way around that.  In other words - if physicians were paid for all of the high volume work that they do - they may be less interested in outside consultation with industry.

There are additional arguments about conflict of interest that nobody seems to talk about.  Physician owned medical facilities are often described as being significant sources of self referral conflict of interest.  But what are the advantages of physician ownership?  Not being managed by non-physicians would seem to be the clear cut advantage.  Would these environments provide higher quality and more professional services?  Would they be more likely to treat physicians fairly and cause less burnout?  Would they be more likely to be able to provide the full spectrum of services that their patients need?  Who has the greater conflict of interest - a physician employee of a managed care company who is paid to ration health care for the company's interest or a physician who owns the business and can provide services based on his or her idea of medical quality?  The evidence that these differences exist is widespread.                      

Finally, how much of this conflict of interest rhetoric focused on physicians is designed to control them and keep them in line?  Although there are always qualifiers about this data including its accuracy, the federal government seems to have upped the ante by their description of the $10,000 marker.  Is this the 21st century equivalent of billing and coding violations from the 1990s?  Those investigations were driven more by politics, convention and rhetoric than any wrongdoing.  I can't think of a better example of that than doing $10,000 worth of consulting work and finding out that your name is now on a list produced by the federal government and some media outlet is implying wrong doing or quid pro quo with pharmaceutical companies.

Those are the facts of the list as I see them.  There has not been much discussion of the article or the theme of this edition.  The data within psychiatry confirms what I have seen and it has never been as shocking to me as it has been typically portrayed either in the media or by groups interested in influencing physicians.

It is not shocking at all.


George Dawson, MD, DFAPA



References:

1:  Tringale KR, Marshall D, Mackey TK, Connor M, Murphy JD, Hattangadi-Gluth JA. Types and Distribution of Payments From Industry to Physicians in 2015. JAMA. 2017 May 2;317(17):1774-1784. doi: 10.1001/jama.2017.3091. PubMed PMID: 28464140.

2:  JAMA May 2, 2017, Vol 317, No. 17, Pages 1707-1812.  This entire issue is about conflict-of-interest and the link is here.


Supplementary 1:

Before sending any inflammatory comments please remember that I don't eat the free lunch or accept industry money from anybody.  Feel free to look that up on any list.

Supplementary 2:

Original form of the table.  I had to convert it to a graphic version at the top of this post.

Per Physician Value of General Payments to Allopathic and Osteopathic Physicians by Specialty in 2015
Percentage of physicians receiving general payments	Percentage of physicians receiving >$10,000
1.	1.
2.	2.
3.	3.
4.	4.
5.	5.
6.	6.
7.	7.
8.	8.
9.	9.
10.	10.
11.	11.
12.	12.
13.	13.
14.	14.
15.	15.
16.	16.
17.	17.
18.  Psychiatry (37.3)	18.
19.	19.
20.	20.
21.	21.  Psychiatry (3.6)
22.	22.
23.	23.
24.	24.
25.	25.
26.	26.

Supplementary 3:

Some additional points of interest from other articles in this supplement:

589,042 of 850,000 active physicians in the US received some type of general payment in 2015 with a mean value of $400 and a median value of $138.

Any physician registered at a sponsored CME event is considered to have received a payment whether they consume provided food or beverages or not.

from:  Steinbrook R. Physicians, Industry Payments for Food and Beverages, and DrugPrescribing. JAMA. 2017 May 2;317(17):1753-1754. doi: 10.1001/jama.2017.2477. PubMed PMID: 28464155.

The threshold for reporting is a $10 transfer to the physician.

"At the same time, most physicians have essentially no meaningful COI."

from:  Lichter AS. Conflict of Interest and the Integrity of the Medical Profession. JAMA. 2017 May 2;317(17):1725-1726. doi: 10.1001/jama.2017.3191. PubMed PMID: 28464163.

          

Hospitalists.....

I was a hospitalist before the word was fashionable.  It was July 1988 and I had just completed a 3 year post residency stint at a community mental health center as part of a public health service scholarship payback.  For one of those years I commuted another 300 miles to keep a community hospital psychiatric unit open.   I headed for the hospital where I did my rotating internship in Internal Medicine, Pediatrics and Neurology.  It was the only real metropolitan inpatient treatment setting I had known at that point.  In my residency program, the interns were split up into two groups and each group worked at one of the major county hospitals in the Twin Cities.  It was a unique setting at that time because psychiatrists provided almost all of the medical coverage.  They had to be able to diagnose and treat a lot of common medical problems, write for all of the patient's medications, attend to acute medical problems and do the appropriate diagnosis and triage.  I had a wide range of medical problems admitted directly to me ranging from gunshot wounds to delirium.  Any psychiatrist working in these conditions realizes that the term "medically stable" is a relative one.  I had many patients admitted to my service with severe medical problems only because they also had a severe psychiatric disorder and were symptomatic at the time.  In many cases I had to rapidly assess them and transfer to medicine or an intensive care setting.

I had excellent back up by consultants and many of them to this day are some of the best physicians I have ever seen.  But they really did not want to hear from me unless I had a very specific probable diagnosis and most of the evaluation was done.  There are not too many places in psychiatry where jobs like that exist anymore.  If anyone asks me about similar positions - I actively discourage them from accepting a similar job.  With this arrangement the work is far too long and all of the medical care is provided for free - psychiatrists do not get any extra credit for it.

In those days there were six of us covering 3- 20 bed wards, five days a week.  The ads for psychiatrists these days often speak of "psychiatric hospitalists" - but every one of them specified no medical coverage.  They also tend to leave out the part that it is basically a rapid triage and discharge position and the job is to either maintain or cooperate with high discharge rates.  The only thing they have in common with the Internists and Family Physicians who have come to be designated as hospitalists is that they work 7 days on and 7 days off.  A schedule that very few people question.

I naturally picked up this week's copy of the New England Journal of Medicine to see what the two perspective pieces on hospitalists (1,2) had to say.  I was also interested because my brother is an Internist and over the years we have discussed the issue at length.  The initial essay by Wachter and Goldman documents the rapid rise of hospitalist care as a medical specialty.  Since 2003 the number of hospitalists has increased 5-fold to 50,000.  That makes hospitalists the largest speciality within Internal Medicine.  They cite the growth of managed care, Medicare DRG payments, and possible evidence as reasons for the growth of the field.  I am always skeptical of the term efficiency especially when it is combined with the term quality.  I guess it is difficult for some people to accept the fact that managed care and Medicare DRG payments are rationing mechanisms that are tied to quality only by the tenuous thread of government and healthcare company rhetoric and advertising.  The other critical question is efficiency for who?  It certainly is more efficient to administer a group of physicians who work 7 days on and 7 days off and happen to all be in the same chain of command.  It is a lot easier to get them to accept the role of rationing care in the interest of the hospital or health care group than the patient's personal physician who may see their part of their role as patient advocacy.

The authors have an interesting take on the deficiencies of the model.  They talk about the 7- days-on, 7-day-off model as implying that during the off period the physician is literally off and suggests that time might be better spent contributing to key institutional programs.  To me - this schedule seems more conducive to burnout and anyone who works it needs the off time to fully recover.  I have never seen a study on the cognitive efficiency during the 7-days-on, but my conversations with hospitalists suggests that by day 6 it starts to plummet.  With hospitalists supplanting specialists and subspecialists as inpatient attendings they suggest that trainees have less exposure to basic and translational science.  Although not stated in the article, the model involves eliminating whole blocks of specialty care.  I worked at a hospital where an entire Neurology service was eliminated by hospitalist care.  When I questioned that decision I was told: "We have an Internist who is interested in strokes."  Changing neurologists from attendings to consultants with hospitalists as the primary physicians for neurological problems changes the entire nature of care.  It also changes the associated nursing care when staff have no ongoing interest in the care of complex neurology patients.  The authors also note that hospitalists do not seem to have focused on investigating common inpatient illnesses.  They suggest possible remedies - but these seem like major problems that will only get worse with the increasing business rather than academic emphasis in medicine.

Gunderman points out that as opposed to the usual delineators of speciality care - patient age, physician skillset and body system hospitalists are delineated only by patient location.  He doesn't make it explicit but what is the relationship between location and his list of putative benefits? Looking at length of stay for example - that could logically follow as a concentrated effort in the location, but is that a clinical effort or an administrative one?  He points out that the increasing number of hospitalists per se,  cannot be taken as evidence of benefit and that perverse incentives exist.  I agree with the most perverse being the low reimbursement incentive for high volume practice. Seeing complex inpatients with a high frequency of initial and discharge assessments may reduce the volume necessary for productivity demands.  When I was a psychiatric hospitalist, this dimension was manipulated in a number of ways.  I was initially told, I was responsible for a set number of inpatient beds.  At some point there was a great deal of pressure for me to start running outpatient clinics because they would be more "interesting" than just seeing inpatients.  I resisted that and had significant leverage because nobody else wanted to do my job.  I eventually did run a Geriatric Psychiatry and Memory Disorder Clinic for many years while continuing inpatient work.  That clinic was eventually closed by administrators because they claimed our productivity was not high enough to work with a nurse.  The neurologist and I needed all of the collateral data that she collected to do our work.  The expectation was that we would see complex dementia patients and do everything that the nurse in our clinic did - so we closed.  In over two decades of political wrangling around inpatient productivity the current consensus is that covering 10-12 inpatient beds is a reasonable approach.  At one point I was covering 20 beds with the help of an excellent physician assistant but at the cost of doing no teaching.

The critical aspect of Gunderman's thesis is his emphasis on the physician-patient relationship exemplified by this sentence:

"The true core of good medicine is not an institution but a relationship - a relationship between two human beings."

He points out that physicians being affiliated with institutions creates significant conflicts of interest,  isolates hospital staff from the rest of the medical community and that naturally leads to less expertise in the entire community.  It also creates the illusion that an institution rather than the relationship is the core of medical care and it is not.  Government-business constructs like Accountable Care Organizations have a similar effect.  I have experienced this first hand many times as I dealt with the iterations of hospitalists consulting on my patients.  In one case I talked with a young hospitalist about a patient with Type 2 diabetes mellitus.  The patient had a trace of renal insufficiency and was on metformin - a medication that is risky in that context.  The hospitalist advised me to call the primary care Internist taking care of the patient because "He has been doing it a long time and probably knows more about it than I do."  In addition to the relationship - there is clear expertise associated with caring for people with multiple complex medical problems for years in an outpatient setting - compared to a few days as an inpatient.  The medical industrial complex does not adequately value that expertise.                             

I think that there is room for hospitalists and psychiatric hospitalists.  They have to be focused on the needs of both the patient and the patient's outpatient physician.  There have to be clear goals for the hospitalization and one of those goals is what the patient's personal physician would like to see accomplished.  Since making the transition to strictly outpatient care - it is clear that the hospitalists no matter who they might be don't have much control over who gets admitted to the hospital and what happens there.  They are having less to say about when a person is discharged.  This is probably more true for psychiatry than medicine and it results in a large number of psychiatric outpatients not being able to access needed care.

And I can't help but notice that inpatient hospital medicine is still a far better resource than inpatient hospital psychiatry.



George Dawson, MD, DFAPA




References:

1:  Wachter RM, Goldman L. Zero to 50,000 - The 20th Anniversary of the Hospitalist. N Engl J Med. 2016 Aug 10. [Epub ahead of print] PubMed PMID:27508924.

2:  Gunderman R. Hospitalists and the Decline of Comprehensive Care. N Engl J Med. 2016 Aug 10. [Epub ahead of print] PubMed PMID: 27509007.

Conflict Of Interest, Primitive Defenses, And Celebrity Death

I don't think there is any good way to say it.  Minnesota's greatest celebrity died recently.  I am not going to use his name or picture on this blog.  It seems fairly obvious that he would not want that.  There was the expected and understandable outpouring of emotion from his tens of millions of fans.  And then he became a projective test for anyone who wanted to sell their idea or opinion or get exposure in the press.  Some of those ideas and exposures included:

1.  The opioid epidemic - he is another statistic.
2.  Opioids are bad drugs and they can kill you.
3.  We could have saved him if he went into treatment.
4.  We could have saved him with Suboxone.
5.  Public scorns buprenorphine (Suboxone) - a medication that could have saved him.
6.  We could have saved him with a treatment intervention.
7.  His problem wasn't addiction at all it was chronic pain.
8.  We could have saved him by treating his chronic pain.
9.  The doctors prescribing these medications need to be disciplined.
10.  The people designated to save him - should have saved him.
11.  His death was "pathetic".
12.  That publicity rights legislation that exceeds copyright protection is necessary for the heirs.

None of these ideas are my ideas and I am sure that by the time you read it - this list is incomplete and outdated.  This is what I have heard or read about his death since it happened.  Some of the dynamics are familiar to me.  The gossip columnists and sites trying to show that they have special contacts and insight and therefore may be more important than other gossip sites.  The insiders proclaiming special knowledge that only a person very close to the celebrity could have.  The very human tendency for some to celebrate the death of those with special talents and capabilities that none of the rest of us have.  Death seems like the ultimate revenge of the mediocre and personality disordered - the final verification that a high flying person dies just like the rest of us.  The entire debacle reminds of a sentence I read somewhere (the reference eludes me): "Only a primitive man celebrates the death of his enemy."  How primitive would the man need to be in order to feel elevated by the death of a superstar?  I realize that these more drastic formulations may be rare.  What fuels all of the controversy?  Some may say morbid curiosity.  They are compelled to look at adverse outcomes whether it is a car wreck on the side of the road or a celebrity death under various circumstances.  It still comes around to what one of my psychoanalytic supervisors described as the most primitive underlying and unspoken thought: "Better him than me!"  The first time an analyst told me that I was somewhat taken aback and then over time I noticed that he was right.  I expected to hear this kind of attitude from non-professionals but not from physicians.  It turned out that I could hear that attitude from a broad spectrum of people.

My biases tend to be at the other end of the spectrum.  I see special capabilities as a celebration of what human beings can do.  Whether that is in athletics, entertainment, art, or my co-workers doing the job in a way that nobody else can do it.  Individual talent and unique capabilities are there to be celebrated and not envied.  I discussed this in an earlier post where the concept is that even people who aren't soccer fans can appreciate the greatness of Pele and just by watching him realize that we are all lifted up by that performance.  Envy seems like a marker that we should all use to determine our own sense of self and our own boundaries.    

In today's conflict-of-interest morality analysis anyone wanting to capitalize on the reputation of the celebrity to sell their wares escapes criticism.  The people involved will say that this is the price of celebrity and if you did not want everything that went along with celebrity you should have avoided it.  You are protesting too loudly when your privacy is invaded in real life or after you die.  There is another argument that the fans are entitled to this information.  To me that would depend on who is dispensing it and what was their reason.  There are numerous analyses of this problem from the perspective of defense mechanisms and the study of life satisfaction based on the level of those defenses.  Defense mechanisms may be interesting to psychiatrists and other mental health professionals but I don't think that they have to be brought out for this discussion.  At some point in life everyone needs to take a close look at how they interpret both misfortunes and good fortunes of others.  What does it really mean to them?  What does it indicate about their philosophy of life?  What does it mean about their life satisfaction?  When you do that - I think that most reasonable people stop for accidents because they are there to help.  They are not spectators.  Human consciousness has the unique property of allowing us to imagine good and bad things happening to us without having to see the real thing happening to somebody else.

I hope that at some point the culture can move past the all too predictable sequence of self aggrandizement and the obvious conflict-of-interest that occurs when a celebrity dies.  Human life and human achievement is worth celebrating and just like a single person can make us all better or at least feel better - it doesn't take much to bring us back down.  In order to break out of these predictable patterns, it takes a conscious awareness of better ways to be or exist in life and that includes examining and rejecting reasons for continuing the old patterns.

I will personally remember his shining star and some of the accolades from the top performers in his field.  He was truly one of a kind and his art was uplifting to me.  


George Dawson, MD, DFAPA

Ioannidis - Why His Landmark Paper Will Stand The Test of Time

John P. A. Ioannidis came out with an essay in 2005 that is a landmark of sorts.  In it he discussed the concern that most published research is false and the reasons behind that observation (1).  That led to some responses in the same publication about how false research findings could be minimized or in some cases accepted (2-4).  Anyone trained in medicine should not find these observations to be surprising.  In the nearly 30 years since I have been in medical school - findings come and findings go.  Interestingly that was a theory I first heard from a biochemistry professor who was charged with organizing all of the medical students into discussion seminars where we would critique research at the time from a broad spectrum of journals.  His final advice to every class was to make sure that you kept reading the New England Journal of Medicine for that reason.  Many people have an inaccurate view of science, especially as it applies to medicine.  They think that science is supposed to be true and that it is a belief system.  In fact science is a process, and initial theories are supposed to be the subject of debate and replication.  If you look closely in the discussion of any paper that looks at correlative research, you will invariably find the researchers saying that their research is suggestive and that it needs further replication.  In the short time I have been writing this blog asthma treatments, the Swan Ganz catheter, and the diagnosis and treatment of acute bronchitis and acute chronic obstructive pulmonary disease are all clear examples of how theories and research about the old standard of care necessarily change over time.  It is becoming increasingly obvious that reproducible research is in short supply.

Ioannidis provided six corollaries with his original paper.  The first 4 regarding power, effect size, the greater the number of relationships tested, and the greater the design flexibility are all relatively straightforward.  The last two corollaries are more focused on subjectivity and are less accessible.  I think it is common when reading research to look at the technical aspects of the paper and all of the statistics involved and forget about the human side of the equation.  From the paper, his 5th Corollary follows:

"Corollary 5: The greater the financial and other interests and prejudices in a scientific field, the less likely the research findings are to be true. Conflicts of interest and prejudice may increase bias, u.  Conflicts of interest are very common in biomedical research [26], and typically they are inadequately and sparsely reported [26,27].  Prejudice may not necessarily have financial roots.  Scientists in a given field may be prejudiced purely because of their belief in a scientific theory or commitment to their own findings.  Many otherwise seemingly independent, university-based studies may be conducted for no other reason than to give physicians and researchers qualifications for promotion or tenure.  Such non-financial conflicts may also lead to distorted reported results and interpretations.  Prestigious investigators may suppress via the peer review process the appearance and dissemination of findings that refute their findings, thus condemning their field to perpetuate false dogma. Empirical evidence on expert opinion shows that it is extremely unreliable [28]"  all from Reference 1.

The typical conflict of interest arguments that are seen in medicine have to do with financial conflict of interest.  If the current reporting database is to be believed they may be considerable.  A commentary from Nature earlier this month (5) speaks to the non-financial side of conflicts of interest.  The primary focus is on reproducibility as a marker of quality research.  They cite the facts that 2/3 of members of the American Society for Cell Biology were unable to reproduce published results and that pharmaceutical researchers were able to reproduce the results from 1/4 or fewer high profile papers.  They cite this as the burden of irreproducible research.  They touch on what scientific journals have done to counter some of these biases, basically checklists of good design and more statisticians on staff.  That may be the case for Science and Nature but what about the raft of online open access journals who not only have a less rigorous review process but in some cases require the authors to suggest their own reviewers?  A central piece of the Nature article was a survey of 140 trainees at the MD Anderson Cancer Center in Houston, Texas.  Nearly 50% of the trainees endorsed mentors requiring trainees to have a high impact paper before moving on.  Another 30% felt pressured to support their mentors hypothesis even when the data did not support it and about 18% felt pressured to publish uncertain findings.  The authors suggest that the home institutions are where the problem lies since that is where the incentive for this behavior originates.  They say that the institutions themselves benefit from the perverse incentives that lead to researchers to accumulate markers of scientific achievement rather than high quality reproducible work.  They want the institutions to take corrective steps toward research that is more highly reproducible.

One area of bias that Ioannidis and the Nature commentators are light on is the political biases that seem to preferentially affect psychiatry.  If reputable scientists are affected by the many factors previously described how might a pre-existing bias against psychiatry, various personal vendettas, a clear lack of expertise and scholarship, and a strong financial incentive in marshaling and selling to the antipsychiatry throng work out?  Even if there is a legitimate critic in that group - how would you tell?  And even more significantly why is it that no matter what the underlying factors - it seems that conspiracy theories are the inevitable explanations rather than any real scientific dispute?  Apart from journalists, I can think of no group of people who are more committed to their own findings or the theory that monolithic psychiatry is the common evil creating all of these problems than the morally indignant critics who like to tell us what is wrong with our discipline.  Knowing their positions and in many cases - over the top public statements why would we expect  them sifting through thousands of documents to produce a result other than the one they would like to see?  

I hope that there are medical scientists out there who can move past the checklists suggested to control bias and the institutional controls.  I know that this is an oversimplification and that many can.  Part of the problem in medicine and psychiatry is that there are very few people who can play in the big leagues.  I freely admit that I am not one of them.  I am a lower tier teacher of what the big leaguers do at best.  But I do know the problem with clinical trials is a lack of precision.  Part of that is due to some of Ioannidis' explanation, but in medicine and psychiatry a lot has to do with measurement error.  Measuring syndromes by very approximate means or collapsing some of the measurements into gross categories that may more easily demonstrate an effect may be a way to get regulatory approval from the FDA, but it is not a way to do good science or produce reproducible results. 


George Dawson, MD, DFAPA




References:  

1:  Ioannidis JPA (2005) Why Most Published Research Findings Are False. PLoS Med 2(8): e124. doi:10.1371/journal.pmed.0020124

2:  Moonesinghe R, Khoury MJ, Janssens ACJW (2007)  Most Published Research Findings Are False—But a Little Replication Goes a Long Way. PLoS Med 4(2): e28. doi:10.1371/journal.pmed.0040028

3:  Djulbegovic B, Hozo I (2007)  When Should Potentially False Research Findings Be Considered Acceptable? PLoS Med 4(2): e26. doi:10.1371/journal.pmed.0040026

4:  The PLoS Medicine Editors (2005) Minimizing Mistakes and Embracing Uncertainty. PLoS Med 2(8): e272. doi:10.1371/journal.pmed.0020272

5:  Begley CG, Buchan AM, Dirnagl U. Robust research: Institutions must do theirpart for reproducibility. Nature. 2015 Sep 3;525(7567):25-7. doi: 10.1038/525025a. PubMed PMID: 26333454.

Silence on Pro Publica's Recent Big Pharma Payment Disclosures

OK silence as far as psychiatry goes.

For the past ten years we have heard both individual psychiatrists and monolithic psychiatry maligned for accepting Big Pharma cash for presentations, expert consultations, or whatever.  The implications being twofold - that there were no legitimate reasons why a physician seeing patients should be in the employ of a pharmaceutical company and (courtesy of the Institute of Medicine) that since you can't really tell what is a real conflict of interest versus the appearance conflict of interest without some additional leg work that we should just consider any potential conflict of interest an actual conflict of interest.  At that point, the body in the US with the most real conflicts of interest that I can think of (Congress) decided that all payments from pharmaceutical companies and device makers should be catalogued in a data base for everyone to see.  When I accessed the database, it was a clear example of government information technology (IT) at its worst.  There are numerous examples of government IT projects being abandoned as unusable after an investment of hundreds of millions of dollars.  The recent hacks exposing the private information of millions of government employees and millions of classified documents are good examples of the lack of quality in government IT.  Why expect any higher bar with payment disclosures to physicians?

Rather than navigate the unnavigable, a better approach is to look at secondary data sources who have the time and staff required to translate the data like Pro Publica.  On their opening web page there is a small window half way down that asks:  "Has Your Health Professional Received Drug Company Money?"  I plugged in my name as a double check on the system and it returned 27 results with either a first or last name George or a last name Dawson.  None of them was me (which is accurate).  Only one of them was a psychiatrist and that physician had received a total of $88.  The remaining physicians had received anywhere from 0 to $18,450.  I would certainly not be very happy if I was included in this database for receiving zero dollars and wonder how often that mistake is made?

The bar graph of what types of fees were paid by the industry is instructive.  The largest single group of payments were for "Royalty or License" and number of current brand name chemotherapy and antiviral drugs were mentioned.  The next category was "Promotional Speaking".  I can't imagine that rheumatologists, endocrinologists, and cardiologists are not in demand to speak to primary care physicians about the latest developments in their fields.  I have spoken at Primary Care Updates in psychiatry for primary care physicians.  Are those presentations classified as "Promotional Speaking" if a pharmaceutical company sponsors it and the speaker does not mention one of their products by name?  I have similar questions about "Consulting Fee".  If a physician has a specific expertise and is paid by the private company for that expertise, in my opinion they are no different than any other University faculty in similar positions.  The idea that a physician's entire life is encompassed in relationship with patients and that this is somehow a sacred trust is a myth that is perpetrated by concerns who are quite willing to exploit all physicians on that basis.  They are all listed in various places on this blog.

One of their lead stories is A Pharma Payment A Day Keeps Docs’ Finances Okay.  In that article they focus on a neurologist who received $594,363 from 29 different pharmaceutical companies.  They looked at the top rated physician and concluded that she received payments from pharmaceutical companies on 286 days out of the year.  14,600 doctors received payments on at least 100 days per year.  A total of 606,000 doctors received payments, but then again there are people listed in my first search who apparently did not receive any money.  And then there was this excerpt:

"The nation's 3,900 rheumatologists in the data averaged 40 days of interactions with drug and device companies, more than doctors in any other large specialty. They were followed closely by endocrinologists, electrophysiologists and interventional cardiologists...."  In my home state of Minnesota they list the top 20 physicians receiving money from pharmaceutical and device companies and 19/20 are surgeons (orthopedic, spine, eye) and one is a cardiologist.

No psychiatrists?

That is a curious phenomenon considering how frequently psychiatrists are maligned for financial conflicts of interest in the popular media and blogosphere.  No Senate investigations of rheumatologists, endocrinologists, neurologists, or cardiologists?  No attacks on their professional organizations?  No suggestions that their diagnoses, interventions, prescriptions, publications or professional behavior are questionable based on their reimbursement from private industry?  Why is that exactly?  I certainly have plenty of good ideas.

In order to clarify the real picture here, I sent an e-mail to Charles Ornstein, the lead author of the  "A Pharma Payment A Day..." article.  I asked him to post the statistics by specialty including the percentages of physicians getting some payment, per capita payments or by whatever metric they chose.  Considering the scope of payments suggested by these tables, my speculation is that there will be several physicians in the tens of millions of dollars category and that none of them will be psychiatrists.   But I am content to wait to see if he posts those results.   

Until then, don't ever believe that what you read about psychiatrists is a random event free from the usual antipsychiatry biases.

No matter what happens with the Pro Publica data - don't believe that anyway.

George Dawson, MD, DFAPA  

1.  Charles Ornstein and Ryan Grochowski Jones.  A Pharma Payment A Day Keeps Docs’ Finances Okay.  ProPublica Web Site.