Beauty Contest or Cynical Marketing Scheme?

 

Beauty Contest or Cynical Marketing Plot?

Well this is the United States so it is a safe bet that the answer will be “cynical marketing plot”, but even then the beauty contest may not be an independent variable.  I just listened to a story on public radio today about how government contractors in Afghanistan basically had blank checks for the services they provided to American troops. We live in a land where the government basically stacks the deck in favor of corporations and there is no clearer example than the healthcare industry.

Today I received a letter in the mail that said

“Dear Dr. Dawson - we are pleased to include you among the Top Doctors to be featured as a Top Neurologist representing Circle Pines, MN.  We will be featuring you in our 2021 Top Doctor list which will appear both online in our nationally syndicated publications. Your expertise in Neurology and dedication to upholding the highest standards of patient care in the diagnosis and treatment of neurological disorders and diseases is something to be recognized. This four-color wall plaque is a beautiful addition to your wall of achievements. Signed, the Selection Committee”.

I was very skeptical of this letter from the outset for obvious reasons.  First, I am not a neurologist. Second, I do not live or work in Circle Pines, MN.  I considered reasons for the letter the most obvious one that it was simply an error. Sarcasm came to mind as I reflected on the many people over the years who told me I was too preoccupied with either neurology or medicine for a psychiatrist.  Was this a sarcastic joke based on that criticism?  Finally, I have encountered some people who think it is hilarious that you are assigned a job title in error. Was this an attempt to do that?  Finally - the marketing aspects.  I had received many solicitations to get listed in various Who's Who publications.  This was probably the medical version.  I have never been compelled to get a copy of Who's Who to find out who the prominent people are.  They are usually obvious - at least the ones that I am interested in.

I don’t know exactly when the “Top Doctors” lists started to appear. The past 15 years - I have received a mailing encouraging me to nominate certain doctors for this award. Lists are compiled by specialty and they don’t seem to change much every year. I glance at the list from time to time and agree with about 20% of the rankings. But in their defense, how should a “Top Doctor” be ranked? When I am personally looking for a “Top Doctor” for my own medical care or the care of my wife I am interested in what their results are. That applies to both medical and surgical care. That data is extremely hard if not impossible to find. Do the physicians doing the voting know these details? In some cases they might. I depend on my primary care physician and his experience with surgical referrals and the results that he sees from those referrals. In the case of nonsurgical care my speculation is that those results are more nebulous. In that case do the rankings have anything at all to do with outcomes or quality of care?

It reminds me of the type of rankings I got every year when I was an employee for a managed-care company. They could fluctuate 180 degrees from one year to the next because they were totally subjective.  One year I was ranked number one in documentation and coding according to subjective chart audits. The next year I was dead last even though nothing had changed in the interim. We also had an anonymous “360° evaluation” where other staff were encouraged to critique us and say just about anything they wanted whether it was relevant to work quality or not. The entire exercise lacked accountability and was demoralizing.  In my annual reviews I started to refer to it as “the beauty contest” reflecting its subjectivity and fickleness. My boss thought that I was joking - but I was not.

These political subjective ratings have a goal to elevate organizations that are run by business administrators while maintaining leverage over the physicians who work in them. There is no clearer example than driving through Anytown in the USA and noticing that they all have a top ranked hospital or medical clinic. There just are not that many top ranked hospitals and medical clinics in the country.   The “Top Doctors” list may be another one of these trends. Some of these lists tend to have many specialists from same clinic.

The beauty contest concept brings to mind Atul Gawande’s essay The Bell Curve from 2004.  He develops the premise that there is very little objective measurement of physician outcomes and even less disclosure. With that data it would be possible to construct a bell-shaped curve and find out where physicians are plotted against their peers. This would be an ideal route to find the Top Doctors list but he is more focused on what happens if you find out you are just average. In any statistical compilations people are bound to be average and even below average, but Gawande points out that settling for average is the problem and he even rolls in the idea of the beauty contest:

“And in certain matters - looks, money, tennis - we would do well to accept this.  But in your surgeon, your child’s pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we expect averageness to be resisted.”

Even though that essay was from 2004, the actual measurement of doctors remains elusive except for a very few instances. Gawande points out some of the reasons including what to measure, who is doing the measurement, what is all means, and what the implications are. He does not comment on the major extraneous factors that may shift the curve. In the last 30 years, the single largest factor is the business management of healthcare and the move away from substance – in particular quality – to advertising and fluff. There is probably no better example than my Top Doctors letter.

I want to be clear that the letter I got was all about signing up for a meaningless plaque to recognize me as the wrong doctor from the wrong specialty in order to get money. Are there other  doctors out there going along with this? Are there doctors who are purchasing meaningless plaques and putting their names on meaningless lists to enhance their resume? That is an investigation that I don’t have time for. This post is all about getting the message out that rankings and proclamations that doctors, hospitals, and clinics are “top rated” is not necessarily something you can hang your hat on.

Be very skeptical of ranking systems especially ones that are self-proclaimed - and try to get reliable information on what counts. With physicians that would include their outcomes, their thoroughness, and the relationship they are able to establish with their patients.  Gawande’s essay points out that relationship may not always be comfortable

Don’t get pulled into a beauty contest…..even though in today’s healthcare landscape they seem unavoidable.

 

George Dawson, MD, DFAPA

 

 

References:

Atul Gawande.  The Bell Curve.  The New Yorker.  November 28, 2004

Graphics Credit: 

Bathing Beauty Contest 1920.  National Photo Company Collection, Public domain, via Wikimedia Commons:  

https://upload.wikimedia.org/wikipedia/commons/0/01/11_women_and_a_little_girl_lined_up_for_bathing_beauty_contest_LCCN2001706323.jpg

Marketing, Advertising, and Safeguarding Objectivity

blame (third-person singular simple present blames, present participle blaming, simple past and past participle blamed)

1.     To censure (someone or something); to criticize.  [quotations ▼]

2.     (obsolete) To bring into disrepute.  [quotations ▼]

3.     (transitive, usually followed by "for") To assert or consider that someone is the cause of something negative; to place blame, to attribute responsibility (for something negative or for doing something negative).

To provide context for this post, I refer any interested readers to the previous post and the comment by Steven Reidbord, MD.  I started typing up a response and decided to just continue it into this post.  I like to post things in regular blog format, because the comment section is uneditable and I make frequent spelling and grammatical errors.  My intent is to provide my perspective rather than disprove any of Dr. Reidbord’s points which are basically critical points about assigning blame, the standard of proof that physicians are affected by marketing and advertising, assertions about the connection between all of the marketing components and the profits of pharmaceutical companies and the need for physicians to “safeguard” their objectivity.

On the issue of blaming Big Pharma, of course they have done all of those things.  I would expect them to because that is typical behavior of corporations.   There are some people that believe this indicates that all corporations are evil.  There is also a blanket level of condemnation of the industry independent of any specific legal charge or incident.  You can certainly find rhetoric against all industrial sectors.  Nobody seems to acknowledge that governments have developed this landscape, including a regulatory landscape that encourages individuals to take risks without worrying about any personal or criminal penalty.  Litigation for large corporations is seen as the cost of doing business.   It seems that if anything, the law is written to incur legal activity and legal fees.  It is probably no accident that most lawmakers are attorneys.   I am no more outraged about Big Pharma corporate behavior than I am about any other industry. 

Before anyone tells me that medical industries are somehow different because they deal with peoples’ lives, if you think about it numerous industries deal with peoples’ lives.  Some are actually toxic to peoples’ lives.  Others  (like medicine) have affiliated professionals with professional responsibilities but unlike physicians those professionals (who also work with industry and receive benefits from the industry) are seldom scapegoated because of it. 

On the issue of marketing, I have made the same arguments that Dr. Reidbord makes to Big Pharma critics for at least a decade.  I am usually met with the response that physicians have a higher calling and that we must somehow place ourselves above advertising so that we are not commercially influenced.  The corollary is all of the “proof” that advertising and marketing influences purchasing and therefore prescribing behavior.  There are many problems with the analogy and that argument.  First, the proof generally refers to a fairly loose body of literature with poorly stated hypotheses and experimental designs that are either nonexistent or inferior to any clinical trial designed by Big Pharma.  I am happy to entertain any evidence for this connection in the event that I have missed something.   Apart from lack of the experimental evidence, it defies common sense.  I am unaware of any multi-billion dollar product-based industry that thrives on advertising an inferior product and not backing it up with anything.  To use the automotive example, if I unwittingly purchase a Toyota based solely on a flashy ad and discover it is a lemon, I may conclude that this is an aberrancy or that all Toyotas are lemons.  Either way they are unlikely to find me as a future customer.   That is not a sustainable business model.  The general assumption about pharmaceuticals is that physicians don’t seem to be able to self-correct by noting deficiencies including a lack of efficacy during hundreds or thousands of prescriptions.  I find that to be much more likely that noting your car is a lemon.  With prescriptions physicians are professionally accountable to purchasers.  That is a higher standard than losing time or money on a car.  Second, if I respond to marketing and go down to my car dealer for a $500 cash rebate, 0% financing, or some other incentive, I will not be placed in some national database that can be used to suggest that I am morally inferior to physicians who are not in that database.  Oh sure,  there will always be the usual disclaimers that being listed in the database is really an appearance of conflict of interest rather than actual conflict of interest, but the implication of wrongdoing is palpable and usually evident by what is being written about this list.  Third, the reality of a general lack of effective medications is never really acknowledged.  I have never seen a study about marketing pharmaceuticals that takes that into account.  It is common in clinical practice even before the advent of DTC advertising to see patients who were desperate to try the next new drug on the market.  In many cases we are still looking for a reliable car in a field of Yugos.  We are not looking for a Corvette.  Does that mean we have been influenced by advertising?  Does that mean that the patient/consumer has been influenced by DTC advertising?  It may simply mean that we are faced with a large number of drugs with a lack of uniform efficacy and significant toxicities.  Fourth, there is an overgeneralization of an imaginary boundary problem between pharmaceutical companies and physicians that seems to flow from the marketing rhetoric.  Suddenly companies are not only marketing drugs, they are selling medical diagnoses and treatment guidelines.  Managed care companies and PBMs get a complete pass on this issue and the idea is that the Big Pharma-Physician alliance is in lock step to sell as many drugs as possible.  That is a rather pathetic characterization of the problem and the pat solution of cutting all industry ties is an equally pathetic pseudosolution.   I do consider the business end of Big Pharma to be marketing and advertising.  I think the effect of that marketing and advertising is a vastly overstated political argument.  I think it is hubris to imagine that physicians can’t self correct in the way that any consumer self corrects when purchasing any advertised product.

With regard to what is necessary – like most criticism of Big Pharma nobody is ever really explicit about their meaning.  Practically all articles written about Big Pharma marketing/advertising tactics especially those that involve physicians imply that everyone in that chain of events is working to enhance the bottom line of the pharmaceutical company.  Working for the monied interest of a pharmaceutical company is the conflict in conflict of interest. If you are asking the question: “Who said this was necessary?” I guess my answer would be; “Just about everybody.”

The last question that I hope to address is the idea of “safeguarding” one’s objectivity.  In the previous response the idea was that the physician psyche is so frail and easily persuaded that we need to avoid all contact with Big Pharma advertising.  If that is the case there are many other sources of discordant special interest information that we should avoid like the plague including less competent attending physicians and colleagues, less dynamic medical school lecturers, all forms of managed care, most hospital and clinic administrators, most media outlets and most federal regulations on billing, coding, and documentation.  Off the top of my head I could add previous standard medical practices like the Swan Ganz catheter,  massive back surgeries for back and neck pain, chronic high dose prednisone for COPD,  and meperidine injections for migraines.  The list is endless.

If my objectivity was that tenuous I would be sitting in a dark room somewhere practicing psychiatry the way it is described in the New York Times.   I would be depending on a blog or pious journal editors to keep me honest!  
   

I have no conflict of interest to declare.  I have rigorously avoided Big Pharma advertising and detailing long before it was fashionable to do so.  My interest in avoiding Big Pharma advertising was that I found it to be disruptive, annoying, and demeaning - largely to the reps seen lugging food up and down hospital and clinic hallways.  I will probably never consider myself too stupid to figure out advertising even at the purported mind-control levels.  If anyone reading this disclosure doubts this statement – feel free to look for my name in the database of corrupted (or not) physicians.
 

As a further point of disclosure, I drive a Toyota.  I have a general policy of driving a car until the 150,000-200,000 mile mark and then buying a new one.   I find that by that time most cars have multiple systems that start to fail and it becomes a long series of expensive repairs and safety problems.   I have been driving Toyotas for 10 years and that follows a long line of Chevrolet, AMC, Plymouth, and Pontiac products.  Irrespective of the advertising, my personal experience is that it is the most reliable and cost effective ride for the money. 

Those are my only interests in both Toyotas and new pharmaceuticals. 

  

George Dawson, MD, DFAPA

Supplementary 1:  Posted definition at the top is from Wiktionary per their open access agreement. I intended to use it here more as a graphic than text as a lead in to the article.  

Supplementary 2:  For anyone considering a post here as a comment - please consider composing your comment in a word processor and cutting and pasting it in here.  The comment section on Blogger is not a reliable area to compose and edit comments.  I have lost several myself and the text may be too small to edit.  If the comment appears to have been posted but it does not appear - please send me an e-mail.  It occasionally gets diverted to a spam folder and I can still retrieve and post.