Howard Brody, medical ethicist, is quoted in our local paper today. ”If the physician is going to be a true professional and not a hired gun, that physician is going to have to be independent. One has to prioritize what is good for the patient above ‘Will I, the doctor, make more money or will the drug company I work for make more money?’”
He is referring to physicians who accept money from drug companies, sometimes for speaking engagements, other times for “research.” He is, of course, correct. Physicians that are “hired guns,” as he says are doing the bidding of who hired them, not the bidding of the patient, or what is necessarily in the patient’s best interest. ”Whose bread I eat, his song I must sing,” or something like that.
Those of you loyal to this blog know exactly where I’m going with this, don’t you? Let’s take his quote and play a substitution game.
“If the physician is going to be a true professional and not a hired gun, that physician is going to have to be independent. One has to prioritize what is good for the patient above ‘Will I, the doctor, make more money or will the_________ I work for make more money?’” Now let’s put words in the blank that are possibilities. The original quote was “drug company.” How about hospital? What? You say, “that’s not fair.” ”The patient’s interest could never be different from the hospital’s interests!” But what if the hospital makes more money if they insist that their hired physicians substitute cheap drugs for more effective ones? What if the hospital requires their primary care doctors to refer patients to their hired surgeons rather than more competent ones, because they cash in on the surgical fees, as well? What if the hospital requires their hired guns to perform unnecessary invasive testing on patients to generate revenue needed to pay these physician’s salaries? I could go on.
How about multispecialty clinic? Some physicians work for giant clinics (often times with a city’s name attached). What if the interests of the XYZ clinic that employees a doctor trump that of the patient? ”Doctor, you must see 49 patients per day and do 13 surgeries a week in order to earn your keep here at this world famous clinic and you must also participate in this drug study that will bring thousands of dollars into our clinic and help pay you. You must enroll 8 patients/week in this study or face the punitive salary cuts in your contract.” You get the picture. You think this doesn’t go on? Really?
How about “insurance company?” Do I even need to elaborate? Remember that HMO’s typically bonus physicians at the end of the year to the extent that they have been successful denying their patients access to specialists and denying care, in general.
“Wait,” you say! ”Dr. Smith, you are part owner of a surgery center. You and your partners are biased to do unnecessary surgery to profit yourself!” I have written about this before, so bear with me. It is precisely because our facility is physician-owned that unnecessary surgeries for profit are less likely to happen. Why is that? Because any idiot that takes this path places all of the partner-owners in harm’s way. If this were to happen, that partner would be dismissed. Immediately. The very existence of our facility depends on the absence of this type of activity. Not so when physicians are not the owners. Those facilities are treated like rental cars, not like vehicles you own and care for. In financial and risk management terms, it matters not to physician “A” if physician “B” operates on patients unnecessarily in a facility that is not physician-owned.
Are physicians who take money from device makers or drug companies compromised? Of course they are. But the logic of this argument brings us to the heart of the sanctity of the doctor patient relationship and how viciously compromised that relationship becomes when the source of the physician’s revenue is other than the patient himself.
G. Keith Smith, M.D.
