The medical profession and the lay community continue to be bombarded on a daily basis with information arising from a myriad of opinions dealing with the escalating costs of care, which according to many, has reached unaffordable and unsustainable levels. Medical care cost has soared to the point where it is responsible for 16% of the national budget expenditures.

The resulting confusion paralyzes progress, while the condition becomes exponentially worse.       For people who like me, possessing only limited understanding of the complexity of the issues involved, all we can do is try to gain additional meaningful knowledge so that when we express individual opinions our voices have a better change of being heard. With that attitude in mind, I discuss my perceptions on two issues where the medical profession can play a major role: rationing of medical care and abuse of services.

The mere mention of rationing provokes an immediate and oftentimes violent reaction from which politicians and extremists readily take advantage. This issue, steeped in cultural and traditional religious reasons, has prevented a serious and candid analysis of its true meaning. Furthermore, it precludes efforts to determine whether or not the time has come for the citizenry of this country to consider if a system with elements of rationing, but without abandoning its foundations, can be found. It is rather sophomoric to negate that several other highly advanced counties around the world have done such a soul searching and adopted health-care delivery mechanisms that ration services but have continued to provide good medical care while lowering its costs. This has been done without compromising basic human values and sensitivities.  In America, the state of Oregon has had in place during the past few years a system with elements of rationing which other states hopefully are carefully studying.

One area where rationing must be carefully and dispassionately addressed is the so-called end of life care. It has been documented that at this time 95% of healthcare dollars are spent in the last 30 days of life. How it is possible is that such an egregious and incomprehensible figure cannot be brought to the center of the political debate rather than deliberately keeping it away from the discussion table?

To look at rationing only as vehicle to reduce health care cost is not appropriate. Objectivity and common sense in related matters are also very important. As physicians we were told from the first days in medical school that uppermost in our professional life we had the responsibility to use all available means to preserve life, never to give up, and adherence to the principle of “Primum non nocere.” However, we much too often lose objectivity and find it difficult to act in a manner that at first glance seems to run contrary to traditional  precepts and values.

A visit to a Surgical Intensive Care Unit is a vivid example of the many times when our commitment to prevent death makes us follow irrational routes. Does it make sense to keep alive for weeks and weeks an octogenarian barely alive, suffering from a long history of debilitating medical conditions, who now suffers from the effects of a stroke? Why is it that these hospital units are always full of patients, many of whom never return home?

The answers given to this reality are not of a universal nature. There are times when the attending physicians sincerely believe that discontinuing the respirator and feeding tubes is not necessarily right since recoveries from the recent event is possible and justify continuing treatment. At other times the treating doctors surrender to pressure from relatives who for reasons dictated by emotion refuse to accept the verdict that life is no longer possible to maintain. Unfortunately, there are other times when keeping such patients under care brings financial benefits to the treating physicians and hospital.

In my case it is difficult to intelligently verify the latter situation because I have never spent time in Intensive Care Units as part of my professional work. I base my suspicion on observations of the manner in which some dishonest surgeons perform major elective surgical procedures, such as total hip or knee replacement, in elderly patients that can be satisfactorily managed symptomatically. Many of these patients die during their hospitalization or shortly afterwards. The greed and avarice of these people result in enriching their pockets.

If a truly confidential polling were to be conducted regarding the need to develop a sensible and humane system to prevent the futility of unrealistic prolongation of life, I suspect the vast majority of people with a modicum of intelligence and education would agree that rationing of some degree would be welcome. Likewise, a comparable means to prevent the performance of unnecessary surgery would be applauded.

Acceptable systems can be structured, though very difficult to gain wide and rapid acceptance. In the case of the end of life issues it would take a coordinated effort where representatives from various segments of the government, religious and educational organizations, the media, the medical profession and society as whole would get together to as dispassionately as possible to educate each other on the seriousness of the problem at hand and the unintended consequences likely to come from a refusal to address it.

When it comes to the abuse of expensive and unnecessary diagnostic and therapeutic modalities and surgeries, the medical profession has the moral power to play a major role in the resolution of the crisis. It would take, however, a deliberate effort to set aside the fruitless perpetuation of the concept that medicine is no longer a profession but a business to be squeezed to the maximum. Organized medicine would play a most pivotal place by divorcing itself from the control of education, research, and patient care that it selfishly relegated to the pharmaceutical and surgical implant industry. Through meaningful mechanisms to prevent continued tolerance of what the Justice Department’s current investigation of what it calls “egregious ethical transgression” in the relationship between orthopaedics and industry, much could be accomplished. Forbidding individuals with conflicts of interest to hold office in organized administrative and educational organizations would be essential.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

“Reason should be the slave of passion.”     David Hume

It is inherent in our nature to believe that views we passionately hold on given issues are correct. However, much too often, eventually we find them wanting. This realization did not keep David Hume, the empiricist/pragmatist par excellence, and one of the most influential figures in the past five-hundred years, to conclude “Reason should be the slave of passion.” (Ref. 1).  The topic of this commentary is an example where I found myself wondering if my long-held conviction of the harm brought about by an inappropriate relationship between orthopaedics and Industry, now spread throughout most of the industrialized world, needed to be questioned and radically modified.

The United States’ Justice Department investigation of serious trespasses and unethical conduct in the relationship, already in its fifth year, does not seem to have had a meaningful impact (Ref. 2). All we hear is that most of the identified culprits had “resolved” the conflicts by claiming that the receipt of moneys from Industry was justified because they represented grants devoted to legitimate educational ventures. It is very likely that this argument was valid in some instances since many educators/researchers are honest and reputable members of the orthopaedic community. On the other hand it is naïve, at best, to believe such an excuse applies to all the accused individuals, particularly in light of the fact that many of the identified parties are not in any way involved in educational or research endeavors.

I have previously reported on episodes where I was either offered by high-industry representatives large amounts of money for the use of implants by the faculty of the department I shared at the time, or even larger funds for accepting to have a total hip prosthesis named after me even though I had nothing to do with its development. After refusing the dishonest “deals’, the response I got was, “But we do this all the time.” In the early 1970s I was invited by Industry to lecture in the capital cities of five Latin American countries. I declined on the grounds that I considered unprofessional the acceptance of the attractive offer. My reply was followed by a letter from the firm’s headquarters saying that they would not have any trouble finding someone to fill my place. I responded by saying that I was aware of the availability of others for such deeds and resentful of the fact his company seemed to consider orthopaedics a bordello, where the choice of a prostitute is simple and uncomplicated. (Ref. 3).

It is most demeaning to our profession that some of our representative organizations as well as directors of residency programs and other people occupying high positions in the hierarchy continue to perpetuate the situation. I suspect it would be very difficult to find at this time many heads of orthopaedic societies and directors of orthopaedic residency programs in America whose dependency in Industry is not significant.

A number of subterfuges are used to justify all kind of questionable activities. Sometimes funds are provided to academic programs to pay the salary of new Fellows and faculty members. Endowed chairs are accepted without hesitation in some places; in other instances the real funding source is camouflaged under the name of some “generous donor,” when the true funding source is Industry.

Would not be anything wrong with Industry’s “generosity” if it were not by the fact that Industry expects a great deal of say in the selection of topics for discussion and the choice of faculty. In addition, it economically compensates for the moneys given away by escalating the costs of their products (Ref. 4). Industry continues to win the battle. The subordination of the orthopaedic profession to Industry’s profit-driven wishes seems complete (Ref. 5).

However, throughout the land, there is a growing number of people in our discipline who are increasingly unhappy with the breakdown of the moral sphere and professionalism in our ranks, and the control of education by Industry. The increasingly large number of orthopaedists in private practice and many in the academic world are not getting sufficient support from their representative organizations, which have chosen to remain silent and comfortably continue to enjoy the status quo.

This crisis may soon become of a serious nature. We most respond with a loud and unequivocal chorus opposing the current practices. If we continue to simply limit our efforts to increasing our financial well-being and to dwell on self-serving pocketbook issues the future our heirs will inherit from us will be an unhappy one.

References:

1)  Hume, David. A treatise of human nature. Oxford, 1888

2) United States Justice Department. Christopher J. Christie. Press Release September 27, 2007

3)  Sarmiento A. Bare Bones. Prometheus, 2005.

4) Sarmiento A.  Medicine Challenged. Publish America,2009.

5)  Sarmiento A. Rise and Decline. JBJS (A) 91:2740-2,  2009.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com.

The term “conflict of interest” means many things to many people but, in the context of an orthopaedic department in an academic medical center, the term applies to the relationship we have with companies in the pharmaceutical and orthopaedic device industries. These companies do business with us and our hospitals (we buy, use, or prescribe their products) and, as in any sales industry, their representatives want to treat us – their customers – well.  Sounds like good customer service, right?

The problem is that the medical profession (physicians and hospitals in particular) is being held to a higher standard regarding conflict of interest than most other professions or industries. Governmental agencies, consumer groups, patients, and law enforcement agencies are increasingly concerned with assuring that those providing healthcare services to patients are not being unduly influenced by the pharmaceutical or device industries. In almost no industry is it legal to accept a monetary “kick-back” for using or buying a specific company’s products, but in healthcare it is even being questioned whether seemingly insignificant gifts – such as pens, lunches, or notepads – might unduly influence the prescribing/ordering habits of a physician providing care for a patient.

We may each have our own opinion as to whether this is fair or unfair. We may each agree or disagree with the research done on the topic indicating that even small gifts can influence a buyer’s attitude towards a seller. We cannot, however, deny that this topic is getting a lot of national attention right now. The US Department of Justice has raised it to the “top of our minds” with allegations against companies for making – and physicians for accepting – improper payments. The American Association of Medical Colleges, the American Medical Association, and just about every other national medical association and industry group have gone on record stating that conflict of interest is an important topic that should be watched and managed carefully. Some academic institutions have gone so far as to ban ALL gifts from their campuses; for example, Yale University School of Medicine prohibits any pens, notepads, lunches, or any other gift in its medical center. Stanford University has taken it one step further, announcing last month it would not allow industry support for any educational activities conducted within its medical school or healthcare system.

So, what does this mean for us in our daily professional lives? Where will it end? Will CME as we know it disappear due to loss of industry support? I don’t know the answer to these questions, but I do know that we all need to acknowledge and understand that conflict of interest is an important issue that many of our patients will be in tune with.  We should be cautious about having, in patient care areas, items that clearly show a manufacturer’s name or logo, as some patients will interpret this as a conflict of interest.  Calendars, notepads, pens, scissors, models – anything that has a company’s name on it, should not be openly displayed in patient care areas. If a patient sees and asks about such items, we should not remark glibly that “they give those to us all the time”, but remind the patient that some items are important to carrying out patient care (such as models, notepads, scissors, etc).

I’m afraid that conflict of interest is a topic we can no longer ignore – it won’t go away. It is a train on a track and is headed right for us. Most medical schools, most medical associations, and most medical companies in the United States are in the process of revising their policies on conflict of interest. While this may be frightening because it may change daily professional life for us, it is probably wise that the “House of Medicine” tackle this issue in a proactive way.  If our own profession does not take an active role in providing a satisfactory response to this issue, then is it likely the federal government will define policies on conflict of interest for us. The only thing worse than having to do things a bit differently would be having the government dictate to us how to do them differently.

Dr. Douglas R. Dirschl is Frank C. Wilson Distinguished Professor and Chair of Orthopaedics at UNC School of Medicine. He also serves on the Own the Bone Steering Committee and chairs the Critical Issues Committee for the American Orthopaedic Association.