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The Destruction of Medicine by Market Forces: Teaching Acquiescence Or Resistance and Change?

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The Destruction of Medicine by Market Forces: Teaching Acquiescence Or Resistance and Change? PUBLIC CITIZEN HEALTH RESEARCH GROUP SIDNEY M. WOLFE, M.D., EDITOR FEBRUARY 2002 + VOL. 18, NO. 2 The Destruction of Medicine by Market Forces: Teaching Acquiescence or Resistance and Change? 1be following article by Dr. Sidney Health Services and Medical profit managed care companies, Wolfe is reprintedfrom Academic Medi­ Education squeezing doctors and patients into cine, Vol. 77, No. 1, january 2002. Among developed countries, the shorter visits and less care, in too many United States is unique in having a instances simply to pay CEOs and edical schools have too often substantial proportion of health ser­ stockholders more. The managed care taught- actively, or passively vices delivered by for-profit businesses. industry has driven teaching hospitals M by example-acquiescence Research has documented that the into an entrepreneurial response that to the increasing trends toward medi­ quality of care is worse in for-profit undermines the critical missions of cine as a business rather than teaching HMOs, kidney dialysis centers, nursing teaching as well as professionalism resistance to those trends in a manner homes, and hospitals than in nonprofits, and service. consistent with medicine as a profes­ just as Flexner documented poor qual­ Resistance to these dangerous di­ sion. A rapidly growing amount of ity education in for-profit medical rections is needed to diminish the research has documented the deleteri­ schools. We are also the only country incursions of for-profit medical care. ous effects of this business model on in the world in which the predominant Research and teaching concerning the doctors and/or patients. But except in mode of health care delivery is for- poorer quality of for-profit care would rare instances, medical curricula for students or residents neither include C () N T E N T S in-depth discussions of such research nor map out strategies for resisting and reversing these dangerous trends, in­ Good Busin.ess Suggestions ......••..•..•......•.•••.•••.••••......•..•..•. 4 cluding encouraging more research in these areas. As we approach the 100th Product Recalls December 6, 2001-:January 10, 2002 Allergy medications, wheelchairs and candles are on our list anniversary of the 1910 Flexner Re­ this month . ................ ................ .. ...... ..................... ... .. ... .. .. ... .... .. ... .............. 4 port, which revolutionized and ratio­ nalized medical education, we must Health Research Group Asks New Mexico to heed his admonition to apply the sci­ Sanction Doctor •....•.................... ~········································ s entific method to all dimensions of medicine, including elucidating evi­ New Study Shows Low Income Min.orlty Seniors Restrict dence for the destruction of medicine Use of Prescription Dn~gs •••....•.•.••••••••••••...•...•.••.•......•.....•. 9 and medical education by market forces. Ironically, the revolution in medical What Ails the Mass. Board of Medicin.e? .•.................•..... 10 education occasioned by that report included the evidence-based elimina­ FDA Action on Red Cross Long Overdue. ... .. ..... ....... .. ...... 11 tion of a large number of poor quality Canadians Begin Recall of Dangerous Drug Supplement medical schools being run on a for­ Ephedra. ..••••..•...•.•...••••••••••••••••••••••••••.•.•.•......•...•.•.........•.... 11 profit basis. The new model that evolved emphasized a non-commercial ethic of The AMA Does It Again ••••••••••••••••.•••••.•..••.•.......•.•.......•..... 12 professionalism and service, but this model is now in jeopardy. VISIT IIEAI.TII H.ESEARCII GROUP'S WEB SITE A1' WWW.CITIZEN.ORG/HRG/ add to the atmosphere and strength of cal trials, corporate sponsors have been influences has been articulated by the resistance. able to dictate the terms of participa­ eminent medical historian and ethicist, But there are two concomitant and tion in the trial---terms that are not David Rothman: "Medical training similarly unique aspects of this market­ always in the best interests of aca­ should not include acquiring a sense of driven system, now caused and con­ demic investigators, the study partici­ entitlement to the largesse of drug trolled by private insurance companies pants, or the advancement of science companies .... Medical schools should ... with an increasing amount of for-profit generally." prohibit all gifts from drug companies care. First is the failure to provide But the publication step is at the to students .... Teaching hospitals should health care as a right to all citizens, end of the research process, and much proscribe drug company sponsorship leaving one seventh of our population, damage can be done by then, espe­ of lunches, conferences, and travel for about 40 million people, without health cially because many of the most alarm­ residents." insurance. Second is the failure of our ing findings of drug-company-spon­ An extensive collection of refer­ government to provide low cost medi­ sored research are not published. Medi­ ences and slides of published articles cal education to all who are qualified to cal schools should prohibit equity in­ refuting the notion that there can be, in enter medical school because of the terest in drug companies by academic the context of the relationship be­ lack of an overall national policy to pay researchers who are doing clinical tri­ tween drug companies and physicians, for medical education. als. The broader issue is that drug a truly free lunch, is available on the Medical schools should end the gen­ companies should fund clinical trials Internet and is frequently updated. eral silence on the absolute necessity but have no control over their design Bob Goodman, of Columbia Univer­ for a single payer, government-financed and implementation, the interpreta­ sity College of Physicians and Sur­ health insurance plan by teaching stu­ tion of data, or publication. More than geons, the founder of the No Free dents its unique advantages. In addi­ merely a change in journal publication Lunch web site, www. nofreeluncb.org, tion, a coalition of medical students policy is needed for this to occur, and is currently developing, with several and faculty should be leading a na­ medical schools need to be at the colleagues, a curriculum for use with tional effort for government subsidy of forefront of advocating such a change. medical students and residents to re­ a much larger part of medical educa­ There has been an increase in deals view this evidence and teach resis­ tion so that socioeconomic-class-based between medical schools and pharma­ tance to the "free lunch" concept. discrimination does not continue to ceutical or medical device manufactur­ Other educational efforts to counter pose barriers for many to attend medi­ ers to develop products under exclusive drug industry influences on prescrib­ cal school and so that medical teaching arrangements that will generate in­ ing practices could include teaching institutions and their faculties are on come for the medical schools and students and residents a process for the firmer financial footing, less depen­ faculty members. The formation of evaluation of newly emerging or older dent on commercial ventures. Another small companies involving faculty to prescription drugs that utilizes publicly important advantage of a single gov­ develop products is, at the least, a available information from the FDA ernment payer for all medical setvices drain on teaching and other non­ web site, wwwfda.gov, or other infor­ would be to overcome the perpetual commercializable research efforts. mation available from the FDA through private health insurance industry's re­ There is good evidence that money the Freedom of Information Act. sistance to such a subsidy. from drug companies or contacts with The Center for Drug Evaluation and them can influence faculty decisions Research (COER) Freedom oflnforma­ The Pharmaceutical Industry and regarding hospital formulary additions. tion web page is located at Medical Schools There is also widespread drug com­ wwwfda.gov/cder/foilindex.btm. The Another important area in which pany funding of hospital rounds, and link can then be made to New Drug medical educators need to be offering contact with drug reps is allowed in Approval Packages. These documents much more resistance involves the many academic medical teaching cen­ are the reviews by FDA scientists of the pharmaceutical industry. Medical jour­ ters. Attendance at free drug-company­ data submitted by a manufacturer to nal articles that distort the actual results sponsored dinners, sports events, and support the approval of a new drug of clinical trials concerning drugs or thinly disguised marketing efforts la­ and include reviews of clinical trials. A other medical products, ghost-written beled as research are often viewed as direct link can be made to the new­ articles, delayed articles and publica­ an acceptable norm. Contrary to a drug approval packages at tion bias as a result of industry pressure recent statement by former AMA Presi­ wwwfda.gov/cder/foilnda/index.htm. have led to guidelines endorsed by dent Alan Nelson, MD, that "Ongoing FDA scientific reviews are also avail­ editors of 13leading international medi­ interaction and strong communication able for drugs not yet approved that go cal journals. The cause was succinctly between physicians and [the pharma­ before public advisory committees. stated in the prologue to the guide­ ceutical] industry is vital for good pa­ These reviews are known as briefing lines. "As CROs (contract
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