24 July 2009

Disclosure of Conflict of Interests

From the department of "Credit where it's due," in the comments of my post on the Lewin Group, Nurse K pointed out the following:
Come on Shadowfax, you're blogging about this stuff and you stand to make A TON of money if it goes through...for awhile...until insurance companies decrease your compensation since you're making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.
Much as I (really, really) hate to admit it, she's absolutely right.  In fact, I'll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn't getting paid a thing for my efforts.  I started keeping track of the number of uninsured I saw every day, just as a pet obsession.  It was a sobering number.  After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc.   For me, this cause became something beyond the personal a long time ago and became a moral imperative. 

But K is right to note the potential for bias, and it's fair for me to acknowledge it.  I hope that my integrity on this point is evident.  The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn't make me popular in EM circles!)

This is something which struck me yesterday, reading the med blogs reaction to Obama's presser.  Quite a few docs mounted their high horse and with great indignation denounced this:
Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out...
Now it's a clumsy clinical scenario written by someone who has no clue about medicine.  But it's a damned fair point.   Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more.  It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab.  It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).

Whether there's a "fix" for that in the current reforms is debatable.  It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified.  I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests.  The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point.  Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.


  1. I've had 4 surgeries in my life and every one of them was preceded by being given the option to wait and see (appendix) and particularly to try other therapies (PT, brace, medications, steroid injections, hormone treatments, etc.). In most cases, the surgery (granted, always expensive) was always done by somebody other than my PCP. I've seen the same thing at our pediatrician's as well.

    The thing that has me most upset is wondering if our President really believes what he said is true.

  2. If health care is a "moral imperative", you should continue to provide it for free to whoever shows up, right, in the same way that, I'm assuming, you'd provide CPR to someone who collapsed in a restaurant you were dining at?

    I would find it hard to argue that everyone being assigned an insurance policy is a moral imperative since having an insurance policy doesn't really mean anything special with regards to health care, esp. in Massachusetts where the average wait for all (good insurance or not) to see a physician is 55 days.

    Throwing around the word "morality" with regards to health care is a dangerous thing, dood.

    I think the only thing that's immoral is that the government is forcing you to provide services for free without legislative protection under penalty of law and that government is legislating health care out of business with these laws. Where's the immorality there?

    I can't wait for my 55-day waits to see a doc after everyone is insured. Then, I will be a fully moral being.

  3. Oh, and props for sort of acknowledging a bias, but -10 for coating it in this flaky "moral imperative" crust. My bias is for things proven over and over again in history to be detrimental to the public AT LARGE to be avoided. I tend to shy away from things that defy logic.

  4. I've been talking about health care as a moral obligation for our society for a long time -- so that's nothing new. For example, in the way-back machine:
    Health Care is not a Right

  5. Quite a few docs mounted their high horse

    Given the amount of time you spend up on your own tall and mighty Liberal Steed, Shadowfax, I'd be worried about nosebleeds If I were you.

  6. You've fallen into the trap that "government-subsidized insurance" is equal to "health care". Sad. Why do you ignore the basic market fact that when the demand for something suddenly goes up, the thing being sought is scarce for all? It'll be like the health care equivalent of Wii Fit on Christmas. People will flock to PMD offices, ERs, etc, and we'll be like everywhere else that rations based on waiting.

    I hope my doc takes bribes.

  7. Ideal situation: Salaried docs who aren't able to be influenced by fee-for-service payments. PLUS docs you can pay under the table to vault ahead in the line/get whatever superfluous procedure you want. Like what they have in Italy.


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