Almost all physicians take call as part of their job. Call responsibilities can be broadly divided into two categories: responsibility for a physician’s own patients after hours and providing coverage for hospitals and emergency rooms (ERs). It is the second of these which is by far the most contentious. Call arrangements between physicians and hospitals vary greatly based on physician specialty, employment status (hospital employed vs. private practice), and local health care market conditions. In general, physicians would prefer to take no ER call, as patients who come to the ER for health care tend to have no insurance or Medicaid and tend to come at inconvenient times, while hospitals would like private practice physicians who operate or admit patients to the hospital to provide call services for free. Hospitals are required by law to provide care to patients who come to their ER and would like to provide specialist care as cheaply as possible. Some specialists will end up being paid to take call, while some will be forced to take call for free in order to have privileges at a hospital, depending on local supply and demand conditions. As a specialist in Otolaryngology, otherwise known as Ear, Nose and Throat, who is employed by a university, I am required to take uncompensated call on a rotating basis (one week at a time) for the university hospital and its ER. It is important to note that the hospital is not owned by the university, but rather by a for–profit hospital chain. This case illustrates the complex economic and legal forces that shape the magnitude of call responsibility.
Two years ago, a simplified referral center for outside physicians was instituted by my hospital, with the stated aim of increasing patient referrals from other hospitals. A single number was provided for referring physicians, including outside ER physicians, to utilize, if they wanted to transfer patients. I learned later that of particular interest to the hospital were stroke patients, who tend to be insured (mostly Medicare) to facilitate growth of a Stroke Center, which offers thrombolysis (clot busting) and other well–reimbursed services. I was informed by my Chairman of ENT, who, like myself, is employed by the University Medical Group that exclusively staffs the for–profit hospital owned by a publicly traded company where we work, that our department’s attending physicians would now be taking direct calls from emergency rooms in the region to provide advice and facilitate transfer when necessary. Previously, we were only responsible for cases that physically showed up in our ER or were transferred to us by other ENT physicians (a rarity). I was told that I would have discretion over which patients to accept in transfer and which to reject; no further guidance was given.
My first week on call under the new system was unbelievable. I was receiving several calls per night from emergency room physicians who did not have ENT coverage at their hospitals, asking for advice or for me to accept their patient in transfer. I was extremely leery of providing advice at hospitals I did not have privileges at and, as was frequently the case in a neighboring state where I did not have a medical license. Illinois, from which the majority of these calls originated, is an area known to have the worst medical–legal climate in the U.S., particularly the adjacent Madison and St. Clare counties. My response was to refuse to take direct calls from outside ER physicians, which constituted 95% of the calls, on the basis that I did not have privileges at the hospitals in question and thus could not be responsible for taking ER call at these outlying hospitals. This was met by a harangue from my Chairman and then another harangue at 3 A. M. from the Hospital CEO for refusing to accept in transfer every ER consult. It became obvious that I was not allowed to use my medical or ethical judgment but was instead being forced to accept all ER consults and transfers in the name of growing patient volume. This struck me as odd, as most of the patients were uninsured and it was unclear why exactly the hospital CEO, an officer of a publicly traded company with a fiduciary responsibility to its stockholder owners, would want uninsured patients, except as part of a strategy to accept the financially good (Medicare strokes) with the financially bad (uninsured facial trauma). It would be illegal to discriminate based on insurance status directly, so while some services such as Neurology would gain patients who needed intervention for stroke at the expense of other services, such as ENT, who would be left with uninsured nose bleeds and trauma patients to take care of. It seemed that the hospital, as part of a growth strategy, had negotiated with smaller outlying hospitals to provide specialty services. Unfortunately, they had neglected to consult with the physicians who they expected to take on this extra workload.
The attendings in our Department responded in anger and asked for a definition of the limits of our call obligation. Were we responsible for emergency rooms in a 25 mile radius? 50 miles? Were we on call for the entire Midwest? The extra burden of this call was entirely unreimbursed and none of the faculty was interested in providing this service. As I looked into the situation further, it became apparent that part of the problem was that the state of Illinois has a law that requires every hospital to have an ER but does not require it to be staffed by any specialists. Thus, small hospitals were trying to use me as their de facto ENT on call physician, which I felt to be unethical. Balanced against this was the fact that large university hospitals have some legal obligation to provide specialty care for patients from surrounding areas when those patients required specialty care not available locally. Unfortunately, almost all the calls I received from outlying ERs involved patients that local ENTs refused to care for by saying they “did not feel comfortable” despite having simple problems like nosebleeds, which all ENTs can care for, by definition. My Chairman ultimately asked the university legal department to define the limits of our call responsibility, but after many months, no lucid reply was ever provided. The situation seemed to revolve around the classic issue of a hospital attempting to milk as much free labor from physicians as possible, although this time to an egregious extent, and with the tacit approval of university administrators.
In the end, the ENT attendings had no interest in being a Band–Aid for a broken health care system, particularly as represented by the neighboring state of Illinois. After repeated vociferous complaints from the faculty, and no clarification from our legal department, the attending call system was discontinued and responsibility for such call given to residents. This, of course, has not solved the problem, but only shifted it out of sight. As far as I know, after an ENT resident is contacted, patients from outlying hospital ERs with ENT problems are now transferred to our ER for further evaluation by our hospital’s ER staff and the residents. Many are then discharged. The tremendous waste of resources involved in two ER visits and an ambulance transfer for simple problems like nose bleeds, not to mention the extra patient suffering involved in prolonging treatment, seems to concern no one.
Copyright © 2011 The Johns Hopkins University Press. Narrative Inquiry in Bioethics, volume 1, issue 2. Used with permission.
In the Fall of 2011, faculty of the Bander Center for Medical Business Ethics contributed stories and commentaries to a special issue of Narrative Inquiry in Bioethics on "conflicting interests in medicine." This project illustrated the value of hearing narratives from physicians about how financial matters affect their practice of medicine. We hope that the Forum will provide a space to continue that dialogue and take it in new directions.
Tuesday, January 29, 2013
To Recruit or Not to Recruit for a Clinical Trial by Sal Cruz–Flores
Ms. J. M. arrived at the emergency room about 11 A.M. in the morning with stroke symptoms in the left side of her body. According to routine procedure with these patients our services were called via the “code stroke” system, to expedite her evaluation. She was a 65 year–old woman who the last time she was seen normal was about 7 A.M. the same morning. This fact is important as the only approved specific therapy for ischemic stroke is intravenous thrombolysis, which has to be administered within three hours from symptom onset or from the last time the patient was seen normal. To get to this point the patient has to be promptly evaluated to establish the time of onset, the severity of the stroke, exclude any contraindications for the use of thrombolysis and have a CT scan performed. All these steps were completed expeditiously but she was not a candidate for the approved treatment as she was clearly beyond the window of opportunity.
On evaluation Ms. J. M. seemed to be suffering a severe stroke affecting a large volume of the right hemisphere of her brain which causes very disabling impairment among survivors. The mortality of this condition is about 30% but might be higher if they develop brain swelling which occurs in many of these patients. The common scenario in most hospitals is that these patients do not receive thrombolysis and are admitted to the hospital for supportive care to avoid complications and start physical and rehabilitation services.
The options and the scenario change in a hospital like the one I practice in as there are more specific options than routine care otherwise offers. One option is the use of invasive interventions aimed at “de–clotting” the occluded intracranial vessel with devices inserted endovascularly through the femoral artery and navigated up to the occluded vessel within the skull. The rationale to use such devices is promulgated on the idea that opening the vessel increases the chance of having a good outcome by limiting the size of the stroke. The use of these devices was approved by the FDA as they are effective in opening the blood vessels however, the devices have not been shown to improve the outcome of stroke. The use of these devices has increased in the last few years and the increase use seems to parallel the appearance of a DRG code that permits the payment for the treatment. Suffice to say the payment for hospitals is considerable per procedure and therefore, they stand to gain financially from these procedures. Despite the uncertainty surrounding the use of these devices many of us feel that the use is justified considering the bad outcome many of these patients have when left untreated.
A second option available in our institution is the voluntary participation in clinical trials aimed at proving whether an intervention improves the outcome of the stroke. These interventions in some trials include the use of intravenous medications and in other trials, the use of the same intra–arterial devices that can be used outside a trial because they have been approved for another purpose (that of opening vessels). Most of these trials require the initiation of treatment usually within 6–8 hours depending on the specific study. Since Ms. J. M. presented within four hours from the last time she was seen normal, it was clear that she was not eligible to received intravenous thrombolysis but was eligible to be treated with an endovascular intervention or to participate in one of the clinical trials.
With these issues in mind my colleagues and I, but particularly myself, started struggling with what was the best decision for Ms. J. M. Why is it that we were struggling? For one, my colleagues were interventionalists and tended to favor the use of the endovascular devices. On the other hand, I was the physician in charge of her care, but I was also the principal investigator in these clinical trials testing treatments for stroke. It was obvious I also had a conflict of interests as I could potentially stand to gain from participation and recruitment of individuals into the trials and those conflict areas included professional prestige and perhaps some financial benefit. So what was best for this patient?
It is clear the patient had a devastating disease that was beyond the window of opportunity for the approved therapy and she could, on the one hand, have been treated with an intervention that might have potentially helped her, although this was yet uncertain, and in addition the hospital and my colleagues stood to benefit professionally and financially from performing the procedure. On the other hand, she could have been signed up for a clinical trial from which she might not have any personal benefit but might help answer a question about the efficacy of a treatment for a stroke victim, however, I stood to gain professional or financial benefit from her participation in the clinical trial.
We firmly believe that in the presence of clinical equipoise, if available, participation in clinical trials should be offered to patients and families, but then again whose equipoise anyway? In our special circumstance how could we approach somebody to participate in a clinical trial testing the efficacy of a device in improving the outcome of stroke and then turn around and say that we could treat him or her with the same device outside the clinical trial?
While disclosing potential conflicts of interests might be useful for these patients and their families, that still may not be helpful to them as they struggle with how much to trust the person presenting the information. Then there is the added issue of how the information is presented, which is known to influence the decision makers.
As I struggled with this decision, the decision, thankfully, was made for me. We could not find a person who could give consent on behalf of the patient and therefore, we could not offer her participation in the trial. This brings up an additional issue; how is it that we could invoke emergency treatment and justify the treatment with the device anyway? In the end, we did not treat her with the device as the intracranial vessel that was initially blocked was now open in the diagnostic angiography.
Copyright © 2011 The Johns Hopkins University Press. Narrative Inquiry in Bioethics, volume 1, issue 2. Used with permission.
On evaluation Ms. J. M. seemed to be suffering a severe stroke affecting a large volume of the right hemisphere of her brain which causes very disabling impairment among survivors. The mortality of this condition is about 30% but might be higher if they develop brain swelling which occurs in many of these patients. The common scenario in most hospitals is that these patients do not receive thrombolysis and are admitted to the hospital for supportive care to avoid complications and start physical and rehabilitation services.
The options and the scenario change in a hospital like the one I practice in as there are more specific options than routine care otherwise offers. One option is the use of invasive interventions aimed at “de–clotting” the occluded intracranial vessel with devices inserted endovascularly through the femoral artery and navigated up to the occluded vessel within the skull. The rationale to use such devices is promulgated on the idea that opening the vessel increases the chance of having a good outcome by limiting the size of the stroke. The use of these devices was approved by the FDA as they are effective in opening the blood vessels however, the devices have not been shown to improve the outcome of stroke. The use of these devices has increased in the last few years and the increase use seems to parallel the appearance of a DRG code that permits the payment for the treatment. Suffice to say the payment for hospitals is considerable per procedure and therefore, they stand to gain financially from these procedures. Despite the uncertainty surrounding the use of these devices many of us feel that the use is justified considering the bad outcome many of these patients have when left untreated.
A second option available in our institution is the voluntary participation in clinical trials aimed at proving whether an intervention improves the outcome of the stroke. These interventions in some trials include the use of intravenous medications and in other trials, the use of the same intra–arterial devices that can be used outside a trial because they have been approved for another purpose (that of opening vessels). Most of these trials require the initiation of treatment usually within 6–8 hours depending on the specific study. Since Ms. J. M. presented within four hours from the last time she was seen normal, it was clear that she was not eligible to received intravenous thrombolysis but was eligible to be treated with an endovascular intervention or to participate in one of the clinical trials.
With these issues in mind my colleagues and I, but particularly myself, started struggling with what was the best decision for Ms. J. M. Why is it that we were struggling? For one, my colleagues were interventionalists and tended to favor the use of the endovascular devices. On the other hand, I was the physician in charge of her care, but I was also the principal investigator in these clinical trials testing treatments for stroke. It was obvious I also had a conflict of interests as I could potentially stand to gain from participation and recruitment of individuals into the trials and those conflict areas included professional prestige and perhaps some financial benefit. So what was best for this patient?
It is clear the patient had a devastating disease that was beyond the window of opportunity for the approved therapy and she could, on the one hand, have been treated with an intervention that might have potentially helped her, although this was yet uncertain, and in addition the hospital and my colleagues stood to benefit professionally and financially from performing the procedure. On the other hand, she could have been signed up for a clinical trial from which she might not have any personal benefit but might help answer a question about the efficacy of a treatment for a stroke victim, however, I stood to gain professional or financial benefit from her participation in the clinical trial.
We firmly believe that in the presence of clinical equipoise, if available, participation in clinical trials should be offered to patients and families, but then again whose equipoise anyway? In our special circumstance how could we approach somebody to participate in a clinical trial testing the efficacy of a device in improving the outcome of stroke and then turn around and say that we could treat him or her with the same device outside the clinical trial?
While disclosing potential conflicts of interests might be useful for these patients and their families, that still may not be helpful to them as they struggle with how much to trust the person presenting the information. Then there is the added issue of how the information is presented, which is known to influence the decision makers.
As I struggled with this decision, the decision, thankfully, was made for me. We could not find a person who could give consent on behalf of the patient and therefore, we could not offer her participation in the trial. This brings up an additional issue; how is it that we could invoke emergency treatment and justify the treatment with the device anyway? In the end, we did not treat her with the device as the intracranial vessel that was initially blocked was now open in the diagnostic angiography.
Copyright © 2011 The Johns Hopkins University Press. Narrative Inquiry in Bioethics, volume 1, issue 2. Used with permission.
An Unexpected Lesson by Laura E. Hodges
Physicians’ interactions with the drug industry can erode trust not only with their patients, but also with the students they teach in the clinic. I learned this first–hand when I started my clinical rotations as a third year medical student. On my first month–long rotation, I was assigned to a hospital with a policy that restricted the presence of pharmaceutical representatives on the premises. Representatives were never seen on the hospital floors or in resident workrooms, and drug promotional paraphernalia was at a minimum. If I saw an occasional pen with a drug logo on it, I knew it had to have come from outside of the hospital. In this, my first full–time month spent in a clinical environment, it never occurred to me that my attending physicians might teach me anything but the most up–to–date evidence–based information.
My assumptions changed during my second rotation, when I was assigned to a hospital with a much more permissive policy towards pharmaceutical representatives. The first patient I saw was a woman with congestive heart failure, a condition commonly seen in hospitals. CHF has a fairly standard set of treatments, a major component of which is one or more diuretic medications. The diuretic allows a person with CHF to urinate excess fluid out of her system, thereby decreasing the fluid load on her weakened heart. The classes of diuretics used for this purpose are common, familiar to any medical student who has taken a course in pharmacology. The night after meeting my patient, I prepared for morning rounds and created a treatment plan for her. While I was still new to formulating a treatment plan, I felt fairly confident that the diuretic I’d chosen was an appropriate choice.
On rounds the next morning, I gave the standard presentation for my patient’s case, and ended with my suggestion to use one of the standard diuretics as part of her treatment. My attending, however, had a different idea. “Her sodium levels are low. Diureseall* might be better for her hyponatremia.”
My team and I gave him a quizzical look. “Diureseall?” I said.
“It’s an ADH inhibitor.” He answered our question before we could fully formulate it.
Like any good medical student, I knew that ADH stood for anti–diuretic hormone, a hormone that is naturally produced by the brain when the body needs to retain fluid; it does this by causing the body to produce less urine. An inhibitor of ADH would reverse this process and cause the body to create more urine, thus acting as a diuretic. However, beyond this basic knowledge, I had never learned about this class of drugs in my fairly thorough pharmacology class. I also had never heard of it as a treatment for congestive heart failure. I said as much to my attending.
“It’s a new drug, recently released on the market,” he said to me. “If you come with me to my office after rounds, I’ll give you an article about it.”
We finished rounds after a couple of hours and I walked with him back to his office. He asked me friendly questions about myself: where I grew up, what I studied as an undergraduate, what specialty I thought I might like to go into. He told me with enthusiasm about his work as an internist and his schedule for the rest of the day. After riffling through a few draws in his desk, he found the article and handed it to me.
Instead of the rough photocopy I had expected, the article was printed as a stand–alone brochure, on nice, heavy stock paper and in full color. I was immediately impressed by the brochure format, as I had never seen a journal article in this form before. The article was of a randomized control trial of Diureseall, and the logo of the well–known journal it was published in was prominently displayed at the top. I thanked my attending for the article and promised that I would read it that night.
As I sat down with my frozen dinner of pasta primavera that evening, I started to look over the Diureseall article. The handout was thick and glossy, and I tried to imagine where my attending could have gotten a copy like this. I remembered some patient education brochures I had seen earlier that day. They were obviously published by a pharmaceutical company, and prominently displayed the name of the medication they were selling on the back of the brochure. I noted them because I hadn’t seen sponsored handouts like that on my previous rotation at the other hospital. In fact, I had noticed several new things that day: a mug next to a computer with the name of an antidepressant printed on its side; a model of an plaque–caked artery with the name of a lipid lowering drug on it; and a pharmaceutical company–sponsored lunch at the noon conference for our department.
I inspected the article in front of me for any logo or other small sign of who might have published the handout. There was no indication of who had printed it, but it looked suspiciously to me as though a pharmaceutical representative who was promoting the new drug had handed it out.
As I started to read the article, I noticed several significant limitations in the study methodology. When I finished, I thought about the standard diuretics used in CHF and realized that the findings of this study printed on glossy thick paper were not sufficient to justify the use of Diureseall over the other gold standard drugs. I also noticed that there was no mention of the cost of Diureseall anywhere in the handout, and so had no information about the cost–effectiveness of the drug.
I put down the article and I could not help but wonder: Why did my attending give me this article? Did he not see the glaring limitations I noted? Was it merely coincidence that a pharmaceutical representative promoted the drug to him? During our training, it’s common for attendings to give articles to students about the most current therapeutics and diagnostic procedures. The article my attending gave me was meant to be educational and help me understand why Diureseall might be a better choice for our patient than any other drug. Even if Diureseall did turn out to be the best choice for our patient, the article I was given was not sufficient to justify the choice of the drug. The lesson my attending taught me by giving me this article conflicted with the principles of evidence–based medicine I had learned up until that point. The next morning, I arrived at rounds ready to discuss what I learned from the article and prepared to argue in favor of using the standard diuretic I originally suggested. Before I even had the chance to present my update for the morning, the senior resident gave us a brief update: he had checked with the hospital’s pharmacy yesterday afternoon and found that they did not have any Diureseall in stock because of the extremely high daily cost of the medication. My resident had already used his prescribing power to go ahead and put the patient on the diuretic I initially suggested.
“I can’t believe it costs so much!” my attending exclaimed. “I thought it would be interesting to try it out, but not at the price.” My attending looked genuinely surprised and more than a little disappointed, but we went ahead with a regiment of standard diuretics. Happily, our patient recovered and was well enough to go home after a few days.
I’m still not 100% sure that my attending received that article from a pharmaceutical representative. Even if he hadn’t, the environment of pharmaceutical representative promotion at our hospital caused me to consider this as a strong possibility. It was this suspicion that in turn caused me to question the reasoning that led my attending to choose Diureseall over any other drug. Whether or not there was an influence from pharmaceutical marketing, the environment in which our interaction was situated led me to suspect some level of industry influence on my education.
This was not the only interaction I had with an attending and the pharmaceutical industry. A week after this event, I noticed a pharmaceutical company flyer that was posted in the resident workroom. The flyer was for a dinner and educational talk being held at our hospital in a few days. After a week of being surrounded by patient education handouts and plastic educational models of knee joints and uteruses emblazoned with various brand name drugs, I was not surprised to see an industry sponsored event advertized in the workroom for medical trainees. What did surprise me was the speaker: it was one of the faculty physicians at the hospital who had given my cohort of students a lecture just a few days ago.
My heart sank as I thought back on the content of the lecture she gave us. Was this a topic she also covered in industry–sponsored lectures? Where had the information come from? Because she was faculty at an academic medical center, I assumed that what she taught us was based on the most impartial and evidence–based information she could find. Was it possible that the content of her sponsored lectures was influenced, even in some small way, by industry funding? Was it possible that this influence also affected the lectures she gave to students?
I do not have the answers to these questions. I have no way of reading into the thought processes of my professors. As far as I know, I am being given teachings based on the most up to date, evidence–based, gold standard medical practices. Of course, even if my instructors’ teachings are influenced by their interactions with the pharmaceutical industry, I can’t believe they are promoting drugs on purpose. After all, pharmaceutical marketing works in large part because it works on a subconscious level. I’m sure that if any of us were shown direct proof of the effects commercial marketing has on us, we would be shocked to see impressions we had no idea existed in us. While I cannot be certain that my instructors have been influenced by their interactions with industry, the possibility exists. I am left to wonder if an academic medical environment that is welcoming of pharmaceutical marketing is conducive to building trust and providing quality medical education to students.
Footnotes
* Diureseall is a fictitious drug name created to protect all parties involved in this true story.
Copyright © 2011 The Johns Hopkins University Press. Narrative Inquiry in Bioethics, volume 1, issue 2. Used with permission.
My assumptions changed during my second rotation, when I was assigned to a hospital with a much more permissive policy towards pharmaceutical representatives. The first patient I saw was a woman with congestive heart failure, a condition commonly seen in hospitals. CHF has a fairly standard set of treatments, a major component of which is one or more diuretic medications. The diuretic allows a person with CHF to urinate excess fluid out of her system, thereby decreasing the fluid load on her weakened heart. The classes of diuretics used for this purpose are common, familiar to any medical student who has taken a course in pharmacology. The night after meeting my patient, I prepared for morning rounds and created a treatment plan for her. While I was still new to formulating a treatment plan, I felt fairly confident that the diuretic I’d chosen was an appropriate choice.
On rounds the next morning, I gave the standard presentation for my patient’s case, and ended with my suggestion to use one of the standard diuretics as part of her treatment. My attending, however, had a different idea. “Her sodium levels are low. Diureseall* might be better for her hyponatremia.”
My team and I gave him a quizzical look. “Diureseall?” I said.
“It’s an ADH inhibitor.” He answered our question before we could fully formulate it.
Like any good medical student, I knew that ADH stood for anti–diuretic hormone, a hormone that is naturally produced by the brain when the body needs to retain fluid; it does this by causing the body to produce less urine. An inhibitor of ADH would reverse this process and cause the body to create more urine, thus acting as a diuretic. However, beyond this basic knowledge, I had never learned about this class of drugs in my fairly thorough pharmacology class. I also had never heard of it as a treatment for congestive heart failure. I said as much to my attending.
“It’s a new drug, recently released on the market,” he said to me. “If you come with me to my office after rounds, I’ll give you an article about it.”
We finished rounds after a couple of hours and I walked with him back to his office. He asked me friendly questions about myself: where I grew up, what I studied as an undergraduate, what specialty I thought I might like to go into. He told me with enthusiasm about his work as an internist and his schedule for the rest of the day. After riffling through a few draws in his desk, he found the article and handed it to me.
Instead of the rough photocopy I had expected, the article was printed as a stand–alone brochure, on nice, heavy stock paper and in full color. I was immediately impressed by the brochure format, as I had never seen a journal article in this form before. The article was of a randomized control trial of Diureseall, and the logo of the well–known journal it was published in was prominently displayed at the top. I thanked my attending for the article and promised that I would read it that night.
As I sat down with my frozen dinner of pasta primavera that evening, I started to look over the Diureseall article. The handout was thick and glossy, and I tried to imagine where my attending could have gotten a copy like this. I remembered some patient education brochures I had seen earlier that day. They were obviously published by a pharmaceutical company, and prominently displayed the name of the medication they were selling on the back of the brochure. I noted them because I hadn’t seen sponsored handouts like that on my previous rotation at the other hospital. In fact, I had noticed several new things that day: a mug next to a computer with the name of an antidepressant printed on its side; a model of an plaque–caked artery with the name of a lipid lowering drug on it; and a pharmaceutical company–sponsored lunch at the noon conference for our department.
I inspected the article in front of me for any logo or other small sign of who might have published the handout. There was no indication of who had printed it, but it looked suspiciously to me as though a pharmaceutical representative who was promoting the new drug had handed it out.
As I started to read the article, I noticed several significant limitations in the study methodology. When I finished, I thought about the standard diuretics used in CHF and realized that the findings of this study printed on glossy thick paper were not sufficient to justify the use of Diureseall over the other gold standard drugs. I also noticed that there was no mention of the cost of Diureseall anywhere in the handout, and so had no information about the cost–effectiveness of the drug.
I put down the article and I could not help but wonder: Why did my attending give me this article? Did he not see the glaring limitations I noted? Was it merely coincidence that a pharmaceutical representative promoted the drug to him? During our training, it’s common for attendings to give articles to students about the most current therapeutics and diagnostic procedures. The article my attending gave me was meant to be educational and help me understand why Diureseall might be a better choice for our patient than any other drug. Even if Diureseall did turn out to be the best choice for our patient, the article I was given was not sufficient to justify the choice of the drug. The lesson my attending taught me by giving me this article conflicted with the principles of evidence–based medicine I had learned up until that point. The next morning, I arrived at rounds ready to discuss what I learned from the article and prepared to argue in favor of using the standard diuretic I originally suggested. Before I even had the chance to present my update for the morning, the senior resident gave us a brief update: he had checked with the hospital’s pharmacy yesterday afternoon and found that they did not have any Diureseall in stock because of the extremely high daily cost of the medication. My resident had already used his prescribing power to go ahead and put the patient on the diuretic I initially suggested.
“I can’t believe it costs so much!” my attending exclaimed. “I thought it would be interesting to try it out, but not at the price.” My attending looked genuinely surprised and more than a little disappointed, but we went ahead with a regiment of standard diuretics. Happily, our patient recovered and was well enough to go home after a few days.
I’m still not 100% sure that my attending received that article from a pharmaceutical representative. Even if he hadn’t, the environment of pharmaceutical representative promotion at our hospital caused me to consider this as a strong possibility. It was this suspicion that in turn caused me to question the reasoning that led my attending to choose Diureseall over any other drug. Whether or not there was an influence from pharmaceutical marketing, the environment in which our interaction was situated led me to suspect some level of industry influence on my education.
This was not the only interaction I had with an attending and the pharmaceutical industry. A week after this event, I noticed a pharmaceutical company flyer that was posted in the resident workroom. The flyer was for a dinner and educational talk being held at our hospital in a few days. After a week of being surrounded by patient education handouts and plastic educational models of knee joints and uteruses emblazoned with various brand name drugs, I was not surprised to see an industry sponsored event advertized in the workroom for medical trainees. What did surprise me was the speaker: it was one of the faculty physicians at the hospital who had given my cohort of students a lecture just a few days ago.
My heart sank as I thought back on the content of the lecture she gave us. Was this a topic she also covered in industry–sponsored lectures? Where had the information come from? Because she was faculty at an academic medical center, I assumed that what she taught us was based on the most impartial and evidence–based information she could find. Was it possible that the content of her sponsored lectures was influenced, even in some small way, by industry funding? Was it possible that this influence also affected the lectures she gave to students?
I do not have the answers to these questions. I have no way of reading into the thought processes of my professors. As far as I know, I am being given teachings based on the most up to date, evidence–based, gold standard medical practices. Of course, even if my instructors’ teachings are influenced by their interactions with the pharmaceutical industry, I can’t believe they are promoting drugs on purpose. After all, pharmaceutical marketing works in large part because it works on a subconscious level. I’m sure that if any of us were shown direct proof of the effects commercial marketing has on us, we would be shocked to see impressions we had no idea existed in us. While I cannot be certain that my instructors have been influenced by their interactions with industry, the possibility exists. I am left to wonder if an academic medical environment that is welcoming of pharmaceutical marketing is conducive to building trust and providing quality medical education to students.
Footnotes
* Diureseall is a fictitious drug name created to protect all parties involved in this true story.
Copyright © 2011 The Johns Hopkins University Press. Narrative Inquiry in Bioethics, volume 1, issue 2. Used with permission.
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