luxury primary care and academic medical centers: the erosion of science and professional ethics...
TRANSCRIPT
Luxury Primary Care and Luxury Primary Care and Academic Medical Centers:Academic Medical Centers:The Erosion of Science and The Erosion of Science and
Professional EthicsProfessional Ethics
Martin DonohoeMartin Donohoe
Academic Medical CentersAcademic Medical Centers
Evidence-based medicineEvidence-based medicine EthicsEthics Providers of last resort to poor and Providers of last resort to poor and
destitute, un- and under-insureddestitute, un- and under-insured Personal experience – university vs Personal experience – university vs
homeless clinichomeless clinic
Financial Crisis:Financial Crisis:ResponsesResponses
Increasing links with Increasing links with pharmaceutical and biotech pharmaceutical and biotech industriesindustries
Recruitment of wealthy, non-US Recruitment of wealthy, non-US citizenscitizens
Luxury primary care / executive Luxury primary care / executive health clinicshealth clinics
Luxury Primary Care/Luxury Primary Care/Executive Health ClinicsExecutive Health Clinics
Most major academic medical Most major academic medical centerscenters
2000-3500 visits per year2000-3500 visits per year
$1500 to $20,000/visit$1500 to $20,000/visit Avg. $2000-$4000Avg. $2000-$4000
LPC Clinic PerksLPC Clinic Perks
Same day appointments/tests, Same day appointments/tests, accompanied consults, vaccines accompanied consults, vaccines
Shorter waiting timesShorter waiting times Low physician/patient ratiosLow physician/patient ratios 24/7 access, house calls24/7 access, house calls
Clients/MarketingClients/Marketing
Large corporationsLarge corporations Tobacco companies, environmental Tobacco companies, environmental
polluters, health insurerspolluters, health insurers Hope for contracts for Hope for contracts for
institution/providers and/or institution/providers and/or corporate donationscorporate donations
Marketed to the “busy executive”Marketed to the “busy executive” Mostly white malesMostly white males
UnknownsUnknowns
Medical student/resident Medical student/resident participationparticipation
Effects on physiciansEffects on physicians Effects on old patientsEffects on old patients How fundedHow funded Where profits go - ?cross-Where profits go - ?cross-
subsidization?subsidization? SecrecySecrecy
LPCs and the Erosion of LPCs and the Erosion of ScienceScience
Tests not clinically indicated or cost-Tests not clinically indicated or cost-effectiveeffective CXRs – lung cancerCXRs – lung cancer CT scans/stress ECHOs – CADCT scans/stress ECHOs – CAD Pelvic US – ovarian CAPelvic US – ovarian CA Whole-body CT scansWhole-body CT scans
radiation~Hiroshima, raise radiation~Hiroshima, raise cancer riskscancer risks
Consequences of Unnecessary Consequences of Unnecessary TestingTesting
False positives False positives → further testing, → further testing, complications, anxiety, ↑ profitscomplications, anxiety, ↑ profits
Diversion of limited resources – Diversion of limited resources – human and capitalhuman and capital
Erosion of evidence-based practiceErosion of evidence-based practice Unsound scienceUnsound science
LPCs and the Erosion of LPCs and the Erosion of Professional EthicsProfessional Ethics
General public subsidizes medical General public subsidizes medical trainingtraining
Physicians limit practice to wealthyPhysicians limit practice to wealthy Increasing differential of care between Increasing differential of care between
poor and wealthypoor and wealthy Financial factors replace clinical Financial factors replace clinical
judgmentjudgment
Contemporary Health CareContemporary Health Care
↑ ↑ wealth disparitieswealth disparities 20-25% of US children live in poverty20-25% of US children live in poverty
↑ ↑ environmental degradation (and related environmental degradation (and related illnesses)illnesses)
↓↓access to careaccess to care 45 million uninsured in US, underinsured, 45 million uninsured in US, underinsured,
dead end jobs, public hospitals closingdead end jobs, public hospitals closing Disparities by social class / race in access to Disparities by social class / race in access to
and outcomes of careand outcomes of care Developing world brain drain; medical tourismDeveloping world brain drain; medical tourism
LPCs and the Erosion of LPCs and the Erosion of Professional EthicsProfessional Ethics
Workups, treatments based Workups, treatments based on ability to payon ability to pay
EthicsEthics RationingRationing Acceptance of double Acceptance of double
standardstandard
LPCs and the Erosion of LPCs and the Erosion of Professional EthicsProfessional Ethics
Increasing cynicism/dissatisfaction Increasing cynicism/dissatisfaction among medical among medical students/residents/practicing students/residents/practicing physicians and patientsphysicians and patients
More providers willing to “game the More providers willing to “game the system”system”
SolutionsSolutions
Renunciation of the measure Renunciation of the measure of the marketplace as the of the marketplace as the dominant standard and value dominant standard and value in health carein health care
Equitable division of resourcesEquitable division of resources
Solutions: Medical Education Solutions: Medical Education and Ethics Trainingand Ethics Training
Increasing emphasis on social, Increasing emphasis on social, cultural, economic and environmental cultural, economic and environmental contributors to health and illnesscontributors to health and illness Health disparities, cultural Health disparities, cultural
competence, occupational and competence, occupational and environmental illnesses (e.g., environmental illnesses (e.g., pesticide-related illnesses, air pesticide-related illnesses, air pollution and asthma)pollution and asthma)
Solutions: Medical Education Solutions: Medical Education and Ethics Trainingand Ethics Training
Heal schism between medicine Heal schism between medicine and public healthand public health
Service-oriented learning, Service-oriented learning, research-based activist courses, research-based activist courses, volunteerism, political activismvolunteerism, political activism
History, literature, role History, literature, role models/mentoringmodels/mentoring
Solutions: Public PolicySolutions: Public Policy
↑ ↑ education of public policymakers education of public policymakers (business leaders, government (business leaders, government representatives, and health care representatives, and health care purchasers)purchasers)
↑ ↑ public educationpublic education
Solutions: Public PolicySolutions: Public Policy
Deans, department chairs, division Deans, department chairs, division chiefs, ethicists, doctor-patientchiefs, ethicists, doctor-patient Ethicists quiet re LPCsEthicists quiet re LPCs
Outcome: ↑ funding for education, Outcome: ↑ funding for education, training, and care of the underserved training, and care of the underserved by academic institutionsby academic institutions
ReferencesReferences
Donohoe MT. “Standard vs. luxury care,” Donohoe MT. “Standard vs. luxury care,” in in Ideological Debates in Family MedicineIdeological Debates in Family Medicine, , S S Buetow and T Kenealy, Eds. (Buetow and T Kenealy, Eds. (New York, New York, Nova Science Publishers, Inc., 2007). Nova Science Publishers, Inc., 2007). Available at Available at http://http://phsj.org/?page_idphsj.org/?page_id=22=22
Donohoe MT. Elements of professionalism Donohoe MT. Elements of professionalism for a physician considering the switch to a for a physician considering the switch to a retainer practice. In retainer practice. In Professionalism in Professionalism in Medicine: The Case-based Guide for Medicine: The Case-based Guide for Medical StudentsMedical Students, Editors: Spandorfer, , Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge Pohl, Rattner, and Nasca (Cambridge University Press, 2008, in press).University Press, 2008, in press).
ReferencesReferences
Donohoe MT. Luxury primary care, Donohoe MT. Luxury primary care, academic medical centers, and the erosion academic medical centers, and the erosion of science and professional ethics. J Gen of science and professional ethics. J Gen Int Med 2004;19:90-94. Available at Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.x10.1111/j.1525-1497.2004.20631.x
Donohoe MT. Retainer practice: Scientific Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical issues, social justice, and ethical perspectives. American Medical perspectives. American Medical Association Virtual Mentor 2004 Association Virtual Mentor 2004 (April);6(4). Available at (April);6(4). Available at http://www.ama-assn.org/ama/pub/categorhttp://www.ama-assn.org/ama/pub/category/12249.htmly/12249.html
Contact InformationContact Information
Public Health and Social Justice Public Health and Social Justice WebsiteWebsite
http://www.phsj.orghttp://www.phsj.org
[email protected]@phsj.org