Everybody knows the good guys lost
Everybody knows the fight was fixed
The poor stay poor, the rich get rich
That's how it goes
Everybody knows
Lyrics - Everybody Knows by Leonard Cohen
The current situation in medicine where everybody knows that the system has been completely corrupted, but nobody wants to change always reminds me of the song 'Everybody Knows' by Leonard Cohen. Huge amounts of $$$ have corrupted universities, researcher, doctors, and everybody knows. But why do we still allow it to happen?
Let's consider several imaginary situations.
- A journalist from the New York Times routinely receives a large gift from home-building companies. He writes an opinion piece that is highly supportive of leveling playgrounds to erect more McMansions and condos. Is this unethical? Absolutely. In fact, the New York Times has a strict code of conduct that specifically prohibits acceptance of gifts, even a slice of pizza. Newspapers has a fiduciary duty to uphold the truth, and financial conflicts of interest among its journalists would erode that trust. Every major newspaper has a similar policy.
- A politician in New York routinely routinely receives large gifts from the home-building industry. He often goes out to free dinners and sees free shows with the salespeople. He is also highly supportive of leveling playgrounds to build more condos. Is the unethical? Absolutely. We would call this corruption and virtually every government employee and civil servant knows that this sort of chicanery is unacceptable. Even a schoolchild knows this is wrong. Politicians have a fiduciary duty to represent all of their constituents and financial conflicts of interest are strictly forbidden. Every city in North America has the same policy.
- A policeman routinely receives gifts from a 'friendly' neighbour. This neighbour drinks and drives regularly, but never seems to get into trouble. Is this unethical? Absolutely. Legally you can't even give a policeman a refreshing lemonade on a hot day. It's called graft, and is completely against the NYPD code of conduct. Policemen can be summarily fired for this offense. This is because police have a sworn duty to uphold the law, and financial conflicts of interest are strictly forbidden. Every major police department has a similar policy.
No similar standards for doctors
The same ethical standards do not apply to physicians, however. Doctors are also in a position of trust and have a fiduciary duty to protect the health of their patients. At the same time, they make decisions that may put thousands of dollars into Big Pharma's pocket. These two decisions routinely conflict, but unlike the politician, policeman or journalist doctors may legally accept hundreds, thousands or hundreds of thousands of $$$.
Other than disclosing this financial conflict of interest, nothing else happens. The graft goes all the way up to the top. Starting with the individual doctors, there's good evidence (as if we needed it) that gifts from pharmaceuticals influences prescribing behavior. It seems kind of obvious that giving lots of money to doctors will make them look favourably on the drug industry (such as this study, from PLOS ONE). Big Pharma can easily influence prescribing practices by paying doctors although it is never called that explicitly. Instead, these numerous financial conflicts of interest (COI) are called research grants, education grants, consulting fees, speaker fees, gifts and free meals.
While studies consistently show that such gifts influence physician behaviour, physicians themselves consistently deny that such gifts has any such influence. This is a case of burying one's head in one's a**, since it seems perfectly obvious that Big Pharma would not waste millions of dollars every year paying out $$$ without a good return. There are none so blind as those that will not see. Studies confirm that increased interaction with pharmaceuticals increases far more branded (expensive) prescriptions, less generic (cheaper) alternatives and helps add these medications to hospital formularies (where they can be prescribed).
The rather elementary logic goes like this. Big pharma pays lots of $$$ to doctors. Doctors prescribe lots of drugs. Big pharma makes more $$$, and pays even more to doctors. Who loses? Patients and the general public. Everywhere else, it's called corruption, graft, payola, grease, or kickback. In medicine, it's called 'the way things work'.
While laws and codes of ethics exist for restricting gifts to almost everybody (journalists, police, civil servants, teachers etc), no such law exists for doctors, other than disclosure. Because it is tacitly encouraged, the list of financial COI can become ridiculous. For example, here's the rather lengthy list of payments for one 'research paper' by Dr. Sievenpiper and colleagues at the University of Toronto arguing that sugar is really a health food. It may not surprise you that this doctor, as well as his hospital (St. Michael's Hospital) and University (Toronto) are receiving $$$ from such altruistic institutions like Coca Cola and the Calorie Control Council (a puppet organization of the soda companies). It's not just the individual doctor that is corrupted - it is the entire academic system. The graft reaches all the way to the top. With enough 'incentive' this university, hospital and doctor would probably even argue that smoking is good for us. Why is this even allowed?
But not everybody thinks this is an acceptable situation. But yet we still allow the exact same thing with our supposed guardians of health - our physicians. IF we care about the health of our world, we must act to end the kickbacks.
The tacit acceptance of these kickbacks is even more infuriating. I have gone to many lectures given by university professors, and when disclosing their COI (conflicts of interest), there is a huge list. Then, he/she will joke that "I'm not biased because I accept money from every drug maker". This draws a knowing laugh from the audience of physicians because this is 'the way things work'. Everybody knows the deal is rotten. Everybody knows the captain lied. Everybody knows the dice are loaded. But nobody speaks. These are the most influential physicians in the world, the ones that lecture thousands of other doctors and the ones that change the practice of medicine more than anybody else. These are the same doctors taking the most money. Isn't this a huge ticking time bomb?
Doctors don't think so. They don't even know they are being influenced. A study of medical residents suggested that 61% of medical residents felt that gifts don't influence their prescribing pattern. Medical students had no problem identifying that gifts are problematic other professions, but not for doctors. Graft and corruption - it's only a problem for everybody else. A study by Orlowski and Wateska tracked use of drugs after 20 physicians at an institution sent to medical education seminars sponsored by drug companies. Afterward, usage of the 2 drugs more than tripled, but tellingly, all but 1 of the physicians denied that seminars influenced them in any way. 95% of the doctors just thought "Hey, free lunch".
Solving the problem
There is no free lunch. Big Pharma is not stupid, you know. They know they are getting a good return on their investment. For physicians, the first part of solving a problem is to admit that one exists. It's instructive that Big Pharma prohibits its own employees from even receiving the smallest of gifts, while giving generously to physicians, universities and hospitals while simultaneously denying that this influences their decisions. The indigo dyer wears white trousers (ancient Japanese proverb).
The study by Wood et al (2017) shows that in virtually every specialty, doctors who received gifts from Big Pharma prescribed more, prescribed costlier medications and more branded prescriptions. This is also true for nurse practitioners as well as physicians assistants.
Indeed, there is a clear dose relationship between the two. When Big Pharma gives small gifts, there is a small increase in prescriptions. When Big Pharma gives big gifts, there is a larger increase. Not rocket science. The cost of the medication, borne by patients and taxpayers, almost doubles while Big Pharma and the doctors drink their expensive wines and eat their fancy meals. The doctors have betrayed the sacred trust since pharmaceutical companies have no such duty to the patient.
It's time to stop the gravy train. The egregious betrayal of public trust happens in every university with a medical school every single day or every single year. While individual doctors are culpable, the universities and academic physicians are far more so. The potential for harm from financial conflicts of interest are exponentially higher. These professors and doctors spend less time treating real patients, instead focusing on research and teaching. Thus, if they embrace certain lucrative drug treatments, they are less likely to see the direct effects. They do not talk to the family who is struggling to afford their $5000/ year medication when another one costing $50 would do just as well.
They are also the doctors most likely to be receive large gifts in the form of direct payments or 'research' money. These are the same doctors who teach medical students their loose code of ethics (hey, taking money and gifts and free dinner from Big Pharma is good). They write biased (the doctors themselves are ignorant of their own biases) guidelines that promote the standard of care. They lecture to other doctors. The solutions are really quite simple.
- Every doctor who teaches at a medical school or university should be prohibited from receiving any form of compensation from anybody else. If you work at a university, you should not be paid off by anybody else. Every major corporation in the world abides by these rules. So should doctors.
- Every organization that publishes guidelines cannot have financial conflicts of interest. Guidelines are not advertisements. If the American Diabetes Association (ADA) wants to write a guideline (which becomes standard of practice) then the ADA cannot be receiving any money other than from members.
- Every doctor on a committee that writes guidelines must not have any financial COI.
- Every editor of a journal should not have any financial COI. This is not allowed for newspapers or major magazines, for example.
While some may feel these are draconian rules, they are really just the same rules that apply to everybody else.
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