By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website
The editors of the prestigious Annals of Internal Medicine just stated they they were shocked, shocked to find out that physicians occasionally express disrespect for patients when the patients cannot hear or see them. The occasion was an editorial signed by three editors whose title included the phrase, “shining a light on the dark side of health care.”(1) The editorial referred to an anonymous narrative that recounted two incidents from the past.(2)
Two Alleged Incidents of Physicians’ Expression of Disrespect for Patients
The first incident, discussed second hand, was of a obstetrician who made a sexist comment about a patient, who was under anesthesia, presumably unconscious, and being prepared for surgery. The second incident, presumably less recent, was of an obstetric/gynceology resident who, after performing an emergency procedure that saved a woman from potentially fatal acute hemmorhage, performed an impromptu dance routine that appeared to disrespect the patient’s ethnicity, until stopped by the anesthesiologist who issued a profance rebuke.
The names of the people involved, the hospitals in which these incidents occurred, and even the years when they happened are unknown. The Annals did not publish anything suggested their veracity was corroborated.
There was no apparent harm to or direct effect on any patient as a result of either incident. Of course, both alleged incidents suggested very disrespectful expression by the two physicians. Their actions appeared unprofessional.
The Editorial Reaction
As noted above, the editorial called the incidents examples of medicine’s “dark side.” It further said they may make “readers’ stomachs churn,” referred to “medicine’s dark underbelly,” and “repugnant behavior,” and characterized the narrative as “disgusting and scandalous,” and having the potential to “damage the profession’s reputation.” The editorial characterized the the behavior of the obstetrician in the first incident as “highly disrespectful,” and said it “reeked of misogyny and disrespect,” while the second “reeked of all that plus heavy overtones of sexual assault and racism.”
That is certainly extreme language. The editors appeared shocked, shocked that any physician could ever express disrespect for a patient, even when the patient could not possible be aware of that. Nonetheless, of course, the behavior alleged to have occurred was certainly inappropriate and unprofesional, and cannot be condoned.
The Media Reaction
The two articles got considerable publicity, and media coverage also made the incidents out to be extremely sordid, using words like,”disturbing,” “astonishing,” “unsavory,” (albeit also “boorish,”) (LA Times); “criminal,” “vulgarity,” (MedPage Today); “appalling,” “troubling,” (NY Times); and “misogynistic,” “abhorrent,” (US News and World Report). I must note that some of the news coverage did reflect doubts that the two Annals of Internal Medicine articles represented some horrendous catastrophe, raising issues such as the humanness of doctors, so that some may be “prone to sociopathy and criminality;” the stress of some medical emergencies leading to letting off steam, or poor attempts at humor; and doubts about the representativeness and validity of the two alleged anecdotes.
Nonetheless, it seemed to me that the Annals articles and the media coverage did suggest an impending crisis due to the sordid behavior of perhaps numerous doctors, and at least the tone of the media coverage they provoked suggested the need for immediate action.
Was the Outrage Justified?
However, first keep in mind that these two incidents involved two individual doctors, one a trainee. There are approximately 800,000 physicians in the US. They are human. Is it any surprise that some are “bad apples,” and that others occasionally behave badly? There is nothing in the two articles to suggest that these incidents reflected more organized, systemic actions.
Furthermore, the articles seemed to ignore the fact that mechanisms, perhaps not flawless, are already in place to address unprofessional behavior by physicians, even if no one involved in the published narrative may have used them. In the US, physicians are subject to discipline from state licensing boards. They may be reported to those boards for unprofessional behavior. The boards can sanction physicians in a variety of ways, up to and including permanent loss of license. Both alleged incidents apparently occurred in teaching hospitals. Attendings and residents at teaching hospital must answer to department chairs, medical school deans and hospital staffs. So mechanisms for policing such behavior exist, even if they may have not been used in this case. A look at state medical board websites reveals that that physicians are often sanctioned for bad behavior that disrespects or even endangers patients.
Finally, the Annals of Internal Medicine used very strong language, involving churning stomachs, reeks of misogyny, sexual assault, and racism, dark underbellies, etc. Was this a proportionate response to two anonymous cases that did not involve allegations of direct patient harm?
The Real Dark Side
Readers of Health Care Renewal know that we often discuss systemic problems in health care, often involving the leadership of large health care organizations, that may produce real harms to patients’ and the public’s health, but for which no good policing mechanisms seem to exist. Worse, these problems seem to be a taboo topic in health care policy discussions, and in medical journals, like the Annals of Internal Medicine.
In my humble opinion, the Annals’ editorial outrage would ring less hollowly if it was accompanied by even greater outrage at such more extreme problems.
Let me start with a recent example.
Example: the Anechoic AllTrials US Launch
Very recently we discussed how the launch of new US AllTrials initiative got almost no notice. Specifically, even though a sponsor of the initiative is the American College of Physicians, that organization’s publication, the Annals of Internal Medicine, did not comment on it. (A search of the journal using the term AllTrials produced no results.)
However, the AllTrials initiative means to tackle the problem of suppressed clinical research. We have long discussed how research may be systematically suppressed when its results do not please its commercial sponsors. Particularly, trials of drugs or devices that do not produce favorable results may be suppressed by their sponsors, usually the companies that make the drugs or devices. Such suppression breaks trust with and therefore hugely disrespects the patients who volunteered to participate in the trials, who believed they were contributing to science and public health. Suppressing data that drugs and devices may be ineffective and harmful may endanger patients by letting them be treated by such drugs and devices in the illusory belief that they are safe. Yet where is the outrage about such dishonest behavior by large and powerful health care organizations that disrespects, and more importantly, endangers patients?
Health Care Corruption
When a pharmaceutical, biotechnology, or device company withholds results of a clinical trial to makes its product look better and enhance its revenue, that is an example of health care corruption.
Transparency International defines corruption as
Abuse of entrusted power for private gain
When health care corporations run clinical trials, we entrust them to do honest research and be worthy of the trust of their research subjects. Withholding the results to enhance revenue is therefore abuse of that entrusted power for private gain.
Health Care Corruption as a Taboo Topic
This blog focuses on the US, and we now have in our archives some amazing stories that document various forms of health care corruption in the US, including numerous allegations of misbehavior by large health care organizations ending in legal settlements, and examples of outright fraud, bribery, kickbacks and other crimes. Some large and profitable health care corporations have made numerous such settlements over recent years. (For example, see the track record to date of Pfizer Inc here and that of Johnson and Johnson here.)
Much of this bad behavior was meant to sell drugs, devices, or clinical services, often in situations in which their benefits did not outweigh their harms. For example, we just discussed the latest settlement by Amgen of allegations that it promoted an epoetin (Aranesp) “off-label” for cancer patients not on chemotherapy. Such “misbranding” was not merely a technical violation, since it has been shown that use of the drug in this situation increases mortality. Such bad behavior thus likely harmed numerous patients.
Furthermore, efforts to police these kinds of corruption have been weak and scattered. Most cases have ended with legal settlements that at most involve fines to corporations, yet the fines are rarely big enough to significantly affect their overall revenues. While the corporations themselves may be thus punished, the people who actually authorized, directed or implemented the bad behavior are usually unscathed. So as we have discussed frequently, such attempts at justice are unlikely to deter future bad behavior.
In fact, people more distinguished than yours truly have been warning about health care corruption for years. In particular, in 2006, the Transparency International Global Corruption Report focused on health care corruption, and asserted in its executive summary, ” the scale of corruption is vast in both rich and poor countries.” It also noted how diverse is health care corruption:
In the health sphere corruption encompasses bribery of regulators and medical professionals, manipulation of information on drug trials, the diversion of medicines and supplies, corruption in procurement, and overbilling of insurance companies. It is not limited to abuse by public officials, because society frequently entrusts private actors in health care with important public roles. When hospital administrators, insurers, physicians or pharmaceutical company executives dishonestly enrich themselves, they are not formally abusing a public office, but they are abusing entrusted power and stealing precious resources needed to improve health.
It further stated how serious the consequences of corruption may be for patients and public health:
Corruption deprives people of access to health care and can lead to the wrong treatments being administered. Corruption in the pharmaceutical chain can prove deadly….
The poor are disproportionately affected by corruption in the health sector, as they are less able to afford small bribes for health services that are supposed to be free, or to pay for private alternatives where corruption has depleted public health services.
Corruption affects health policy and spending priorities.
Occasionally, something is published about health care corruption in the US in the medical literature.
– In 2009, qualitative interviews by Pololi et al in the Journal of General Internal Medicine produced many striking anecdotes suggesting corruption in US academic medicine. Four of the interviews were with faculty whose leaders allegedly used deception for personal and professional gain (i.e., “a situation of major unethical use of funding,” “fraudulently creating data for a research project,” “we’re lying to the people who are doing our school evaluations, we’re putting things on paper that we do that we don’t do,” “that’s what I think he felt he had to do—hide money, lie about money, or at least cook the books a little bit.”)(4) These results produced few echoes, particularly not any strident editorials about the need to address corruption.
– In 2011, an article in the Lancet suggested that “there is more corruption in the G8 countries than in the whole of Africa,” but for any health care professional to acknowledge that would be “professional suicide” (see this post).(3)
– Finally, in 2013, a Transparency International survey showed that 43% of Americans believe their health care system is corrupt. Yet this received no media attention, and to my knowledge has never been mentioned in a major US medical journal. (Look here.)
So health care corruption remains a largely taboo topic. (On Health Care Renewal, we call corruption “anechoic,” since evidence of health care corruption produces few echoes.)
The Annals of Internal Medicine, like most major medical journals, has long avoided discussion of health care corruption, and how systemic corruption harms patients’ and the public’s health.
Of course, the unwillingness to discuss global health care corruption, health care corruption in the US, and the relationship of health care corruption in the US to corruption in other sectors may arise from the fear, as stated by one person interviewed in Charles Ferguson’s documentary Inside Job, that discussion could lead to investigation, and investigation could “find the culprits”.
It is perfectly fitting and proper for the Annals of Internal Medicine to call attention to various kinds of unprofessional behavior by physicians and health care professionals, such as sexist, disrespectful expression, even if such behavior is already subject to sanctions by medical boards, accrediting organizations, etc. In my humble opinion, however, if such disrespectful comments by physicians should generate outrage, corrupt behavior by large health care organizations that may harm patients and the public health, and which often goes largely unchallenged by civil authorities, should deserve more outrage.
Of course, it is one thing to criticize individual physicians, and ask physicians to “call out our colleagues” who behave unacceptably.
It is another to call out large, powerful, wealthy organizations and the executives who have become rich running them. Such executives command well funded marketing and public relations departments, and corps of attorneys ready to take on perceived critics.
But if we really want better health care and public health, we all have to step up. In particular, I urge the editors of the Annals of Internal Medicine, and other major health and medical journals to take on health care corruption as vigorously as they would take on physicians’ expressions of “misogyny and disrespect.”
See original post for references
Comments enabled at the request of the author
Gee, I’m SO surprised that the LA Time and NY Times would print pearl-clutching articles about a doctor who made a “sexist” comment about a woman who was unconscious, while saying nothing about the corruption of pharmaceutical companies, et. al..
I’ve read enough articles from both of those rags to know that their journalistic standards leave much to be desired.
Really – “Doctor Makes Sexist Remark” sells more of their papers than “Data from medical clinical trials is tainted.” Although, that may say more about their readership than it does about them….
The Annals editorial has a subtext: “Except for isolated bad apples like the anonymous ones we are chastising here, the health care system is morally and ethically on solid ground. If you doubt this -and some of our readers do doubt this- we want to emphasize the goodness of the system by editorially expressing our outrage about these individual incidents.”
I agree with you Jeremy. This subject is in the same vein as people getting unduly exercised by the Old Dominion frat boy banner fiasco. While what the frat boys did was wrong, juvenile, etc., people are quick to jump on the easy target – the one-off misogynist doctor, a few black protestors, unthinking kids, etc. and then miss the bigger picture of health care corporation corruption, governmental indifference/corruption, or University leadership behavior/apathy towards rape, etc. Seems the media wants to make every issue or problem binary in nature, in that you’re for or against something, or you have to react to something one way or another, without considering a third, fourth or more options.
Can you say Vioxx….
Amen, Dr. Poses!!! Your post is an exercise in perspective. Badly needed perspective.
I’m not so sure about the post’s first premise: that individual doctors are subject to regulation and suspension. Consider this story from the Washington Post:
Here’s a surgeon who deliberately and perversely injures patients and rather than calling the cops his colleagues merely refer to him as a “sociopath.” Baylor is being sued for allowing him to continue to work (he is now in another state with medical license suspended but nowhere near a jail cell).
Horrible. This article shows just how bad physician oversight is. However, he may be closer to a jail cell than you think. From the article:
The article doesn’t say whether he is currently in jail awaiting trial, nor does it say what the result of yesterday’s bail hearing was.
Thank you for your information and comments.
May I add that there is not only an anechoic nature to articles that comment upon personal and a la mode concerns but also a _”0h, look over there, a distraction” purpose served. People are able to respond to personal and emotional slights delivered to others but usually ( at least from my experiences) quickly lose interest in any talk about policy involving bucks and delivery of service. Comments usually echo the beliefs that all administrators, et., are crooked or foolishly incompetent but there’s nothing to be done about it. Learning details and so on is just too too hard. Personal insult, either verbal or physical – now that’s something vexatious.
On CBC we had a series of programs by Dr. Brian Goldman about the dark side of medicine called “White Coat, Black Art” (See: http://www.cbc.ca/radio/whitecoat ). You can also hear 34 episodes on iTunes. I especially was interested to see his take on Dr. Oz who has been promoted by Oprah. There is BS everywhere!
I think it would also be useful for medicine to give more attention to the social/economic problem of inequality and the toll it takes on people’s health and well-being. In ‘The Spirit Level: Why Greater Equality Makes Societies Stronger’, two public health experts Richard Wilkinson and Kate Pickett unexpectedly found strong correlations between inequality and anxiety, distrust and other mental and physical ailments.
“Long before the financial crisis which gathered pace in the later part of 2008, British politicians commenting on the decline of community or the rise of various forms of anti-social behaviour, would sometimes refer to our ‘broken society’. The financial collapse shifted attention to the broken economy, and while the broken society was sometimes blamed on the behaviour of the poor, the broken economy was widely attributed to the rich. Stimulated by the prospects of ever bigger salaries and bonuses, those in charge of some of the most trusted financial institutions threw caution to the wind and built houses of cards which could stand only within the protection of a thin speculative bubble. But the truth is that both the broken society and the broken economy resulted from the growth of inequality.”
It seems to me that the problem of suppressed research could be handled simply by routing all the research used in the drug approval process through the FDA. The FDA could bill the pharmaceutical company, even solicit input from the company on the trial design, but the final product would be from the FDA and the results of the research would be public. You could also have the trial design be approved by a board of researchers.
Thank you, Dr. Poses. Your points are very well taken. Where health care corruption is concerned, how about the FDA declining to take action on more than 700 generic drugs produced in India and China for which the European Union has now suspended sales, pending further investigation?
White House Is Pressed to Help Widen Access to Hepatitis C Drugs via Medicaid
Whether these drugs are the miracle cure as claimed was the subject of a post at NC back in July:
Bill Clinton, Paid to Speak to Biotech Conference, Extolled $1000 Pill to Prevent “Liver Rot,”
Despite Lack of Evidence that It Does
Saying and doing disrespectful things behind people’s backs is so common that I’m a bit surprised at all the pearl clutching. This surely isn’t Heart of Darkness territory. If we knew what retail workers or cashiers, firefighters and police, or even our friends say when we’re out of sight, we might be offended and surprised, but that’s the point. They do it when we cannot hear. Almost always, they wouldn’t dream of saying these things to our faces, as real persons. But as jokes, affectionate exaggerations, stress relievers, concerned gossip, or questioning speculations about possible problems these kinds of commentary are built in.
Oh damn, I’m arguing for rude speech. Argh.
Well, carry on.
When our friend misses a party yet again, due to work, toddlers, or a host of life pressures, we joke about her being “our invisible friend.” No, really! She’s a real person!
When a wealthy but scatterbrained lady phones our contractor to change her kitchen flooring choice AGAIN, we joke that she’s going to have a “fourth floor kitchen,” and maybe she will order an elevator, too.
When a brother-in-law phones up to borrow grocery money till next week, we talk about it among ourselves and wonder where his salary is going.
Would we say any of these things to the people themselves? Probably not. We don’t want to make them uncomfortable or angry, but trading quips about them can be a route to fondness, tolerance and concern.
Of course, it can be a channel for contempt and hatred. But hey, people can always find a way to do that.
This is one of those areas in which the high lighting of the “few bad apples’ is worse than useless- it distracts from the larger systemic problem that Medicine As Business is , of its very nature corrupt, especially in a third party payment environment.
Every Doctor/Patient interface under our current system involves an unspoken ( and surprisingly under examined ) conflict of interest: is the Patient an individual whose welfare you, as socially privileged Professional, have a Sacred Duty to place first or is Joe Sixpack a Revenue Source ? http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
ObamaCare merely feeds millions more into an inherently corrupt system.
The singling out of goofball, sophomoric physicians for public ridicule in the press also silences many would-be critics of glaring healthcare problems like corruption. Nearly everyone at some point has done something dumb, goofy, offensive or personally embarrassing – and fears becoming the target of a story like this one. Vested interests in healthcare are fully committed to protecting their turf and will happily trash the reputation of anyone lifting the curtain. In the era of online reviews, facebook likes, google + and the rest, no one can risk becoming the whistleblower without realizing the personal attacks that they will likely face.
This comment is in no way a defense of the actions of the doctors in this article. Like Dr. Poses, I agree that coverage of clickbait stories at the expense of real journalism is harmful to the public and inexcusable by those who consider themselves journalists.
San Francisco restaurant manager William Nelson, who oversees a workforce of around 25 in the city, tells The Daily Beast that many restaurants are hesitant to put out any additional money and the overall costs for covering all employees is high, so what a lot of places are doing is hiring another person or two and reducing hours from all hourly workers to cover the requirements of providing health care.