{"id":4550,"date":"2010-12-12T12:00:27","date_gmt":"2010-12-12T17:00:27","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=4550"},"modified":"2010-12-12T12:58:59","modified_gmt":"2010-12-12T17:58:59","slug":"deprofessionalization","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2010\/12\/12\/deprofessionalization\/","title":{"rendered":"deprofessionalization&#8230;"},"content":{"rendered":"\n<div align=\"justify\">Looking at something else entirely, I ran across this blog post referenced in a comment. It deserves more attention that I can give it. It&#8217;s by Dr. Roy Poses, webmaster of the <strong><a target=\"_blank\" href=\"http:\/\/hcrenewal.blogspot.com\/\">Health Care Renewal Blog<\/a><\/strong>.      <\/div>\n<blockquote>\n<div align=\"center\"><strong><a target=\"_blank\" href=\"http:\/\/hcrenewal.blogspot.com\/2009\/06\/why-did-us-physicians-give-up-their.html\"><font color=\"#200020\">Why Did US Physicians Give Up Their Ability to Enforce Their Own Professional Standards?<\/font><\/a><br \/>         <font color=\"#400040\">Healthcare Renewal<\/font><\/strong><br \/>         by Roy Poses<\/div>\n<div align=\"center\"><strong><font color=\"#990000\">June 26, 2009 <\/font><\/strong>         <\/div>\n<p>         <\/p>\n<div align=\"justify\"> In his recent review of Dr Ezekiel Emanuel&#8217;s book, [<em>Healthcare, Guaranteed: A Simple, Secure Solution for America<\/em>,] Dr Arnold Relman, Editor-Emeritus of the New England Journal of Medicine, <strong><a target=\"_blank\" href=\"http:\/\/www.nybooks.com\/articles\/22798\">discussed<\/a><\/strong> the history of the deprofessionalization of American physicians.<\/div>\n<ul>\n<div align=\"justify\">The  behavior of US physicians has been changed by the commercialization of  medical care, and this too has increased costs. US medical practice has  traditionally relied on fee-for-service, which has always given it some  of the attributes and incentives of a business. However, <em>the  American Medical Association (AMA) maintained for many years that  medical practice was a profession, not a business. The AMA&#8217;s ethical  guidelines therefore advised physicians to limit their income to  reasonable earnings from the care of patients, and to refrain from  advertising and from entering financial arrangements with drug and  device manufacturers<\/em>. <em>Those restrictions were lifted after the  US Supreme Court decided in 1975 that lawyers, and by extension members  of other professions, including physicians, are engaged in interstate  commerce and therefore must be subject to antitrust law<\/em> [from which they had largely been exempt].<\/div>\n<p>          <\/p>\n<div align=\"justify\"><em>This  decision had an enormous effect on the medical profession, but its  consequences have received relatively little public attention<\/em>.  Although the courts did not initiate the commercialization of medicine,  they certainly accelerated it and gave it legal justification. <em>In  1980, after medical organizations lost some costly antitrust trials, in  which they were accused of such offenses as limiting doctor fees or  denying staff privileges, the AMA changed its ethical guidelines,  declaring medicine to be both a business and a profession. This lowered  the AMA&#8217;s barriers to the commercialization of medical practice<\/em>, allowing physicians to participate in any legal profit-making business arrangement that did not harm patients&hellip;<\/div>\n<\/ul>\n<div align=\"justify\"> Writing  about the decline of physicians&#8217; professionalism in 2007 [<a target=\"_blank\" href=\"http:\/\/jama.ama-assn.org\/cgi\/content\/full\/298\/22\/2668\"><strong>Relman AS.  Medical professionalism in a commercialized health care market. JAMA  2007; 298: 2668-2670<\/strong><\/a>], Dr Relman had briefly alluded to the effect of the 1975 Supreme Court decision [see our post <strong><a href=\"http:\/\/hcrenewal.blogspot.com\/2007\/12\/relman-in-jama-on-threats-to-physicians.html\">here<\/a><\/strong>]: <\/div>\n<div align=\"justify\">\n<ul> The  law also has played a major role in the decline of medical  professionalism. The 1975 Supreme Court ruling that the professions were  not protected from anti-trust law undermined the traditional restraint  that medical professional societies had always placed on the commercial  behavior of physicians, such as advertising and investing in the  products they prescribe or facilities they recommend. Having lost some  initial legal battles and fearing the financial costs of losing more,  organized medicine now hesitates to require physicians to behave  differently from business people. It asks only that physicians&#8217; business  activities should be legal, disclosed to patients, and not inconsistent  with patients&#8217; interests. <em>Until forced by anti-trust concerns to change its ethical code in 1980, the American Medical Association had held that &#8216;in  the practice of medicine a physician should limit the source of his  professional income to medical services actually rendered by him, or  under his supervision, to his patients&#8217; and that &#8216;the practice of medicine should not be commercialized, nor treated as a commodity in trade.&#8217;<\/em><em> These sentiments reflecting the spirit of professionalism are now gone.<\/em><\/ul>\n<\/p><\/div>\n<\/blockquote>\n<div align=\"justify\">This happened in what might be called &quot;the dead zone&quot; at my house. We were living in rural England from 1971 until 1974 [Air Force], then came back and I started a Psychiatric Residency [and we had a small child]. So we missed politics, popular tv shows, an era of music, everything from 1971 until around 1976. When people talk about things like the <strong>Taxi<\/strong> sitcom or the <strong>ABBA <\/strong>singing group, we look at each other knowingly [or maybe unknowingly]. I had no knowledge of this Supreme Court decision [goldfarb v. virginia state bar] until today, though I sure know something in Medicine is different now from when I first arrived &#8211; something not so hot. I&#8217;m sort of glad there&#8217;s a reason. I thought it was just some kind of creeping moral decay.<\/div>\n<p align=\"justify\">I guess I have an anachronistic Medical Superego &#8211; the one I was taught in the 60&#8217;s. I&#8217;m kind of glad I didn&#8217;t know about the change. The old way makes more sense to me. I don&#8217;t accept honoraria when I give talks, or when I do outside work. I paid out of pocket for my Training Analysis rather than use insurance. My fees were lower than most. It is, to me, a standard that seems to be one of the great things about Medicine &#8211; &quot;<em>the  American Medical Association (AMA) maintained for many years that  medical practice was a profession, not a business&quot; &#8211; <\/em>something to be proud of<em>.<\/em> I&#8217;ll be the first to acknowledge that there are some solid neurotic reasons for having held that position for over forty years. There always are. We all have childhoods to grapple with. But understanding those intrapsychic conflicts didn&#8217;t change much. People sometimes act like I&#8217;m being <em>pathologically humble<\/em> or <em>naive<\/em> when I don&#8217;t join in the business thing &#8211; some kind of warped idealism. I&#8217;m not the one to evaluate that assessment. But what it feels like to me is a rational part of a doctor-patient covenant &#8211; that it&#8217;s more about trying to relieve suffering than about making profits. Medicine pays well enough doing it my way to have a decent life and retirement.     <\/p>\n<p align=\"justify\">I&#8217;m saying this because of that article up there and because of <a target=\"_blank\" href=\"http:\/\/finance.senate.gov\/hearings\/hearing\/?id=dc6efa3a-e47a-86db-2281-bf16970558e6\"><strong><font color=\"#300030\">this<\/font><\/strong><\/a> &#8211; the document cache amassed by Senator Grassley and Paul Thacker in their investigation of Emory and Dr. Nemeroff. In particular, there&#8217;s a <a target=\"_blank\" href=\"http:\/\/finance.senate.gov\/imo\/media\/doc\/Nemeroff%27s%20GlaxoSmithKline%20Speaker%20Events.pdf\"><strong><font color=\"#300030\">listing<\/font><\/strong><\/a> of his dinner meeting speaking engagements from <strong><font color=\"#300030\">GSK<\/font><\/strong> [makers of <strong><font color=\"#300030\">Paxil<\/font><\/strong>] from 2000 to 2006 that I&#8217;ve never looked over. This is <strong><font color=\"#200020\">1 page of 39 pages!<\/font><\/strong><\/p>\n<p align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"520\" height=\"512\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/nemeroff-speaker.gif\" \/>&nbsp;<\/p>\n<p align=\"justify\">And <strong><font color=\"#300030\">GSK<\/font><\/strong> was not his only customer during the period. Here are some of the <a target=\"_blank\" href=\"http:\/\/finance.senate.gov\/imo\/media\/doc\/Grassley%20Letter%20to%20Emory%20University%20%28Sep%2016,%202008%29.pdf\"><strong><font color=\"#300030\">others<\/font><\/strong><\/a> [notice &quot;Selected&quot;]:<\/p>\n<div align=\"center\"><img loading=\"lazy\" decoding=\"async\" width=\"520\" height=\"319\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/nemeroff-speaker-2.gif\" \/><\/div>\n<div align=\"justify\">By 2004, Emory was after him for his conflicts of interest and his industry ties. He <a target=\"_blank\" href=\"http:\/\/finance.senate.gov\/imo\/media\/doc\/Nemeroff%20signature%20on%20COI%20findings%20%28July%206,%202004%29.pdf\"><strong><font color=\"#300030\">promised<\/font><\/strong><\/a> to do better, but as the table demonstrates, he didn&#8217;t.&nbsp; I won&#8217;t bother to repeat his <em>dog ate my homework<\/em> excuse [his excuses through the years might well be a topic for a later post]. <\/div>\n<p align=\"justify\">He clearly never even heard of the old standard that I liked so much: <strong><em><font color=\"#300030\">&#8216;in  the practice of medicine a physician should limit the source  of his  professional income to medical services actually rendered by  him, or  under his supervision, to his patients&#8217;&nbsp; &#8216;the practice of medicine should not be commercialized, nor treated as a commodity in trade.&#8217;<\/font><\/em><\/strong> But I&#8217;m pretty sure that he didn&#8217;t even live up to the new standard, &quot;<strong><font color=\"#300030\">&#8230; <\/font><\/strong><em><strong><font color=\"#300030\">allowing physicians to participate in any legal profit-making business arrangement that did not harm patients<\/font><\/strong><\/em>.&quot; The Internet bristles with people who think he did just that &#8211; made business arrangements that actually harmed patients.<\/p>\n<p align=\"justify\">From the tenor of his lawyers&#8217; letters in his response to POGO, they threaten to&nbsp; bring damage suits&nbsp; and his lawyers seem to think that they can limit the suit to the fact that the documents in the POGO letter don&#8217;t <u><strong><font color=\"#300030\">prove<\/font><\/strong><\/u> that the book was ghost-written [it <em>quacks like a duck<\/em> to me&#8230;]. They further seem to think that they can make it an ad hominem suit because of Thacker&#8217;s previous work with Senator Grassley. And they would likely try to keep data like that above or of other cases involving STI out of the suit altogether &#8211; limit things to simply the &quot;ghost-writing&quot; of that specific book. I frankly think they&#8217;re smoking something. Nemeroff&#8217;s overall relationship with GSK is relevant. All documents from STI having to do with this book and other such cases are relevant. So Nemeroff is playing with opening himself [and GlaxoSmithKline] to a level of legal discovery that could bury them all.<\/p>\n<p align=\"justify\">I think there&#8217;s an unfortunate twist to this story. It seems clear to me that it would be in Medicine&#8217;s best interest to move back closer to the pre-1975 standard. Being &quot;just another business&quot; is no way to posture for our future or our patients&#8217; future, particularly with the rising costs of healthcare guaranteeing that some form of healthcare reform is on our horizon &#8211; even more than the recently passed version. Physicians as simply a cog in the industry wheel lose something valuable &#8211; patients lose something valuable too. At least that&#8217;s what I think. The unfortunate part of this Nemeroff story is that it tarnishes the whole profession, particularly by staying on the front burner so long &#8211; yet it&#8217;s just too ludicrous to call attention to the overall destructive trend of &quot;businessification&quot; in medicine. The Nemeroff apple is so thoroughly rotten that it eclipses looking at the rest of the barrel &#8211; just like the Madoff story is too off-the-wall to focus us on the overall Hedge Fund Industry.  <\/p>\n<div align=\"justify\">The best outcome for the case in point is the one suggested in the <a href=\"http:\/\/www.pogo.org\/pogo-files\/letters\/public-health\/ph-iis-20101129.html\" target=\"_blank\"><strong><font color=\"#200020\">POGO letter<\/font><\/strong><\/a> itself, putting a plug in the NIH jug: <\/div>\n<blockquote>\n<div align=\"justify\">NIH must take a firm stance against ghostwriting, both to protect public  health and the integrity of NIH funding. We ask that you implement new  policies that will require institutions to ban ghostwriting, and to make  NIH funding contingent upon periodic certification from institutions  that ghostwriting is strictly prohibited and that enforcement mechanisms  such as disciplinary action and dismissal are in place. Setting this  example will improve the integrity of federally funded science.  Additionally we ask that you fund seminars and research on ghostwriting  to educate physicians about this practice and ensure that it disappears  from biomedical research altogether.<\/div>\n<\/blockquote>\n<div align=\"justify\">And as for the broader issue of the core values of Medicine in general, <a href=\"http:\/\/hcrenewal.blogspot.com\/2009\/06\/why-did-us-physicians-give-up-their.html\" target=\"_blank\"><strong><font color=\"#200020\">Dr. Poses concludes<\/font><\/strong><\/a>:<\/div>\n<blockquote>\n<div align=\"justify\">It seems to me that Dr Relman has elucidated one of the &quot;missing links&quot;  that help explain the current sorry state of physicians&#8217; core values,  and the broader continuing health care crisis. I am amazed that this bit  of history seems to have been so thoroughly forgotten. Dr Relman did  write about it before 2007, but in publications that few physicians and  other health care professionals were likely to see. Other than Dr  Relman, almost no one writing in the medical and health care literature  seems to have interest in this issue&#8230; Yet in my humble  opinion, every physician and health care professional ought to know that  the profession once foreswore the commercialization of medical  practice, but gave up on its ability to police its own conflicts of  interest after the US Supreme Court decided that professionals are  subject to anti-trust law. But knowing this important bit of history raises more questions than it answers:   <\/p>\n<ul>\n<li>The  Supreme Court decision apparently involved interpretation of law, not  the constitution. Therefore, why didn&#8217;t organized medicine pursue a  change in the law that would allow physicians to continue to enforce  their traditional professional values? <\/li>\n<li>The Supreme Court  decision was primarily directed at lawyers, not physicians. Since the  decision, to my knowledge, the law profession has maintained strict  rules about conflicts of interest [For example, no legal CME is  sponsored by corporations whose products they seek to have the attendees  favor]. Why did the decision wreck physicians&#8217; but not lawyers&#8217;  abilities to regulate their own conflicts of interest? <\/li>\n<li>The  Supreme Court decision only affects US law. Why have physicians in other  countries also abandoned their traditional values about commercial  entanglements? <\/li>\n<li>Why did this application of US antitrust law  have such significant effects during an era when antitrust enforcement  in health care was generally declining [Insurance companies and  hospitals that dominate local markets have not feared antitrust  enforcement]?<\/li>\n<li>Why did only Dr Relman and Prof Bloche seem to care about this up to now?<\/li>\n<\/ul>\n<p>  Inquiring minds want to know&#8230;. And answering these questions might bring us back on the path of true medical professionalism. <\/p><\/div>\n<\/blockquote>\n<div align=\"justify\">He raises points for us all. Nemeroff is a loud symptom of something wrong in academic medicine, but what&#8217;s wrong in academic medicine is itself a loud symptom of something rotten in the whole state of medicine.&nbsp; I doubt that one Supreme Court decision was the sole factor that caused the decline in our core values, but it&#8217;s a great place to start. And it doesn&#8217;t need to go on in the rarefied atmosphere of an academic bioethics seminar, it&#8217;s a floor-of-Congress topic if there ever were one. Instead of becoming another whining self-serving trade union, organized medicine would be a lot better off trying to get something back that we seemed to have given away &#8211; something of value. And operating at an ethical level <u>below<\/u> our legal counterparts seems like the substrate for a whole genre of new jokes&#8230;  <\/div>\n","protected":false},"excerpt":{"rendered":"<p>Looking at something else entirely, I ran across this blog post referenced in a comment. It deserves more attention that I can give it. It&#8217;s by Dr. Roy Poses, webmaster of the Health Care Renewal Blog. Why Did US Physicians Give Up Their Ability to Enforce Their Own Professional Standards? Healthcare Renewal by Roy Poses [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-4550","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/4550","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=4550"}],"version-history":[{"count":0,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/4550\/revisions"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=4550"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=4550"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=4550"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}