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”.

Summary

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.”

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