Guest Blog: Advice to the Young Physician

Richard Colgan, MD, is a practicing family physician, Associate Professor and Director of Undergraduate Education in the Department of Family and Community Medicine at the University of Maryland School of Medicine. He is a Past President of the Maryland Academy of Family Physicians and serves as editor-in-chief of the Maryland Family Doctor. This guest post is excerpted from the conclusion to his recently published book, Advice to the Young Physician, which he describes as a book "for those who believe that there is an art to medicine, but are not sure where to turn to learn where to find it, beyond the role modeling which their exemplary teachers display. By looking through the history of medicine, the author identifies some of the recurring themes of the art of medicine, as taught or displayed by some of history's greatest physicians." You can preview the book's cover on my Shelfari bookshelf.

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THE HEALER'S PRAYER

God, let me begin each clinical encounter by always putting my patient's needs first. Grant me the strength to not be seduced by the allure of worldly pleasures, so as to be the best healer I can be, as I look to be thorough and careful in practicing my art. Guide me as I practice this sacred vocation. May I have the wisdom to learn from the lessons of my teachers, as I contemplate how to best serve each person who seeks my counsel. Help me to use all of my senses as I strive for excellence in caring for my patients, and to understand that if I cannot help someone, then at a minimum I will do no harm.

Strengthen me to have an inner and outer calmness when faced with the inevitable difficulties that lie before me. Show me how to best educate my patients on how to live longer and healthier lives, while being open to learning from those whom I serve. Show me how to be temperate and modest as I look to assist nature by incorporating proper diet, exercise and my patient's own resources in their overall care. Never let me forget that I am caring for someone who is suffering from a disease, and not taking care of a disease.

May I never forget my duty to practice medicine based upon a conviction of pursuing altruistic beneficence, marked by showing compassion for others as I commit myself to a life of service. May I not abandon, but look to serve the poor and advocate for those who suffer because of disparities in our health care system. Remind me to keep matters between physician and patient confidential and that I am accountable for my actions. May I always show respect and care for myself and my family, while being kind in my everyday interactions with others.

I ask you for humility in knowing the limitations of my art. May I always end each encounter with my patient knowing that I have done my best in assisting you by applying the bandages, while taking comfort in the fact that only power greater than I heals.

- Richard Colgan

Doctors' conflicts of interest can harm your health - Part 2 of 3

For the uninitiated (which aptly described me when I attended my first conference, the American Academy of Family Physicians Scientific Assembly in Orlando in October 2004), medical conferences can be truly awe-inspiring things. I'm not talking about the quality of the lectures, procedural workshops, or other officially sanctioned learning activities. I'm talking about the mammoth Exhibition Hall filled with wall-to-wall twelve-foot tall displays marketing the latest blockbuster drugs, medical devices, and electronic gizmos to physicians. Impeccably attired, physically attractive (and in some cases, stunning) salesmen and saleswomen beckoning conference attendees toward their wares - I remember that the Exhibition Hall that year included several high-end massage chairs, an operational 3-dimensional pregnancy ultrasound, and countless smaller "goodies" such as free pharmaceutical company-emblazoned bags, flash drives, cellular phone headsets, prescription pads, and penlights.

The supposed rationale for providing a separate "exhibit hall" is to cordon off commercial activities from genuine medical education. Conference speakers are generally required to disclose affiliations with industry that might represent conflicts of interest (COI); for example, a speaker who works for Pfizer (maker of the popular cholesterol-lowering drug Lipitor) could hardly be expected to give unbiased recommendations regarding threshold levels for cholesterol treatment. Cynics note that because conference organizers rarely make an effort to verify the accuracy of such disclosures, many speakers fail to disclose disqualifying affiliations. Judging from a recent study published in the New England Journal of Medicine, the cynics are right.

In this study, investigators compared the COI disclosure statements of speakers at the 2008 meeting of the American Academy of Orthopaedic Surgeons with publicly reported information from manufacturers of orthopedic devices. They found that more than 20% of speakers failed to disclose payments related directly to the topic of their presentation, and fewer than half of speakers disclosed payments that were judged to be less related to the presentation topic. More than 80 percent of these payments were greater than $10,000; more than 40 percent were for more than $100,000. (By comparison, before I become a federal employee, the largest honorarium I ever received for giving a talk was $800.) Speakers were statistically more likely to disclose payments greater than $10,000 - but it's not as if $9,999 is exactly chump change!

So what do I conclude from this study? That I should never again trust an orthopedic surgeon who tries to teach me something? That I clearly chose the wrong medical specialty, if financial success was my measuring stick? I prefer to look on the bright side: at least these conflicts of interest, and the myriad ways that unscrupulous physicians and commercial interests try to game the disclosure system, are finally seeing the light of day. As President Reagan said about his policy toward arms control during the waning days of the Cold War, "Trust, but verify." That maxim should be medical education's policy, too.

Public option or no public option: that is not the question

I'm interrupting a series of posts on conflicts of interest in medicine in order to say something about health care reform, which is approaching a critical point as Senate and House negotiators try to combine the various bills that have emerged from different committees. One widely reported point of contention is whether or not the final bill should include a so-called "public option," a government-sponsored insurance product that its supporters feel would provide needed competition with private insurers and make the cost of insurance more affordable. Opponents believe that the public option would end up driving private insurers out of business and end up being the only option. While I think that this idea is hardly revolutionary - Medicare, after all, is a "public option" for senior citizens that's been around for 45 years - I also believe that it's a distracting side issue to what our health care system really needs: comprehensive cost control.

Public option or no public option, health care premiums are on a course to consume the entire average income of an American household by 2025 - a mere 16 years from now, when my oldest child will be entering college. While you might think it's okay in an abstract sense to spend a million or more dollars to save one life (especially if it's your life or that of someone you love), even the wealthiest nation on the planet can't afford to pay for every possible intervention that promises a tiny bit of improved health or longer life for somebody. We need to make choices, as a society, about our collective health priorities.

Other measures that have the potential to address skyrocketing costs (but are being underemphasized or completely ignored in the focus on the "public option") include:

1) Flat-fee primary care combined with insurance for catastrophic medical events. Your car insurance doesn't pay for oil changes, your home or rental insurance doesn't pay for furniture, and your health insurance shouldn't pay for basic primary care visits.

2) No-fault compensation programs for all but the most egregious medical errors (e.g., if your surgeon cuts off the wrong leg, or your internist prescribes toxic drugs for conditions you don't have, you would still have the right to sue).

3) Reforming medical education and continuing medical education to provide safeguards against conflicting interests (e.g. pharmaceutical and medical device companies) that lead to inappropriate or potentially unsafe prescribing practices. More on this in future posts, but I think we have a long way to go.

4) Let the insurance "bureaucrats" make informed decisions based on cost-effectiveness of medical interventions. I know that this is an unpopular position. I'm not talking about setting up death panels, or even dialysis panels, which actually existed in the past. And I'm not saying that insurance shouldn't cover every medication or surgery with a high price tag. What I'm advocating is that we take a hard look at what we're getting for the billions we spend on health care, the way you make decisions about how to spend your own limited budget. After all, drug companies still do business with the United Kingdom, even though their National Institute for Health and Clinical Excellence (NICE) applies strict cost-effectiveness criteria to determine whether drugs are worth paying for. If a drug doesn't meet NICE's standard, the company will often lower the cost of the drug so that it does. Not so in the U.S. - which is why we generally pay the highest prices.