As we grow into adulthood, each of us develops a personal comfort zone located on the continuum between paranoia and gullibility. A few of us are highly suspicious by nature, a few are unwitting dupes; most of us are in between. Mental health professionals are no exception, and it shows in our work. Is a request for tranquilizers or stimulants legitimate, or are we abetting a substance abuser? When told of horrific past abuse, do we believe every word, or do we allow for possible exaggeration or distortion? Credulity and skepticism exist in dynamic balance: too much of either impairs clinical work.
Our pride animates these assessments. On the one hand, we see ourselves as sensitive and caring. Empathy seems to require believing people’s stories, to be “on their side.” On the other hand, we feel vulnerable and ashamed when fooled (as we sometimes are), and safer and proud of ourselves when we don’t fall for it. Fueled by pride, proponents defend various points on the credulity continuum. Some psychiatrists declare that they never prescribe tranquilizers because doing so invites manipulation by drug-seeking patients. Conversely, some equally proud therapists never question the meaning of their clients’ cancellations, because doing so “lacks empathy.”
Like most doctors, I’m a critical thinker by nature. This is a nice way of saying my comfort zone lies slightly closer to paranoid than gullible. The perverse logic of the Freudian unconscious thus comes naturally to me. Patients who claim complete marital satisfaction may be in denial, or at least recalling selectively. Impassioned pronouncements of adoration may be “reaction formation,” telegraphing the exact opposite. Dramatic hatred or disgust may hide a fascination, even an attraction. The trick here, lest we treat our prejudice and not the real person in front of us, is to entertain such possibilities without becoming too attached to them. It’s also important to distinguish empathy from blind agreement, belief, or endorsement. I can empathize with a delusional person’s fear and panic without endorsing the delusions themselves.
A funny thing happened to me the other day. A mental health professional in a remote land emailed me, seeking online psychotherapy for himself. I was flattered that this colleague searched the world over and chose me. He sought exactly the type of psychotherapy I like to conduct. If not for distance — which would ultimately be a deal-breaker in any case, as I consider online therapy a poor substitute for the in-person kind — it seemed almost too good to be true. Thus, wary of falling prey to my own pride and narcissism, I immediately suspected a scam. After all, if something looks too good to be true, it probably is. I imagined this email went to many therapists, and that it was a con, like those Nigerian emails that promise great riches and are now an internet cliche. This is precisely what con artists do so well: appeal to one’s greed or pride. They hook you, then reel you in. I wasn’t going to let that happen.
As a savvy internet user, I knew just what to do. I found the person online, and wrote him directly via his website. I included the bogus email I received, to let this far-flung colleague know I wasn’t about to be taken in, and also that his identity was likely stolen for nefarious purposes. I was rather proud of myself.
It turned out the original email was legitimate. Adding injury to insult, I also violated the privacy of my correspondent, who doesn’t read his own website email. I had unwittingly turned an earnest request into an awkward encounter by being too incredulous and self-protective. In rushing to defend my pride against an imaginary threat, that very pride distanced me from someone who sought my help, and even hurt him. It was an important and humbling lesson.
I sometimes share with patients that there is no disproving paranoia; it’s the safer stance at any moment. Why ever let your guard down? Unfortunately this safety, which is sometimes only illusory in the end, comes at significant cost: isolation, viewing others as threats, constant fight-or-flight tension. Sometimes this is the best self-protection we can muster in the aftermath of emotional abuse or betrayal. However, it’s not the best we can do as human beings. A degree of credulity, in contrast, brings vulnerability. We can be hurt, humiliated, and diminished. But it also allows relatedness, connection, and love.
In order for dynamic therapy to lead to change, psychotherapists must get caught up in our patients’ dynamics. Not too much, such that we lose perspective and act like everyone else in the patient’s life. Nor too little, such that no genuine connection or relatedness occurs. Both parties ideally permit themselves enough credulity to be drawn into emotional engagement, while maintaining enough skepticism (or “observing ego”) to note what is happening. Ideally, that is, for we therapists are the more obliged to maintain a watchful eye, and must balance credulity and critical thinking more carefully.
Logical argument is unlikely to convince the paranoid to be more credulous, nor the gullible to be more skeptical. Our comfort zones are established early and unconsciously, based on emotion not logic. The emotional power of dynamic psychotherapy and psychoanalysis, as well as close, healthy relationships in everyday life, can nudge our comfort zone in a direction that serves us better — and serves our patients better, if we happen to be psychotherapists ourselves. Meanwhile, reflecting on prideful attachment to a particular stance on this continuum may offer us perspective and more flexibility.
Image courtesy of Ambro at FreeDigitalPhotos.net
Two of the most commented posts on my blog are about charging patients for missed sessions and how psychotherapies end. As there is no single correct approach to either of these, there’s plenty of room for practices legitimately to vary, and plenty of room for patients, i.e., most of my commenters, to express their likes and dislikes. By my reading, many commenters assume that cancellation and termination policies mainly feed their therapists’ wallets; they tend to dismiss clinical rationales that are not obvious common sense. I’m often drawn to defend the field and their therapists, and to point out that insight doesn’t always come painlessly.
Other times, though, I’m just dumbfounded (or the more hip term, gobsmacked). One therapist reportedly starts sessions ten minutes late on a regular basis, and repeatedly cancels with less than a day’s notice for home furniture deliveries and the like. Another conducted a therapy session “lying half dead on the couch. Her eyes were literally half closed – she was sick but didn’t call ahead of time to reschedule.” Yet another disappeared in mid-treatment and was later found to be practicing without a valid license. Another psychotherapist left a voicemail at 6 pm to cancel a 7 pm appointment because her 6 pm cancelled and she wanted to go home. And most recently, a patient wrote that her therapist revealed her own diagnosis of borderline personality disorder “with narcissistic overlay,” then went on to cancel the writer’s regular weekly therapy appointment, without advance discussion or notice, following an apparent misunderstanding.
It’s important to consider that these reports may be distorted. That is the nature of transference. For example, patients have accused me of “yelling” at them when I clearly had not; some are certain that I want them to end treatment when that isn’t true. It’s possible that these therapeutic missteps are fantasies or exaggerations of the truth. But I have no reason to think so. The reported behavior sounds all too human.
Why do therapists — my colleagues — act like this? We all have momentary lapses due to fatigue or personal crises. These are unfortunate but usually rare and short-term. A good therapist gets back on track quickly, acknowledges (and apologizes for) any hurt feelings, and repairs the damage done. Sometimes a particular patient really “pushes our buttons,” i.e., stirs up strong countertransference, and we lose our composure as we are swept up in the patient’s narrative. Ideally, these enactments are also brief, lasting only until we step back and gain perspective. According to some schools of psychotherapy, they may even be helpful. However, since countertransference can be partially or wholly unconscious, they may unfortunately go on much longer than ideal. The therapist’s own therapy may mitigate, if not eliminate, these reactions.
Beyond this, however, some therapists seem impaired. A psychotherapist who has little tolerance for strong emotion, who routinely engages in power struggles, who can’t stand rejection, who is excessively self-interested (or self-sacrificing!), or who has outsized needs for adoration or deference — well, that’s like hiring a one-armed surgeon. (Not to denigrate any actual one-armed surgeons out there, but you have to admit it’s a disadvantage.) Certainly in traditional dynamic psychotherapy, and to some extent in any professional helping relationship, our own personalities and social skills are part of what we offer. We need to be healthy enough to “be there” for patients, and not add to their problems. Surely it’s possible to pursue a career as a psychotherapist even if one suffers “borderline personality disorder with narcissistic overlay.” But it’s a significant handicap, much like the challenges facing a surgeon who is missing an arm.
Don’t get me wrong. Overcoming such challenges is courageous and noble. I’d have great respect for a one-armed surgeon if I ever met one. I have similar respect for those who overcome debilitating psychiatric conditions to pursue their dreams. But from the patient’s point of view, the idea is not to give the underdog a chance. The idea is to get help. Given the choice, most patients would not opt for a one-armed surgeon. Most would not opt for a psychotherapist who acts in erratic or traumatizing ways. The difference is that the surgeon’s impairment is obvious and the therapist’s is not.
There’s a cliche that mental health professionals (MHPs) enter the field to figure ourselves out, or to deal with our own inner demons. Like most stereotypes, it contains a kernel of truth. What’s important is the degree to which we’ve succeeded in gaining that insight and conquering those demons. What’s even more important is how our personality affects our patients — however far we’ve traveled and whatever we’ve overcome.
It’s a blessing and a curse that we humans are such adept conceptualizers and heuristic thinkers. We continually compare our perceptions about the world to paradigms in our head, performing quick, unconscious goodness-of-fit assessments. We instantly sense danger when a large furry beast rapidly advances. We don’t waste time discerning whether it’s a lion or a tiger. (If it ends up being a friendly dog we breathe a sigh of relief, but better safe than sorry.) Immediately categorizing a new situation as dangerous versus safe is an indispensable survival skill. It many cases arriving at a decision right away is more important than perfect accuracy; some “false positives” are acceptable.
We’re not the only animal to react this way. Lab experiments with mice, rats, and other creatures demonstrate their ability to abstract categories and react rapidly in order to stay safe or further their interests. However, when it comes to assessing our fellow human beings, we elevate this skill to an art form. We instantly judge whether a person approaching us is dangerous, whether a negotiator is honest, whether to give weight to what another person says. These intuitions are woven into everyday life, yet are hard to account for in detail. Observing even one or two qualities we associate with dishonesty, e.g., a shifty gaze or inconsistent narrative, may be enough for us to withhold trust. The stakes involved, and our past experience in similar situations, color our judgments in complex ways.
Expertise in any area of life is the gradual replacement of conscious, cognitive assessment by more fluid, less conscious impression. A beginning surfer decides which wave to ride; an experienced surfer rides a wave that looks and feels right. A new driver tensely scans and analyzes the scene; a long-time driver takes in the scene as a whole, anticipating traffic problems in advance. A medical student concludes that a patient has a serious disease; an experienced physician walks into the patient’s room and immediately surmises this. Experience leads to intuition, a sense about the situation. It’s implicit pattern recognition: “yes, I’ve seen one of these before.”
In this way we are all experts about other people. We get a gut feeling, a sense, a vibe. When it comes to getting along with one another, we’re like the experienced surfer, long-time driver, and seasoned doctor. We don’t consciously analyze, conclude, or decide; the calculus happens unconsciously. And although some of us are better judges of character than others, most of us are right most of the time.
Stereotypes and prejudice are the price we pay for this expertise. The Swiss psychologist Jean Piaget explained how children fit (“assimilate”) their observations about the world into their pre-existing assumptions, and only more reluctantly change (“accommodate”) their assumptions to fit new observations. This is a good description of how adults operate too. Pattern recognition fails when valid new observations don’t fit the old pattern. We call it prejudice when past experience with criminals of a certain appearance leads police officers to assume that others who look like them are criminals too. We call it stereotyping when female health professionals trigger “nurse” before “doctor,” even though there are plenty of male nurses and female physicians.
Mental paradigms change slowly. “Consciousness raising” can help, but fundamentally it takes repeated exposure to countervailing examples to change assumptions. After all, those assumptions and paradigms have saved us more often than not. Our common, repeated exposure to friendly dogs tempers our inherent reaction to large furry beasts, and repeated exposure to different kinds of people refines our expertise in this area as well.
The history of American medicine is the story of the rise and fall of a professional guild. In the 19th and early 20th Centuries, physicians distinguished themselves from other healers by banding together to form professional associations dedicated to science-based practice. Even more important, medical ethics put the patient first, above considerations of personal gain or even collective social goods. The medical guild may have been insular, self-protectively territorial and paternalistic, but it was also self-sacrificing and altruistic. Doctors earned the public’s trust one patient, or family, at a time.
The last quarter of the 20th Century saw this guild wither under waves of commercialism and populism. Third party payers started “managing” care, trumping medical decisions with budgetary ones. Large medical corporations leveraged economies of scale to provide services at lower cost. Meanwhile, government oversight gradually replaced the guild’s self-policing. Since the days of Vietnam and Watergate, no authority in America, even medicine, gets a free pass. With oversight comes infrastructure, formalized quality control, reporting requirements. Unfortunately, sensible-sounding social policy may be unworkable on the ground. Private medical practices are gradually disappearing.
The weakening grip of physicians over the practice of medicine re-opened the door for commercial innovation — or pandering, depending on one’s perspective. Generations ago, patients were drawn to inexpensive folk remedies, expensive patent medicines, and traveling road shows. The modern parallels are free information on the internet, ads for expensive prescription drugs on television, and slick smartphone apps. Patients now see a doctor for a one-time encounter online, at an urgent care clinic, or in a “Minute Clinic” behind a chain drugstore. Enhanced access and convenience, often at lower cost, is the upside. The downside is fragmentation of medical care rendering it an impersonal commodity, where doctors are interchangeable and patients are widgets on an assembly line.
The hard lesson of the marketplace is caveat emptor. Little wonder that patients only reluctantly divulge personal matters to strangers in white coats, and increasingly prefer to do their own online research. A trusting doctor-patient relationship, once the soul of medicine, begins to sound as quaint and precious as “old world craftsmanship” — nice if you can afford a concierge doctor who still offers it.
A number of battles are being waged in this larger war between professionalism and commercialism. On one side are physicians rallying under the traditional banner of uncompromising standards, and prizing the individual patient over cost and social considerations. Detractors, however, paint this stance as paternalistic, and say doctors are clinging to the last scraps of guild status and privilege. On the other side are entrepreneurs happy to “disrupt” the status quo and give the public what it wants, namely lower cost, faster service, and transparency. Detractors, however, say these entrepreneurs pander to a fast-food mindset that cuts corners and increases medical risk.
The Texas Medical Board ruled earlier this year that doctors must examine patients in person (or “face to face”) before treating them online, essentially declaring telemedicine an adjunct to in-person care, not a replacement. Teladoc, the largest U.S. telemedicine provider, filed an antitrust lawsuit in U.S. District Court, which suspended the Board’s ruling. The court’s decision suggests it is not up to doctors to set a standard of medical care. It’s a marketplace decision. If people want to be diagnosed without the benefit of a physical examination, and companies choose to provide that service, that’s their right. It will be interesting to see whether medical malpractice will be harder to prove once the marketplace lowers the standard of care.
Likewise, doctors favor follow-up visits to discuss certain test results, particularly those with life or death implications. This is motivated by benign paternalism: putting the results in context, softening the blow of bad news, helping the patient not jump to conclusions, framing the next steps. Many service professionals, from caterers to auto mechanics, offer at least a little of this contextualization. But it’s a value-added service that costs real money in medical practice. Many patients prefer to get their results online or directly from the lab instead: it’s faster, less expensive, and feels more transparent. Interpreting the results with the help of Dr. Google is a risk that saves time and money.
The tension between traditional medical values and expanding commercialism, amplified in this age of instant online information and services, puts the squeeze on physicians. We need to explain our rationales carefully and stand up for high quality in the face of expediency. Yet we also need to choose our battles. We may be forced to accept a role for medical fast food as well as fine dining. And this is not only for the sake of affordability, although that’s one very real consideration. Americans crave speed and convenience, as distasteful as that may be to old-world craftspeople, Cordon Bleu chefs, and principled physicians. Speed, cost, quality — pick any two.
Popularized telemedicine — that is, teleconferencing with a physician over one’s smartphone — worries many critics because it assumes patients can be evaluated without a physical exam. The critics are right that those with a financial interest in “disrupting” health care typically minimize the trade-offs. Convenience and lower cost are trumpeted, while risks of misdiagnosis and mismanagement are waved off. The concerns of practicing physicians are dismissed as self-serving and illegitimate. Common sense supplants expertise; repudiation of experts, or perhaps a rebellion against them, lies just under the surface. Startup culture celebrates and sometimes handsomely rewards brash Big Thinkers who don’t let a few practical matters, like the fact that diagnosis isn’t always a slam dunk, impede progress. Steven Jobs wasn’t the only one with a reality distortion field.
The tension between professionalism and commercialism isn’t new or limited to medicine. Misgivings by medical personnel about “Dr. Google” and smartphone telemedicine parallel misgivings by attorneys about do-it-yourself wills and divorces, and by CPAs about at-home tax return software. In each domain professionals lament the erosion of quality, and their inability to provide it, while business disruptors revel in expanded markets.
It’s also well accepted that providing high quality products or services, and wide availability at the same time, is an elusive challenge. Usually it’s one or the other. Although the marketplace accommodates fine dining and fast food, the fiduciary role of doctors, attorneys, accountants, and banks separates these fields from the restaurant business. Banking is a prime example: no amount of convenience or access make up for uncertainty about the safety of one’s money. And while profit, or making a living, motivates professionals as much as it does the businesspeople who aim to unseat them, only the former maintain longstanding traditions and ethical codes to put their patients or clients before profit. The stale charge that heel-dragging professionals are financially self-serving applies far more to the gung-ho disruptors themselves. Medical care has always been about high quality and wide availability, which is why health care reform is genuinely hard. Trading away quality for availability or expediency is simply cutting corners. We could have done that all along.
Smartphone telemedicine doesn’t currently allow physical examination. There are a range of scenarios (“use cases”) where this makes little difference, and many others where it matters a lot. But technology is a moving target. It’s a safe bet that remote examination technology will improve, gradually putting this concern to rest. Criticism of telemedicine is not about what it someday may become — “Star Trek” style holodecks with virtual physicians? — but about today’s enthusiasts getting ahead of themselves. That is, selling science fiction, not science. This creates a peculiar dynamic: innovators speak in vague but urgent tones of our shiny future and the need for traditionalists to step aside for progress, while critics walk a tightrope between condoning exploration and improvement, and at the same time keeping everyone safe. This resembles nothing so much as parental oversight over a teenager. Like good parents, professionals must step aside to allow entrepreneurs to try new things, learn from their mistakes, and yes, ultimately make the world better than they found it. But we can’t be negligent either. Some cool new toys are risky, some daring adventures bring unanticipated danger. It’s no coincidence that the language of “disruption” sounds adolescent, and that pushback from the disruptors sounds like a teenager complaining that his or her parents are old-fashioned, uncool, and self-interested.
There’s a direct parallel in my specialty. For over 35 years, advocates of a neurobiological approach to psychiatry have oversold what we actually know. From now-discredited “chemical imbalances” to current talk of circuitopathies, neurobiology enthusiasts dismiss humility (and occasionally honesty) as old-fashioned and uncool. This began with an Oedipal victory over Papa Freud in the 1970s, was codified into DSM-III in 1980, celebrated as the Decade of the Brain in the 1990s, and has shaped the NIMH and psychiatric research ever since. Neurobiology has become the dominant paradigm, a matter of faith. But aside from a limited range of scenarios (“use cases”) involving addiction and bonafide brain injury, it’s vaporware so far. We psychiatrists are told to think neurobiologically, and to educate our patients using the language of brain circuitry — even though it’s often an educated guess, and even though it doesn’t actually change our treatment.
Surely time is on the side of the innovators. It’s a safe bet we’ll learn much more about the brain, gradually discovering the causes of at least some disorders we currently call psychiatric. Thoughtful criticism of neurobiological psychiatry is not about what it someday may become. It’s about today’s advocates getting ahead of themselves, selling wishes and half-truths as established science. Neurobiology disruptors speak in vague but urgent tones of our imminent bright future and a need for the older generation to step aside for progress. Meanwhile, critics play the parental role, walking a tightrope between encouraging exploration and improvement, while keeping everyone safe with care for the brain and the mind.
It’s not easy parenting adolescents. Sophomoric self-righteousness, know-it-all smugness, and knee-jerk rebellion can be irritating as hell. Suddenly, adults are idiots and “just don’t understand.” The young resist all guidance and veer toward obvious trouble. It’s nerve-wracking to hang back and watch this happen; to refrain, except in extreme circumstances, from wagging a parental finger and chiding, “you have a LOT to learn!” And all these challenges grow in complexity when the “adolescents” are actually adults, sometimes even colleagues, and when professional expertise and decades of hands-on experience invite only suspicion, not authority or respect. Even if our concerns are dismissed as the bloviation of myopic dinosaurs, we still hope our colleagues, business counterparts, and larger society grow up fast enough to see past the seduction of disruption and rebellion. We need to weigh the real trade-offs we face.
The New England Journal of Medicine (NEJM) called the question: Has criticism of the pharmaceutical industry, and of physician relationships with that industry, gone too far? Are self-righteous “pharmascolds” blocking the kind of essential collaboration that brought streptomycin and other lifesaving treatments to market? The editorial by Dr. Jeffrey Drazen and the lengthy three–part piece by Dr. Lisa Rosenbaum push back against a rising skepticism that obviously feels unfair to them, and presumably to many.
Drazen, editor in chief at NEJM, stands in sharp contrast to former editors Drs. Arnold Relman, Jerome Kassirer, and Marcia Angell, all of whom warned of corrosive commercial influence in medicine. According to Drazen, an unfortunate divide between academic researchers and industry has arisen “largely because of a few widely publicized episodes” of industry wrongdoing. He underscores the ongoing need for collaboration and guides readers to Rosenbaum’s exposition.
In her first of three articles, Rosenbaum correctly notes that skepticism about financial ties may obscure other biases of arguably greater influence. For example, industry marketing and promotion, i.e., influence that is not directly financial, also affects physicians. But what to do about it? Rosenbaum claims “the answer still largely eludes us,” partly due to the “overwhelming complexity” of the variables:
I think we need to shift the conversation away from one driven by indignation toward one that better accounts for the diversity of interactions, the attendant trade-offs, and our dependence on industry in advancing patient care.
Rosenbaum cites the social psychologist Robert Zajonc, who researched how feelings influence thinking. According to this account, critics hear “canonical conflict-of-interest stories and pharmaceutical marketing scandals” and this leads to emotional bias: “we worry about ‘corrupt industry’ interacting with ‘corruptible physicians’.”
Our feelings about greed and corruption drive our interpretations of physician–industry interactions…. reasoned approaches to managing financial conflicts are eclipsed by cries of corruption even when none exists.
Of course, indignation runs both ways. Rosenbaum fails to note that Zajonc’s findings apply equally well to apologists who hear or experience positive relationships, and are thereby reassured that “friendly, helpful industry” interacts with “ethically impervious physicians.” Perhaps reasoned approaches to managing conflicts of interest and marketing scandals are eclipsed by cries of innocence even when corruption exists.
Rosenbaum’s second installment takes a more adversarial and defensive tone, introducing the derisive “pharmascold” label to describe critics. Her own criticism of Relman’s seminal 1980 editorial on “The Medical-Industrial Complex” seems misplaced:
Relman wanted to mitigate undue influence by curtailing physicians’ financial associations with companies, but his concern seemed as much about appearance as about reality. Noting the uncertainty about the magnitude of physicians’ financial stake in the medical marketplace, he wrote, “The actual degree of involvement is less important than the fact that it exists at all. As the visibility and importance of the private health care industry grows, public confidence in the medical profession will depend on the public’s perception of the doctor as an honest, disinterested trustee.”
Rosenbaum acknowledged in her first article that the influence of an industry gift or payment may be unrelated to its monetary value. Relman agrees: the “degree of involvement is less important than the fact that it exists.” And while public confidence in the medical profession is partly a matter of appearance, Relman was not talking about putting on an act. He was urging doctors to remain honest, disinterested trustees — a theme to which we shall return.
In holding that we “lack an empirical basis to guide effective conflict management,” Rosenbaum says we don’t know whether commercial bias actually harms patients. The evidence is only suggestive. This is particularly weak rhetoric, as there is a great deal of suggestive evidence, some of which she cites herself, and very little, suggestive or otherwise, to oppose it. Her stance is reminiscent of arguments that staying up all night is good for medical trainees and their patients — because it’s traditional, and because there is no empirical data from those specific groups showing harm. Never mind that thousands of studies of sleep deprivation exist, and that it is almost uniformly deleterious. One may likewise point to entire industries, e.g., advertising and public relations, founded on the very influence that is so curiously hard to pin down here. Is there harm in having medical research and clinical decisions affected by those who stand to gain financially? Not in every case, but surely the burden of proof lies with those who claim to be an exception.
Rosenbaum correctly notes that disclosure and transparency may not mitigate bias, nor its effect on listeners. Most consumer advertising is very transparent in its intent; this doesn’t appear to sap its effectiveness in the least. She ends her second installment by revisiting psychology and the “self-serving bias” which may fuel both pro- and anti-industry positions. She aptly notes that stereotypes and ad hominem arguments may be unfair. Why the pharmascold slur then?
The last installment is clearly the best of the three, and could have stood alone as a stronger statement. Rosenbaum opens with how the culture of medical training has dramatically swung from an unthinking acceptance of industry influence to intense skepticism and peer pressure to avoid it. She cites yet another psychologist, Philip Tetlock, who focuses on how certain “sacred values” like health prevent us from contemplating inevitable trade-offs. She also cites psychologist Jonathan Haidt, who found that “people who were offended by social-norm violations worked hard to cling to a sense of wrongdoing, even when they couldn’t find evidence that anyone had been hurt.” She applies these findings to unbending critics, and to those who either invent harm, or who claim wrongdoing without evidence that anyone has been hurt. Rosenbaum points out that doctors may be more risk-averse and conflict-avoidant than some patients prefer. More examples follow of allegedly unfair criticism of industry ties. “The bad behavior of the few has facilitated impugning of the many.” Medical progress stops if we scare people away. We unwittingly replace expertise with conflict-free mediocrity. And so forth. She ends with this:
The answer is not a collective industry hug. The answer will have to be found by returning to this question: Are we here to fight one another — or to fight disease? I hope it’s the latter.
Some responses to the NEJM series were quick and biting. My own reaction is mixed. Rosenbaum raises several good points. It isn’t right to stereotype. Academic collaboration is necessary to move medical science forward. Witch hunts serve no one. The appearance of a conflict of interest (COI) isn’t the same as having one, and even that isn’t the same as being biased. Many psychological blind spots attributed to defenders of industry collaboration may apply as well to its critics. Perfectionism in avoiding COI may carry costly trade-offs. Vague indignation is pointless.
However, Rosenbaum goes astray by misconstruing professional ethics and by overlooking its Kantian, deontological nature. Relman wrote his editorial not for the sake of appearance, but to remind readers of the physician’s ethical duties. As with other fiduciaries, our standards are higher than usual business ethics; Tetlock is free to call this a “sacred value” if he wishes. Medical ethics doesn’t wait for “evidence that anyone has been hurt” — just as judges recuse themselves absent such evidence, and bribing public officials is prohibited without waiting for proof of harm. Haidt’s social-norm violations, e.g., defacing an American flag, may be considered a dereliction of duty and therefore wrong, even if no one is hurt.
As medical fiduciaries, we have a positive duty to avoid COI when we reasonably can. This is best framed as an attitude, not a pure or absolute set of behavioral rules. It’s not a crime to talk to a drug rep or to attend an industry sponsored talk. Under certain circumstances these may be the best way to enhance patient care. But usually they’re not: expedience is rarely worth the price of having to evaluate commercially biased material. And make no mistake, commercial bias is the raison d’être of business. While academic physicians should collaborate with industry when appropriate — and feel proud to do so — they should also recognize it may color their clinical thinking.
As will many other sources of bias. Rosenbaum is right to point this out, even if it doesn’t exonerate the influence of money. Her example of sleep deprivation is a good one. Rather than declaring these influences too complex and myriad to do anything about, let’s try. If clinical care is adversely affected by the on-call doctor’s need for sleep, maybe the on-call doctor should be well rested. If clinical care is harmed by draconian regulations and paperwork, let’s work to improve that. Money can be an obvious, concrete COI, but it’s certainly not the only COI out there.
Rather than focusing on do’s and don’ts, shills and pharmascolds fighting one another, medicine needs to regain its ethical footing. In the 1940s, Dr. Waksman could collaborate with Merck to produce streptomycin, and later to write a review article on the drug, because his ethics, and probably Merck’s, were above reproach. This was long before off-label drug promotion, ghostwritten articles, KOL targeting, and all the rest. If medicine is again to be respected in this way, our best argument can’t be that harm hasn’t been proven yet. We can’t minimize the mistrust that “a few widely publicized episodes” can bring. We can’t defend the profession against critics by ridiculing and dismissing the radical fringe.
Will some extreme “pharmascolds” continue to decry all Pharma, without regard to reason or consequences? Undoubtedly. Yet we don’t declare pollution a sham because fringe groups of radical environmentalists exist. We don’t abandon our critical faculties when others are excessively critical. We should accordingly still scrutinize physician COI resulting from commercial influence, and from other sources as well, and seek to minimize it in ourselves and in our profession. If we can do it without overheated rhetoric and unfair stereotyping, all the better.
Image courtesy of Vichaya Kiatying-Angsulee at FreeDigitalPhotos.net
Compared to most others in society, physicians endorse, and are held to, higher ethical standards. (To illustrate, here are ethical codes from the AMA and the World Medical Association.) High standards apply to professionals in other fields as well, especially fiduciaries such as attorneys, accountants, schoolteachers, and judges. But standards of medical ethics may be among the most stringent. We put patient welfare first, and anything that interferes with this primary aim, particularly personal gain, is deemed a conflict of interest (COI). For example, it is legitimate to make money as a physician, i.e., to earn a living, but not in any way that detracts from patient welfare. These are not black and white distinctions, however, and line-drawing controversies abound. Offering unneeded treatment solely to boost income is always unethical. But what about limiting one’s practice in lucrative or otherwise pleasant ways: orthopedic surgeons practicing in ski towns, plastic surgeons who only do cosmetic surgery? What about choosing a more lucrative specialty in the first place? Accepting only certain types of insurance, or none at all? Charging for missed or late-cancelled sessions? Without attempting to resolve any of these examples here, it’s noteworthy how much concern is voiced, and ink spilled, over how physicians practice. To completely escape controversy, we’d have to take a vow of poverty and offer our services for free.
In contrast, many other businesses that affect health do not share the physician’s ethics. Precise line-drawing plainly doesn’t apply. Beverage companies peddle diabetes along with refreshment, supplements come adorned with dubious health claims. Snack food can be unhealthy. Manufacturers and retailers of exercise equipment need not refer customers to more suitable products from competitors. One can even argue that new cars, not to mention video games, movies, and many other products, discourage people from exercising. “Patient welfare” simply isn’t a priority for most firms — they aren’t dealing with patients. There is no general code of business ethics that makes health its primary aim. Thus, in extreme cases the government — we the people — step in, by limiting tobacco and alcohol ads for example, or by inspecting meat. This is one reason we have government: to set priorities, including ethical priorities, that an ungoverned free market cannot or will not.
Some firms do explicitly deal with patients, yet still do not share the physician’s ethical standards. Insurance companies run feel-good ads that obscure their cost-containment mandate. Medical corporations attract customers or subscribers who are “covered lives” as opposed to individual patients. Pharmaceutical companies entice the public with all the irrational tricks used to sell other products, then tack on “ask your doctor” to absolve themselves of any medical responsibility. Pharmacy benefit managers (PBMs) can disallow a physician’s prescription wholly on the basis of cost, and without taking medical responsibility. These are all huge “conflicts of interest” from a physician’s point of view. But COI doesn’t apply the same way to entities with less stringent professional ethics, where the primary aim is profit, not health.
This makes our burden harder. For the most part, it isn’t up to pharmaceutical companies to avoid biasing doctors with their promotional efforts. It’s up to us. Moreover, it’s up to us to counter unhealthy biases instilled in the public, like the willingness to use an antipsychotic with significant side-effects to treat routine depression. Likewise, as long as insurers and PBMs are corporations, no one will compel them through moral persuasion or ethical codes to sideline their economic interests. It’s not a conflict for a business to maximize return for its shareholders; it’s the main reason they exist. Indeed, too much concern for patient welfare might be criticized, e.g., at a shareholder meeting, as a COI that impedes this primary aim.
Doctors are held to standards that would be absurd in virtually any other business. Historically, these higher ethical standards gave us a special status in society, and earned our patients’ trust. The erosion of this special status, and of patient trust, is both a cause and an effect of a health care environment with lower, more businesslike, ethical standards. The accelerating corporatization of American medicine replaces traditional medical ethics with the looser standard of business ethics. MD decisions are now vetoed by MBAs. As a result, patients may see us as replaceable technicians in a corporate infrastructure, and lose the benefits of a personal physician. In parallel, physicians who are viewed by their patients and employers as mere cogs in the wheel of a large system are more apt to relax their own high ethical standards. I fear for both our profession and the public as this vicious cycle continues.
While we doctors are busy maintaining our ethics and watching out for COI, other “stakeholders” in health care operate under fewer ethical constraints and enjoy greater profits, often directly at our expense. It can be maddening, yet physicians have no unified voice to defend ourselves and our work. Proposed solutions are inescapably political, and polarize us along deeply divided political lines, left versus right. Ultimately, though, traditional medical ethics and public welfare are on the same side. Doctors exist to help individual patients — and we will all be individual patients someday. The looming challenge is whether we can put our internecine struggles aside long enough to save ourselves, our families, and our neighbors.
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