Our first discussions with health professionals about the causes of health care dysfunction(1) quickly revealed concerns about influences that push professionals towards unethical actions. We first heard about cases in which physicians were influenced to suppress clinical research whose results threatened vested interests, and punished when they did not cooperate. These included the cases of Dr David Kern in the US, Dr Nancy Olivieri in Canada, (look here for summary) and Dr Aubrey Blumsohn in the UK (look here). We also heard about numerous cases of whistleblowers who also were punished after revealing research misconduct, quality problems, mismanagement, financial malfeasance, etc, etc, etc.
We found evidence that many young medical faculty members felt pressured by leaders who put money ahead of professional core values. Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(2) (Also, see our comments on this paper)(3) Pololi and colleagues' large survey of US medical faculty showed that over half were being pressured to put revenue generation for the organization ahead of all else, including their professional values.(4)
Many attempts to influence health care professionals used financial incentives that generated conflicts of interests. Some rose to the level of kickbacks or bribery. On the other hand, some used threats, including intimidation and extortion. In nearly all the cases the physicians were pushed towards behavior that would help out large organizations and those who lead them, including hospitals and hospital systems, insurance companies, and drug, device and biotechnology companies.
However this week we heard two instances involving attempts to influence one physician that seemed to come from an alternate universe.
Donald Trump Dictated the Content of a Letter His Physician Signed, Describing Trump's Health in Glowing Terms
First on May 1, 2018, NBC reported, and then CNN reported on May 2, 2018 that a well publicized letter Donald Trump's former private physician, Dr Harold Bornstein, signed in 2015 about Trump's health was in fact written by Mr Trump. To quote CNN,
When Dr. Harold Bornstein described in hyperbolic prose then-candidate Donald Trump's health in 2015, the language he used was eerily similar to the style preferred by his patient.
It turns out the patient himself wrote it, according to Bornstein.
'He dictated that whole letter. I didn't write that letter,' Bornstein told CNN on Tuesday. 'I just made it up as I went along.'
Bornstein's signature on a letter whose content was largely dictated by Trump was obviously deceptive and unethical, and possibly illegal. A brief article in RawStory quoted President Obama's former physician.
CNN anchor Erin Burnett asked. 'And is there any issue you have ethically with this, that Trump dictated it and the doctor would sign it?'
'Yeah, if the doctor signed it and it’s not his medical report, it’s fraudulent,' Dr. [David] Scheiner explained.
An article in Fortune quoted a physician who believes Dr Bornstein's actions were medical misconduct.
Dr. Anirban Maitra, an oncologist at the MD Anderson Cancer Center in Houston, pointed out on Twitter that Bornstein’s admission about the dictated doctor note could amount to misconduct under New York law. 'Permitting, aiding, or abetting an unlicensed person to perform activities requiring a license' is indeed listed under the state’s Office of the Professions definitions of professional misconduct by doctors.
This raises a big question. Why did Dr Bornstein do something so patently dishonest? Nothing published so far establishes an answer. IMHO, it does not seem unreasonable to suppose that he was intimidated by Mr Trump, a billionaire known to use aggressive and well-funded legal tactics against anyone who opposed him. The second part of Dr Bornstein's story corroborates the intimidation scenario.
Trump Organization Functionaries Confiscated All Copies of President Trump's Medical Records
NBC also reported on May 1, 2018, that President Trump sent minions, including two lawyers from the Trump Organization, and his former personal bodyguard, to Dr Bornstein's office to confiscate all the records Dr Bornstein had for Trump
In February 2017, a top White House aide who was Trump's longtime personal bodyguard, along with the top lawyer at the Trump Organization and a third man, showed up at the office of Trump's New York doctor without notice and took all the president's medical records.
The incident, which Dr. Harold Bornstein described as a 'raid,' took place two days after Bornstein told a newspaper that he had prescribed a hair growth medicine for the president for years.
In an exclusive interview in his Park Avenue office, Bornstein told NBC News that he felt 'raped, frightened and sad' when Keith Schiller and another 'large man' came to his office to collect the president's records on the morning of Feb. 3, 2017. At the time, Schiller, who had long worked as Trump's bodyguard, was serving as director of Oval Office operations at the White House.
Bornstein said he was not given a form authorizing the release of the records and signed by the president known as a HIPAA release — which is a violation of patient privacy law.
Bornstein said the original and only copy of Trump's charts, including lab reports under Trump's name as well as under the pseudonyms his office used for Trump, were taken.
Another man, Trump Organization chief legal officer Alan Garten, joined Schiller's team at Bornstein's office....
An AP story explained why it may have been unethical, or illegal, for Dr Bornstein to hand over the records in these circumstances.
Patients have a right to a copy of their medical records but the original physical record belongs to the doctor, said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado.
'If a patient wants a copy, they can have a copy, but they don't get the original. Patients can also ask for their records to be transferred to a new doctor, but that also involves making copies (i.e., transferring the information), not literally packaging up the originals and sending them off,' Wynia said in an email.
Most states require doctors to keep and maintain records, Wynia said. Federal patient privacy law bars doctors from relinquishing records without a signed release from the patient or an authorized representative.
Nonetheless, per NBC
White House Press Secretary Sarah Huckabee Sanders said that taking possession of medical records was 'standard operating procedure for a new president' and that it was not accurate to characterize what happened as a "raid."
'Those records were being transferred over to the White House Medical Unit, as requested,' said Sanders.
In my humble opinion, third parties confiscating all copies of a patient's records from a physician's office, whether or not at the behest of the patient, is the opposite of standard operating procedure.
Again, in this case, Dr Bornstein appears to have violated HIPAA regulations, and probably New York State law on the integrity of medical records. However, it also appears that he did so under duress from three men, two of which he described as "large," presumably meaning physically intimidating, and two of which were top lawyers for the Trump Organization.
Why Mr then President Trump was so intent on covering up his medical records is yet another queston about which speculation seems fruitless at this point.
As noted above, we have seen many cases in which health care professionals were pressured to violate their core values and ethical norms by outside parties, most often large health care organizations seeking financial gain.
Now, in this new case, we see a single health care professional twice pressured to violate core values and ethical norms by a patient, a wealthy billionaire corporate CEO who became President of the United States. Thus we are now in a situation in which the President of the US, to whom all federal health care regulatory and law enforcement agencies at least nominally report, has shown contempt for the core values and ethical standards of the medical profession.
This lowers whatever minimal expectations we might have had that the US government might help health care professionals defend their values and ethics. However vulnerable health care professionals used to feel to outside pressure from large private organizations, they now must feel much more vulnerable.
We used to rant that health care professionals' values and ethics needed better defense, and that the government should be urged to take a greater role in providing it. Now the government under Trump seems to be raising the threat level to health care professionals. True health care reform now seems to require not just changes in government processes and attitudes, but a new person to sit at the head of government.
1. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here
2.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
3. Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link .
4. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here