Saturday, May 07, 2011

"We're Only In It for the Money" - Big Businesses Pretending to be Medical Schools Discussed in Main-Stream Medical Journal

This is a first, the contention that medical schools are only in it for the money has appeared in a prestigious, main-line, large-circulation medical journal(1). The author started by noting that medical schools are now academic in name only.
US medical schools have evolved into big businesses that derive most of their income by providing healthcare services and securing extramural research grants. In 2009, for example, 53% of medical school revenues came from clinical services and 29% from extramural grants. By comparison, less than 4% came from tuition.

These big businesses disguised as academic institutions behave like other big businesses:
Academic medical centers vie for clinical market share through direct-to-consumer advertising. To increase referrals, they offer free continuing medical education that boost the visibility of their most profitable services to community providers. Physicians with MBA degrees are becoming increasing common at academic medical centers....

Then University of Utah cardiology professor Matthew Movsesian clearly asserted that faculty realize that they are only valued for the money they bring in:
It's worth noting that medical school faculty members perceive that their-revenue-generating activities are of paramount importance in the eyes of academic leadership. In a recent survey of US medical schools, 51% of respondents agreed that 'the administration is only interested in me for the revenue I generate'; a less extreme statement might have elicited [even] more widespread concurrence.

Emphasis on revenue generation by faculty is evident in the incentive plans that typically compensate clinicians in proportion to the billable services they provide. And researchers understand that their salaries for time spent on research must be paid, sometimes in full, from extramural grants.

Dr Movsesian implied who the main beneficiaries of this revenue generation are:
Executives at these teaching institutions are paid industry-level salaries.

All of this should be familiar to those who have been reading Health Care Renewal.  We first wrote about how medical school leaders mainly evaluated faculty by their revenue generation, and dismissed those who did not generate sufficient revenue as "welfare recipients," here in 2007.  We discussed the survey that revealed that medical school faculty realize their supervisors only value their revenue generation here in 2010.  But the first post was derived from an interview in the SGIM newsletter, and the survey noted above so far is only publicly available in an on-line abstract.  To my knowledge, the notion that medical schools have abandoned their primary mission of discovering and disseminating the truth in favor of making money, perhaps mainly for the benefit of their top leaders, has not heretofore appeared in a main-stream medical or health care journal.  So this new publication marks an important weakening of the anechoic effect.

Late in 2010, we discussed an important new report in the Lancet about the reform of global health care education(2)(see post here).  It hinted at some of the threats to the academic medical mission we have long discussed on Health Care Renewal.  An accompanying editorial stressed the need to uphold the academic mission, implying that it was in some way threatened, but again did not discuss what actually threatened it.(3)(See our post here which listed some of threats that should be considered.  The threats are reprinted in the box below.)  Now the peril to the mission of US medical, and by extension, perhaps global health care education has made it into polite discussion.  Maybe it is not too late to address threats to global health care education before the system collapses from its internal contradictions.

Threats to the Global Health Care Education Mission (the "Thirteen Plagues")

Health Care Renewal, is largely concerned with threats to health care's core values, including threats to the mission of academic medicine, largely from concentration and abuse of power.  The largest set of threats come from the ascendancy of financial goals amidst the commercialization of health care (mentioned briefly both in Frenk et al and the editorial).  

  • Abandonment of traditional prohibitions of the commercial practice of medicine - In the US, a Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition.  The result was increasing, now rampant commercialization.  See posts  here and here.

  • Making money takes precedence over education -  A recent survey showing that more than half the faculty at multiple US medical schools felt they were valued more for how much money they brought in than their teaching or patient care abilities (here), confirming previous anecdotal reports (see here). 

  • The medical school re-imagined as a biotechnology company -  In 2000, a Vice President of the American Association of Medical Colleges(4) wrote that research universities must respond to "societal demands that they become engines of economic development…."  Many universities now defend lax conflict of interest policies with similar arguments.  For more details, go here

  • Faculty become employees of industry - For numerous examples of this and other kinds of conflicts of interest, go here.  A survey by Campbell et al suggested that approximately two-thirds of medical academics get significant payments from industry.(5)

  • Academics become "key opinion leaders" paid to market drugs and devices - Marketers regard "key opinion leaders" as salespeople who appear more credible because of their professional guise.  See anecdotal evidence here

  • Control of clinical research given to commercial sponsors - A study by Mello et al showed how universities' grant administrators are willing to sign contracts giving commercial sponsors control over key aspects of human research studies.(6)  See post here

  • Conflicts of interest allow manipulation and suppression of clinical research - Commercially sponsored research design, implementation, and dissemination are often manipulated to favor the sponsor's interests.  When such manipulation fails to produce favorable results, the results may simply be suppressed

  • Academics take credit for articles written by commercially paid ghost-writers - Such ghost-writing is often part of organized stealth marketing campaigns. 

  • Whistle blowers are discouraged, or worse, and academic freedom is damaged.  Discussion of some examples of what may happen to whistle blowers is here.  The survey mentioned earlier (here) showed that about one-third of faculty fear they may be punished for speaking  out. 

  • Leadership of academic medical centers by businesspeople - Ill-informed management may result from leaders who have no background or training in actual health care. 

  • Leaders of teaching hospitals and universities become millionaires -  A recent example is here, and more may be found here.  Leaders of academic medical centers and the parent universities of medical schools often make more than $1 million a year in the US.  When such amounts are in play, executives may focus more on short-term measures that lead to even more pay than on upholding the mission. 

  • Medical school leaders become stewards (as members of boards of directors) of for-profit health care corporations - A recent example is here, and a summary of how we discovered this phenomenon in 2006 is here.   The conflict of interest is severe because directors of for-profit corporations are supposed to have unyielding loyalty to the interests of the corporation and its stockholders, although they are frequently accused of acting mainly as cronies of the top hired executives (see here and here).

  • Leaders of failed finance firms become stewards of academic medicine - We have found numerous examples, recently here, here, and here, of top executives and/or board members of the finance firms who helped bring on the global financial collapse also being trustees of medical schools, academic medical centers, or their parent universities.  Such "stewards" may bring to the academic environment the "greed is good" culture now pervasive in finance. 

  • Reference
    1.  Movsesian M. Intramural conflicts of interest warrant scrutiny, too. Nature Medicine 2011; 17: 21. Link here.
    2.  Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.  Lancet 2010; 376: 1923-1958.  Link here.
    3.  Horton R. A new epoch for health professionals' education.  Lancet 2010; 376: 1875-7.  Link here.
    4. Korn D. Conflicts of interest in biomedical research. JAMA 2000; 284: 2234-2237. Link here.

    5. Campbell EG, Gruen RL, Mountford J et al. A national survey of physician–industry relationships. N Engl J Med 2007; 356:1742-1750. Link here.
    6. Mello MM, Clarridge BR, Studdert DM. Academic medical centers' standards for clinical-trial agreements with industry. N Engl J Med 2005; 352: 21. Link here.

    Title with apologies to the late Frank Zappa.


    InformaticsMD said...

    Now perhaps I know why I get an increasing number of annoying CME brochures from area AMC's.

    -- SS

    1boringoldman said...

    You may have said it before, but never so clearly. It's a tragic story - tragic for science, tragic for physicians, tragic for patients, and tragic for a culture that needs something of value that doesn't change. Thanks for making it explicit.

    Cetamua said...

    The so-called "best health care in the world" won't be so for long if this situation is allowed to persist, say, another decade.

    Anonymous said...

    Is it any wonder that lay people (patients) become increasingly skeptical (cynical) about the practitioners of this once-vaunted profession? Personally, each time I consider whether medical intervention may be necessary, I consider the non-existent "partnership" between doctor & patient, weigh it against the cha-ching factor, and then settle for searching the internet for alternative measures. Yeah, I know the perils of treating one's self; I also know the perils of prescription-pad physicians.


    Afraid said...

    These institutions are simply tools to increase the power and wealth of those that squirm their way to the top. They are above the law, fearless despots who by peter principal rise far enough to become "made men" by the leadership.

    The public knows the truth, but like in politics and big business, we seem to have no recourse. How does one boycott the dominant healthcare supplier in a market?

    I have spoken to a great many people who are actually afraid that if they speak out they will get poor healthcare when needed.

    Very telling, many believe those charged with helping us would actually hurt us to maintain their hold on power.

    The next chapter in research on this problem could expose this truth efficiently with some simple direct to consumer polling.

    Our politicians may see speaking for a fearful block of voters as very attractive.

    Anonymous said...

    Regarding the concept of physicians as MBA’s I can only think of a conversation with the Dean of my program at the end of my studies. He made it very clear that of my many failings I was not pretentious enough for this degree. I then, and continue to have, issues with authority. The Dean hired two instructors who had problems, not me.

    Recently I was met with a dismissive attitude by a member of the clergy who made it quite clear I did not recognize certain “talents” exhibited by another individual. We do not have problems, only opportunities for me to grow in my acceptance of others failings.

    The limits, and positive reinforcement I was taught during the 1970’s, has given way to a very selfish based management system where it is winner take all, and when that fails we have this wonderful passive/aggressive position to fall back upon of blaming the victim for not understanding.

    My reality is that the very institutions we looked to in past have become, in many ways, more corrupt than business in general due to trading on their previous position as ethics leaders. We expect the used car salesman to be shady, but the reality is regulations have made this a somewhat open industry. Everyone can look up car prices and histories.

    Education, and by extension, medicine, theology, and even business itself, has become the domain of small pretentious people who’s only interest is personal gain. The backlash to this situation cannot come soon enough.

    Steve Lucas

    Afraid said...

    Indeed Steve, the shroud of piety is an added defense for these types.

    Unknown said...

    Great post, Roy! I'm glad to see that medical journals like Nature Medicine are finally waking to the reality of medical schools as big business. As I revealed in Side Effects, this was especially true at Brown University School of Medicine, where medical officials valued rainmakers like Martin Keller more than they cared about ethical scientific conduct.

    Afraid said...

    Alison, How had Brown changed since being revealed for valuing rainmakers more than ethical scientific conduct?