Johns Hopkins: Thanks to EHRs, time with patients seems “squeezed out” of medical training, investigator says

Question:  Who would have thought it?  That there is yet another potentially deadly unintended consequence of bad health IT and health IT hyper-enthusiasm?

Suggested answer:  anyone who truly understands the issues at the intersection of medicine, information science, information technology, and Social Informatics - which probably excludes 95% of the health IT "experts", pundits and opportunists.

Which only goes to show how dense such people can be - as the medical trainees of today will be treating them, their families, and their children in the future:

Johns Hopkins Medicine

Release Date: 04/23/2013

Time with patients seems “squeezed out” of training, investigator says 

Medical interns spend just 12 percent of their time examining and talking with patients, and more than 40 percent of their time behind a computer, according to a new Johns Hopkins study that closely followed first-year residents at Baltimore’s two large academic medical centers. Indeed, the study found, interns spent nearly as much time walking (7 percent) as they did caring for patients at the bedside.

I can honestly say much if not most of my time in training, several decades ago, was spent at the bedside.

Compared with similar time-tracking studies done before 2003, when hospitals were first required to limit the number of consecutive working hours for trainees, the researchers found that interns since then spend significantly less time in direct contact with patients. Changes to the 2003 rules limited interns to no more than 30 consecutive hours on duty, and further restrictions in 2011 allow them to work only 16 hours in a row.

“One of the most important learning opportunities in residency is direct interaction with patients,” says Lauren Block, M.D., M.P.H., a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of General Internal Medicine. “Spending an average of eight minutes a day with each patient just doesn’t seem like enough time to me.”

An understatement, as most critical information comes from the H&P and ongoing patient interaction - not from cybernetics.  Further, that's probably all the time a butcher spends processing a slab of meat...

“Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training,” says Leonard Feldman, M.D., the study’s senior author and a hospitalist at The Johns Hopkins Hospital (JHH).

For the study, trained observers followed 29 internal medicine interns — doctors in their first year out of medical school — at JHH and the University of Maryland Medical Center for three weeks during January 2012, for a total of 873 hours. The observers used an iPod Touch app to mark down what the interns were doing at every minute of their shifts. If they were multi-tasking, the observers were told to count the activity most closely related to direct patient care.

The researchers found that interns spent 12 percent of their time talking with and examining patients; 64 percent on indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork; 15 percent on educational activities, such as medical rounds; and 9 percent on miscellaneous activities. 

Researching the history is made more complex by today's low-usability EHR systems, so much so that I personally know of cases (through my legal work) where trainees and even attendings did not know the patient's history.  In the past, this would have been considered a severe medical faux pas.

The researchers acknowledge that it’s unclear what proportion of time spent at the bedside is ideal, or whether the interns they studied in the first year of a three-year internal medicine training program make up the time lost with patients later in residency. But 12 percent, Feldman says, “seems shockingly low at face value. Interns spend almost four more times as long reviewing charts than directly engaging patients.”

Not to be critical of the Hopkins piece, it is excellent - but academics often use disclaimers and softeners in their conclusions as a custom and tradition.  At a blog I can be more direct:  12% is shockingly low.  No "seems" is actually necessary.

Feldman says questions raised by his study aren’t just about whether the patients are getting enough time with their doctors, but whether the time spent with patients is enough to give interns the experience they need to practice excellent medicine. 

Personally, I would really be nervous under the care of graduates who'd only spent a tenth of their clinical hours actually seeing, speaking to and examining patients, and a majority of their time frittering around with computers.

With fewer hours spent in the hospital, protocols need to be put in place to ensure that vital parts of training aren’t lost, the researchers say.

“As residency changes, we need to find ways to preserve the patient-doctor relationship,” Block says. “Getting to know patients better can improve diagnoses and care and reduce medical errors.” 

As opposed to getting to know the (needlessly complex and confusing) EHR better, which adds little.

The researchers say better electronic medical records may help reduce time spent combing through patient histories on the computer.

After several decades of the health IT industry being in business,  it's sad that an organization of the (deserved) stature of Johns Hopkins has to provide remedial education 101 to that industry in 2013.

Perhaps that's the most important finding of all in this study.

There's some wisdom in this comic strip.  Click to enlarge.

-- SS
 

BLOGSCAN - A Not So Tough Policy on Industry Interactions

On the Carlat Psychiatry Blog, Dr Daniel Carlat dissected Johns Hopkins' heralded new "tough" policy on interactions with industry. It turns out to be not so tough, banning only the smallest gifts, but failing to ban various kinds of larger payments that cause more intense conflicts of interest. Dr Carlat summarize the policy as mainly designed to generate "good PR."

Suing Poor Patients in Maryland

The Baltimore Sun published a series of articles reporting how some Maryland hospitals have been zealous in their pursuit of money from poor patients, in spite of a state program that is supposed to make sure hospitals are fairly reimbursed for the care of the poor. The series opened with this case:

Willie Mae White began worrying how she'd pay the $36,224 bill from Johns Hopkins Bayview Medical Center a few weeks after having emergency brain surgery. She lived off Social Security and food stamps after decades working as a housekeeper. So she was thrilled when Bayview informed her in writing that her bill would be forgiven, at least in part. The hospital had little to lose, since it can recover its costs of free and unpaid care under a unique state program. Instead, the hospital sued her 15 months later to collect the bill. Fearing she'd lose her Waverly rowhouse and too sick to defend herself in court, she agreed to pay $500 right away plus $50 a month. At that rate, it would have taken her 59 years to get out of debt.

'It wasn't fair. But what could I do? I said, 'Lord, it's in your hands,'' said White, 66, who remains too weak to work.

In the aggregate, the Sun's investigation found:

• Hospital debt collection lawsuits spiked sharply between 2003 and 2006 before falling slightly last year. In all, hospitals filed more than 132,000 of these suits in the past five years, winning at least $100 million in judgments.

• In some cases they added annual interest at twice the rate allowed for other types of debts. And despite national hospital industry guidelines that caution against routinely placing liens on houses, Maryland hospitals placed at least 8,000 liens in the past five years.

• Maryland, unlike some other states, lacks uniform standards and practices to determine who is eligible for free or reduced-price care at hospitals. Some people wind up facing lawsuits even though they have little means to pay their bills.

• State officials have never resolved critical gaps in the system. For instance, they don't monitor debt collection practices to ensure that patients are being treated fairly, and they cannot be sure hospitals aren't getting paid twice for some of the same bills. Hospitals deny they collect bills twice.

• A majority of Maryland's hospitals have received surpluses from free and unpaid care in recent years, even though the system is supposed to ensure that they merely break even over time, according to state figures.

The hospital and hospital systems vary in the their debt collection practices. Apparently the most aggressive debt collectors included the state's most prominent academic medical center:

Johns Hopkins Hospital, Maryland's largest hospital, and Johns Hopkins Bayview Medical Center have filed about 14,000 collections lawsuits between them over the past five years. In a written statement, the Hopkins system said it sues fewer than 1 percent of its patients and that it now sues less often than it did several years ago - although it acknowledged that it consistently refers about 20 percent of its patients to collection agencies. It said it sues only those patients who have the ability to pay.

Furthermore,

Johns Hopkins officials acknowledged in interviews that they generate surpluses from the system. Hopkins, Bayview and the University of Maryland Medical Center showed combined surpluses of at least $130 million in the past five years in the final numbers provided by the commission.

The second article in the series documented instances of other highly aggressive and legally dubious collection practices.

Some hospitals have won judgments against patients covered by Medicaid for bills the giant government health plans didn't pay, despite a Maryland law outlawing that, The Sun found in sampling more than 200 court files. Hundreds of patients have filed complaints with state regulators over billing issues, including allegations that hospitals tried to collect amounts beyond what they agreed to accept under insurance company contracts by going directly after patients.

And some hospitals have sued patients three or more years after their stays ended, raising questions about whether the statute of limitations had expired, The Sun found.

Hospitals routinely seek to add interest at the legal maximum of 12 percent a year on judgments, starting 60 days after the patient was discharged. That is legal under a Maryland law that applies to hospitals. But the practice is criticized as unnecessarily aggressive even by some other debt collection lawyers. The Maryland Constitution sets interest rates at 6 percent for most debts, but hospital debts are exempt.

In one case, a hospital sought to collect from a patient after her insurer supposedly refused coverage, but apparently she would have been covered if the hospital had filed the correct paperwork on time.

Tamara Byrd was driving home from her job at the city Department of Social Services on Sept. 9, 2003, when a teenage driver collided with her car, sending Byrd's car smashing into a house. She spent seven days in the trauma center at Sinai Hospital in Baltimore with rib fractures and internal bleeding.

'When I first came home, my parents literally had to tuck me into bed every night. My mother had to bathe me. She had to help me get dressed,' said Byrd, 40, who lives in Randallstown.

Byrd thought her bill was covered by her HMO. But more than two years later Sinai, through Thaler, sued her for $21,595. Byrd's case was on the docket on July 16, 2006. Thaler met her prior to the hearing to discuss a possible settlement.

She recalls encountering a traffic jam of sorts as lawyers for hospitals sought to find the people they were suing to set up conferences. 'It was like a total business,' said Byrd.

Byrd agreed to pay $100 a month after talking to Thaler. She complained to the judge that she didn't think it was fair to be stuck with the bill when she had insurance, but thought she had little choice but to settle. Judge Dorothy J. Wilson marked Byrd's case settled, remarking: 'Well, good luck to you, ma'am,' according to a transcript.

Two months later, Byrd found out that she never legally owed the bill to begin with.

A friend advised Byrd to file a complaint with the Maryland Insurance Administration, which ruled in September 2006 that Byrd was not liable for the charges.

Byrd's HMO had agreed to pay the charges once it was billed by Sinai. But the hospital failed to send the bill within six months as required by state law. Instead, it sued Byrd on Dec. 22, 2005, stating in court papers that she 'refuses to pay the sums due.'

The insurance administration ruled that the hospital acted improperly in suing her, adding that hospitals can't bill patients for covered services that their health plans decline to pay. Officials call these sorts of disputes 'balance billing.'

When asked about some of these practices, hospital leaders seem to put their bottom lines ahead of a mission to treat the poor with compassion. For example, from the first article in the series:

Hospital administrators said they need to pursue unpaid bills because all patients cover the costs of those bills under Maryland's rate-setting system. Hospitals also argue that they must balance their charitable missions against the need to be paid for services.

'The board of trustees expects us to have prudent business practices,' said Ronald R. Peterson, president of the Johns Hopkins Health System. 'We could have bad behavior from people who are in that category of deadbeats.'

(Note that Mr Petersen's total compensation was reported by the Sun to be in excess of $1.4 million a year in 2003.)

I can't comment on the legal issues raised in these articles. But the hospitals' alleged conduct contrasts with the idealistic way they present themselves.

For example, the Johns Hopkins Hospital and Health System evokes its tradition thus:

Mr. Hopkins wanted a hospital with the finest physicians and staff; a hospital which was a charity for the poor of Baltimore without regard to race, color or creed; a hospital which had amenities for those able to pay, so that charity to the poor could be sustained. He wanted a hospital to be a part of or a partner with the University medical school and faculty, with a training school for nurses. He envisioned a place of compassion and caring, high skill, research and education.

Similarly, the Sinai Hospital evokes its tradition thus:

Sinai Hospital was founded in 1866 as the Hebrew Hospital and Asylum and has evolved into a Jewish-sponsored health care organization providing care for all people. Sinai is a nonprofit institution with a mission of providing quality patient care, teaching and research

The attempts to collect from Ms White above do not seem to be a way to sustain charity to the poor. Not much charity infused the characterization of "deadbeats" by Hopkins CEO Peterson. Sinai may have taken care of Ms Byrd's immediate problem, but its collection attempt did not seem to indicate that it cared for Ms Byrd. Many prominent hospitals publicly proclaim their high-minded goals, but their management often seems hostile to their missions.

Questions About the Board of the New Reagan-Udall Foundation

On PharmaLot, Ed Silverman noted questions raised about the leadership of the new Reagan-Udall Foundation, which is supposed to help the US Food and Drug Administration (FDA) streamline drug and device development. The foundation's financing through the pharmaceutical industry had already raised one obvious set of questions.

New questions were raised by the just announced membership of the Foundation's board. Silverman focused on the presence of Dr Tadataka Yamada, billed as President, Global Health Program, Bill & Melinda Gates Foundation. Dr Yamada, however, was previously a GlaxoSmithKline executive, and had been accused of trying to intimidate one of the early critics of Avandia (rosiglitazone). (See our post here.)

I should also point out that another member of the board is Dr William Brody, billed as President of Johns Hopkins University. But Brody also is a director of Medtronic Inc, a large manufacturer of medical devices, and as such has a fiduciary responsibility for that company's finances and operations. Thus, he seems to represent device manufacturers, but I suspect was not appointed as such. Brody was also recently involved in the creation of a speech-code at his university which threatens punishment of any student who is "rude" or "disrespectful." (See our post here.)

Thus, the leadership of this new foundation seems more tilted towards industry than perhaps it ought to be. Furthermore, it is disturbing that it contains at least two individuals who have been identified with efforts to suppress expression that "our new ruling class" might not like.

Johns Hopkins Administration Attempts to Outlaw Rudeness

We have posted before about institutional threats to free expression at Johns Hopkins University, home to one of the most renowned medical schools and teaching hospitals in the US. The story continues, as per the Johns Hopkins Newsletter,

Members of the Student Council (StuCo) expressed frustration with some of the University's newest policies concerning equality and respect in the workplace -- including those endorsed by President William Brody himself -- in a meeting with members of the administration Tuesday night.

The council met with administrators to discuss alleged ambiguities of the Principles for Ensuring Equity, Civility and Respect policy endorsed by Brody and the Johns Hopkins Committee on the Status of Women.

In a letter sent in Dec. to Susan Boswell, dean of Student Life, the Student Council expressed their confusion with the policy.

'How ought a student act in order to abide by this code? A student feels pressured to avoid communicating any idea that could be considered offensive in any way to anyone at any time ... this is counterintuitive to the nature of a research university, which should be a source of free, independent thought,' Student Council said in its letter.

The new principles are the basis for future policies and plans in hopes of promoting equity, equality, civility, and respect at Hopkins and throughout Baltimore. A commission chaired by Vice President of Human Resources Charlene Hayes and Chairman of the Department of Medicine Myron Weisfeldt has been organized to implement these principles.

'It's difficult to develop specific guidelines on rudeness, but there is common sense. We have to choose what's rude, disrespectful, and civil. That's our starting place,' Hayes said.

'One main question is rudeness versus racism,' another council member said. 'Where's the line that you draw that equals harassment?'

Student Council's frustrations centered on five of the principles established by the policy [including, in particular]:

- rude, disrespectful behavior is unwelcome and will not be tolerated

- every member of the community will be held accountable for creating a welcoming workplace for all

FIRE (the Foundation for Individual Rights in Education), a watch-dog with increasingly big teeth on behalf of civil liberties in academia, has kept on top of this case. Giving a university administration the power to punish students for "rude, disrespectful behavior," and enforce the creation of a "welcoming" workplace is antithetical to an academic mission that requires free enquiry. After all, disagreeing with someone else's facts, theories or ideology could be considered "rude" or "disrespectful." Honest disagreement may be interpreted as not being "welcoming."

Thus, for an academic administration to propose such a code of conduct is yet another example of mission hostile management.

Parenthetically, one wonders whether academic administrators who may be affected by conflicts of interest are particularly prone to favor speech codes that might discourage anyone from questioning their financial ties. We previously posted about the Dr Brody, the President of Johns Hopkins University, who also as a director has fiduciary responsibility for Medtronic Inc, a large manufacturer of medical devices. We wonder whether any Hopkins student or faculty member would dare publicly question the President's apparent dual allegiance, for fear of being branded "rude," "disrespectful," and failing to create a "welcoming" environment.

Johns Hopkins President (and Medtronic Director) Claims Right to Punish Speech He Deems "Not Substantive and Serious"

Manifestation of concentration and abuse of power that we discuss frequently on Health Care Renewal are attempts to suppress free expression. These attempts are usually directed at expression that those in power find offensive. Two recent examples include: attempted suppression of clinical research that suggested an increased incidence of adverse effects due to the drug aprotonin (most recent post here), and the prolonged silencing of a whistle-blower who questioned the financial conduct of a hospital CEO (see most recent post here). (The CEO was later convicted of fraud.)

Some insight into the thinking of those who attempt to suppress free expression in health care may come from a recent case at Johns Hopkins University, parent university for one of the world's most renowned medical schools and academic medical centers. The recent controversy started when a JHU undergraduate student posted an invitation on the web to a campus party which included crude language. Some found the language offensive, if not racist. It was not surpising that the student received fierce condemnation. However, the university then charged him with “failing to respect the rights of others and to refrain from behavior that impairs the university’s purpose or its reputation in the community,” violating the “university’s anti-harassment policy,” “failure to comply with the directions of a university administrator,” “conduct or a pattern of conduct that harasses a person or a group,” and “intimidation.” His punishment was a year's suspension, and that he complete 300 hours of community service; read 12 books and write a reflection paper on each; and attend a workshop on diversity and race relations.

The University's actions were condemned by the FIRE (Foundation for Individual Rights in Education), which has stood up forcefully for free speech and academic freedom in US institutions of higher education. A FIRE spokesperson stated, “Hopkins’ unconscionable treatment of [the student] ... should shock anyone who values free speech,” Furthermore, “Johns Hopkins must not be allowed to promise free speech to its students and then deliver heavy-handed repression.”

However, JHU President Dr William R Brody attempted to justify the university's actions in an article in the Johns Hopkins Gazette. Although he condemned past attempts by the university to suppress speech "of a substantive and serious nature," he then argued:

But I think we all know that it stretches our credulity to assert that two crude and tasteless invitations to a fraternity party posted on an Internet Web site rise to this standard of seriousness of purpose or intent. What I see here is not a courageous trespass of taboo speech but rather a fundamental breach of civility of the sort that is so commonly displayed in disparagement, mockery or epithets drawn along racial or ethnic lines. It is, simply put, common name-calling. This is what I believe we should agree is unacceptable in our community of free and open discourse. Let us not forget that true civility is not a program of fair treatment for this or that constituency but rather an underlying and fundamental commitment to showing respect for everybody.

So Brody asserted that only "substantive and serious" speech is protected. And Brody reserved to himself the right to determine what speech is "substantive and serious." Brody's "community of free and open discourse" would not protect discourse which its leader deemed to be only "common name-calling," or a "fundamental breech of civility." Yet, claims that free speech is protected ring hollow when the only speech protected is that which the powers that be find acceptable.

The Torch, the blog sponsored by FIRE, provided this telling quote from FIRE's Guide to Free Speech on Campus:

[John Stuart] Mill addressed one of the major rationales for imposing constraints on free speech on campuses today, namely that speech should be 'temperate' and fair.' Mill observed that while people may claim they are not trying to ban others’ opinions but merely trying to banish 'intemperate discussion…invective, sarcasm, personality, and the like,' they never seek to punish this kind of speech unless it is used against 'the prevailing opinion.' Therefore, no one notices or objects when the advocates of the dominant opinion are rude or uncivil or cruel in their denunciations of their detractors. Why shouldn’t their opponents be equally free to show their disdain for the dominant opinion in the same way? Further, Mill warned, it always will be the ruling orthodoxy that gets to decide what is civil and what is not, and it will decide that to its own advantage.

Although the particulars of the current case at Johns Hopkins University seem far afield from the issues of concern to Health Care Renewal, Dr Brody did not limit the application of his argument to party invitations posted by undergraduates to the internet. His ability to punish any speech not deemed to be sufficiently "substantive and serious" should thus give pause to anyone at JHU who might publish clinical research that could offend vested interests, blow the whistle on health care quality issues, or question hospital or university administrators. Dr Brody's ability to punish such speech also seems to contradict the University's mission statement, which aims to "foster independent and original research, and to bring the benefits of discovery to the world."

Finally, I should note that Dr Brody's writings may also give insight into how little leaders of commercial health care organizations respect free speech, free expression, and academic freedom. Note that Dr Brody leads not only Johns Hopkins University, but also, as a Director, Medtronic Inc, "the global leader in medical technology." According to Medtronic's 2006 proxy filing, Dr Brody's yearly compensation as Director is $80,000 in cash, and $70,000 in stock options. Dr Brody currently owns more than 72,000 shares or the equivalent in the company's stock (worth more than $3,900,000 at the stock price of $54.28 /share today). Yet, I wonder if he would regard any questions about whether this part-time job, entailing fiduciary responsibility to a company which has "research and/or business relationships" with JHU, and which "periodically makes donations and/or grants" to JHU, constituted an important conflict of interest as not "substantive and serious," but mere "common name-calling?" I doubt anyone at JHU will try to find that out.

Hopkins Retreats from Cosmetics Venture

Recently, we posted about Johns Hopkins Medicine's unique collaboration with a cosmetics manufacturer.

After the relationship was publicized and criticized, the Baltimore Sun reported that Johns Hopkins quickly decided to revise it. Johns Hopkins will no longer receive stock or a seat on the board of directors of the cosmetics company. Hopkins asked that company marketers "withdraw all references to JHM (Johns Hopkins Medicine) except for certain limited information - on product packages and in previously printed promotional material - that disclose JHM's consulting role," although so far the Sephora web-site's page for Klinger Advanced Aesthetics Cosmedicine has not been modified (as of April 10, 2006).

Johns Hopkins has to get some credit for deciding to rapidly retreat from some of the most questionable parts of this relationship, which was criticized for being irrelevant, and possibly at odds with the institution's mission, and for posing a (possibly unique new form of) conflict of interest.

Johns Hopkins: The Most Trusted Name in ... Skin Care?

The Baltimore Sun and the Wall Street Journal reported (the latter available here via the Pittsburg Post-Gazette) the latest venture by the revered Johns Hopkins University. They are collaborating with a cosmetic company whose products will be labeled as produced "in consultation with Johns Hopkins Medicine."

The Cosmedicine "premium skin-care line," per the Journal, will be sold by Sephora, a unit of LVMH Moet Hennesy Louis Vuitton, and manufactured by Klinger Advanced Aesthetics, a unit of TrueYou.com Inc. According to Dr Edward Miller, Chief Executive of Johns Hopkins Medicine and Dean of the School of Medicine (and also on the board of directors of Bradmer Pharmaceuticals, a Canadian biotechnology company), "We have been pretty clear about our role. We are reporting on the scientific validity of studies done by outside testing agencies." But, according to the Journal, "Johns Hopkins will also work with Klinger to develop clinical 'best practices for the company's chain of spa-clinics." Their offerings include "'light medical' services, such as Botox and Restylane shots...."

The Cosmedicine web-page proclaims, "Cosmedicine, the only skincare line tested for performance and safety in clinical studies designed and analyzed in consultation with Johns Hopkins Medicine, a world leader in healthcare, education, and research."

The idea of the Johns Hopkins collaboration developed out of Klinger CEO Rich Rakowski's idea of developing products "through the lens of healthy skin and not anti-aging." The company "adopted what he calls a 'healing strategy' for its products." The company decided it wanted to offer products with "measurable" benefits, and then approached Johns Hopkins to help with the measurements. The Journal reported that Professor Frederick Brancati, Chief of the Division of General Internal Medicine, championed the collaboration, but had to work "to overcome significant faculty opposition."

Prof Brancati "and other officials declined to disclose the fees Johns Hopkins Medicine received from Klinger or to estimate how much revenue the venture may one day bring. Klinger, a unit of a publicly traded company, TrueYou.com, Inc., plans to give the institution a yet-to-be-determined equity stake." The Sun also reported that the University will get a "board seat."

According to the Journal, the motivation to work with Klinger was Hopkins' "need for funding the traditional research and teaching mission." Prof Brancati said, "that is what sold it for me and to the leaders of the institution. We have to be innovative and creative" The Sun reported that Brancati "hopes his division might get a six-figure sume from the deal to help fund its mission, which includes care for the poor."

The deal has drawn criticism now that it has been made public.

Product Endorsement (as a Mission Violation) - One issue is that Hopkins' role appears to be close to endorsement of a product. The Journal quoted Prof Arthur L Caplan of the University of Pennsylvania Department of Medical Ethics, "unless you have acute vision and a lot of time to read [the small print], this is going to look like a product endorsement." The Sun quoted Mildren Cho of Stanford Center for Biomedical Ethics, "what is the consumer supposed to take away from the fact that Hopkins' name is attached to this product?" The Sun also quoted Dr Amy Newburger, a practicing dermatologist, "this is a weapon of mass promotion. The university's name is going to be used to promote this [product] ... to the exclusion of other, perhaps more effective products that have not forged a relationship with the university." Unsaid here, but important is that the university appears to be endorsing a product in exchange for money, in apparent contrast with its academic mission to conduct free and honest inquiry. In contrast, the Sun quoted Rakowski, "they are not endorsing this product, nor have I asked them."

Conflict of Interest - Caplan also stated that it would be a conflict of interest to "study what you own." The Sun quoted Dr Marcia Angell, former editor of the New England Journal of Medicine, "you can't evaluate a product that's made by a manufacturer that's hired you. The thing is riddled with conflict of interest." Johns Hopkins Medical Dean Miller countered by saying that the Hopkins scientists who are examining Cosmedicine data do not personally own equity shares in the company that makes the product, although they do received consulting fees of an undisclosed size.

Irrelevance to Mission - Finally, the Sun quoted Dr Peter Lurie of Public Citizen Health Research Group charged, "it's an educational institution that's willing to completely stray from its true function, whic is to do education, research, and provide clinical services."

In my humble opinion, the criticisms are apt. It particularly saddens me that a division of general medicine within a wealthy university, whose budget is $2.4 billion, endowment, $1.695 billion, and hospital and health system revenue, $1.661 billion apparently feels so impoverished that it needs to help sell cosmetics to raise money to support its basic academic mission.