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The Lancet Emphasizes the Threats to the Academic Medical Mission

We just <a href="http://hcrenewal.blogspot.com/2010/12/health-professionals-for-new-century.html">discussed</a> an important article in the Lancet calling for major global reforms of health care education.(1)  An accompanying editorial(2) argued for the critical importance of upholding the mission of higher education, because that mission is critical to human civilization: <blockquote>Louis Menand has investigated the current role of the modern university in his startlingly powerful book, The Marketplace of Ideas. Menand argues that: 'The pursuit, production, dissemination, application, and preservation of knowledge are the central activities of a civilisation.' More importantly still, 'the ability to create knowledge and put it to use is the adaptive characteristic of humans'. The goal of the university is 'to make more enlightened contributions to the common good'.</blockquote> The editorial argued strongly for the revitalization of the university's mission: <blockquote>'It is the academic's job in a free society to serve the public culture by asking questions the public doesn't want to ask, investigating subjects it cannot or will not investigate, and accommodating voices it fails or refuses to accommodate.' The education of doctors, nurses, and public health workers must seek to: strengthen the overall intellectual culture of a society; define principles for public aspiration; give life to and enlarge the best and most proven ideas of the age; refine the grounds for the private exchanges that take place in our lives; facilitate the exercise of political power; and enable professionals to detect what is important and discard what is irrelevant, accommodate oneself with others, have common ground between colleagues across societies, ask good questions and find the means to answer them, and have the resources to adapt to national and global circumstances. Some readers might recognise that these words are adapted from John Henry Newman's On the Scope and Nature of University Education. In England, Newman argued for the university as a centre of intellectual liberty, a vital force for progress in society. Menand writes about the university as a 'zone of autonomy'. The importance of tertiary education as a means to advance health, reason, democracy, and justice needs to be rediscovered.</blockquote> But arguing so forcefully for upholding the academic mission makes sense only if that mission is under threat. The Lancet editorial only briefly alluded to why this might be: <blockquote>What this Commission argues for is nothing less than a remoralisation of health professionals' education. For decades, health professionals have colluded with centres of power (governmental, commercial, institutional, even professional) to preserve their influence. The result? A contraction of ambition and a failure of moral leadership. </blockquote> While the original article by Frenk et al suggested that health professionals' education has shortcomings, it did not argue that the academic mission is threatened.  Although the message of the accompanying editorial is that the mission needs a strong defense, it did not clearly explain the extent of the threat to it.  However, this blog, <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>, 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).  We have discussed the nature of the threats in detail.  For example, <ul><li>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  <a href="http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html">here</a> and <a href="http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.html">here</a>.</li><li>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 (<a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">here</a>), confirming previous anecdotal reports (see <a href="http://hcrenewal.blogspot.com/2007/04/medical-schools-to-faculty-show-me.html">here</a>).  </li><li>The medical school re-imagined as a biotechnology company -  In 2000, a Vice President of the American Association of Medical Colleges(3) 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 <a href="http://hcrenewal.blogspot.com/2010/11/who-you-gonna-call-how-should-young.html">here</a>.</li><li>Faculty become employees of industry - For numerous examples of this and other kinds of conflicts of interest, go <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">here</a>.  A survey by Campbell et al suggested that approximately two-thirds of medical academics get significant payments from industry.(4)</li><li>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 <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">here</a>.  </li><li>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.(5)  See post <a href="http://hcrenewal.blogspot.com/2005/05/troubling-study-of-contracts-between.html">here</a>. </li><li>Conflicts of interest allow manipulation and suppression of clinical research - Commercially sponsored research design, implementation, and dissemination are often <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulated</a> to favor the sponsor's interests.  When such manipulation fails to produce favorable results, the results may simply be <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppressed</a>.</li><li>Academics take credit for articles written by commercially paid ghost-writers - Such <a href="http://hcrenewal.blogspot.com/search/label/ghost%20writing">ghost-writing</a> is often part of organized <a href="http://hcrenewal.blogspot.com/search/label/stealth%20marketing">stealth marketing</a> campaigns.  </li><li>Whistle blowers are discouraged, or worse, and academic freedom is damaged.  Discussion of some examples of what may happen to whistle blowers is <a href="http://hcrenewal.blogspot.com/search/label/whistle-blowers">here</a>.  The survey mentioned earlier (<a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">here</a>) showed that about one-third of faculty fear they may be punished for speaking  out.  </li><li>Leadership of academic medical centers by businesspeople - <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">Ill-informed management</a> may result from leaders who have no background or training in actual health care.  </li><li>Leaders of teaching hospitals and universities become millionaires -  A recent example is <a href="http://hcrenewal.blogspot.com/2010/08/more-hospital-ceos-join-millionaires.html">here</a>, and more may be found <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">here</a>.  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.  </li><li>Medical school leaders become stewards (as members of boards of directors) of for-profit health care corporations - A recent example is <a href="http://hcrenewal.blogspot.com/2010/12/duke-divinity-students-protest-pay-of.html">here</a>, and a summary of how we discovered this phenomenon in 2006 is <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">here</a>.   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 <a href="http://hcrenewal.blogspot.com/2010/07/new-york-times-reports-university.html">here</a> and <a href="http://hcrenewal.blogspot.com/2010/01/one-small-step-towards-reducing.html">here</a>).</li><li>Leaders of failed finance firms become stewards of academic medicine - We have found numerous examples, recently <a href="http://hcrenewal.blogspot.com/2010/04/failed-leaders-of-citigroup-as-leaders.html">here</a>, <a href="http://hcrenewal.blogspot.com/2010/04/wamu-worry-more-overlaps-between.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2010/03/members-of-board-of-now-bankrupt-lehman.html">here</a>, 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.  </li></ul>So the threats are real and substantial.  However, their scope generally generally gets little attention.  Even when specific threats appear in the academic literature, their importance may be soft-pedaled, and their confluence with other threats ignored.  Of course, trying to discuss the full breadth and depth of these threats, as we endeavor to do on this blog, threatens in turn those who have personally profited from the current system.  Hence, we frequently cite the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>, the phenomenon that important threats to health care's core values are often just not discussed in polite company. Therefore, we applauded the article by Frenk et al for concatenating some of the most important challenges to health care professionals' education, and we now applaud the Lancet editorial for emphasizing the threat to the academic medical mission.  We hope that these two articles, appearing in one of the most prestigious and well-read medical journals, will help to combat the anechoic effect.  Meanwhile, we will continue to blog about threats to core values in the hope that discussing them will lead to solutions. References 1.  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 <a href="http://www.rockefellerfoundation.org/uploads/files/cc71deb1-1dd6-4a97-a4e3-678f520a0bc6-lancet.pdf">here</a>. 2.  Horton R. A new epoch for health professionals' education.  Lancet 2010; 376: 1875-7.  Link <a href="http://www.lancet.com/journals/lancet/article/PIIS0140-6736%2810%2962008-9/fulltext">here</a>. 3. Korn D. Conflicts of interest in biomedical research. JAMA 2000; 284: 2234-2237. Link <a href="http://jama.ama-assn.org/cgi/content/full/284/17/2234">here</a>. 4. Campbell EG, Gruen RL, Mountford J et al. A national survey of physician–industry relationships. N Engl J Med 2007; 356:1742-1750. Llink <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa064508">here</a>. 5. Mello MM, Clarridge BR, Studdert DM. Academic medical centers' standards for clinical-trial agreements with industry. N Engl J Med 2005; 352: 21.  Link <a href="http://content.nejm.org/cgi/content/short/352/21/2202">here</a>.

The Lancet Emphasizes the Threats to the Academic Medical Mission

We just discussed an important article in the Lancet calling for major global reforms of health care education.(1) An accompanying editori...

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"Health Professionals for a New Century": Calling for "Ethical Conduct," a "New Professionalism," and Improved "Stewardship" and "Social Accountability"

A major article just published in the Lancet urged global reform of health care education  [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 <a href="http://www.rockefellerfoundation.org/uploads/files/cc71deb1-1dd6-4a97-a4e3-678f520a0bc6-lancet.pdf">here</a>.] The problems it recognized included <ul><li>"Pitifully modest" spending for health professional education, compared to overall health spending</li><li>Health care systems that are "dysfunctional and inequitable," due in part to "commercialism in the professions," leading to "breakdown ... especially noteworthy within primary care, in both poor and rich countries."</li><li>For profit medical education leading to "a so-called de-Flexnerisation process ... in which low-quality professional schools might be proliferating...."</li><li>Health care corruption, e.g., "the Indian press has reported illegal payments by new private schools seeking accreditation...."</li></ul>The solutions it advocated included - Fostering "ethical conduct" by professionals, developing a "new professionalism," earning trust "steered by ethical commitment and social accountability." - Improving "stewardship mechanisms, including socially accountable accreditation" It is nice to be in such good company.  While the report was written in the subtle, diplomatic language of international public health, it was the only such authoritative report to appear in a widely circulated, highly respected medical journal that I can recall that was this direct about the seriousness of such problems. In fact, not only is little spent on actual medical education within academic medical institutions, but faculty members are <a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">valued more for the money</a> they bring in than for their teaching.  Commercialism in health care has been institutionalized in the last 30 years (for discussion of its history in the US, look <a href="http://hcrenewal.blogspot.com/2007/12/relman-in-jama-on-threats-to-physicians.html">here</a>, <a href="http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2010/08/how-fallacy-of-perfect-health-care.html">here</a>.)  The <a href="http://www.transparency.org/publications/gcr/gcr_2006">Transparency International Global Corruption Report of 2006</a> asserted "the scale of corruption is vast in both rich and poor countries," yet has gotten almost no notice in medical, health care research, and health care policy circles.  In 2009, the US Institute of Medicine published a detailed report including fairly strong recommendations on <a href="http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx">Conflict of Interest in Research, Education and Practice</a>.  The <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a>, however, has dictated that discussion of striking examples of <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">mission-hostile management</a>, <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a>, and outright <a href="http://hcrenewal.blogspot.com/search/label/crime">crime</a> and corruption is simply not done, especially in medical, health care, or health policy venues and journals.  The 2006 TI and 2009 IOM reports have infrequently been cited, and their recommendations have widely been ignored. I do hope that the appearance of a publication as authoritative as the article by Frenk et al leads to some soul-searching by the leaders of health care around the world.  They need to realize that despite the article's measured tones, the problems really are severe, and even more broad than the article implied.  We have discussed in detail how health care education (and all of health care) are hurt by concentration and abuse of power, by governance that lacks accountability, integrity, and transparency; by leadership that ignores the <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">context</a>, <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">core values and mission</a>, promotes self-interest and <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a>, and sneers at ethics; and by results such as <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppressed</a> and <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulated</a> research, deceptive and dishonest education (look <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">here</a>, <a href="http://hcrenewal.blogspot.com/search/label/medical%20education%20and%20communication%20companies">here</a>, and <a href="http://hcrenewal.blogspot.com/search/label/stealth%20marketing">here </a>for examples), stifling of <a href="http://hcrenewal.blogspot.com/search/label/academic%20freedom">academic freedom</a> and <a href="http://hcrenewal.blogspot.com/search/label/whistle-blowers">whistle-blowers</a>, then dissatisfied, burned out faculty (<a href="http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html">here</a>), and finally the final common pathway of rising costs, declining access, and poor quality.   It is heartening that the importance of our concerns has been corroborated in such a notable venue.  I hope this report gathers less dust than the 2006 Transparency International Global Corruption Report and the 2009 Institute of Medicine conflict of interest report. I suggest that to truly reform health care education (and health care itself), we will have to attend to the sorts of problems we write about on Health Care Renewal.  On one hand, we will need to improve the stewardship, governance, and leadership of health care education itself, and reduce the pervasive conflicts of interest that ensnare the faculty.  On the other, we will need to make sure education prepares students to deal with these problems in health care at large. It would be nice if the appearance of the Lancet article signifies that help will soon be at hand to tackle the huge amount of work that needs to be done, in the face of likely withering opposition from those who have enriched themselves from the dysfunctionality of the current system.  We at Health Care Renewal will continue to try to draw attention to these issues, accompanied I am sure by our fellow bloggers (as are listed in the right hand column).  However, a small group of voluntary "citizen journalists," and health care professional curmudgeons cannot solve this problem on our own. I hope we will soon have some more support. ADDENDUM (14 December, 2010) - See also comments by Paul Levy <a href="http://runningahospital.blogspot.com/2010/12/will-this-cause-change.html">on the Running a Hospital blog</a>.

"Health Professionals for a New Century": Calling for "Ethical Conduct," a "New Professionalism," and Improved "Stewardship" and "Social Accountability"

A major article just published in the Lancet urged global reform of health care education [Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Ev...

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NIST Provides Healthcare IT Industry with Remedial Undergraduate Computer Science Education

The National Institute of Standards & Technology (<a href="http://www.nist.gov/index.html">NIST</a>) has published a guide entitled: <blockquote style="font-weight: bold;">NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records</blockquote> It is available free at this link in PDF: <a href="http://www.nist.gov/itl/hit/upload/Guide_Final_Publication_Version.pdf">http://www.nist.gov/itl/hit/upload/Guide_Final_Publication_Version.pdf</a> (hat tip to an AMIA colleague for posting the URL on an AMIA mailing list.) The NIST was commissioned by HHS/ONC to study Health IT issues such as usability and report on them. I find the publication both welcome, and pitiable. As I started to read ch. 6, for example, I observed material that is suitable for undergraduate computer science instruction: <blockquote>6. User-Centered Design Process in EHRs User-centered design is a bedrock principle for creating usable systems and devices. [You don't say? - ed.] One of the most common reasons why systems are poorly designed is that designers and developers fail to engage users in appropriate ways at appropriate times. [Hear that, my young Paduan learners? - ed.] At its core UCD is a process that relies on systematic understanding of users and their environments, and iterative design and testing based on user performance objectives. (Details on usability testing are provided in Section 9.) UCD has been shown to be effective in many fields. In aviation, for example, this method has been used to develop cockpit navigation displays for low-visibility surface operations. [22] By taking the limitations and capabilities of the flight crew into account, navigation errors have decreased by almost 100%. The adoption of UCD has also been shown to be effective in the design of personal computers. When working on a redesign of the laptop computer, a UCD process was employed. Users were asked to offer feedback about the current model and to offer input about ways to improve the current design. User-centered design was successful in increasing market share, brand equity, and customer satisfaction. [23] In fact, user-centered design has been elevated to an ISO standard. [24] UCD serves to engineer improved human performance into a system or device, and has been crystallizing for several decades as a design philosophy. [25] While there is no singular model of UCD, the instantiations embody the following principles: <ul><li>Understand user needs, workflows and work environments </li><li>Engage users early and often </li><li>Set user performance objectives </li><li>Design the user interface from known human behavior principles and familiar user interface models </li><li>Conduct usability tests to measure how well the interface meets user needs </li><li>Adapt the design and iteratively test with users until performance objectives are met</li></ul> [HHS needs ONC to commission NIST to provide schooling for the HIT industry on these bons mots? - ed.] As an iterative process, UCD is a cycle that serves to continually improve the application. For each iteration, critical points and issues are uncovered which can be improved upon and implemented in subsequent releases. An illustration of the UCD process is included in Figure 1. </blockquote> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCeXmQLDNiFN1s7bUKPqNFj5u1GzQAZ6RYgY1NfPbVuaMGwbmztiy9F5gOglSBjvDyRxSrxayi9qjTKlcSN6DBbduiG6xqvkWdr7-YYmJsnARUeRRv_mWSUr-nyrEFh7KbxGNwpxtwGR31/s1600/nist1_2.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5550153043886569762" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCeXmQLDNiFN1s7bUKPqNFj5u1GzQAZ6RYgY1NfPbVuaMGwbmztiy9F5gOglSBjvDyRxSrxayi9qjTKlcSN6DBbduiG6xqvkWdr7-YYmJsnARUeRRv_mWSUr-nyrEFh7KbxGNwpxtwGR31/s320/nist1_2.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 393px; height: 238px;" /></a>"User centered design process in EHR's." Undergraduate-level computer science 101 instruction from NIST for the healthcare IT industry? (click to enlarge) </div> Here is Figure 1: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC8bx_fX9IurOfiaLaeDNBmGmhodqgK4AKhRJd0zkuVgGR5n8EFoFq6GjzuGPwGPPNzZSb1DUrJdWHwMk8Oxy_ZDQPochzM883p5B-e5YYLwaNxXDUr_STJfzIffVH7zJVDrUgHOTlXzQU/s1600/nist3.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5550153139649700610" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC8bx_fX9IurOfiaLaeDNBmGmhodqgK4AKhRJd0zkuVgGR5n8EFoFq6GjzuGPwGPPNzZSb1DUrJdWHwMk8Oxy_ZDQPochzM883p5B-e5YYLwaNxXDUr_STJfzIffVH7zJVDrUgHOTlXzQU/s320/nist3.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 216px; height: 265px;" /></a>User centered design 101 (click to enlarge) </div> I might even have used this in teaching high school students about computer programming. Readers can download the entire report at the above URL. I find this publication, or, rather, the need for it to exist at all in 2010, remarkable. Absurd and an embarrassment, in fact. Master of the Obvious [1] material that apparently was not so obvious to this industry. This is after all a multi-billion dollar industry making claims its products will "revolutionize medicine" and other exceptional claims (but without exceptional evidence). These claims have been pushed so hard that many tens of billions of dollars (with penalties) have been earmarked to either entice -- or coerce -- physicians and hospitals to use these products. What has this industry, including vendors and highly paid management consultants and contractors, been doing, exactly, for the past thirty+ years? What have been their product design and development practices, such that leaders of their own trade group HIMSS (as I pointed out in other posts) opine we should be "patient" for them to figure it all out about how to do health IT better and they need more time, and that the technology does not support its users properly due to lack of efficiency and usability of EMRs currently available? (As at my July 2010 post "<a href="http://hcrenewal.blogspot.com/2010/07/national-program-for-health-it-in-us.html">The National Program for Healthcare IT in the U.S., and the Elephant in the Living Room</a>".) That HHS needs NIST to provide undergraduate level remedial teaching to the multibillion dollar health IT industry is a very poignant commentary indeed on the priorities of that industry regarding engineering rigor, talent management, attention to safety, and other factors affecting human lives. These observations speak strongly to the need for regulation for this industry, for a talent management and trade association shakeup of major proportions, and most especially for an awakening of our government servants to exactly what the real situation is with respect to HIT on the ground. 12/14/10 addendum: it struck me that the Guide might need another chapter. I suggest a chapter entitled: <blockquote>"Listening to informatics experts when they say your product will kill people, instead of <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=lawsuit">firing them</a>."</blockquote> -- SS [1] This was another pithy line from my early medical mentor, pioneering cardiothoracic surgeon Victor Satinsky, MD at Hahnemann Medical College.

NIST Provides Healthcare IT Industry with Remedial Undergraduate Computer Science Education

The National Institute of Standards & Technology ( NIST ) has published a guide entitled: NIST Guide to the Processes Approach for Impro...

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On the Interconnectedness of the Leadership of Health Care Organizations: the Abbott Laboratories Case

We just <a href="http://hcrenewal.blogspot.com/2010/12/abbott-laboratories-and-pig-roasts.html">posted</a> about some misbehavior by Abbott Laboratories: a physician Abbott paid as a "key opinion leader" to help market its cardiac stents was accused of inserting stents in many patients who had no need for them; Abbott settled for over $400 million a lawsuit alleging the company defrauded Medicare and Medicaid; and it settled an unrelated suit for over $40 million alleging the company paid kickbacks to physicians for prescribing its drugs.  I thus thought it would be interesting to see how well paid are the corporate leaders who presided over these activities, and who are the board members who were supposed to be providing stewardship of this company. According to the company's <a href="http://www.abbottinvestor.com/phoenix.zhtml?c=94004&p=irol-sec">2010 proxy statement</a>, the five highest-paid executives were: Miles D White, Chairman of the Board and CEO - $26,213,966 total compensation Thomans C Freyman, Executive Vice President, Finance, and CFO - $9,561,227 Olivier Bohuon, Executive Vice President, Abbott Pharmaceutica Group - $5,232,589 Laura J Schumacher, Executive Vice President, General Counsel, and Secretary - $5,724,060 James V Mazzo, Senior Vice President, Abbott Medical Optics - $10,394,085 Now, let us turn to the company's board of directors.  Note that I looked for board members who also held leadership positions in other health care organizations whose interests may not be aligned with the corporation.  I also looked for those who held leadership positions in the discredited financial services corporation who helped usher in the global financial collapse.  (I  used similar methodolgy <a href="http://hcrenewal.blogspot.com/2010/12/boards-who-ought-to-be-accountable-for.html">here</a>.) Abbott currently has 12 board members, including <ul><li>Robert J Alpert MD - Ensign Professor of Medicine, Professor of Internal Medicine, and Dean of the Yale School of Medicine.  He also "serves as a Director on the Board of Yale-New Haven Hospital."</li><li>Roxanne S Austin - President and Chief Executive Officer, Move Networks Inc, and President, Austin Investment Advisors</li><li>William M Daley -"Vice Chairman and Head of the Office of Corporate Responsibility and Chairman of the Midwest, JP Morgan Chase & Co."  He is the board of directors of  "Loyola University of Chicago and Northwestern University."</li><li>W James Farrell - Retired Chairman and Chief Executive Officer of Illinois Tool Works Inc</li><li>H Laurence Fuller - Retired Co-Chairman of BP Amoco, former chief executive officer of Amoco</li><li>William A Osborne - Retired Chairman and Chief Executive Officer of Northern Trust Corporation and the Northern Trust Company.  He is "Chairman of the Board of Trustees of Northwestern University."</li><li>Rt Honorable Lord Owen - Chairman of Europe Steel Ltd</li><li>Roy S Roberts - Managing Director, Reliant Equity Investors.</li><li>Samuel C Scott III - Retired Chairman,  President and Chief Executive Officer of Corn Products International.  He "currently serves on the board of directors of Bank of New York Mellon Corporation."  He also is on the board of "Northwestern Healthcare."</li><li>William D Smithburg - Retired Chairman, President and Chief Executive Officer of Quaker Oats Company.  He is on the "board of trustees of Northwestern University."</li><li>Glenn F Tilton - Chairman, President and Chief Executive Officer of UAL Corporation and United Airlines Inc.  He is on the "board of directors of Northwestern Memorial Hospital."</li><li>Miles D White - Chairman of the Board and Chief Executive Officer, Abbott Laboratories, "is on the board of trustees of "Northwestern University."  </li></ul> Of Abbott's 12 directors, seven have leadership positions at teaching hospitals, academic medical centers, medical schools or their parent universities (Northwestern University, its medical school and teaching hospitals, in particular, are stewarded by six Abbott directors).  Two have leadership positions in  financial services corporations that were implicated in the global financial collapse.  (Note that JP Morgan Chase staffers helped to invent some of the kinds of financial derivatives widely viewed as causative of the collapse, but the firm itself did not fail. [See Tett G. <a href="http://books.simonandschuster.com/Fool%27s-Gold/Gillian-Tett/9781439100134">Fool's Gold</a>.]  Through TARP, the US government took preferred equity stakes in both JP Morgan Chase and Bank of New York Mellon.  [See Ritholtz B.  <a href="http://bailoutnation.net/">Bailout Nation</a>. p. 222])  Two more are leaders of financial services firms.  All but one are current or former high-level hired executives (seven are or were CEOs), or chairpersons or co-chair persons of corporations (the one exception is a dean of a medical school.)  Note how similar our findings were here to those found after our perusal of the boards of Genzyme and Medtronic (see post <a href="http://hcrenewal.blogspot.com/2010/12/boards-who-ought-to-be-accountable-for.html">here</a>).   So we find again that executives of health care organizations who preside over various questionable activities not only rarely pay any penalty, but usually become extremely wealthy in the process. We also find how interconnected is the leadership of health care.  The boards and leadership of drug and device companies overlap with the boards and leadership of medical schools, teaching hospitals, and their parent universities.  Yet, as we have noted before, there are obvious conflicts.  In particular, teaching hospitals and medical schools are supposed to provide unbiased teaching, including about issues relevant to drug and device corporations, such as choice of diagnostic strategies and treatments, and relevant health policy.  They are supposed to perform unbiased research, including research that evaluates drugs and devices.  They are supposed to provide the best possible patient care at a reasonable cost, which relates to choices of and prices paid for drugs and devices.  On the other hand, drug and device companies are supposed to put making a profit for their share-holders first.  The directors of such companies, like the directors of all for-profit corporations, are supposed to show an unyielding loyalty to their companies' financial health and profits, although contemporary corporate directors have been accused of acting more like cronies of the hired management.  (See this <a href="http://hcrenewal.blogspot.com/2010/01/one-small-step-towards-reducing.html">post</a>.) Also, we note that the vast majority of people chosen as stewards of a given health care organization are current or former top hired executives of other corporations.  The board members, that is, stewards of health care organizations, to whom the top hired executives reports, are usually not people with large ownership interests in the organizations (in the case of public, for-profit corporations.)  For the most part, they also do not seem to be people with clearly demonstrated devotion to the values of health care, in particular, putting the care of individual patients first, and advancing health care teaching and research.  Instead, they seem to be people with the perspective of hired executives, who may be prone to putting the interests of hired executives, rather than patients, doctors, teachers, scientists or the public at large, first. So here is another admittedly limited case study of the board of directors, that is, the ostensible stewards of a health care corporation, selected this time because of its history of ethical missteps, which showed  - that the leadership of health care organizations is incredibly interrelated, interlocked, incestuous.  Again, it appears that top leaders of various health care organizations may be more familiar with and identify more with each other, and with other hired executives and managers, than with their organizations, their organizations' missions, and their organizations' professionals, staff, students, clients, and patients. So to repeat- I strongly believe that there needs to be much more investigation, academic, journalistic, and perhaps legal, of the identity, nature, and culture of the leaders of health care, and their relationships. A few bloggers cannot do it all. Obviously, the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">anechoic effect</a> mitigates against medical and health care academics looking into their own leaders. However, failing to understand who is leading our march to the brink of health care failure ought not to be something such academics would want on their conscience. Finally, and obviously, health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

On the Interconnectedness of the Leadership of Health Care Organizations: the Abbott Laboratories Case

We just posted about some misbehavior by Abbott Laboratories: a physician Abbott paid as a "key opinion leader" to help market it...

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Don't Worry, the Feds Say Your Medical Information Will Be Kept Absolutely Private

With the planned burgeoning of health IT nationally and the formation of information "exchanges", ensuring information privacy, confidentiality and security become paramount. Systematic threats to medical privacy, confidentiality and security could do significant damage to our Republic. Yet, according to Modernhealthcare.com in "<a href="http://www.modernhealthcare.com/article/20101207/BLOGS02/312079999">Looking to loosen privacy rules in Calif</a>." (Dec. 7, 2010): <blockquote>The head of a federal privacy and security advisory committee and a lawyer for a prominent consumer affairs organization are scheduled to press California officials this week to revise that state's health information exchange (HIE) guidelines [which have strong opt-in consent requirements -ed.] to conform to less-stringent federal privacy recommendations. </blockquote> Joseph Conn, author of the article relates: <blockquote>Deven McGraw, director of the Health Privacy Project at the Center for Democracy & Technology, a Washington think tank, and Mark Savage, a San Francisco-based lawyer for Consumers Union [McGraw is also an appointee to a prominent role in the federally charted HHS Health IT Policy Committee; see below - ed.], are to participate via telephone Thursday in a meeting of the California Privacy and Security Advisory Board [CalPSAB]. </blockquote> Here's the problem: <blockquote>The CalPSAB advises the state's health secretary on healthcare privacy and security policy. Given the traditional leadership role that California plays in the healthcare industry, the board's recommendations could influence how patient consent is handled in electronic health information exchanges nationwide.</blockquote> Why these recommendations? To satisfy the needs of the reckless rush to national health IT: <blockquote>McGraw, a lawyer, is a member of the federally charted Health IT Policy Committee, created pursuant to the American Recovery and Reinvestment Act of 2009 to advise the Office of the National Coordinator for Health Information Technology at HHS. McGraw also serves on five work groups or subcommittees of the Health IT Policy Committee. She is chairwoman of its privacy and security workgroup and co-chairwoman of its privacy and security tiger team. [The name "tiger team" makes me wonder who's going to get mauled - ed.] McGraw and Savage sent a letter Oct. 6 to California Health and Human Services Sec. S. Kimberly Belshe along with a copy of the tiger team's recommendations on privacy and security for health information exchange originally sent to ONC head David Blumenthal on Aug. 19. They also sent Belshe a 10-page "briefing paper" summarizing those recommendations and a follow-up letter Dec. 5. The briefing paper urged California to "adopt a comprehensive framework of privacy protections such as that recommended by the tiger team." [I.e., that are less stringent than California's - ed.] </blockquote> They threw a little fear into their recommendations: <blockquote> The brief also warned that with the first stage of a federal IT incentive program beginning soon, without a consent policy in place, "California's privacy and security framework for patient health information cannot be completed." Furthermore, if that framework isn't completed, the brief asserted, "eligible providers cannot achieve the meaningful-use criteria and benefit from the substantial federal reimbursements."</blockquote> In other words, "The feds have rushed you to such a point that you cannot possibly have enough time to seriously consider and put into place rigorous privacy regulation, so adopt our 'tiger team' recommendations (or you ain't gonna get money from the feds)." This is not reassuring. Among other issues, it seems another example, as in HITECH itself, of the Federal Government setting timelines and policies and using the "fear, uncertainty and doubt" (FUD) principle to manipulate and strong-arm the States into ceding their rights to regulate healthcare. Such Federal overreach seems to be common these days. Only now, due to the nature of the data involved, this gets personal. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0jr2W-IRwa8PGIXFL9VT9RE0kkM_j0pzj1J9Bl2suoolWzMQhysFIuD3UdevwPob5muw-9m07-FKx146ssviAOaokIwkV9Uq42UDeLyQ0HNkSdyD06lfNwEGX0-Q3B7r8w4cl9LNMTWSi/s1600/tony-the-tiger.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5549066445644747170" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0jr2W-IRwa8PGIXFL9VT9RE0kkM_j0pzj1J9Bl2suoolWzMQhysFIuD3UdevwPob5muw-9m07-FKx146ssviAOaokIwkV9Uq42UDeLyQ0HNkSdyD06lfNwEGX0-Q3B7r8w4cl9LNMTWSi/s320/tony-the-tiger.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 188px; height: 164px;" /></a>Listen to us, we're the Tiger Team! </div> Of course, there's always plausible deniability: <blockquote>Officially, the ONC is not a party to the push by McGraw and Savage to leverage the federal tiger team's work in California, according to the ONC. Asked whether the ONC was aware of and supports the efforts of McGraw in California, spokeswoman Nancy Szemraj said, "We have no knowledge of this letter."</blockquote> Again, not very reassuring or credible, considering: 1) as above, that McGraw and Savage sent a letter Oct. 6 to California Health and Human Services Sec. S. Kimberly Belshe along with a copy of the tiger team's recommendations on privacy and security for health information exchange originally sent to ONC head David Blumenthal on Aug. 19. and: 2) McGraw's role on five work groups or subcommittees of the Health IT Policy Committee: <blockquote><a href="http://healthit.hhs.gov/portal/server.pt?open=512&objID=1269&parentname=CommunityPage&parentid=5&mode=2">Health IT Policy Committee</a> (A Federal Advisory Committee) The Health IT Policy Committee will make <a href="http://healthit.hhs.gov/portal/server.pt?open=512&objID=1815&parentname=CommunityPage&parentid=7&mode=2&in_hi_userid=11113&cached=true">recommendations</a> to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information. The American Recovery and Reinvestment Act of 2009 (ARRA) provides that the Health IT Policy Committee shall at least make recommendations on standards, implementation specifications, and certifications criteria in eight specific areas. </blockquote>-- SS Addendum Dec. 10, 2010: This post generated a comment containing a significant logical fallacy, apparently from <a href="http://www.cdt.org/personnel/harley-geiger">Harley Geiger</a>, staff counsel of the CDT (Center for Democracy and Technology) which is one of the key actors mentioned in the Modern Healthcare story. The comment and my comment back can be seen in the comments section at this post. If the comment was truly from Mr. Geiger, I would be even less confident than before that an organization whose staff counsel will not or cannot proffer a logically coherent argument will protect our precious freedoms. -- SS

Don't Worry, the Feds Say Your Medical Information Will Be Kept Absolutely Private

With the planned burgeoning of health IT nationally and the formation of information "exchanges", ensuring information privacy, co...

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ECRI: Healthcare IT In Top Ten Health Technology Threats to Patient Safety

Number 5, that is. The <a href="https://www.ecri.org/About/Pages/default.aspx">ECRI Institute</a> is an independent, unbiased, evidence-based healthcare research, information, and advice provider. They have been in operation for more than 40 years and are one of only a handful of organizations designated as both a Collaborating Center of the World Health Organization and an Evidence-Based Practice Center by the U.S. Agency for Healthcare Research and Quality. I've cited their code of ethics at HC Renewal as a model of commendable healthcare conduct <a href="http://hcrenewal.blogspot.com/2009/02/histalk-defends-cchit.html">before</a>: <blockquote>Conflict of Interest - The Integrity of IndependenceRemaining unbiased is difficult, if not impossible, when conflicts of interest are present. That is why we strictly enforce our conflict-of-interest rules and have carefully developed an environment that maximizes objectivity, productivity, and integrity of process. We accept no grants, gifts, finder’s fees, or consulting projects from, and our employees are not permitted to own stock shares in, medical device or pharmaceutical firms. To make sure that is the case, we examine each employee’s federal income tax return after it is filed. And, we accept no advertising revenues from any source.</blockquote> (Full disclosure: I was a contributor on health IT issues to their 2008 book "<a href="https://www.ecri.org/Documents/RM/POSG_Acknowledgments.pdf">Physician Office Fundamentals in Risk Management and Patient Safety</a>.") ECRI's most recent report is "The Top Ten Health Technology Threats to Patient Safety" for 2011 available <a href="https://www.ecri.org/Forms/Pages/2011_Top_10_Technology_Hazards.aspx">at this link</a>. Their Dec. 7 press announcement is <a href="https://www.ecri.org/Press/Pages/Top-10-Health-Technology-Hazards-List-2011.aspx">here</a>. I'd mentioned an earlier edition of the report at my Sept 2010 post "<a href="http://hcrenewal.blogspot.com/2010/09/health-it-danger.html">Health IT: Danger</a>" as was spoken about by Dr. Ross Koppel at Univ. of PA, but will present more detail here now that the 2011 report is available to the public. I am citing the WSJ health blog on this report, as ECRI requests linking to their registration and downloading page for the full report, rather than direct dissemination, posting, or republishing of this work, without prior written permission: <blockquote>December 8, 2010, 6:15 PM ET <a href="http://blogs.wsj.com/health/2010/12/08/the-top-ten-health-technology-threats-to-patient-safety/">The Top Ten Health Technology Threats to Patient Safety</a> WSJ Health Blog By Katherine Hobson For the fourth year running, the nonprofit ECRI Institute has put together a list of what it judges to be the top ten health technology hazards on which health-care facilities should focus their efforts. The list in descending order of importance, doesn’t necessarily reflect the devices or problems with the most reported errors. That’s a factor, but so is “the severity of the problem, whether or not there’s a way to fix or mitigate the problem, and the high-profile” nature of the problem, Jim Keller, vice president for health technology evaluation and safety at ECRI, tells the Health Blog. </blockquote> Among risks such as radiation therapy overdose and other dosing errors (#1), alarm hazards (#2), cross-contamination from flexible endoscopes (#3), high radiation dose of CT scans (#4), and luer misconnections (#6, misconnections of various infusion tubes), there's this: <blockquote>#5 Data loss, system incompatibilities and other health IT complications: Problems with electronic-health records and other health IT systems can lead to problems including lost data, the need for repeat testing and even patient injury or death. </blockquote> Then another obvious concern is raised: <blockquote>While Keller says both he and ECRI support the push for digitized systems, the <a href="http://blogs.wsj.com/health/2010/09/10/survey-most-hospital-cios-plan-to-get-first-round-it-incentives/">rush for federal incentives</a> raises “concern that some of the kind of problems we are describing will be overlooked.”</blockquote> It's not a "concern" to me, it's a fact. So, here we have it: An independent, nonprofit organization that for more than 40 years has been dedicated to bringing the discipline of applied scientific research to discover which medical procedures, devices, drugs, and processes are best, with unique ability to marry practical experience and uncompromising independence with the thoroughness and objectivity of evidence-based research, reports: <blockquote style="color: rgb(255, 0, 0); font-weight: bold;">"Problems with electronic-health records and other health IT systems can lead to problems including lost data, the need for repeat testing and even patient injury or death."</blockquote> The degree of risk is unknown (cf.: Joint Commission 2009 <a href="http://www.jointcommission.org/assets/1/18/SEA_42.PDF">Sentinel Event Alert on Health IT Safety</a>, PDF): <blockquote>"There is a dearth of data on the incidence of adverse events directly caused by HIT overall."</blockquote> This does not seem the best environment for the ethical, rapid diffusion of this technology nationwide, under penalty of loss of income and loss of Board Certification and even licensure for non-adopters. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUy4oiBc0LRmPIDpPEW9FdQhLBoX-u2gyfQE8JqVeK5Z9JbeeP6f2Q5t2wNYw6MDM2NdQCLC9hjV7o1AHxL8G2RxSG6GlTQOD4rs-f8tLFL3LC8aNTKksNqaudzktiPl1e8MijY8kvhAYM/s1600/cornucopia.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5548766172120016866" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUy4oiBc0LRmPIDpPEW9FdQhLBoX-u2gyfQE8JqVeK5Z9JbeeP6f2Q5t2wNYw6MDM2NdQCLC9hjV7o1AHxL8G2RxSG6GlTQOD4rs-f8tLFL3LC8aNTKksNqaudzktiPl1e8MijY8kvhAYM/s320/cornucopia.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 170px; height: 146px;" /></a>For those of different ethics than ECRI, health IT is a literal cornucopia. </div> Addendum: I note this comment from a nurse at the WSJ health blog story's <a href="http://blogs.wsj.com/health/2010/12/08/the-top-ten-health-technology-threats-to-patient-safety/tab/comments/">comment section</a>: <blockquote>8:50 am December 9, 2010 The list was predictable, emanating from my observations as a registered nurse. It has become impossible to give patients care that they need. Corners are cut. It is easier for doctors to order scans than it is to examine patients. I would rather examine patients but the hospital requires that I click everything in to the electronic record, and [t]hat takes a long time. The reference to the CPOE is true. It is a nightmare because of the mistakes it promotes and it intereferes with communication disrupting my team’s care of the patient.</blockquote> This must be one of those "anecdotal" reports that constitute a growing corpus of irrelevant "anecdotes", to be safely ignored because they were not obtained as part of a scientific experiment. -- SS Addendum Dec. 10, 2010: From an <a href="http://hcrenewal.blogspot.com/2010/05/david-blumenthal-on-health-it-safety.html">earlier post of mine</a> (of which I was reminded via a viewing from IP 150.148.0.#, FDA.gov, on a <a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&q=health+it+safety&btnG=Google+Search">Google search on "health IT safety"</a> this morning), we don't need to worry about HIT risks. ONC chair David Blumenthal said so: <blockquote>... [Blumenthal's] department is confident that its mission remains unchanged in trying to push all healthcare establishments to adopt EMRs as a standard practice. "The [ONC] committee [investigating FDA reports of HIT endangement] said that nothing it had found would give them any pause that a policy of introducing EMR's could impede patient safety," he said.</blockquote> -- SS

ECRI: Healthcare IT In Top Ten Health Technology Threats to Patient Safety

Number 5, that is. The ECRI Institute is an independent, unbiased, evidence-based healthcare research, information, and advice provider. T...

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Abbott Laboratories and Pig Roasts, the "Philly Mob," and Legal Settlements

Help.... The health care muck is now being raked so fast I can't keep up. Abbott Laboratories, Prolific Stenters, Pig Barbecues, Etc In the last week, multiple media outlets picked up the story of the cozy relationship between Abbott Laboratories and a doctor now accused of implanting too many cardiac stents for too much money.  The essentials were, as summarized from <a href="http://www.nytimes.com/2010/12/06/health/06stent.html">New York Times</a>, <a href="http://online.wsj.com/article/SB10001424052748704493004576001582557244592.html">Wall Street Journal</a>, and <a href="http://www.baltimoresun.com/health/bs-bz-hancock-stents-abbott-20101206,0,5226901.column">Baltimore Sun</a> articles - Dr Mark Midei was a prolific user of cardiac stents for patient with coronary artery disease (blocked cardiac arteries) <blockquote>In the June deposition, Dr. Midei estimated that in 2005 — before research revealed that many stents were unnecessary — he performed about 800 stent procedures. Instead of dropping in subsequent years, however, the number of stents Dr. Midei inserted rose to as many as 1,200 annually, he estimated. In a 2007 internal document, Abbott Laboratories ranked Dr. Midei’s use of stents behind only five other cardiologists in the Northeast, including those at hospitals four and five times St. Joseph’s size. [NYT] </blockquote> Therefore, hospitals sought him out <blockquote>He had been one of the most sought-after clinicians in his region. Trained at Johns Hopkins University, he was a co-founder of MidAtlantic, a practice with dozens of cardiologists that controlled much of the cardiac business in Baltimore’s private hospitals. Dr. Midei was one of the practice’s stars. When MidAtlantic negotiated a $25 million merger with Union Hospital in 2007, the deal was contingent on his continued employment. St. Joseph was so concerned about losing Dr. Midei’s business that the hospital offered a $1.2 million salary if he would leave MidAtlantic and join the hospital’s staff. [NYT]</blockquote> However, it appeared he performed the procedures on patients who would not benefit from them. <blockquote>The hospital engaged a panel of experts who reviewed 1,878 cases from January 2007 to May 2009 and found that 585 patients might have received unnecessary stents. When asked to review the cases himself, Dr. Midei found far less blockage than he had initially, according to the Maryland Board of Physicians. The hospital suspended his privileges and eventually sent letters to all 585 patients. Hundreds of lawsuits against Dr. Midei and St. Joseph followed, including from patients treated well before January 2007. [NYT]</blockquote> Nonetheless, Abbott Laboratories had been rewarding him for frequent use of their products <blockquote>Word quickly reached top executives at Abbott Laboratories that a Baltimore cardiologist, Dr. Mark Midei, had inserted 30 of the company’s cardiac stents in a single day in August 2008, 'which is the biggest day I remember hearing about,' an executive wrote in a celebratory e-mail. Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei’s home, according to a report being released Monday by the Senate. The dinner was just a small part of the millions in salary and perks showered on Dr. Midei for putting more stents in more patients than almost any other cardiologist in Baltimore. [NYT]</blockquote> When his over-use was alleged, Abbott continued to use him as a key opinion leader. <blockquote>Abbott responded to the controversy by hiring Dr. Midei as a consultant. 'It’s the right thing to do because he helped us so many times over the years,' an Abbott executive wrote in a January e-mail cited in the Senate report. [NYT]</blockquote> Also, <blockquote>After St. Joseph barred Dr. Midei from practicing there in May 2009, Abbott arranged consultant work for him, according to emails released by the Senate committee. In December 2009, an Abbott senior vice president wrote in an email that he was 'very open' to having Dr. Midei do consulting 'to see how it might go—either getting the word out in China/Japan, medical or safety work.' The following month, the Sun reported on the allegations against Dr. Midei and St. Joseph. According to the Senate report, an Abbott executive subsequently said in an internal company email, 'We recommend that we not use Dr. Midei in the U.S. at this time (the press is just too hot).' Charles Simonton, the medical director of Abbott's vascular division, said in another email cited by the report that Dr. Midei should 'clearly avoid' the Baltimore area, but Dr. Simonton encouraged colleagues to 'please find key physicians or cath labs you'd like him to get in front of with our data.' Abbott wanted to hire Dr. Midei 'because he helped us so many times over the years,' yet another Abbott executive said in an email. Dr. Simonton didn't return phone calls seeking comment. Abbott sent Dr. Midei to Japan to promote the Xience stent, but bad publicity caused that trip to be cut short in late January, the report says. In total, Abbott paid the doctor $30,623 to help market the Xience, the Senate investigators found. [WSJ]</blockquote> When the relationship was criticized, Abbott executives responded with threats, or were they jokes? <blockquote>I called David Pacitti, vice president of global marketing for Abbott Laboratories' cardiac-plumbing division, to ask why he seems to want goons to beat me up in the newspaper parking lot. 'Don't you have connections in Baltimore?????' Pacitti e-mailed a subordinate regarding a January column I wrote on heart-artery stents. 'Someone needs to take this writer outside and kick his ass! Do I need to send in the Philly mob?' Pacitti and other Abbott execs apparently don't care for suggestions that their expensive vascular devices often do patients little good and that a star Baltimore doctor took their encouragement to be 'truly outstanding' a bit too much to heart. [Sun]</blockquote>Furthermore, <blockquote>Pacitti didn't return my phone calls, but an Abbott flack got in touch on Monday. 'We sincerely apologize if this caused you any concern or distress,' the company spokesman said. Pacitti's comment, he said, 'wasn't meant to be taken seriously.' Yeah, that's what King Henry II said after they whacked Thomas Becket. [Sun]</blockquote>So here is a particularly vivid case showing how big health care corporations make <a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">"key opinion leaders"</a> out of doctors apparently just because they use or prescribe a lot of the company's products, regardless of the doctors' expertise, or ethics.  As we noted before, "key opinion leaders" are seen by corporate marketing executives as fellow travelers or useful idiots (see posts <a href="http://hcrenewal.blogspot.com/2010/10/not-best-and-brightest-drug-marketers.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2008/06/key-opinion-leaders-were-sales-people.html">here</a>). It again appears is that all that health care corporate marketers care about is selling product. Whether their pitches are honest or ethical is besides the point. Those who get in their way are treated with contempt, and maybe, just maybe are threatened with violence The physicians who are flattered at being called "key opinion leaders," or "thought leaders" have got to realize that the marketers think they are chumps. If they think they are providing honest information, or education, they are deluded. This case has already been widely discussed in the blogsphere.  See, in particular, posts by Dr Howard Brody <a href="http://brodyhooked.blogspot.com/2010/12/embarrassing-light-on-unnecessary.html">on the Hooked: Ethics, Medicine and Pharma blog</a>, and Larry Husten <a href="http://cardiobrief.org/2010/12/06/senate-report-on-mark-midei-and-abbott-30-stents-in-1-day-pig-roasts-and-more/">on the CardioBrief blog</a>. But if that were not enough, on the heels of this story came several more about Abbott Laboratories Abbott Laboratories Settles, Twice As <a href="http://www.latimes.com/news/nationworld/nation/wire/sc-dc-1208-drug-promotions-20101207,0,1770487.story">reported</a> by the Los Angeles Times, while Abbott was trying to hide Dr Midei overseas, it was also busily negotiating settlements of completely separate charges: <blockquote>Abbott Laboratories and two other pharmaceutical firms agreed to pay more than $421 million to settle claims of defrauding Medicare and Medicaid in the latest in a string of nine- and ten-figure health care fraud settlements announced by the Justice Department. The drug companies charged one set of prices to doctors and pharmacies but reported another set of inflated figures that were used as benchmarks by government insurers reimbursing health care providers. The spread, or difference, amounted to kickbacks to the companies' customers, according to Tony West, assistant attorney general for the Justice Department's civil division, who announced the settlements on Tuesday.</blockquote> In particular, <blockquote>Abbott, of North Chicago, Ill, agreed to pay $126.5 million to settle accusations that it charged the government inflated prices for products ranging from sterile water and saline solution to vancomycin, an antibiotic. An Abbott spokesman said the company believes 'that we have complied with all laws and regulations' and settled the case to avoid 'the uncertainty associated with continued litigation.'</blockquote> At least he did not threaten the Department of Justice officials with an attack by the "Philly mob." But that is not all. The Wall Street Journal <a href="http://online.wsj.com/article/SB10001424052748703296604576005674095414668.html">reported</a> that Abbott had to make a second, unrelated settlement: <blockquote>Separately on Tuesday, the Justice Department announced an unrelated $41 million settlement with Abbott subsidiary Kos Pharmaceuticals Inc. on charges that it paid kickbacks to doctors and other health professionals to encourage them to prescribe or recommend the cholesterol drugs Advicor and Niaspan. As part of that settlement, Kos entered into an agreement that will allow it to avoid prosecution on criminal charges. 'These actions occurred prior to Abbott's acquisition of Kos in 2006 and Abbott has not been accused of any wrongdoing,' an Abbott spokesman said.</blockquote> However, Abbott chose to acquire a company that allegedly chose to pay kickbacks of this sort. The apparent resemblance to Abbott's payments to Dr Midei in the case above are striking. By the way, the Los Angeles Times article also noted previous black marks on Abbott's record: <blockquote>Abbott also paid $614 million in civil and criminal penalties in 2003 to end a federal investigation of the company's marketing practices and Medicaid and Medicare reimbursements. In 2001, TAP Pharmaceutical Products Inc., of Lake Forest, Ill., an Abbott joint venture, agreed to pay $875 million and plead guilty to a criminal charge of conspiring with doctors to overbill Medicare. At the time, the TAP penalty was the largest health care fraud settlement in U.S. history, but it has since been eclipsed by at least two others.</blockquote> So we once again illustrate how punishing wrong doing by fining large corporations, when the fines are just seen as a cost of doing business, in the absence ofany negative consequences on the real people who authorized, directed, or implemented the bad behavior fails to deter future bad behavior. This remarkable confluence of cases suggest how rotten are the ethical foundations of even large and previously respected health care organizations. I imagine, though, that as long as these corporations richly reward their executives regardless of the ethics of their actions, and regardless of the long term effects on the organizations' reputations, and as long as their are no externally imposed negative consequences on these leaders, the practices will continue, and will get worse. Health care costs keep rising, access keeps declining, quality gets worse. We moan and wring our hands, but as long as we allow the rot to worsen, and the muck to grow, expect these trends to continue until the whole smelly mess collapses of its own weight (with all those rich executives escaping to their mansions.) If we really want high quality accessible, reasonably priced health care, we need true health care reform that reduces concentration of power in large organizations, and makes health care organizations' leadership accountable, ethical, and transparent. That will not be easy. ADDENDUM (8 December, 2010) - See also comments by Maggie Mahar <a href="http://www.healthbeatblog.com/2010/12/stent-scandal-a-shocking-story-but-not-news-.html#more">on the HealthBeat blog</a>, David Williams <a href="http://www.healthbusinessblog.com/?p=4072">on the Health Business Blog</a>, and Paul Thacker <a href="http://pogoblog.typepad.com/pogo/2010/12/digging-for-gold-a-nugget-from-senate-report-on-baltimore-cardiologist.html#more">on the Project on Government Oversight blog</a>.

Abbott Laboratories and Pig Roasts, the "Philly Mob," and Legal Settlements

Help.... The health care muck is now being raked so fast I can't keep up. Abbott Laboratories, Prolific Stenters, Pig Barbecues, Etc In ...

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