Wednesday, April 02, 2008

Looking in the Mirror

The left-leaning National Physicians Alliance blog has decided to take on the American College of Cardiology.

Now as a Fellow in the American College of Cardiology, I don't agree with these guys on many things, but I think regarding the above post, they are right on the money as they describe the complicated interplay between the pharmaceutical and medical device industries and those of physicians' need for continuing education.

It was interesting to note that the ACC heavily promoted their "Quality First" initiative at this year's meeting and solicited input from physicians to garner "our feedback" in a survey distributed to the doctor-attendees. I found the survey hidden amongst the multitude of pharmaceutical swag and program outlines residing inside my handy-dandy co-branded Lipitor-ACC.08 shoulder bag. (I regret that I did not get the 1 GB USB drive they promised to the first 500 survey participants as I never saw this survey until I arrived home).

But their list of "key features" embodying the ACC's Quality First Campaign were presented unilaterally, without physician discussion. On the surface, they seem so necessary. What right-minded doctor would not want these things?

Here's what we were asked to rank (from "not important" to "very important") and my initial thoughts as I read these features in italics:
  • "Provide universal access through an expansion of public/private financing" (What? Does this mean "support universal health care?" - a buzz-word of the Dems? Does expanding public/private financing mean promote Health Savings Accounts - a buzz-word of the Repubicans? Hellllloooo, people! What the hay are we talkin' 'bout here?)
  • "Increase patient value through the delivery of evidence-based, high quality care" (Excuse me, isn't that what we're already doing? Are you asking for another 74 "quality measurements" to keep track of (like shorter door-to-balloon times) with even more bureaucracy and documentation so we can pat ourselves on the back and be on the "100-best hospital list" one more time?
  • Manage care by disease state and across sources and sites of care (Huh? I never liked "managed care." Is this what you mean? Or are we promoting the EMR here?)
  • Implement a payment system that rewards quality, value, and coordinated care management (Oh, my God! Pay for Performance! eeeeeeekkkkk! Please, lets call this covert rationing scheme what it is: "Less Pay for Performance," okay?)
  • Involve patients as partners in their own care Uh, excuse me, who has more of a vested interest in their care than the patient with the health problem? What the heck is this supposed to mean?
So what is the ACC's policy direction with these questions? Are they really interested in physician's input and a two-way discussion? Or are such surveys really manipulations of doctors for political intent? How, exactly, will this survey data be used? I can hear it now as our ACC leaders stand before congressional subcommittees and extol: "According to our carefully-conducted (and coerced survey through the use of a 1GB USB storage drive), 65% of surveyed physicians want pay for performance initiatives."

Finally, is our "quality" in cardiology so bad? Haven't we seen a dramatic decline in the incidence of cardiovascular morbidity and mortality over recent years?

Increasingly, large meetings struggle to balance marketing, policy, and educational missions in the backdrop of the medical industry's Big Money. But given the covert and conflicted issues at play, disclosure of these conflicts might no longer be enough: disentanglement of interests might be the better norm.

Maybe first re-evaluating our real priorites regarding the objectives of these meetings should be the "key feature" of the ACC's next Quality First Initiative.

After all, others already have taken the lead and I like the other guys' meeting space better.



Ian Furst said...

All well and good Wes but where does the disentanglement start and finish? Do I still get some really good Chinese food at rounds? What about a round of golf from a supplier? Let's take it a step further -- when a GP and specialist are in a shared practice where does the referral for specialist care go? By definition, two practitioners can't have a conflict of interest in the eyes of our College but does one ethically exist? I think that declaring interests is enough. Once registered you have an ethical obligation to do what is in the best interests of the patient. If you cannot handle that responsability you should not be in the job. Rather than trying to regulate the suppliers, maybe the colleges should create a higher standard of practice? Personnally, I think my collegues are smart and ethical and can [generally] seperate education from marketing.

DrWes said...

Ian -

Thanks for your thought-provoking comments. While the conflicts as you suggest are indeed pervasive, the costs involved to our healthcare for such grandiose marketing displays and advertising continue to cost someone, somewhere handsomely. While our capitalist ideals have forwarded remarkable innovation and marketing helps pay for that innovation, eventually, these costs trickle back to the patients or the government (i.e. you and me) to pay. Some of the displays at the ACC where HUGE (and therefore costly). Is that necessary? How much longer should we turn a blind eye to the costs involved?

Additionally, the "Quality First" initiative, while nobel in intent, uses cardiologists to forward agendas which appear politically motivated in a venue that does not permit adequate vetting of the manpower requirements (and costs again) for their implementation and interjects significant sampling bias.

An organization as large of the ACC has a formidable task when it attempts to obtain input from its members (and certainly they should be commended for this effort). But even an e-mail survey explaining the issues more clearly would be MUCH more efficient than the skewed, biased format with which the ACC was obtaining input in the case of the survey found amongst drug paraphernalia.

Lisa said...

"Involve patients as partners in their own healthcare" is insurancesse for "You pay us for coverage, but we shift the burden to cover your medical costs back to you, because everyone knows your illness is all a lifestyle choice."