Trust has always been essential to medical care. Of what use are the best communication skills, physician empathy, or clinical knowledge if patients don’t trust the advice and information that their doctors give them?
Even the most psychologically disturbed or misanthropic TV doctor—from Doc Martin to Gregory House—can always be trusted to put his patients first; this is precisely because this trustworthiness is so central to our understanding of being a physician. While this sort of idealization is commonplace and reassuring, it has become more and more problematic. For, in today’s medical world, the lines are blurring between doctors’ clinical decision making and their business decisions. We grant our physicians access to our bodies and allow them to place us in situations of great peril. Without trust, we could not emotionally undergo many medical treatments.
But more and more, a visit to the doctor can become a business meeting, and more specifically, a sales meeting where very expensive goods and services are sold to customers. While facing this fact can be emotionally difficult for patients making potentially life changing medical decisions, it allows us to navigate more effectively in this brave new world of American medicine. If our physicians are thinking and acting more like business people, so must patients.
As A Patient And A Physician
As both a cancer survivor and a surgeon, I’ve seen this from both perspectives. I’ve reached deep into my patients to place screws or implants, broken their bones, and peeled scar tissue from off of their spinal cords. As a patient, I’ve trusted my doctors to inject me with toxins powerful enough to kill me — culminating in the destruction of my own bone marrow so that my brother’s could be planted inside me. This was a procedure done at great risk and in the face of recurrent cancer. I undertook it despite bitter set-backs and occasional missteps in my care because I trusted my doctors to look out for my health and well-being. I could not have persevered against my disease without this faith.
Because of the necessary and comforting trust we bestow on our doctors, we typically do not view health care decisions as business transactions in any way and leave our natural skepticism and instincts as smart consumers at the doctor’s office door. When a patient contemplates surgery or other unpleasant or dangerous treatments, even the most jaded and cynical among us wants to believe that his or her physician is thinking only of their best interest with absolutely no other motivations in play.
When my doctors discussed my own stem cell transplant for recurrent lymphoma, it was emotionally necessary for me to believe that the advice I was receiving lacked any motivations other than my own well being. Furthermore, when we discuss proposed surgical options, I know that my patients place that same trust in me. However, the truth is that most American doctors are small business owners who, like other business people, run their medical practices to maximize and grow their profits. This is part of the reality of practicing medicine in America, and it comes with an agenda that patients don’t really want to acknowledge and doctors don’t want to discuss; it’s uncomfortable for all of us.
Doctors In Business
Physicians’ role as business people has become more central to medical practice as we have moved into the 21st century. This has, unfortunately, been shown to affect the clinical decisions that doctors make. Physicians now partner with finance companies, from GE Capital to Wells Fargo to Citibank, to encourage patients to pay their bills with medical credit cards and lines of credit.
In these arrangements, doctors are fully paid up front for their services, but their patients can end up saddled with credit lines carrying interest rates of up to 30 percent. Financing is all arranged by the physician’s billing staff with the cooperation and encouragement of the treating physician. Doctors increasingly own medical device distributorships — companies that buy and sell implants such as spine surgery hardware or joint replacement components.
These surgeon-owners then sell this hardware to the hospitals where they operate, and they then buy it for their patients when they use it in their surgeries. Such arrangements can generate additional thousands of dollars per procedure in revenue to surgeons. Should we be surprised that recent studies indicate that one-third of total knee replacements and up to 40 percent of recommended spine surgery is unnecessary?
Doctors routinely own surgery centers and advanced imaging centers. Here, too, research has shown that conflicts of interest can sway treatment decisions. Last June, the Government Accountability Office (GAO) released its fourth and final report on physician referrals. The GAO audit found that the growth rate of self-referred services outpaced non–self-referred services by a 7 to 1 margin for MRI scans and by a 3.5 to 1 margin for CT scans. More disturbingly, the GAO report also found that doctors are swayed by financial conflicts of interest, not just for diagnostic studies, but also for treatment decisions — even for treatments with potentially very serious or even deadly side effects and complications.
The GAO auditors evaluated one such treatment: intensity modulated radiation therapy (IMRT) for prostate cancer care. IMRT is one of many treatment options available for prostate cancer; it involves the delivery of high doses of radiation to the affected organ — in this case, the prostate gland. IMRT in this setting is associated with the risk of chronic long-term complications such as erectile dysfunction, rectal bleeding, and diarrhea, and it carries a small risk of causing new cancers to grow. It is also a very lucrative business. According to the GAO, from 2004-2010, its use by urologists who owned IMRT equipment exploded by as much as 356 percent, while its use by urologists with no ownership interests actually declined by 5 percent as most doctors began switching to less toxic treatments.
It should be noted that urologists, like all doctors who build their own treatment centers, are making a conscious decision to become and think more like business people. Startup capital costs run into the millions of dollars, and the centers must be supplied with a steady stream of new patients in order to yield profits. Financial analysts and consultants are involved with every step in the development and marketing of these centers.
Researchers have also studied how practice patterns change when doctors purchase their own surgery centers. Scientists studying coronary artery bypass surgery and angiography in Medicare patients found that the rates of these procedures increased when doctors opened their own specialty cardiac hospitals. Similarly, physician ownership of orthopedic or spine hospitals has been correlated with higher rates of spine surgery. In these situations, doctors must keep these centers busy with procedures in order to generate profits and prevent losses; overhead costs are high, including financing, staffing, lease arrangements, and insurance. However, a busy center becomes a lucrative profit center for owning physicians.
Action Steps For Patients
When faced with data such as this, it is important that Americans realize the truth about medical care and throw away our comfort and complete trust. There are many actions that can be promoted to help patients avoid inappropriate care secondary to physician financial conflicts.
First, insurers and quality agencies should encourage patients to regularly check the federal government’s Open Payments database to see if their doctors receive payments from drug makers or medical device manufacturers. The Centers for Medicare and Medicaid Services (CMS) should continue to improve this database. Not only should it be made more accessible, user-friendly, and interactive, it would become a more meaningful tool for patients by including links to common products sold by the companies making payments. Such a step would ensure that patients could readily see if their prescriptions are tainted by conflict of interest. While the current web site is a huge step forward, the company information alone is of limited relevancy to patients.
Second, patients should be engaged to unapologetically quiz their physicians for other potential conflicts of interest — those not reported on the Open Payments website. These financial conflicts include ownership of surgery or imaging centers.
In all my years of medical practice, I’ve never once been questioned about this by a patient. When asking patients why they never broach the subject, I’ve learned that most people never even consider that their doctor might engage in these financial arrangements; for others, it is too painful to believe that their doctors might have financial conflicts that could impact their care. All these patients could benefit from education on this issue. Organizations that otherwise attempt to educate patients and encourage shared decision making, such as the ABIM’s Choosing Wisely campaign or the Informed Medical Decision Foundation, shy away from this topic, likely for fear of losing physician support.
However, if patients are encouraged to ask their doctors every question about their treatment other than those regarding financial conflicts, patients will continue to be hesitant about this issue, and it will remain largely hidden from patient sight. Patients should always ask whether their physicians own the facility where tests or procedures will be scheduled, and whether they own the company that will sell the hardware needed for their surgery.
If a doctor will not discuss these matters, a patient should be encouraged to look elsewhere for care. While this can be difficult in urgent situations or in our era of narrow networks, patients should attempt the discussion; they can also involve their insurance carrier. Furthermore, if a doctor reveals that they have a financial interest in the procedure or diagnostic test that they are recommending, this should raise a very serious red flag; the doctor has just admitted that they have motivations in their patients’ care other than their health and well being.
Finally, and perhaps most importantly, patients should vote with their feet; if consumers seek out doctors who refuse financial conflicts, this will quickly change physician attitudes toward these financial arrangements. This can only happen if we work to change our medical culture sufficiently so that patients feel free to speak with their physicians about this issue. Then both patients and doctors can enjoy relationships built on the mutual trust that makes the practice of medicine so rewarding to professionals and comforting and safe for our patients.