Alert and Oriented

The Institute of Medicine and the doctrine of perpetual conflict.

Michel AccadJune 15, 2015December 13, 2016Healthcare policyconflict of interestLeave a comment

The Institute of Medicine’s 2009 report on Conflict of Interest in Medical Research, Education, and Practice aims to encourage institutions to develop conflict of interest (COI) policies to safeguard against circumstances in which individual members of the institution, or the institution itself, could risk neglecting primary professional interests (e.g., the welfare of patients or the integrity of medical research) in favor of secondary interests, such as financial gain.

As the IOM correctly notes, the means by which COI leads to a failure of professional responsibility is through bias, conscious or unconscious. Conflict of interest policies, then, are codes of conducts erected to prevent bias from unduly influencing one’s professional actions.

I have no objection to the aim of the report or to the way in which the IOM defines COI (p. 46). But given that the overwhelming bulk of the document’s analysis and recommendations serve to specifically guard against conflicts of interest arising from financial relationships and, furthermore, from financial relationships with commercial rather than non-commercial entities, it is worth examining whether this emphasis does not itself reveal a bias or prejudice against private enterprise.Continue reading “The Institute of Medicine and the doctrine of perpetual conflict.”

Austin Frakt’s conflict of interest disclosure

Michel AccadJune 11, 2015December 13, 2016Healthcare policyconflict of interestLeave a comment

Austin Frakt is a health care economist, creator of The Incidental Economist website, and a regular contributor at the New York Times’ Upshot. A few days ago, he published a great piece about the best evidence for the treatment of insomnia. I enjoyed reading it, learned from it, and passed it on to personal connections who suffer from insomnia. As of now, this article is still at the top of the “most emailed” list for the NYT, and I will keep it as a reference for my patients.

In that piece, Frakt presented to the reader the objective information comparing different treatments for insomnia. To do so, he reviewed the medical literature about clinical trials where drug treatment was tested against a form of psychotherapy (cognitive behavioral therapy). The results Frakt reported seem to clearly favor behavioral therapy over drugs.

Yet, for all his claim to simply present objective data, Frakt disclosed a number of personal biases that could very well have influenced his interpretation of the medical literature and put him in conflict with his stated goal.Continue reading “Austin Frakt’s conflict of interest disclosure”

Is medicine a scientific enterprise?

Michel AccadJune 10, 2015April 24, 2019Healthcare policy, Medical practicedoctor-patient relationship, Flexnerian medicine, information asymmetry, licensing13 Comments

I was recently involved in a Twitter tiff triggered by the following Mayo clinic announcement:

#Energytherapies offer support in healing for #cancersurvivors #LivingWithCancer http://t.co/AUyX8cLj4w pic.twitter.com/0N30G7VL65

— Mayo Clinic (@MayoClinic) June 7, 2015

Readers were promptly outraged:Continue reading “Is medicine a scientific enterprise?”

The murky call for transparency

Michel AccadJune 5, 2015December 13, 2016Healthcare policyconflict of interestLeave a comment

Yesterday, Bill Gardner weighed in on the conflict of interest firestorm set-off by Lisa Rosenbaum. On the surface, his New Republic article seemed to offer a middle-of-the-road and nuanced counterpoint to the vigorous—and at times spiteful—counterattacks to Rosenbaum’s NEJM series. But despite his efforts to achieve a balanced perspective, Gardner failed to resolve the question with clarity.

While he conceded that Rosenbaum made valid points, Gardner advanced the standard and seemingly indisputable 3-part argument in favor of COI disclosureContinue reading “The murky call for transparency”

Three questions for the Missionaries of Quality

Michel AccadJune 3, 2015December 13, 2016Healthcare policy, PhilosophyFlexnerian medicineLeave a comment

Two thoughtful healthcare analysts (a physician and an economist) wonder about health care quality:

@ethanjweiss I agree. If nobody can assess quality or productivity in any way,* that’s a deep problem, isn’t it?

— Austin Frakt (@afrakt) May 26, 2015

They are not alone. Even though the Institute of Medicine’s 2001 epic poem mobilized legions of missionaries of quality, it is far from obvious that we have clarity about the overall aim of the crusade.

Our eyes may have been opened to the sins of medical errors, the shame of healthcare disparities, the wastefulness of therapeutic inefficiencies, and the guilt of runaway costs, but if quality care is in fact the goal, and not a pretext for bureaucratic do-goodism, agreement on its meaning seems to be of the essence lest the campaign to “cross the chasm” turn instead into a crossing of the Styx.Continue reading “Three questions for the Missionaries of Quality”

On the sagging of medical professionalism

Michel AccadJune 3, 2015September 10, 2021Ethics, Medical practice, Medical scienceLeave a comment

[The following article is published with the kind authorization of its author, Herb Fred, MD, MACP. It first appeared in the Fall 2004 issue of the Texas Medical Board Bulletin.]

For the past two decades, medicine has been a profession in retreat, plagued by bureaucracy, by loss of autonomy, by diminished prestige, and by deep personal dissatisfaction.¹ These ills would be bad enough by themselves. But another malady confronts us—the sagging of our professionalism.Continue reading “On the sagging of medical professionalism”

The history behind the MOC®kery

Michel AccadMay 27, 2015December 13, 2016Healthcare policy, Medical practicecertification, licensingLeave a comment

For those affected or scandalized by the way MOC® programs are being foisted on doctors, the following Wikipedia entry may provide an explanatory frame of reference:

A union security agreement is a contractual agreement, usually part of a union collective bargaining agreement, in which an employer and a trade or labor union agree on the extent to which the union may compel employees to join the union, and/or whether the employer will collect dues, fees, and assessments on behalf of the union.

Of course, the American Board of Medical Specialties (ABMS) is not a physician union in the strict sense of the term. From the vantage point of ABMS executives, the situation is far better. ABMS bosses can impose enrollment into MOC® without needing to grant doctors membership—and therefore voting rights—in the organization.Continue reading “The history behind the MOC®kery”

COI and empirical fundamentalism

Michel AccadMay 22, 2015December 13, 2016Ethics, Medical science, Philosophyconflict of interest4 Comments

Over at the Incidental Economist, Austin Frakt has published a thoughtful commentary on Lisa Rosenbaum’s NEJM series on the obsession over conflict of interest. Frakt is supportive of Rosenbaum’s position but also touches on a dimension to the story which I did not address in my admittedly polemical piece yesterday.

Frakt’s most important statement is actually not in the post itself but in a Tweet linking to it.

I view COI disclosure as (meta) data. Like all data it doesn’t self-interpret. This is the source of all COI-debate: http://t.co/qIyds8T6Bu

— Austin Frakt (@afrakt) May 22, 2015

Frakt is absolutely right and his statement points to a very fundamental assumption that underlies not only the COI concerns, but the legal practice of medicine in general. Namely, the assumption is that in science and medicine, we should “let the data speak for itself.”Continue reading “COI and empirical fundamentalism”

COI in medicine: the pharisees exposed!

Michel AccadMay 21, 2015January 19, 2017Ethics, Healthcare policyconflict of interestLeave a comment

Irvine Page’s 1987 medical textbook Hypertension Mechanisms begins with the following acknowledgment:

My special thanks are due to the Ciba-Geigy Company, who not only has contributed generously to the financing of this book, but who–over the years and more than any corporation–has recognized and encouraged the development of research in hypertension

The famed Cleveland Clinic physician-scientist, who died 4 years after the book was published, would not live long enough to have to apologize publicly for this colossal evidence of conflict of interest (COI). It would take a few more years and a few scandals to set into motion the current phobia against industry influence. In fact, Page would undoubtedly be stupefied by the rituals we now go through to show that our research and opinions are unblemished by the taint of for-profit corporations.Continue reading “COI in medicine: the pharisees exposed!”

Against the war on obesity

Michel AccadMay 15, 2015September 10, 2021Ethics, Medical practice, Medical scienceobesityLeave a comment

[This essay was published in the May 2015 issue of San Francisco Medicine. The entire issue is devoted to obesity and you may find it on-line here. ]

A war on obesity has been declared. Public health authorities have identified excess body mass as an epidemic threat. With a great sense of urgency, they are mobilizing resources to address this preeminent health concern. To bolster the effort, the American Medical Association has recently decreed obesity as a disease. Local, state, and national political powers are now engaged in its eradication and have enlisted the assistance of a number of celebrities.

But does the war on obesity have clear objectives and a sound strategy? Will the campaign be conducted as a targeted strike with a well-defined exit plan, or will it turn into an open-ended conflict with limited prospects for victory? Will the offensive conform to “just war” principles, or will it be mired in moral confusion? Whatever the answers, I have reasons to object to this war.Continue reading “Against the war on obesity”