Category Archives: Culture

Rerun: What the Talmud teaches about drug company gifts to doctors

In honor of the Jewish New Year I’m re-running a post on Judaism’s insights into pharmaceutical sales and marketing practices. L’shana Tova!

Recently I heard a Rabbi discuss the prohibitions against bribes in Jewish law. He shared the Talmudic insight that “a gift blinds the eyes of the wise” and taught that this refers not just to obvious bribes but even to small, innocent-seeming gestures that appear too insignificant to influence another person but that actually do cause a conflict of interest. I told him this sounded very similar to contemporary relationships between pharmaceutical companies and prescribing physicians, where small gifts like pens and take-out lunches are tools of the trade –viewed as innocuous by their recipients but seen as a good investment by the givers.

I revisited a blog post I wrote on the topic back in 2006 along with a JAMA article (Health industry practices that create conflicts of interest: a policy proposal for academic medical centers) by Brennan et al. from the same era. I looked at the list of articles citing the Brennan piece to see if I could find something more current. Lo and behold I discovered Unconscious conflict of interest: a Jewish perspective by Gold and Applebaum in the Journal of Medical Ethics, which probes this issue in more depth. They write:

The Talmud [Tractate Kethuboth folio 105b] suggests that, due to the unconscious mechanism of influence between the giver and the receiver, the prohibition of receiving a gift is not limited to physical gifts, but extends to any other personal benefits, including ‘a bribe of words’:

Our Rabbis taught: ‘And thou shalt take no gift’; there was no need to speak of [the prohibition of] a gift of money, but [this was meant:] Even a bribe of words is also forbidden, for Scripture does not write, ‘And thou shalt take no gain.’ What is to be understood by ‘a bribe of words’? –As the bribe offered to Samuel (a Talmudic scholar who served as a judge). He was once crossing [a river] on a ferry when a man came up and offered him his hand. ‘What,’ [Samuel] asked him, ‘is your business here?’ –‘I have a lawsuit,’ the other replied. ‘I,’ came the reply, ‘am disqualified from acting for you [ie, as a judge] in the suit.’

In a meticulous reading of the story mentioned above, it is not clear whether Samuel, the Talmudic scholar, actually accepted assistance from that ‘courteous’ man. In fact, his reaction of disqualifying himself from serving as a judge seems to be related solely to the man’s offer. That man’s gesture –offering his arm– was a sufficient cause for the disqualification. The gesture alone was perceived by Samuel as a sort of speech-act that emanated –perhaps unconsciously– from the man’s desire to influence his judgement. In other words, the offering of the arm was ‘a bribe of words’.

To me this is fascinating stuff and suggests that to truly avoid the unconscious conflict of interest in the pharma/physician relationship it would be necessary to cut off all contact between pharma rep and doctor. Even when a drug rep is prohibited from distributing tsotchkes or tapping his restaurant budget, the physician still knows the rep would give him things if he could. Under this logic, the “no see” policies of some physician organizations toward pharma reps make good sense.

There is another solution, which is to educate physicians about unconscious biases and the objectives and tactics of pharma companies, device companies, health plans, and other would-be influencers. Even better would be to couple this education with conscious efforts to counteract any biases that are introduced.

Physicians are notoriously skeptical of the notion that they are influenced by gifts large or small. Therefor the article wisely concludes:

For those disinclined to accept either the insights of sociologists and anthropologists or the findings of modern neuroscience on the tendency towards reciprocity in response to the receipt of gifts and favours, perhaps the wisdom of the ancients provides a reason to rethink the unconscious influence of even small benefits on physician behavior.

Can violent sports survive the impact of concussions?

As studies and accompanying news coverage about the long-term dangers of head trauma have emerged over the past few years I’ve been thinking about what American sports will look like a generation from now. The NFL’s recent $765M settlement with retired players has me thinking about it again.

In the US, football players are our modern gladiators, and we love to watch. A century ago, the survival of football was threatened due to the uproar over 19 fatalities in 1905. Rules were changed and the game became somewhat safer, but as we now are starting to understand, signs of serious damage may not emerge for years after retirement.

Will football and other violent sports survive? And if so, how will they look compared with today?

At the one extreme, I think it’s possible that football and boxing will be banned and that the rules of hockey and soccer will change substantially as a result of awareness of head injuries. If that seems extreme, consider how dramatically social norms on an issue like smoking can change over time.  The Surgeon General first made noises about the danger of cigarettes in the 1960s, but when I was growing up in the 1970s and complained about secondhand smoke my mother told me to “get used to it.” It was inconceivable to me then that in 2013 smoking would be banned in so many places and so heavily stigmatized.

On the other hand, it’s been obvious forever that boxing is a dangerous endeavor. While there have been changes over time to ensure the safety of fighters the sport is still around and not all that different from what it was a generation back. So if boxing is the model then the modest changes we’ve seen so far in the other violent sports may be about as far as it goes.

One of the keys to the equation is what happens with youth sports. Parents of high school athletes are aware of the newer research on head trauma, and leagues and coaches have made reasonably strong moves to protect players with concussions from aggravating those injuries. But what of the parents who are having kids now? Will they be as eager as current and past generations to let their kids get involved in the more dangerous pursuits? I’m not sure.

An area to keep an eye on is technological change. Football helmets to protect players from death and serious injury inadvertently made things worse in some ways by encouraging spearing. With a better scientific understanding of head trauma and a desire to prevent it, equipment makers may be able to devise helmets and other gear to make the games safer without making them slower or less physical. That’s my hope.

Workplace clinics: All good

A Wall Street Journal piece (The Office Nurse Now Treats Diabetes, Not Headaches) notes the benefits of workplace clinics but also emphasizes the potential downside of loss of privacy or employer intrusion into the personal lives of employees. The ever-skeptical Deborah Peel is trotted out to lay out an Orwellian scenario.

Workplace clinics address the big, big issues of access and convenience, and do so in ways that align the interests of employers and employees. It’s a hassle to get an appointment at a doctor’s office. Even when you have an appointment it takes time to get there and waits can be long. It almost always means time off from work. Onsite clinics are set up to be convenient and to respect the value of employees’ time. The employers are the customers. They care about time away from work and access to care. They also generally are interested in evidence based medicine, consistency, and patient safety. All of those things benefit the employee.

It can be difficult for even well-educated, well-insured people to navigate the health care system, and partially as a result there are many people walking around with conditions that they are neglecting. This example from the article struck me as a good one:

John Martin, an accounts-payable specialist at Hanesbrands, visited the company clinic in January after leaving his Type 2 diabetes untreated for seven years. Tests confirmed that the 53-year-old’s blood sugar was high and that he also suffered from hypertension. Clinic nurse practitioners put Mr. Martin on medication for both conditions and arranged for free or discounted pills. A CHS health coach helped him lose 25 pounds in two months through dietary changes and an exercise program.

“This has made me change the way I live my life,” Mr. Martin said of the clinic.

This kind of intervention is a positive thing for all involved. I know I’d be more likely to want to work for a company offering this sort of support.

Welcome to summer –and sun protection

This is a blog about the business of health and health care policy so I don’t often delve into the realm of personal health tips. But since it’s the first day of summer and I’m a sun-sensitive bald redhead, I’ll make an exception.

It’s the time of year that newspapers write about sunscreen. A Washington Post article talks about the safety of sunscreens, contrasting “physical” sunscreens that block sunlight by reflecting it back,with chemical sunscreens that absorb the sun’s rays and keep them from damaging skin. The fear is that chemical sunscreens may be absorbed into the skin and cause trouble, e.g., by producing free radicals that cause damage to cells.

I share this concern about sunscreen safety, but my worries are also more practical and immediate. In particular, I’ve found that when I use sunscreen at the beach I often miss a spot –like the tops of my feet or some place on my back– and end up with a big, bad burn.

Twenty years ago I was working on a consulting project at an academic medical center in New York City. I was interviewing a dermatologist who took a look at me and couldn’t resist offering the advice that I should wear sun protective clothing, especially at the beach. Since then I’ve worn sun protective gear from Solumbra in the summer. I’m partial to their zip-front swim shirts, which I wear religiously. They’re comfortable in the water or on shore and I don’t worry about getting burned or needing to reapply sunscreen once I’ve gotten wet.

This year my wife asked me to try something a little more stylish than the plain, blue Solumbra swim shirt I favor. So I bought one from Coolibar, which looks better but is honestly not nearly as good.

If you’re sun sensitive like me, or just sun sensible, I hope you’ll take care of your skin by wearing sunscreen or protective clothing.

See you at the beach!

Of ACOs and the over-imaging of children

Today’s news feeds feature a big new study on pediatric CT radiation doses. Anyone who’s been paying attention will not be surprised by the results:

  • The use of CT scans in pediatrics rose dramatically from 199 to 2005 before leveling off
  • Some kids get huge doses of radiation –with the amount of exposure per scan varying dramatically
  • Thousands of people will eventually get cancer due to the CT scans they had as kids

Scans are popular because they provide lots of information for diagnosis, produce pretty pictures that patients can relate to, and because they are well-reimbursed. But the harms are real and the medical community as a whole has not done enough to get things under control. There are exceptions, though. The Image Gentlycampaign has called attention to this issue for years, and I have personally seen remarkable attention given to weighing the benefits and harms of CT at Boston Children’s Hospital. I’m sure they are not alone.

One of the fastest, most effective ways to address the problem of over-imaging in the broader pediatric community is through payment reform. In particular, when health systems have incentives to hold down costs and improve quality –as they do with Accountable Care Organizations (ACOs)– I suspect doctors will be much more careful about what they order. And when patients have to pay more out of pocket they may also initiate a discussion with their provider about whether the scan is needed.

Meanwhile, if your kid has had more CT scans than they need or if you yourself have had too many, you have a right to  be worked up about it.

Wanted: Entrepreneurial business models for doctors

My perception is that doctors in previous generations were more likely to devote their entire lives (professional and “personal” time) to the practice of medicine. Today’s doctors are more likely to consider lifestyle and not automatically put everything into doctoring. This is partly cultural –as younger professionals in general have put more emphasis on balance– but a large part is structural, because residents are working fewer hours by law and because more doctors are working for others, which encourages an employee mentality.

I don’t really have a problem with doctors who want to have a life outside medicine, but overall I prefer to be treated by someone who’s really dedicated and wants to devote most of their waking hours to it. By the way I feel the same about other professionals I work with.

So I’d like to see some of the structural issues addressed to encourage those who want to go all out to do so. Kaiser Health News has an article on the topic today (Doctors Transform How They Practice Medicine), which gets at my point at least indirectly. The article discusses how physicians are opening “medical homes” to provide more coordinated care or opening concierge-style practices that limit the number of patients and charge extra fees.

Those are both kind of interesting but also a bit ho hum. I’d rather see a broader array of offerings including those that include more remote services and incorporate specialty care. I hope and think they’ll come because despite the fact that many docs are rushing into hospital employment, I believe many would rather work for themselves if there were a viable way to make it happen.


By David E. Williams of the Health Business Group.

What to do about heroin and oxycontin

USA Today has a full page article on the rise of heroin addiction in the suburbs, but adds absolutely nothing to what’s already widely known. (See, for example, my post on the topic from early 2012.) Teens and adults start by abusing the painkiller oxycontin, which is available by prescription, then turn to shooting heroin once they figure out how pricey it is to acquire oxycontin on the street.

The article presents no real ideas on what to do about the problem. If anything the article implies that it would be better to make oxycontin more widely available in order to stem the use of heroin. That’s a nonsensical approach as far as I’m concerned.

There are alternative approaches that might be more promising.

One idea is to establish better guidelines on the prescribing of painkillers after surgery. Many patients –maybe you’ve been one of them– receive an overly generous supply of oxycontin or vicodin after a minor surgical or dental procedure. Sometimes the patient gets addicted from that initial supply, other times the extras end up in the family medicine cabinet where teens might find them and try them out. It’s not always obvious how to dispose of these medications, which contributes to them hanging around.

One hurdle to overcome is that follow-up visits are inconvenient and also not very profitable for doctors. Perhaps if there were quality measures associated with good practices that would change the equation and tighten the initial supply.

Another issue relates to so-called “drug seekers.” We’ve all heard about drug seeking patients who come to the emergency room to get drugs. There are IT systems coming online that can at least identify such drug seekers and alert doctors, but this only works if the systems are consulted, which may not happen when middle-class patients are involved. It’s easy to label patients as “drug seekers,” which makes them sound like bad people. Some are. But many others are patients who are somewhere down the path toward dependency. They’re not trying to become oxycontin addicts and certainly aren’t looking to move to heroin. Rather than turning people away it would be better to have a path to refer these patients into treatment and then to track their progress.

There are great opportunities for physicians, payers, employers, consumers and pain management experts to work together to develop a more comprehensive view of the problem, to develop a strategy to address it, create new quality and safety measures related to achieving the strategy, and align incentives so that physicians are rewarded for doing the right thing.

We won’t solve the problem of painkiller abuse in one shot. But it’s reasonable to start by tightening up on the relatively easy places, such as cutting down on the distribution of unneeded post-surgical pain meds and figuring out how to better direct “drug seekers.”