The discussion has focused almost exclusively on pecuniary, or financial, interests. But these may play a relatively minor role in medicine. Most doctors or researchers don’t do what they do primarily to increase their material wealth. If making money was their primary goal, they could choose more effective ways of doing so.
The motivations that underlie most decisions in medicine are not financial. Rather they range from an interest in patient care or research or public welfare, to a commitment to certain ideas, principles or values and the desire for personal advancement in career, reputation or status.
These factors are powerful drivers of decisions and actions and are no less capable of generating conflicts than the prospect of monetary rewards. Division of loyalties between the roles of clinician, researcher, administrator or public health practitioner may create serious concerns or anxieties; personal religious or political commitments may undermine the operation of an ethics or policy committee; and the quest for international recognition may overcome the natural caution or circumspection required of clinical judgement.
http://theconversation.edu.au/dont-show-me-the-money-the-dangers-of-non-financial-conflicts-5013
Friday, March 30, 2012
Wednesday, March 28, 2012
lack of adequate management of conflicts of interest among experts generating clinical guidelines in Australia
http://theconversation.edu.au/show-and-tell-conflicts-of-interest-undeclared-for-clinical-guidelines-3890
Tuesday, March 27, 2012
between 44,000 and 98,000 people die in US hospitals each year as a result of preventable medical errors
http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx
the medical profession is so trusted that its activities are rarely questioned
By Paul Komesaroff, Monash University; Ian Kerridge, University of Sydney, and Wendy Lipworth, University of New South Waleshttps://theconversation.edu.au/big-debts-in-small-packages-the-dangers-of-pens-and-post-it-notes-4949
Monday, March 26, 2012
Adverse events in surgical patients in Australia
The AE (adverse events) rate for surgical admissions was 21.9%. Disability that was resolved within 12 months occurred in 83%, 13% had permanent disability, and 4% resulted in death. Reviewers found that 48% of AEs were highly preventable. The risk of an AE depended on the procedure and increased with age and length of stay.
http://www.ncbi.nlm.nih.gov/pubmed/12201185
http://www.ncbi.nlm.nih.gov/pubmed/12201185
The Quality in Australian Health Care Study
Med J Aust. 1995 Nov 6;163(9):458-71.
Source
Royal North Shore Hospital, North Sydney, NSW.Abstract
A review of the medical records of over 14,000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an "adverse event", which resulted in disability or a longer hospital stay for the patient and was caused by health care management; 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9% the patient died.http://www.ncbi.nlm.nih.gov/pubmed/7476634?dopt=Abstract
Comment in
while evidence-based medicine is a noble ideal, marketing-based medicine is the current reality
While much excitement has been generated surrounding evidence-based medicine, internal documents from the pharmaceutical industry suggest that the publicly available evidence base may not accurately represent the underlying data regarding its products. The industry and its associated medical communication firms state that publications in the medical literature primarily serve marketing interests. Suppression and spinning of negative data and ghostwriting have emerged as tools to help manage medical journal publications to best suit product sales, while disease mongering and market segmentation of physicians are also used to efficiently maximize profits. We propose that while evidence-based medicine is a noble ideal, marketing-based medicine is the current reality.
http://www.springerlink.com/content/b674622731k4850q/?p=780854c9fdb64f988dd69a0651085be7&pi=10
http://www.springerlink.com/content/b674622731k4850q/?p=780854c9fdb64f988dd69a0651085be7&pi=10
It is only because there is no paper or money trail that the conflicts of interest based on power go unmentioned and uncorrected
Committees are the fastest growing things in health care — teamwork, collaboration, consultation, liaison, planning, strategy, development, review are just some of the buzzwords used to justify downing tools and having a yak.
We can’t just blame government for this — have a look at how many committees the AMA has created.
Many committees are very influential. A number have remuneration and benefits attached, not to mention the time off work. They can also offer the natural companion of power — prestige.
The appointments to these committees are often driven by politics, connections and geography rather than by merit.
Some are even implementing gag clauses on doctors and even medical students. If someone is subject to a gag clause it should be declared as a conflict of interest.
As a profession we need to be asking about who decides appointments, how they are decided and whether members of committees are nominees or representatives. The latter have to tow a line, the former can be independent.
Power can manifest as workforce manipulation, even without monetary gain. Examples of this are the colleges, universities, regional training providers (RTPs) and hospital networks.
How many times have we seen the students or the registrars of the professor given the best jobs? How often do the supervisors on the boards of colleges and RTPs get the best registrars while others have to make do with the lower achieving ones or none at all?
Can doing a PhD under a certain boss somehow lead to a prime hospital appointment regardless of the academic merits of the thesis? Splashing the name of the boss on a few publications — with his/her minimal input — is a way to seal the deal.
There is certainly a culture of “doing one’s time” or “being seen” that prevails within our profession. When such candidates are given jobs over those with more merit, you cannot but help conclude that major conflicts of interest are at play.
http://www.mjainsight.com.au/view?post=aniello-iannuzzi-conflict-of-power&post_id=8543&cat=comment
We can’t just blame government for this — have a look at how many committees the AMA has created.
Many committees are very influential. A number have remuneration and benefits attached, not to mention the time off work. They can also offer the natural companion of power — prestige.
The appointments to these committees are often driven by politics, connections and geography rather than by merit.
Some are even implementing gag clauses on doctors and even medical students. If someone is subject to a gag clause it should be declared as a conflict of interest.
As a profession we need to be asking about who decides appointments, how they are decided and whether members of committees are nominees or representatives. The latter have to tow a line, the former can be independent.
Power can manifest as workforce manipulation, even without monetary gain. Examples of this are the colleges, universities, regional training providers (RTPs) and hospital networks.
How many times have we seen the students or the registrars of the professor given the best jobs? How often do the supervisors on the boards of colleges and RTPs get the best registrars while others have to make do with the lower achieving ones or none at all?
Can doing a PhD under a certain boss somehow lead to a prime hospital appointment regardless of the academic merits of the thesis? Splashing the name of the boss on a few publications — with his/her minimal input — is a way to seal the deal.
There is certainly a culture of “doing one’s time” or “being seen” that prevails within our profession. When such candidates are given jobs over those with more merit, you cannot but help conclude that major conflicts of interest are at play.
http://www.mjainsight.com.au/view?post=aniello-iannuzzi-conflict-of-power&post_id=8543&cat=comment
Publication bias concerns grow
CONCERN that published research does not provide doctors with the full evidence base about medications is increasing, with an analysis of antipsychotic trials finding several examples of publication bias.
The research, published in PLoS Medicine, analysed 24 trials registered with the US Food and Drug Administration of eight second-generation antipsychotics. (1)
The study found that four of the trials were never published. Of these, three failed to show that the study drug was significantly better than placebo, and one showed the drug was statistically inferior to the active comparator.
It is the latest example of researchers using data from published and unpublished research in their analysis — and finding discrepancies between the two sources.
An analysis of antidepressant trials by the same researchers in 2008 found that publication bias nearly doubled the apparent proportion of positive trials and increased the apparent effect size of antidepressants by one third. (2)
A recent reanalysis of neuraminidase inhibitors for influenza using primary trial data was conducted after researchers found that 60% of patient data from oseltamivir trials had never been published. The reanalysis found that oseltamivir did not seem to reduce hospitalisations, contrary to the findings of published reports. (3)
One of the authors of the oseltamivir review was Professor Chris Del Mar, professor of public health at Queensland’s Bond University. Professor Del Mar told MJA InSight that the latest research on antipsychotics showed that if doctors only read published research, they would get a biased view of these medications.
“This is another indication that, at the moment, our system for providing information to clinicians about the efficacy of commercially sensitive products is broken. More and more, it seems to look as if medical journals are simply becoming the marketing arm of commercial interests such as the pharmaceutical industry”, he said.
While the association between trial outcome and publication status in the latest research did not reach statistical significance — probably due to the low number of relevant trials — Professor Del Mar said the numbers speak for themselves.
He said although the publication bias in the latest analysis was not as strong as found for antidepressants or neuraminidase inhibitors, it was another example of the problem.
“We’re beginning to see a pattern that what goes through the regulators is not what we see in journals”, he said.
Professor Gordon Parker, Scientia professor of psychiatry at the University of NSW, said the latest analysis of antipsychotics showed that “if we are to rely on the evidence base, then we do need to examine the data from unpublished studies as well as published”.
However, he said the bigger issue was the real-world effectiveness of psychopharmacological drugs.
He cited the 2005 Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, which unexpectedly found that a first-generation antipsychotic, perphenazine, performed generally as well as newer atypical antipsychotics, with fewer side effects. (4)
http://www.mjainsight.com.au/view?post=publication-bias-concerns-grow&post_id=8579&cat=news-and-research
The research, published in PLoS Medicine, analysed 24 trials registered with the US Food and Drug Administration of eight second-generation antipsychotics. (1)
The study found that four of the trials were never published. Of these, three failed to show that the study drug was significantly better than placebo, and one showed the drug was statistically inferior to the active comparator.
It is the latest example of researchers using data from published and unpublished research in their analysis — and finding discrepancies between the two sources.
An analysis of antidepressant trials by the same researchers in 2008 found that publication bias nearly doubled the apparent proportion of positive trials and increased the apparent effect size of antidepressants by one third. (2)
A recent reanalysis of neuraminidase inhibitors for influenza using primary trial data was conducted after researchers found that 60% of patient data from oseltamivir trials had never been published. The reanalysis found that oseltamivir did not seem to reduce hospitalisations, contrary to the findings of published reports. (3)
One of the authors of the oseltamivir review was Professor Chris Del Mar, professor of public health at Queensland’s Bond University. Professor Del Mar told MJA InSight that the latest research on antipsychotics showed that if doctors only read published research, they would get a biased view of these medications.
“This is another indication that, at the moment, our system for providing information to clinicians about the efficacy of commercially sensitive products is broken. More and more, it seems to look as if medical journals are simply becoming the marketing arm of commercial interests such as the pharmaceutical industry”, he said.
While the association between trial outcome and publication status in the latest research did not reach statistical significance — probably due to the low number of relevant trials — Professor Del Mar said the numbers speak for themselves.
He said although the publication bias in the latest analysis was not as strong as found for antidepressants or neuraminidase inhibitors, it was another example of the problem.
“We’re beginning to see a pattern that what goes through the regulators is not what we see in journals”, he said.
Professor Gordon Parker, Scientia professor of psychiatry at the University of NSW, said the latest analysis of antipsychotics showed that “if we are to rely on the evidence base, then we do need to examine the data from unpublished studies as well as published”.
However, he said the bigger issue was the real-world effectiveness of psychopharmacological drugs.
He cited the 2005 Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, which unexpectedly found that a first-generation antipsychotic, perphenazine, performed generally as well as newer atypical antipsychotics, with fewer side effects. (4)
http://www.mjainsight.com.au/view?post=publication-bias-concerns-grow&post_id=8579&cat=news-and-research
The loss of trust in the medical profession
Although rarely explicitly stated, it’s expected that physicians will act with humanity, integrity and care. And, on an individual level, it seems that most do.
Those training as doctors also make a substantial personal investment of resources, time and intellect. Lengthy years of training coupled with high levels of individual responsibility and professional accountability are the norm.
In return for their efforts, doctors are given considerable professional autonomy, respect, social prestige and financial reward. As a result of their specialised knowledge – and the unique power that comes with it – they are afforded privilege and trust above that of many other professional groups.
This reciprocity is the basis of the social contract in medicine, which emerged in the 19th century. In return for status and financial rewards, physicians would meet the medical needs of society through service and altruism.
In his recent analysis of Medicare expenditure, former director of the Professional Services Review (PSR), Tony Webber, noted that an estimated two to three billion dollars are inappropriately spent every year. Much of this, he claims, arises from misuse of medical benefits scheme funding by individual physicians and corporate owners of medical businesses. Such observations undermine public trust in doctors and in their social contract.
Regarding medical care purely as a business transaction places the clinical encounter at the intersection of commerce and science – away from its traditional place at the nexus of humanity and science. For the public, this may be seen as a moral shift that signals doctors will place self-interest above the common good.
Finally, high profile failures of the medical profession to effectively self-regulate (another benefit traditionally bestowed them under the social contract) have contributed to recent legislative change. The introduction of national registration now requires mandatory reporting of poorly performing, or impaired colleagues across Australia. Public perception that the profession as a group has failed to act in the public interest and effectively sanction unprofessional colleagues has further eroded public trust.
Sylvia Cruess notes, “The loss of trust in the medical profession (although not necessarily in individual physicians) comes from a better informed citizenry, which is demanding greater levels of accountability, more transparency, and greater assurance of quality. The greatest challenge to medicine’s professional status at the present time comes from the general public.”
If health care is a shared social good funded primarily through public investment, the public deserves a stronger role in determining how these goods are distributed. In the United Kingdom and in the state of Oregon in the United States stronger public participation in key areas of health care has been achieved with some success through citizen’s juries. Such models could be considered in Australia.
http://theconversation.edu.au/power-and-duty-is-the-social-contract-in-medicine-still-relevant-3941
Those training as doctors also make a substantial personal investment of resources, time and intellect. Lengthy years of training coupled with high levels of individual responsibility and professional accountability are the norm.
In return for their efforts, doctors are given considerable professional autonomy, respect, social prestige and financial reward. As a result of their specialised knowledge – and the unique power that comes with it – they are afforded privilege and trust above that of many other professional groups.
This reciprocity is the basis of the social contract in medicine, which emerged in the 19th century. In return for status and financial rewards, physicians would meet the medical needs of society through service and altruism.
Threats to the social contract
The expectation of reciprocity inherent within this social contract still arguably influences how health care is funded and structured in this country. But the fundamental spirit of this contract appears under threat on a number of fronts.In his recent analysis of Medicare expenditure, former director of the Professional Services Review (PSR), Tony Webber, noted that an estimated two to three billion dollars are inappropriately spent every year. Much of this, he claims, arises from misuse of medical benefits scheme funding by individual physicians and corporate owners of medical businesses. Such observations undermine public trust in doctors and in their social contract.
Regarding medical care purely as a business transaction places the clinical encounter at the intersection of commerce and science – away from its traditional place at the nexus of humanity and science. For the public, this may be seen as a moral shift that signals doctors will place self-interest above the common good.
Finally, high profile failures of the medical profession to effectively self-regulate (another benefit traditionally bestowed them under the social contract) have contributed to recent legislative change. The introduction of national registration now requires mandatory reporting of poorly performing, or impaired colleagues across Australia. Public perception that the profession as a group has failed to act in the public interest and effectively sanction unprofessional colleagues has further eroded public trust.
Sylvia Cruess notes, “The loss of trust in the medical profession (although not necessarily in individual physicians) comes from a better informed citizenry, which is demanding greater levels of accountability, more transparency, and greater assurance of quality. The greatest challenge to medicine’s professional status at the present time comes from the general public.”
If health care is a shared social good funded primarily through public investment, the public deserves a stronger role in determining how these goods are distributed. In the United Kingdom and in the state of Oregon in the United States stronger public participation in key areas of health care has been achieved with some success through citizen’s juries. Such models could be considered in Australia.
http://theconversation.edu.au/power-and-duty-is-the-social-contract-in-medicine-still-relevant-3941
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