Rodwin's book looks at conflicts of interest in medicine across the board. Very roughly, one could divide the COI he discusses into three general categories--COI in how physicians are reimbursed for direct patient care; COI in other financial aspects of the health system (e.g., physician ownership of hospitals or labs); and COI created by relationships with third parties such as the pharmaceutical and device industries. Rodwin then looks in some depth at three medical systems: the US, France, and Japan. he compares how the three quite different systems address all the various COIs. He concludes by making some policy recommendations, based on a comparison among what seems to have worked best, or not worked, in each of the three countries.
Compared to most previous material in this blog, Rodwin's approach has a downside and an upside. The downside is that a lot of time and energy are focused on COIs that have nothing to do with the medicine-Pharma interface, and for which the necessary solutions are therefore quite different. The upside is that on occasion, looking at COI with drug and device companies from a more general perspective illuminates the issues in a novel way. I was worried about the downside as I slogged through the acronym soup that was requireed to give a detailed analysis of each health system, but in the end I was persuaded that the upside triumphed.
Rodwin ends up at somewhat the same point I did in HOOKED, arguing that in the end, COI with Pharma will require both addressing physician professionalism, and also instituting a number of legal and regulatory changes. But he has some fresh things to say about how those two different approaches relate to each other.
First, a side trip into the lessons from the three nations. If you were looking for pillars of professional ethics in the French and Japanese systems, you'll be sadly disappointed. At first blush, when you see that those systems come in at about 8-10% of GDP going to health care, while still managing to provide universal coverage for their populations, and the US is about at 17% and has a large swath of the population uninsured--then you might imagine that physicians in France and Japan are professionalism role models, compared to the profligate (and presumably profit-driven) habits of their US counterparts. Rodwin shows that any such view would be terribly overromanticized. France and Japan, to summarize briefly, have professional medical organizations holding a level of power over public policy that the AMA would kill for. Yet neither has taken step one to limit the contacts or the bribe-taking of physicians with Pharma. Moreover, while the French medical society has taken the lead in prohibiting a number of entrepreneurial types of practice, the Japanese society has essentially functioned as a doctors' union pure and simple, doing next to nothing to restrain greed and profit among its members. In short, the international track record, no less than the experience within the US, suggests that professionalism, as a tool to deal effectively with COI and Pharma, is a flop.
So what does Rodwin then propose? He says, "Ironically, professionalism requires a medical economy under mixed rather than professional control, and it functions best when the medical profession, the market, and the state have overlapping authority, each with checks on the others." This is a fairly radical departure from one view of professionalism, which argues that the whole idea behind professionalism is the autonomy of the professional group--that as soon docs end up under the thumb of economic interests or the state, goodbye to all professional ethics. Rodwin claims by contrast that allowing unfettered power in any portion of the system--including the professional group itself--will never lead to optimal ethical behavior around COI at least. Checks and balances is the name of the game.
His prescription is as follows: “How should we deal with physicians’ conflicts of interest in the future? I propose the following. Individual physicians and organized medicine should restrict activities that create conflicts of interest for practitioners and physician organizations. Physicians can change the way they conduct their own medical practice as well as participate in broader change through professional organizations and civic engagement. Physician organizations can develop ethical standards and policies for medical practice, continuing medical education (CME), and other medical activities. Even more important is another step that many physicians will find difficult. Physicians should accept the authority of federal and state government and laymen to reform the medical economy in ways that reduce and regulate physicians’ conflicts of interest.”
As we saw in the last post, that means that Rodwin is in favor of a straight legal ban on Pharma gifts/bribes. He also advises taxing the industry, hospitals, and physicians to fund CME, and turning the funds over to a neutral agency. The agency should assess need and then decide on CME content, rather than allow industry and the speakers to decide what they want to talk about. Rodwin notes that we taxpayers now pay for CME anyway via pass-through of costs, so we might as well have a say in what topics are taught.
If docs need a stick rather than a carrot to accept his recommendations, Rodwin adds, “If physicians want to control their work and influence practice and policy in a robust way, they need to assure the public that their judgment, advice, and advocacy are not compromised. This will require physicians to curb many of their entrepreneurial activities. If they do not, then the state or private entities—spurred by patients, other professionals, and various economic interest groups—probably will.”
Rodwin MA. Conflicts of interest and the future of medicine: the United States, France, and Japan. New York: Oxford U. Press, 2011.