Dishonest Doctors

One of the critical questions to ask whenever reading a medical journal article is, “Who funded the study?” In most journals, researchers are required to identify their sources of funding, so what’s the problem? Well, researchers can obscure the true origin of financial support: They can hide it, disguise it, or even launder the money through a front group. A case in point is a study downplaying the risks of lung cancer that was funded in part by the Foundation for Lung Cancer: Early Detection, Prevention, and Treatment. That doesn’t sound so bad until you realize it was underwritten by millions of dollars from a tobacco company. There’s no obligation to “disclose a funding source’s source of funding,” which allows “companies to evade financial disclosure requirements” and makes it harder to “follow the money trail.”

As I discuss in my video Disclosing Conflicts of Interest in Medical Research, why does the funding source matter? Every single one of eight reviews covering over a thousand studies found that research funded by industry is more likely to make conclusions that are favorable to industry. For example, why do some review articles on the health effects of secondhand smoke reach different conclusions than others? The only factor found was whether an author was affiliated with the tobacco industry. “This is a disturbing finding. It suggests that, far from conflict of interest being unimportant in the objective and pure world of science…it is the main factor determining the result of studies.”

Not that we’d even know, because 77 percent of authors failed to disclose the sources of funding. And that’s another problem: The responsibility to disclose funding sources is left entirely up to the authors. So, how many researchers divulge the truth? Evidently, a law was passed in Denmark requiring physicians to register any time they worked with industry, which allowed researchers to cross-reference the studies physicians published to see how honest they were. Forty-eight percent of the time, the conflicts of interest were not disclosed, “reinforc[ing] the perception that physicians simply don’t take conflict of interest seriously” (or at least Danish physicians don’t).

What about the United States? Historically, there had been “no means of confirmation or verification” when an American doctor said they had no conflict of interest. Then in 2007, hip and knee replacement companies were forced to pay hundreds of millions of dollars in fines for giving orthopedic surgeons illegal kickbacks. “[M]any orthopedic surgeons in [the] country made decisions predicated on how much money they could make—choosing which device to implant by going to the highest bidder….[W]e expect doctors to make decisions based on what is in the best interests of their patients,” said the Department of Justice’s U.S. Attorney of the District of New Jersey, “not the best interests of their bank accounts.” Part of the settlement was that the companies would have to make public all the payments they made to physicians. The release of those records offered a rare opportunity to see if physicians were telling the truth on disclosure forms. And, lo and behold, more than half of payments were not disclosed, totalling millions of dollars.

That was for surgeons and medical device companies. What about doctors and drug companies? The same thing happened: Drug companies were forced to disclose who they were paying off. In looking at the publications of the doctors who got the most money—at least $100,000—the study found that they were worse than the surgeons. In 69 percent of the cases, they failed to disclose their industry ties. The problem is that we just assume researchers are going to be honest and tell the truth, but these “findings suggest that the accuracy and completeness of [conflict-of-interest] disclosures cannot be assumed.” So, even when a paper says no conflict of interest, who knows if it’s really true.

A long-time editor-in-chief of the New England Journal of Medicine wrote a scathing piece on drug companies and doctors who failed to disclose hundreds of thousands of dollars from drug companies like GlaxoSmithKline, which has been fined literally billions of dollars for activities such as bribing and suppressing data. When GSK got results that were “commercially unacceptable,” the company just buried them. Billions of dollars in fines get assessed, but for drug companies, that may just be the cost of doing business. “As reprehensible as many [drug] industry practices are…much of the medical profession is even more culpable.” We can expect drug companies to prioritize the bottom line, but maybe we should expect more from the healing profession.


What else might your doctor not be telling you? See:

Good examples of conflicts of interest include:

Instead of just disclosing conflicts of interest, how about getting rid of them? That’s the subject of my video Eliminating Conflicts of Interest in Medical Research.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Find Out If Your Doctor Is on the Take With Just Two Clicks

A long-time editor of a prestigious medical journal started his editorial on physicians’ conflicts of interest by describing a fantasy: “Doctors treat patients using simply the best evidence and their experience. They are not influenced by money or self-interest.”

“This is, of course, nonsense,” he wrote. There is a reason “pharmaceutical companies spend billions of dollars on the influencing, education, and entertainment of doctors around the world.”

As discussed in my video Find Out If Your Doctor Takes Drug Company Money, the vast majority of physicians in the United States take gifts from the pharmaceutical industry, and, ironically, cardiologists, whose practice centers around diseases that can largely be prevented and treated with lifestyle changes, receive the most payments of all. A previous compilation of surveys from the 1980s and 1990s found that, on average, doctors met face-to-face with drug industry representatives about once a week. Today, your family doctor may meet with drug company employees on average 16 times a month. There are only 20 workdays a month, so that’s nearly every day.

What does the public think about this? Only about half even appear to know what’s going on. Therefore, “if 83% of doctors receive gifts, it is likely that a significant percentage of patients are not aware that their personal physician receives industry gifts.” We’re not just talking about a token Viagra paperweight or soap dispenser. For marketing, pharmaceutical companies spend $15,000 per physician every year, making conflicts of interest one of the most pressing problems in American health care.

How do doctors feel about it? Most generally approve of the gifts. However, tellingly, physicians don’t want gift relationships made public. “Physicians’ disagreement that it is inappropriate to accept gifts, but their reluctance to disclose the gift relationship to the public, suggests that they must recognize that the public would not appreciate the practice.” To analyze how doctors resolve this contradiction, researchers conducted a series of physician focus groups. It turns out physicians use a variety of denials and rationalizations, including avoiding thinking about it, and denying responsibility. Physicians readily acknowledged the inherent conflict of interest, but this didn’t stop them. In fact, some complained that the gifts were getting more modest.

“We [doctors] tend to deny that we have any conflict of interest if a pharmaceutical company buys us a nice dinner. We tend to insist that it won’t affect our judgement in any way”—as if drug companies just like wasting money for the heck of it. Most physicians contend that their colleagues are susceptible to industry influence…but not them.

Though physicians don’t want these gift relationships to be public, that’s just too bad. Thanks to Republican Senator Chuck Grassley, the Sunshine Act was inserted into Obamacare. “For the first time, patients will now be able to see what, if any, financial ties their own doctor has with a drug or device maker.”

Doctors can’t hide anymore.

The Sunshine Act was designed to give patients some insights when choosing a provider, and law enforcement agencies can also use it see who’s getting money from industry to investigate illegal kickback schemes. Right now, it might just be embarrassing, but this could allow attorneys general to go after doctors to see the kinds of incentives they may be getting for writing a lot of prescriptions. The database is live right now at openpaymentsdata.cms.gov/search/physicians or, for a more user-friendly version, Propublica’s Dollars for Docs page. The drug industry spends billions trying to influence doctors, and, for the first time, you can see if your physician, or any physician, has their hand out.

Senator Grassley hoped this would help save our nation money. It could reduce healthcare costs if patients viewed such doctors as less trustworthy and chose doctors less in bed with industry. It could also change physician behavior: Physicians may want to avoid financial relationships with companies to guard against patient distrust or becoming the target of an exposé or investigation.

Or they could just try to cover it up.

The American Academy of Family Physicians advised physicians how to “avoid getting burned” by the Sunshine Act. For example, drug companies now have to report when they give doctors free meals valued over $10. So, should family physicians just stop accepting free food from drug companies? No way! You just have to give the drug sales reps the right head count to ensure that the meal cost dips below $10 per person.

The former long-time editor of the New England Journal of Medicine said it best: “Although the spotlight has been on the failure to disclose (or adequately disclose) financial relationships with industry, the problem with [conflicts of interest] is not the lack of disclosure but the existence of the conflict itself.” Rather than just disclosing them, the best approach to financial conflicts is to have none.


No wonder physicians undervalue lifestyle interventions! See The Actual Benefit of Diet vs. Drugs and Why Prevention Is Worth a Ton of Cure. Inundated by Big Pharma without so much as a free mug from Big Broccoli, Physicians May Be Missing Their Most Important Tool. And, even worse, sometimes the drugs can do more harm than good. See my video on How Doctors Responded to Being Named a Leading Killer.

Financial arrangements can affect prescribing behavior for more than just drugs. See my video Should We All Get Colonoscopies Starting at Age 50?.

PS: I have never knowingly accepted gifts from the pharmaceutical industry, but “knowingly” is an important caveat. If you search for my name in the Dollars for Docs database you’ll see I apparently accepted money from a vision care company five years ago. I was giving a continuing medical education lecture at an optometric physicians conference and unbeknownst to me they had the corporation pay for my travel and lodging.

In health,
Michael Greger, M.D.

PPS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

 

Risks vs. Benefits of Colonoscopies

Though colonoscopies can cause serious harm in about 1 in every 350 cases, sigmoidoscopies, procedures that use shorter and smaller scopes, have ten times fewer complications. But, do colonoscopies work better? Is their total risk-benefit better? We don’t know since we don’t have results from any randomized, controlled colonoscopy trials, and we won’t until the mid-2020s. So, what should we do in the meanwhile?

As I discuss in my video Should We All Get Colonoscopies Starting at Age 50?, the U.S. Preventive Services Task Force (USPSTF), the official prevention guidelines body, considers colonoscopies just one of three acceptable colon cancer screening strategies. Starting at age 50, we should either get our stool tested for hidden blood every year, which doesn’t involve any scoping at all; get a sigmoidoscopy every five years, along with stool testing every three; or get a colonoscopy every ten years. In terms of virtual colonoscopies or the new DNA stool testing, there is insufficient evidence to recommend either of those two strategies.

Though the USPSTF recommends ending routine screening at age 75, that assumes you’ve been testing negative for 25 years since your 50th birthday. If you’re 75 and have never been screened, then it’s probably a good idea to get screened at least into your 80s.

If there are three acceptable screening strategies, how should one decide? The USPSTF recommends that patients work with their physician in selecting one after considering each option’s risks and benefits. For patients to participate in the decision-making process, though, they have to be given the information. The degree to which health providers communicate the necessary information was not known until researchers conducted a study in which they audiotaped clinic visits looking for the nine elements of informed decision-making: discussing both the patient’s role and that role in making the decision, what kind of decision has to be made, the alternatives, the pros and cons of each option, and the uncertainties associated with the decision, as well as assessing the patient’s understanding and whether they desire input from those they trust, and, finally, asking them what they would prefer. That’s the role of a good doctor. It’s your body; it’s your informed decision.

How many of these nine crucial elements of informed decision-making were communicated to patients when it came to colon cancer screening?

Care to hazard a guess?

In most of the patients, none. The average number addressed? One out of nine. As an editorial in the Journal of the American Medical Association put it, “There are too many probabilities and uncertainties for patients to consider and too little time for clinicians to discuss them with patients.” So, doctors just make up the patients’ minds for them. And what do they choose? Most often, as in this survey of a thousand physicians, doctors recommend colonoscopy. Why? Other developed countries mostly use the stool tests, with only a few recommending colonoscopies or sigmoidoscopies. That may be because most physicians in the world don’t get paid based on how many procedures they do. As one U.S. gastroenterologist put it, “Colonoscopy is the goose that laid the golden egg.”

A New York Times exposé concluded that the reason doctors rake in so much money is less about “top-notch patient care” and more about business plans maximizing revenue, lobbying, marketing, and turf battles. Who sets the prices for procedures? The American Medical Association, the chief lobbying group for physicians, does. No wonder gastroenterologists pull in nearly a half-million dollars a year, and the American Gastroenterological Association wants to keep it that way. Referring to these exposés, the president of the association warned that “gastroenterology is under attack and colorectal cancer screening and prevention may be reduced in volume and discounted.” But, they then go on to share tips for how to succeed in the coming nightmarish world of accountability and transparency.

Why would primary care doctors push colonoscopies? Because many doctors get what are essentially financial kickbacks for procedure referrals. Studying doctor behavior before and after they started profiting from their own referrals, it’s estimated that doctors make nearly a million more referrals every year than they would have if they there were not personally profiting.


Serious harm in 1 out of 350 colonoscopies? See What to Take Before a Colonoscopy for all the gory details.

Too often, truly informed consent is a joke in modern medicine. For more on this, see:

How do you know if your doctor is on the take? Check out Find Out If Your Doctor Takes Drug Company Money.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations: