Luxury primary care and academic medical centers the erosion of science and professional ethics
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Luxury Primary Care and Academic Medical Centers: The Erosion of Science and Professional Ethics. Martin Donohoe. Academic Medical Centers. Evidence-based medicine Ethics Providers of last resort to poor and destitute, un- and under-insured Personal experience – university vs homeless clinic.

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Luxury primary care and academic medical centers the erosion of science and professional ethics

Luxury Primary Care and Academic Medical Centers:The Erosion of Science and Professional Ethics

Martin Donohoe


Academic medical centers
Academic Medical Centers

  • Evidence-based medicine

  • Ethics

  • Providers of last resort to poor and destitute, un- and under-insured

  • Personal experience – university vs homeless clinic


Financial crisis responses
Financial Crisis:Responses

  • Increasing links with pharmaceutical and biotech industries

  • Recruitment of wealthy, non-US citizens

  • Luxury primary care / executive health clinics


Luxury primary care executive health clinics
Luxury Primary Care/Executive Health Clinics

  • Most major academic medical centers

  • 2000-3500 visits per year

  • $1500 to $20,000/visit

    • Avg. $2000-$4000


Lpc clinic perks
LPC Clinic Perks

  • Same day appointments/tests, accompanied consults, vaccines

  • Shorter waiting times

  • Low physician/patient ratios

  • 24/7 access, house calls


Clients marketing
Clients/Marketing

  • Large corporations

    • Tobacco companies, environmental polluters, health insurers

    • Hope for contracts for institution/providers and/or corporate donations

  • Marketed to the “busy executive”

    • Mostly white males


Unknowns
Unknowns

  • Medical student/resident participation

  • Effects on physicians

  • Effects on old patients

  • How funded

  • Where profits go - ?cross-subsidization?

  • Secrecy


Lpcs and the erosion of science
LPCs and the Erosion of Science

  • Tests not clinically indicated or cost-effective

    • CXRs – lung cancer

    • CT scans/stress ECHOs – CAD

    • Pelvic US – ovarian CA

    • Whole-body CT scans

      • radiation~Hiroshima, raise cancer risks


Consequences of unnecessary testing
Consequences of Unnecessary Testing

  • False positives → further testing, complications, anxiety, ↑ profits

  • Diversion of limited resources – human and capital

  • Erosion of evidence-based practice

    • Unsound science


Lpcs and the erosion of professional ethics
LPCs and the Erosion of Professional Ethics

  • General public subsidizes medical training

  • Physicians limit practice to wealthy

    • Increasing differential of care between poor and wealthy

  • Financial factors replace clinical judgment


Contemporary health care
Contemporary Health Care

  • ↑ wealth disparities

    • 20-25% of US children live in poverty

  • ↑ environmental degradation (and related illnesses)

  • ↓access to care

    • 45 million uninsured in US, underinsured, dead end jobs

  • Disparities by social class / race in access to and outcomes of care

  • Developing world brain drain; medical tourism


Lpcs and the erosion of professional ethics1
LPCs and the Erosion of Professional Ethics

  • Workups, treatments based on ability to pay

  • Ethics

  • Rationing

  • Acceptance of double standard


Lpcs and the erosion of professional ethics2
LPCs and the Erosion of Professional Ethics

  • Increasing cynicism/dissatisfaction among medical students/residents/practicing physicians and patients

  • More providers willing to “game the system”


Solutions
Solutions

  • Renunciation of the measure of the marketplace as the dominant standard and value in health care

  • Equitable division of resources


Solutions medical education and ethics training
Solutions: Medical Education and Ethics Training

  • Increasing emphasis on social, cultural, economic and environmental contributors to health and illness

    • Health disparities, cultural competence, occupational and environmental illnesses (e.g., pesticide-related illnesses, air pollution and asthma)


Solutions medical education and ethics training1
Solutions: Medical Education and Ethics Training

  • Heal schism between medicine and public health

  • Service-oriented learning, research-based activist courses, volunteerism, political activism

  • History, literature, role models/mentoring


Solutions public policy
Solutions: Public Policy

  • ↑ education of public policymakers (business leaders, government representatives, and health care purchasers)

  • ↑ public education


Solutions public policy1
Solutions: Public Policy

  • Deans, department chairs, division chiefs, ethicists, doctor-patient

    • Ethicists quiet re LPCs

  • Outcome: ↑ funding for education, training, and care of the underserved by academic institutions


References
References

  • Donohoe MT. “Standard vs. luxury care,” in Ideological Debates in Family Medicine, S Buetow and T Kenealy, Eds. (New York, Nova Science Publishers, Inc., 2007). Available at http://phsj.org/?page_id=22

  • Donohoe MT. Elements of professionalism for a physician considering the switch to a retainer practice. In Professionalism in Medicine: The Case-based Guide for Medical Students, Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge University Press, 2008, in press).


References1
References

  • Donohoe MT. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.x

  • Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical perspectives. American Medical Association Virtual Mentor 2004 (April);6(4). Available at http://www.ama-assn.org/ama/pub/category/12249.html


Contact information
Contact Information

Public Health and Social Justice Website

http://www.phsj.org

martindonohoe@phsj.org