My discussion of the reporting on the extremely high rate of major spinal fusion surgery in Louisville has generated its own follow-up. On Jan 17, Courier-Journal reporter Patrick Howington contributed a front-page article about the legal battle of five Louisville orthopedic surgeons over an estimated $60 million in royalty fees.
Wow! The Chamber of Commerce must be proud. This is the kind of big-time health care and research money on which Louisville’s city fathers, and its business and university communities have pinned their hopes for the future. So why am I embarrassed over this? Should I be? Would I be if the money were coming to me? I think there is plenty of embarrassment to go around.
It is embarrassing for me as a physician to see other physicians fighting so publicly over money. While certainly within their legal rights, this dispute over money by these professionals reminds us that even for physicians, the practice of medicine is at its base a business. There has always been an inherent tension in the patient-physician relationship: what is best for the patient may not always be what is best for the physician. The professional ideal resolves any such conflicts in favor of the patient. As more and more outside players insert themselves between and around the patient-physician relationship, the vectors of tension become more complex and more difficult to resolve. I predict we will increasingly appreciate such policy difficulties as the structure of our healthcare system changes. Our debates over capitation, managed care, or physicians as employees provide examples where the nature of the patient-physician relationship has been tested. During the last year in Louisville, several prominent contract battles between insurance companies, doctors, and hospitals continues to disrupt the vulnerable contract between patients and their physicians.
All five physicians are reported to be employees of Norton Hospital. This whole matter has not put the hospital in a good light, exposing as it does the controversy of how much surgery is necessary and good, and highlighting the potential distorting factor of money in medical decision-making. The hospital advertises their spine center heavily. In my opinion, the back-to-back reports this month tarnish its reputation. It troubles me that despite their legal conflict, it is reported that the five surgeons agree to keep their business and financial information secret. Does that mean that their employers at Norton Hospital and the University of Louisville are kept just as much in the dark as the rest of us patients or potential patients? I have no knowledge if Norton Hospital has any ownership rights over the medical devices in question. I do know that at least one other hospital in Louisville invested in ownership rights of the intellectual property of a University faculty member. It did not seem healthy to me at the time for a non-profit hospital to have such an interest. Let me say at the outset that I like Norton Hospital. I go to Norton Hospital. The issues this hospital is facing are not unique to it but shared by other Louisville hospitals and in particular its teaching hospitals.
I am even more embarrassed for the University of Louisville. [Disclosure. I was a tenured Professor of Medicine at the University of Louisville for over twenty years and more recently a government affairs officer. I am still Professor Emeritus there.] The University’s top priority over the past ten years has been to increase its research activities with a goal to increase income and business investment. The Courier-Journal report is silent on the issue, but the University also seeks to capture the royalty and research-related income of its faculty for the institution. Do any of these orthopedic royalties flow to the University? If not, why not? If I were another faculty member who had to share my income with the University and saw that other and perhaps more powerful faculty members did not, I might feel upset. Of course, there may be grandfathered issues involved of which we are unaware. The fact is that the faculty of the University have had a long history of outside businesses, corporations, and foundations that the University Administration has neither knowledge of nor control over. The list of salaries of University faculty prepared by the Courier-Journal and other websites have always been a joke to insiders. In my first month as a faculty member at the University, an officer of a major clinical department attempted to intimidate me physically when at a faculty meeting I spoke in favor of transparency for faculty salaries at this public university. Even the Dean of the Medical School had/ has no idea how much money his faculty are making. In fairness, the University has wanted to have more control over the professional activities of its faculty and a larger portion of its clinical income, but has had limited success. I am not surprised. For example, did the University even know of the activities of Passport Managed Care company that recently caused it considerable public embarrassment? The University seeks to generate both clinical and research revenue from the activities of its faculty. To protect its reputation, it seems to me that the University has a vested interest in assuring the public that it is worthy of its confidence. I think it needs to do a better job.
I am surprised to learn from the article that the Chairman of the Department of Orthopedic Surgery and several of his faculty are employees of Norton Hospital. I thought that employment by Norton was a practice over which the University went to the mats to forbid. The University recently fired all its neurosurgeons (and its oncologists in the past) who had become employees of Norton Hospital. What is different about Orthopedics? I would like to believe that there is a reason for selective enforcement other than arbitrariness or perhaps hypocrisy. Wouldn’t you? Of course, virtually all of the University’s clinical faculty have been employed in the past by Personal Services Corporations or other corporate forms over which the University had no control. Should any of this make any difference to us? Is the nature of a faculty members employment material to the missions of education, patient care, research, or service to which the University aspired? The very fact that this issue has been so publicly and painfully argued suggests to me that the answer to my question is yes.
The national trend of Medical Schools and their parent universities to emphasize profit from the research they do has considerably distorted the traditional academic environment. I was once in a position to see this nationally, but observed the consequences first hand in my own institution. Precious faculty positions in the clinical disciplines are given to faculty whose primary role is to generate economic development from their research and who do little or no teaching. To be “exposed” to such faculty was given as a sufficient educational justification for their hiring. A previous requirement that faculty in a clinical department be Board Certified to hold the position of Associate Professor or above was abandoned. An effort was made, perhaps successfully, to insert patents and license arrangements into the traditional criteria for promotion along with publications and excellence in teaching. Faculty have told me they have avoided publishing their research because they do not want the clock to start ticking on the process of patenting their findings. This is an anathema to science where research findings are published to allow others to judge the validity or attempt to reproduce the work. Faculty have focused on developing their research as medical devices rather than drugs because it is much easier to get a medical device approved by the FDA. (The standard of whether a medical device actually works is much lower than for a drug.) Agreements over ownership and conflicts of interest can linger unresolved between the University and its faculty for years, compromising the principle that full disclosure and institutional policy mitigate against conflict of interest by the university and its faculty with respect to their patients. Given the magnitude of the new emphasis, how could education and clinical programs not suffer? For example, an effort was made to identify existing endowments and special accounts being used for lectureships, scholarships, and the like; and to convert them into research money. I can only hope the University put a stop to such redirection of educational funds, but I do not know. Plans were made to admit out-of-state medical students in preference to Kentucky students solely because they could be charged the higher out-of-state-tuition that might be used for other purposes. I can only hope that did not happen. (Kentucky law requires admission preference to Kentucky medical students but this was not considered an obstacle.) As you might discern, I became quite disillusioned at it all.
Of course it can be said that I am just an old fashioned dinosaur for whom time has passed by. I suppose I am comfortable with that appellation. I think that medical schools and their faculty should be the most trustworthy source of medical information available to the public. After all, they are continually teaching our next batch of doctors. I must sadly confess that I feel our schools of medicine and their faculty are losing the right to automatically claim this authority. They have essentially delegated the continuing education of physicians to the pharmaceutical and medical device industries. To the extent that our Medical Schools attempt to become drug companies themselves, the authoritative gap is widening. Do we really want our future physicians trained in an environment where generation of clinical and research income is such a visible priority, or where we play so nicely with pharmaceutical companies? Do we think our students and residents will not notice?
Enough ranting for now. You probably get the picture that I am concerned about the environments in which we teach and practice medicine. I will have more to say about this in the future. Earlier today I was discussing this blog with a physician colleague who also had insider’s knowledge about medical education. Their initial comment was that we need a new Flexner Report on medical education. It is ironic that the first Flexner Report was written here in Louisville. Louisville’s medical school lies today astride the Abraham Flexner Way. Flexner surveyed medical education in 1910 and concluded that the system was failing us. He advocated for the more scientific and experience-based curriculum for medical education that became the model we use today. I think my former UofL colleague is on to something. Ironically from my perspective, it is a misdirected emphasis on academic research as a commercial commodity, and clinical medicine as a collection of profit centers that is at the root of many of my concerns. Perhaps in another posting I can elaborate on what I think medical schools and hospitals should be doing for us.
What do you think the proper role of a medical school or teaching hospital should be? Are things going in the right direction for our three Kentucky schools of medicine? Are you content with what you are seeing in our state? Feel free to leave a comment or correct any of my errors.