{"id":54,"date":"2011-01-20T12:07:40","date_gmt":"2011-01-20T16:07:40","guid":{"rendered":"http:\/\/www.khpi.org\/wp\/?p=54"},"modified":"2011-01-20T14:30:48","modified_gmt":"2011-01-20T18:30:48","slug":"battles-royale-in-louisville","status":"publish","type":"post","link":"http:\/\/www.khpi.org\/blog\/battles-royale-in-louisville\/","title":{"rendered":"Battles Royale in Louisville"},"content":{"rendered":"

My discussion of the reporting on the extremely high rate of major spinal fusion surgery in Louisville has generated its own follow-up.\u00a0 On Jan 17, Courier-Journal reporter Patrick Howington contributed a front-page article<\/a> about the legal battle of five Louisville orthopedic surgeons over an estimated $60 million in royalty fees.<\/p>\n

Wow!\u00a0 The Chamber of Commerce must be proud.\u00a0 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.\u00a0 So why am I embarrassed over this?\u00a0 Should I be?\u00a0 Would I be if the money were coming to me? \u00a0 I think there is plenty of embarrassment to go around.<\/p>\n

It is embarrassing for me as a physician to see other physicians fighting so publicly over money.\u00a0 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.\u00a0 There has always been an inherent tension in the patient-physician relationship:\u00a0 what is best for the patient may not always be what is best for the physician.\u00a0 The professional ideal resolves any such conflicts in favor of the patient.\u00a0 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.\u00a0 I predict we will increasingly appreciate such policy difficulties as the structure of our healthcare system changes.\u00a0 Our debates over capitation, managed care, or physicians as employees provide examples where the nature of the patient-physician relationship has been tested.\u00a0 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.<\/p>\n

All five physicians are reported to be employees of Norton Hospital.\u00a0 This whole matter has not put\u00a0 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.\u00a0 The hospital advertises their spine center heavily.\u00a0 In my opinion, the back-to-back reports this month tarnish its reputation.\u00a0 It troubles me that despite their legal conflict, it is reported that the five surgeons agree to keep their business and financial information secret.\u00a0 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?\u00a0 I have no knowledge if Norton Hospital has any ownership rights over the medical devices in question.\u00a0 I do know that at least one other hospital in Louisville invested in ownership rights of the intellectual property of a University faculty member.\u00a0 It did not seem healthy to me at the time for a non-profit hospital to have such an interest.\u00a0 Let me say at the outset that I like Norton Hospital.\u00a0 I go to Norton Hospital.\u00a0 The issues this hospital is facing are not unique to it but shared by other Louisville hospitals and in particular its teaching hospitals.<\/p>\n

I am even more embarrassed for the University of Louisville.\u00a0 [Disclosure.\u00a0 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.] \u00a0 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.\u00a0 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.\u00a0 Do any of these orthopedic royalties flow to the University?\u00a0 If not, why not?\u00a0 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.\u00a0 Of course, there may be grandfathered issues involved of which we are unaware.\u00a0 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.\u00a0 The list of salaries of University faculty prepared by the Courier-Journal and other websites have always been a joke to insiders.\u00a0 In my first month as a faculty member at the University,\u00a0 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.\u00a0 Even the Dean of the Medical School had\/ has no idea how much money his faculty are making.\u00a0 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.\u00a0 I am not surprised.\u00a0 For example, did the University even know of the activities of Passport Managed Care company that recently caused it considerable public embarrassment? \u00a0 The University seeks to generate both clinical and research revenue from the activities of its faculty.\u00a0 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.\u00a0 I think it needs to do a better job.<\/p>\n

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.\u00a0 I thought that employment by Norton was a practice over which the University went to the mats to forbid.\u00a0 The University recently fired all its neurosurgeons (and its oncologists in the past) who had become employees of Norton Hospital.\u00a0 What is different about Orthopedics?\u00a0 I would like to believe that there is a reason for selective enforcement other than arbitrariness or perhaps hypocrisy.\u00a0 Wouldn’t you?\u00a0 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.\u00a0 Should any of this make any difference to us?\u00a0 Is the nature of a faculty members employment material to the missions of education, patient\u00a0 care, research, or service to which the University aspired?\u00a0 The very fact that this issue has been so publicly and painfully argued suggests to me that the answer to my question is yes.<\/p>\n

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.\u00a0 I was once in a position to see this nationally, but observed the consequences first hand in my own institution.\u00a0 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.\u00a0 To be “exposed” to such faculty was given as a sufficient educational justification for their hiring.\u00a0 A previous requirement that faculty in a clinical department be Board Certified to hold the position of Associate Professor or above was abandoned.\u00a0 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.\u00a0 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.\u00a0 Faculty have focused on developing\u00a0 their research as medical devices rather than drugs because it is much easier to get a medical device approved by the FDA.\u00a0 (The standard of whether a medical device actually works is much lower than for a drug.)\u00a0 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.\u00a0 Given the magnitude of the new emphasis, how could education and clinical programs not suffer?\u00a0 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.\u00a0 I can only hope the University put a stop to such redirection of educational funds, but I do not know.\u00a0 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.)\u00a0 As you might discern, I became quite disillusioned at it all.<\/p>\n

Of course it can be said that I am just an old fashioned dinosaur for whom time has passed by.\u00a0 I suppose I am comfortable with that appellation.\u00a0 I think that medical schools and their faculty should be the most trustworthy source of medical information available to the public.\u00a0 After all, they are continually teaching our next batch of doctors. \u00a0 I must sadly confess that I feel our schools of medicine and their faculty are losing the right to automatically claim this authority.\u00a0 They have essentially delegated the continuing education of physicians to the pharmaceutical and medical device industries.\u00a0 To the extent that our Medical Schools attempt to become drug companies themselves, the authoritative gap is widening.\u00a0 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?\u00a0 Do we think our students and residents will not notice?<\/p>\n

Enough ranting for now.\u00a0 You probably get the picture that I am concerned about the environments in which we teach and practice medicine.\u00a0 I will have more to say about this in the future.\u00a0 Earlier today I was discussing this blog with a physician colleague who also had insider’s knowledge about medical education.\u00a0 Their\u00a0 initial comment was that we need a new Flexner Report on medical education.\u00a0 It is ironic that the first Flexner Report was written here in Louisville.\u00a0 Louisville’s medical school lies today astride the Abraham Flexner Way.\u00a0 \u00a0 Flexner surveyed medical education in 1910 and concluded that the system was failing us.\u00a0 He advocated for the more scientific and experience-based\u00a0 curriculum for medical education that became the model we use today.\u00a0 I think my former UofL colleague is on to something.\u00a0 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.\u00a0 Perhaps in another posting I can elaborate on what I think medical schools and hospitals should be doing for us.<\/p>\n

What do you think the proper role of a medical school or teaching hospital should be? \u00a0 \u00a0Are things going in the right direction for our three Kentucky schools of medicine?\u00a0 Are you content with what you are seeing in our state?\u00a0 Feel free to leave a comment or correct any of my errors.<\/p>\n

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