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

Professional EthicsProfessional Ethics

Martin DonohoeMartin Donohoe

Academic Medical CentersAcademic Medical Centers

Evidence-based medicineEvidence-based medicine EthicsEthics Providers of last resort to poor and Providers of last resort to poor and

destitute, un- and under-insureddestitute, un- and under-insured Personal experience – university vs Personal experience – university vs

homeless clinichomeless clinic

Financial Crisis:Financial Crisis:ResponsesResponses

Increasing links with Increasing links with pharmaceutical and biotech pharmaceutical and biotech industriesindustries

Recruitment of wealthy, non-US Recruitment of wealthy, non-US citizenscitizens

Luxury primary care / executive Luxury primary care / executive health clinicshealth clinics

Luxury Primary Care/Luxury Primary Care/Executive Health ClinicsExecutive Health Clinics

Most major academic medical Most major academic medical centerscenters

2000-3500 visits per year2000-3500 visits per year

$1500 to $20,000/visit$1500 to $20,000/visit Avg. $2000-$4000Avg. $2000-$4000

LPC Clinic PerksLPC Clinic Perks

Same day appointments/tests, Same day appointments/tests, accompanied consults, vaccines accompanied consults, vaccines

Shorter waiting timesShorter waiting times Low physician/patient ratiosLow physician/patient ratios 24/7 access, house calls24/7 access, house calls

Clients/MarketingClients/Marketing

Large corporationsLarge corporations Tobacco companies, environmental Tobacco companies, environmental

polluters, health insurerspolluters, health insurers Hope for contracts for Hope for contracts for

institution/providers and/or institution/providers and/or corporate donationscorporate donations

Marketed to the “busy executive”Marketed to the “busy executive” Mostly white malesMostly white males

UnknownsUnknowns

Medical student/resident Medical student/resident participationparticipation

Effects on physiciansEffects on physicians Effects on old patientsEffects on old patients How fundedHow funded Where profits go - ?cross-Where profits go - ?cross-

subsidization?subsidization? SecrecySecrecy

LPCs and the Erosion of LPCs and the Erosion of ScienceScience

Tests not clinically indicated or cost-Tests not clinically indicated or cost-effectiveeffective CXRs – lung cancerCXRs – lung cancer CT scans/stress ECHOs – CADCT scans/stress ECHOs – CAD Pelvic US – ovarian CAPelvic US – ovarian CA Whole-body CT scansWhole-body CT scans

radiation~Hiroshima, raise radiation~Hiroshima, raise cancer riskscancer risks

Consequences of Unnecessary Consequences of Unnecessary TestingTesting

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

Diversion of limited resources – Diversion of limited resources – human and capitalhuman and capital

Erosion of evidence-based practiceErosion of evidence-based practice Unsound scienceUnsound science

LPCs and the Erosion of LPCs and the Erosion of Professional EthicsProfessional Ethics

General public subsidizes medical General public subsidizes medical trainingtraining

Physicians limit practice to wealthyPhysicians limit practice to wealthy Increasing differential of care between Increasing differential of care between

poor and wealthypoor and wealthy Financial factors replace clinical Financial factors replace clinical

judgmentjudgment

Contemporary Health CareContemporary Health Care

↑ ↑ wealth disparitieswealth disparities 20-25% of US children live in poverty20-25% of US children live in poverty

↑ ↑ environmental degradation (and related environmental degradation (and related illnesses)illnesses)

↓↓access to careaccess to care 45 million uninsured in US, underinsured, 45 million uninsured in US, underinsured,

dead end jobsdead end jobs Disparities by social class / race in access to Disparities by social class / race in access to

and outcomes of careand outcomes of care Developing world brain drain; medical tourismDeveloping world brain drain; medical tourism

LPCs and the Erosion of LPCs and the Erosion of Professional EthicsProfessional Ethics

Workups, treatments based Workups, treatments based on ability to payon ability to pay

EthicsEthics RationingRationing Acceptance of double Acceptance of double

standardstandard

LPCs and the Erosion of LPCs and the Erosion of Professional EthicsProfessional Ethics

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

More providers willing to “game the More providers willing to “game the system”system”

SolutionsSolutions

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

Equitable division of resourcesEquitable division of resources

Solutions: Medical Education Solutions: Medical Education and Ethics Trainingand Ethics Training

Increasing emphasis on social, Increasing emphasis on social, cultural, economic and environmental cultural, economic and environmental contributors to health and illnesscontributors to health and illness Health disparities, cultural Health disparities, cultural

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

Solutions: Medical Education Solutions: Medical Education and Ethics Trainingand Ethics Training

Heal schism between medicine Heal schism between medicine and public healthand public health

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

History, literature, role History, literature, role models/mentoringmodels/mentoring

Solutions: Public PolicySolutions: Public Policy

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

↑ ↑ public educationpublic education

Solutions: Public PolicySolutions: Public Policy

Deans, department chairs, division Deans, department chairs, division chiefs, ethicists, doctor-patientchiefs, ethicists, doctor-patient Ethicists quiet re LPCsEthicists quiet re LPCs

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

ReferencesReferences

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

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

ReferencesReferences

Donohoe MT. Luxury primary care, Donohoe MT. Luxury primary care, academic medical centers, and the erosion academic medical centers, and the erosion of science and professional ethics. J Gen of science and professional ethics. J Gen Int Med 2004;19:90-94. Available at Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.x10.1111/j.1525-1497.2004.20631.x

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

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Public Health and Social Justice Public Health and Social Justice WebsiteWebsite

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martindonohoe@phsj.orgmartindonohoe@phsj.org