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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. 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

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  1. Luxury Primary Care and Academic Medical Centers:The Erosion of Science and Professional Ethics Martin Donohoe

  2. 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

  3. Financial Crisis:Responses • Increasing links with pharmaceutical and biotech industries • Recruitment of wealthy, non-US citizens • Luxury primary care / executive health clinics

  4. Luxury Primary Care/Executive Health Clinics • Most major academic medical centers • 2000-3500 visits per year • $1500 to $20,000/visit • Avg. $2000-$4000

  5. LPC Clinic Perks • Same day appointments/tests, accompanied consults, vaccines • Shorter waiting times • Low physician/patient ratios • 24/7 access, house calls

  6. 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

  7. Unknowns • Medical student/resident participation • Effects on physicians • Effects on old patients • How funded • Where profits go - ?cross-subsidization? • Secrecy

  8. 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

  9. 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

  10. 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

  11. 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

  12. LPCs and the Erosion of Professional Ethics • Workups, treatments based on ability to pay • Ethics • Rationing • Acceptance of double standard

  13. 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”

  14. Solutions • Renunciation of the measure of the marketplace as the dominant standard and value in health care • Equitable division of resources

  15. 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)

  16. 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

  17. Solutions: Public Policy • ↑ education of public policymakers (business leaders, government representatives, and health care purchasers) • ↑ public education

  18. 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

  19. 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).

  20. 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

  21. Contact Information Public Health and Social Justice Website http://www.phsj.org martindonohoe@phsj.org

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