October 26, 2010

Why Do Doctors Accept Gifts, And What Would Happen If They Didn't?

fine, I'll just do psych

Is the acceptance of Pharma gifts/honoraria/grants a way of supplementing an income that the medical student expected he would earn, or expected he deserved, in the future-- that didn't materialize?

Apparently not.  A study of medical students found they underestimated their future incomes.

students perception of incomes.png

Pre 1980, med students overestimated the salaries.  After 1980, they underestimated them. Let it sink in, it's pretty easy to retrofit an explanation: after the healthcare overhaul of the 80s (and the lead up to it), post 1980 medical students were trained by doctors who felt "harmed" by the changes.  "Man, it was so much better 5 years ago..." and etc.

The the Clinton years-- both Clintons-- and the prospect of even more severe changes made students even more pessimistic about their salaries.

But think about this.  In order for them to have underestimated, what they thought was going to happen must not have actually happened.  e.g. a 1993 med student made a prediction based on Hillary Clinton's reforms-- which didn't happen.

So a medical student today, making predictions about the future based on the current health care debates, will either be accurate, or will underestimate.


But, as usual, it's more complicated than that.

That graph shows the means of the students' errors.  How variable were the guesses?  Hugely. 10% of the 4th year students overestimated the incomes by 40%.  Did they go on to take Pharma money? 

While most specialties were underestimated, where did students overestimate?  Psychiatry, by 23%!

Worse, 10% of first year students overestimated incomes in surgery, pediatrics, and psychiatry by 60%.  That would be a life plan oops, solved only by...

So while the proposed reforms in internal medicine didn't happen-- or docs were able to compensate for them-- psychiatry did, in fact, dramatically change.  And, not surprisingly (from an economic standpoint) psychiatry found a stop gap.


Along with expectations, there is the reality that doctor salaries (with notable exceptions) have been fairly static since 1969:

physician salaries 1996.png
even as the cost of living, price of homes, college, etc have gone up.  And medical school debt.  

But what's not pictured here is how the atual work of medicine has changed, even if the incomes are the same.  1969 psychiatry was slower, more therapy based than today's 15 minute med checks.  You read medical journals-- and books-- at work.  Now you don't even read your text messages. You can argue the merits of either, but the current system incentivizes doctors to see more patients, faster, for more limited problems.  In 1969 a GP would handle multiple problems; now multiple doctors handle each problem.  I'd predict that the time spent by all 2010 docs collectively is still less than the one guy spent in 1969.

Could a psychiatrist able to make Pharma money just turn his back on $40k extra a year?  It's a cold decision to make when you got one kid in college and another on deck, suddenly public ethics takes a back seat to private ethics: what would you do for your children?  Jean Valjean a bakery?   Sling crack?  Sell it if it was legal?   Rob a crack dealer?   Well, you don't have to yet: just give a lecture about Effexor.


The part of this that is absent from the healthcare debate is that the people who would most likely complain about the changes in psychiatry are less motivated to do so because their incomes are being supplemented by Pharma.

My point here isn't to engage in an ethical debate, but to bring up the practical one: if you stopped all Pharma money to those that receive most of it-- e.g. academic docs who "also"  get grants to do research, etc-- it's almost certain that they would mobilize to demand higher reimbursement rates, not passively accept lower ones.  The healthcare debate would be turned upside down, from finding ways to "cut costs" to finding ways to "more fairly reimburse doctors."

"Psychiatrists shouldn't do it only for the money!"  Of course, but it's hardly less honorable to not go into psychiatry and go into neurology instead.  Leaving it to be staffed by NPs, which is the immediate problem in family practice.  Of course I know most psychiatrists don't take/aren't offered Pharma money.  But, to repeat, the ones who are likely to be most influential in setting healthcare policy-- academics-- do.  As do the academic departments, who rely heavily on grants to pay for salaries, overhead, and that new Research Centre that just went up.  I'm not blaming them, they may not even realize just how much of their existence is subsidized by Pharma, I'm simply stating a fact.  Stop the Pharma money, and you are quite likely to arouse a sleeping giant.  Harvard's gotta eat.

I am almost tempted to wonder if the rise of Pharma money 1996-2008 wasn't consciously encouraged by policymakers precisely to allow the policymakers the cover to get away with the sort of changes that happened in psychiatry.  Another mercantilist conspiracy theory, I guess.

No doubt people are going to respond that doctors make plenty of money already.  This is not the point.  Each individual doctor is making that determination for themselves, even if they're wrong you won't be able to convince them they're wrong.  And their perception, wrong or right, is going to drive them to make choices like: take Pharma money, go actually work for Pharma, go to another field, go to another job, do/not do only 15 minute med checks, leave Cleveland for San Francisco, etc.

No doubt, doctors universally would be happier with higher reimbursements and no Pharma money. It's not obvious patients would be better served-- psychoanalysis was not Pharma sponsored-- but things would defintely change in some way. 

Time: "The new legislation adds a 10% bonus to primary-care physicians' Medicare reimbursement salaries. But this is nowhere near enough. We need to see a 30% to 50% increase in salaries overall to make any real change in the system," says Dr. Lori Heim, president of the AAFP.
But I'm not sure it's actually possible.


An interesting experiment is to open a forum to solicit practical ideas for reform that takes into account the unintended consequences of the reform, and accounts for them.   To crowd source a crowd's problem. 

It's an experiment because-- hypothesis-- people don't actually care about practical solutions, they are much more interested in their own anger, and will sabotage a potentially useful forum in order to vent it.  They will sabotage the country, just to be able to yell.

If I had to name the specific problem with political debate post 1992, that would be it.  And yes, there's a word for it.

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