Entrepreneurialism Unchecked by Professionalism
My job is different from selling. My job is not to sell you, as my patient, as much health care as you want, rather it is to provide you what you need. My ethics as a physician lead me to deliver only as much health care as my hard-won professional judgment tells me you need - and no more. That's because, as we all know in our profession, every intervention we recommend can do harm. A salesperson's job, on the other hand is to find out what you want and sell it to you. It doesn't really matter if you don't need that much refrigerator or that much car or that much house. If you want it and can pay for it, a salesperson's job is to sell it to you. I'm not implying that salespeople are inherently unscrupulous - not at all. But I maintain that their job is to sell you what you want, not merely what you need.
My concern is that, in health care, I see an increasing trend toward selling and away from the professional restraint that has long been our ethical framework. I recognize there is a slippery slope here, and that some degree of entrepreneurialism has long been a part of medicine and it has largely been for good. But in the past few years, there have been some dramatic events that highlight the differences between the credo of selling and the credo of caring: the mere rebranding of the cheap, compounded, 17-P progesterone into Makena and charging more than 75 times as much to prevent recurrent premature births; the regrettable Mr. Shkreli, having learned from the Makena success, getting brand-only status for generic pyrimethamine as Daraprim and hiking the price of this medicine, so essential to HIV patients, some 50-fold; and the sadly similar Epi-Pen and Narcan price gouging scandals.
But the less dramatic things seem more disturbing. The slippery slope may be getting more slippery. Examples include things like increasing physician self-referral to imaging centers they own; prominent academic surgeons in our state with massive conflicts of interest arising from tens of millions of dollars in payments from device makers; the growing trend of "medi-spas" that some physicians are involved in; or even just selling the remedies you recommend in your own office.
Conflicts of interest do not inevitably cause ethically questionable behavior, but the risk is real. Also real is the risk that even those doctors whose practice is characterized by the ideals of "diagnostic elegance and therapeutic parsimony"1 will give in to pressure from patients, or to excessive concern about the results of patient satisfaction surveys, to do more than is necessary.
These risks are only managed properly when we constantly bring our focus to what is necessary to care for the patient, informed as much as possible by science - not to upsell them with the health care equivalent of a special rustproofing package for that new car; and not to say yes to a request to do more, just to have another satisfied customer. To steal a line from the 80s show Hill Street Blues: Let's be careful out there.
1. A phrase I often heard repeated by someone I was fortunate to learn from, Edmund Pellegrino, MD.
Ken Schellhase, MD
The mission of WAFP is to promote excellence in health care and to improve the health of the people of Wisconsin through the advancement of the art and science of Family Medicine, the specialty of Family Medicine and the professional growth of Family Physicians.