Author Insights: Leaders at Academic Centers Often on Drug Company Boards

Walid F. Gellad, MD, MPH, of the University of Pittsburgh and staff physician at the Pittsburgh VA Medical Center and colleagues, found many leaders at academic medical centers are paid to serve on pharmaceutical company boards. Image: iStock.com/graffoto8

Walid F. Gellad, MD, MPH, of the University of Pittsburgh and colleagues, found many leaders at academic medical centers are paid to serve on pharmaceutical company boards. Image: iStock.com/graffoto8

Many leaders at academic medical centers are doing double duty, serving on the boards of pharmaceutical companies and being paid handsomely for it, finds an analysis published in JAMA today.

Nearly half of the top 50 pharmaceutical companies worldwide have leaders from top academic medical centers on their boards. Of the 17 US drug companies, 16 count academic center leaders. These individuals, who included 2 university presidents, 6 deans, 6 hospital system executives, and 7 department chairs or directors. The average compensation they received for board service was $312 564. By comparison, the average dean of medicine earns $445 781, and the average associate dean at a medical school makes $196 212, according to a 2012-2013 survey by the College and University Professional Association for Human Resources.

Walid F. Gellad, MD, MPH, assistant professor of medicine at the University of Pittsburgh and staff physician at the Pittsburgh VA Medical Center, discussed the study’s findings with news@JAMA:

news@JAMA: Why did you and your colleagues decide to do this study?

Dr Gellad: There’s a lot of interest in identifying potential conflicts of interest in medicine. There is the Physician Payment Sunshine Act, which reveals payments companies make to physicians. The issue is of great interest to medical trainees, especially because there are limits on receiving free pens or lunches. The issue of dual leadership at academic centers and on corporate boards has received less attention.

news@JAMA: Do you think this is a new phenomenon?

Dr Gellad: I don’t think it is new at all. One study in 2007 in JAMA looked at the corporate relationships of department chairs.

news@JAMA: Were you surprised by the number of administrators serving on pharmaceutical company boards?

Dr Gellad: Yes. There are different grades of leadership represented. They are not all deans or chief executives, but all have some leadership role. This is about individuals holding dual leadership responsibilities at academic and pharmaceutical companies.

news@JAMA: What about the magnitude of the compensation?

Dr Gellad: I think it is pretty standard for someone who serves on a corporate board. This is from public data. It also includes stock and charitable donations made on behalf of these individuals. These numbers are striking when the salaries of most academic center leaders are not that much higher than what they are receiving for serving on a corporate board. It is way greater than the average salary of most people in the country.

news@JAMA: What do you think can or should be done?

Dr Gellad: Our hope is that this paper gets people to ask that question. It’s up to university ethicists and other university leaders to decide what should happen. We need to understand the risks and benefits of these relationships. I think a lot of people are not aware these relationships exist.

news@JAMA: Is there anything you’d like to add?

Dr Gellad: We wanted to make clear in putting this together that we wanted this study to focus not on individuals but on the topic.

Author Insights: Drug and Device Companies Give Millions of Dollars to Groups Offering Online CME

Sheila M. Rothman, PhD, of Columbia University, New York City, and colleagues found that some organizations offering online continuing medical education courses have received millions of dollars in grants from drug and device companies and may share physician information with unnamed third parties. (Image: Columbia University)

Sheila M. Rothman, PhD, of Columbia University, New York City, and colleagues found that some organizations offering online continuing medical education courses have received millions of dollars in grants from drug and device companies and may share physician information with unnamed third parties. (Image: Columbia University)

Some medical communications companies such as Medscape/WebMD that offer online continuing medical education (CME) programs receive millions of dollars from pharmaceutical and device manufacturers and share information such as a physician’s licensing number and specialty with unnamed third parties, warn researchers whose findings appear today in JAMA.

In 2010, for the first time, 13 pharmaceutical companies and 1 medical device company posted grant registries on their websites, as a result of legal settlements in some cases and voluntarily in others. These registries included the names of health care organizations, including medical communication companies, that received at least 1 grant; the grant’s purpose; and the grant’s dollar amount. These postings go beyond the provisions of the Sunshine Act, which require reports of payments only to physicians and teaching hospitals.

A medical communications company was defined as an organization whose primary mission is to disseminate information about disease states, disease prevention or management, medical devices, or drugs and other therapies. In addition, to be classified as a medical communications company, the organization may not be a subsidiary of other recipient organizations, such as an academic medical center.

The 14 companies offered grants totaling $657.6 million in 2010. About 26% ($170.8 million) was given to medical communication companies, followed by 21% to academic medical centers and 15% to advocacy organizations targeting specific diseases. Of the 363 medical communication companies, 18 received more than $2 million each and were approved by the Accreditation Council for Continuing Medical Education to deliver CME courses. Medscape/WebMD received the most grant money ($20.3 million).

Of the 18 medical communications companies receiving the largest grants, 17 offered online CME courses, which gave them the opportunity to collect personal data and create digital profiles of physicians without the latter’s explicit consent. The researchers wrote, “It is possible that physicians using [medical communication company] websites do not appreciate the full extent of [medical communication company]-industry financial ties or are aware of data sharing practices.”

Lead author Sheila M. Rothman, PhD, Columbia University, New York City, discusses her team’s findings.

news@JAMA: Why did you do the study?

Dr Rothman: I’ve been very interested in the issue of conflict of interest. Then pharmaceutical and device companies put all their grant registries online, and for the first time, we could look at not just grants to physicians but also to institutions.

news@JAMA: How do medical communications companies work?

Dr Rothman: These organizations are fairly obscure and haven’t been studied. They essentially are groups that provide information they get from pharmaceutical companies and give it to consumers and physicians. They also take information from consumers and physicians and “give” it back to pharmaceutical companies.

news@JAMA: What should physicians take from your findings?

Dr Rothman: These companies are involved in online CME, and what surprised us, when we looked more thoroughly, were the privacy policies. Not only do they ask for a physician’s e-mail address, they want license numbers and specialty information. It became clear to us they shared and sold this information.

news@JAMA: Are these online CME courses then suspect?

Dr Rothman: We showed how much CME is online, but we analyzed the number of physicians going online, not the content. We want physicians to be aware of the privacy issues, that in the process of taking an online course to maintain your professional status, the group giving it may be selling your information to someone else.

Too Few Generalist Physicians Doesn’t Necessarily Mean Too Many Specialists

Aaron Carroll, MD, MS

Aaron Carroll, MD, MS

It’s hard to find an article or op-ed about the implementation of Obamacare next year that doesn’t mention the looming “doctor shortage.” The reason is clear: there are too few physicians in the United States to care for today’s insured population, let alone the potential 30 million people who will be newly insured in 2014.

A recently released article in Washington Monthly, “First Teach No Harm,” takes a hard look at the educational system producing our physician workforce. While addressing the issue of physician education, it takes to task residency programs in general. It’s not cheap to train a physician: most teaching hospitals are given about $100 000 a year for each resident slot, or about half a million dollars on average to train each physician. But the article’s author says the money isn’t being spent as wisely as it should be:

America does indeed face a looming shortage of medical professionals, but because of the way it’s spent, that $13 billion subsidy isn’t helping us fill the gap. The nation’s residency programs are producing too many of the wrong kinds of doctors in the wrong places, while not producing enough of the kinds of doctors we most need to sustain the US health care system.

Specifically, the programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. Meanwhile, residency programs are producing a dwindling number of primary care physicians and other generalists, who are already in chronically short supply in most parts of the country and are desperately needed to implement the kind of reforms to the health care delivery system necessary to improve its quality and efficiency.

There is some truth to this. The United States does have a higher specialist-to-generalist ratio than pretty much any comparable country in the world. It’s also true that most specialists tend to go on to practice in areas where physicians aren’t in short supply. Furthermore, the article correctly points out that many of the top residency programs in the world are turning out very few primary care physicians, and most of these do not go on to practice in the parts of the country that need physicians most.

Some of the blame can be laid at the feet of the medical education system. The vast majority of time spent in residency education is in inpatient, often critical care, settings. People practice what they see, and when it comes to residency, most of what trainees see is hospitalized patients with a lot of subspecialty-focused issues. Given that we need many of these training to become primary care physicians, the relative lack of exposure to such clinicians is somewhat odd.

But not all of the blame can be placed on educational programs. The reimbursement system of the US health care system heavily favors subspecialty care. Given that many students graduate with a significant debt, and given the fact that in a capitalist system higher-paying jobs are more attractive than lower-paying ones, it’s not surprising that many trainees tend to gravitate away from generalist fields. It’s sometimes hard to justify the money they give up by not choosing a specialty.

It’s also important to recognize that although we may have too few generalists, that doesn’t mean we have too few specialists. Here’s a graph I made with data from the Organisation for Economic Co-operation and Development to show the number of general practitioners we have per 1000 people, compared with other similar countries.

carroll GPs

Given the rhetoric often used, many wonder what a similar graph for specialists might look like. The results may surprise you.

carroll specialists

The United States doesn’t have too many specialists compared with other countries. It has a rather average number of specialists. It’s just that we have so few generalists, it feels like we have too many specialists.

Many people, including the author of the Washington Monthly article, call for a reduced number of specialist training spots. What that might do, however, is give us too few specialists compared with other countries. What we may need to do is drastically increase the number of primary care training spots while not reducing our specialist capacity. Such an undertaking is sure to be expensive. That will make it unpopular. But that doesn’t mean it’s not necessary.

***

About the author: Aaron E. Carroll, MD, MS, is a health services researcher and the Vice Chair for Health Policy and Outcomes Research in the Department of Pediatrics at Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

About The JAMA Forum:  JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

JAMA Forum: Making the Most of the Medical Degree’s Versatility

Eli Adashi, MD, MSThe arduous track leading to the medical degree generally continues along a single path toward equally taxing residencies and fellowships. What usually follows is a lifetime of comforting and healing in private, public, or academic settings. Few professions can claim to be as admirable or noble.

Still, one cannot help wondering if consideration should be given to alternative paths. Is there more to a medical degree than meets the traditional eye? Is it all that it can be? Are current aspirations of those who attain it commensurate with present-day needs and opportunities? Are medical students exposed to the unconventional, let alone encouraged to explore it?

These and related questions first came calling during my tenure as a medical school dean, when students who were grappling with career decisions would come to me for advice. All too frequently, a guilt-filled confession would presage a conversation revolving around nonclinical professional interests. Would I approve of unorthodox career choices? Might I frown upon a road less traveled?

Their concerns couldn’t be further from the truth, because I have come to realize that the medical degree’s versatility is woefully undervalued. Other professions have long seen the light. For example, how many proud owners of the Juris Doctor degree argue cases in court as a matter of course? In all likelihood, precious few. Instead, lawyers put their talents to good use in numerous walks of life.

So I would encourage those with a medical degree who are drawn to an unconventional path to by all means “Go West, young medical man and woman!” and seek new kinds of opportunities. A medical education provides insights that are invaluable to diverse fields of human inquiry and pursuit that are complementary to comforting and healing—and are no less relevant.

In an economy in which health care expenditures account for close to one-fifth of the gross domestic product, opportunities abound. Furthermore, with globalization well under way, US-trained physicians are no longer confined to familiar shores as vast new needs and opportunities unfurl. Although precise numbers are hard to come by, there can be little doubt that growing numbers of them are being thrust into positions of leadership in parts of the globe where their expertise is highly valued. Leading the way will be physicians who attained additional training in fields as diverse as business, public health, public administration, and law.

Perhaps the most obvious outlets for physician leadership are health systems, free-standing hospitals, skilled nursing facilities, hospices, and other institutions of care. However, physician leadership is equally central to health plans, think tanks, professional associations, and of course the corridors of government.

Physician leadership need not be limited to government’s executive branch. Much could be said for increasing the ranks of physicians in the US Congress, which currently has 3 physician legislators (3%) in the Senate and 22 (5%) in the House. By comparison, 169 members of the House (38%) and 57 members of the Senate (57%) have law degrees.

Physician leadership also constitutes a key ingredient of a vibrant private sector. It is difficult to envision commercial success in the health care arena without physician leadership in the pharmaceutical industry and the universe of biotech startups, not to mention venture capital enterprises, hedge funds, consultancy shops, and private equity firms.

When I visit with medical students and residents in training, I inquire about alternative career paths, and I am generally left with the sense that interest in alternatives to the well-trodden track remains low. Such is the power of tradition and culture. Only the occasional student seems to resonate with the notion of expanded vistas and voices these thoughts in public or in private.

Still, such conversations about alternative career paths are occurring at a time when concepts about our health care system are evolving. In this time of change, I cannot help feeling that all enterprises that affect health and health care would do well to seek and embrace the input of medical professionals.

***

About the author: Eli Y. Adashi, MD, MS (Eli_Adashi@brown.edu) is Professor of Medical Science at the Warren Alpert Medical School of Brown University in Providence, RI. A member of the Institute of Medicine, the Council on Foreign Relations, the Association of American Physicians, and the American Association for the Advancement of Science, Dr Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, and ethics. A former Franklin fellow, Dr Adashi served as a senior advisor on Global Women’s Health to the Secretary of State office of Global Women’s Issues during the Obama Administration.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Author Insights: Internal Medicine Residents Are Reluctant to Pursue Primary Care Careers

Colin P. West, MD, PhD, Mayo Clinic in Rochester, Minn, and a colleague found a large percentage of residents training in internal medicine programs plan to pursue a career in a subspecialty rather than in primary care. (Image: Mayo Clinic)

Colin P. West, MD, PhD, Mayo Clinic in Rochester, Minn, and a colleague found a large percentage of residents training in internal medicine programs plan to pursue a career in a subspecialty rather than in primary care. (Image: Mayo Clinic)

A large majority of internal medicine residents, including a majority of residents in primary care programs specifically designed to promote general medicine careers, are planning to enter subspecialty careers rather than become general internists. The findings, appearing today in JAMA, are based on data from an annual survey linked to the Internal Medicine In-Training Examination taken in October of 2009-2011.

Of the 16 781 graduating third-year residents surveyed, only 21.5% reported planning a general internal medicine career. For graduating third-year residents enrolled in primary care programs, only 39.6% were considering such a livelihood. Women and US medical school graduates were more likely to report general internal medicine career plans than men and international medical graduates.

The study was conducted by Colin P. West, MD, PhD, and Denise M. Dupras, MD, PhD, of the Mayo Clinic in Rochester, Minn. Dr West discusses their findings: Continue reading

ACP to Congress: Fix Broken Politics to Preserve Needed Health Programs

The American College of Physicians called on Congress to preserve key health programs by adopting alternatives to automatic budget cuts slated to begin next year. (Image: vicm/iStockphoto.com)

The American College of Physicians (ACP) took aim today at the country’s “broken politics,” telling Congress that it should replace $1.2 trillion in across-the-board budget cuts beginning in 2013 with a new budget package that preserves essential health programs while achieving similar or greater savings.

“As we enter a 2012 election that may determine the direction of health care for decades to come, ACP calls on the candidates to rise above the fray and provide clear answers on how they would improve American health care, not use vague rhetoric about the value of the status quo or the past,” said ACP President Virginia Hood, MBBS, MPH, during a teleconference. Continue reading

Author Insights: Medical Schools Offer Little Training on Caring for LGBT Patients

In a study initiated at Stanford University School of Medicine, Mitchell R. Lunn, MD (now a resident Brigham and Women’s Hospital and a clinical fellow at Harvard University) and colleagues found that medical schools offer little training in the health needs of lesbian, gay, bisexual, and transgender individuals. (Image: Madika Bryant)

Most US medical schools report dedicating only 5 hours to educate physicians-to-be about the health needs of patients who are lesbian, gay, bisexual, or transgender (LGBT), according to the results of a survey published today in JAMA. And about one-third offer no such clinical training at all.

A recent Institute of Medicine report highlighted the need for physicians and clinical researchers to pay closer attention to the health needs of patients who are part of the LGBT community, which historically has been underserved by the medical establishment. To correct this disparity, the report noted, physicians must be aware of the health issues that may affect LGBT individuals, such as higher rates of depression or substance use among youths, lower rates of cervical cancer screening among lesbian women, and increased risk of sexually transmitted infections among men who have sex with men. But there have been limited data available about coverage of LGBT health care in medical education. Continue reading