Dr's influenced by money? Am I naive to think it's rare?

Anonymous

I had a conversation last night with someone I know who is an oncologist (she specializes in lung cancer - but treats others). I hadn't seen her for awhile and found out she had recently quit the oncology practice she was working for (which I happen to go to) and was about to start a new job with a non-profit cooperative.

Call me naive, but part of the conversation was genuinely surprising to me. When talking about her job change...she said it "will be nice for her to be able to say again that the treatment she is recommending has nothing to do with financial gain". She started working for this partnership practice a couple years ago (after working as an oncologist in the military) and she told me that she didn't like the focus on profits. You needed to see X amount of patients... And the one that got me... was that chemo was one of their biggest "money makers". The more chemo they prescribe, the more money the practice makes...the more money the partners make. 

I did, and still do, go to the practice she just quit. My MO, who happens to be a partner, actually discouraged me from chemo based on my Oncotype score of 14...said he'd advise the same to wife/daughter. So I know not all of them are motivated by money/unethical. But it still leaves a bad taste in my mouth that they make "more money" for certain treatments.

I suppose it doesn't really surprise me..I mean, if you're not non-profit, then you obviously make/want a profit. Somehow my naive self thinks all the docs would never be unethically motivated by money. But what if they get an early stage patient in (like me).. that could easily be on the fence about chemo??  Their practice makes a lot more money if the patient does chemo AND tamoxifen as opposed to just tamoxifen. And both recommendations would be within guidelines and ethical.... but how many docs (in a private practice) might be slightly/subconsciously/consciously biased to recommend chemo for the additional financial gain?

Makes me think "on the fence" patients should get at least one opinion from a non- profit.

christina0001

I might be naive too, and there are always exceptions, but I cannot imagine any oncologist would recommend unnecessary treatment in order to increase profits. And in the event that one did, fortunately (!) most of us have medical insurance companies that would likely deny the claim.

Unfortunately healthcare is a business, and the business people that run healthcare organizations do put pressure on physicians to see X number of patients, or do other things, to increase profits. I work in healthcare, and there is definitely pressure to do whatever employees can to increase profits. While I respect that a company has to bring in revenue to stay afloat, pay employees and continue to provide services, a company also has an obligation to not encourage unethical behavior in their efforts to stay profitable.

Don't think for one second that this does not happen at non-profits, because it absolutely does. The only difference is that instead of the profit going to shareholders, it stays within the company.

I worried about this when I had my consult with my rad onc, and he recommended rads. He's a sweet guy who clearly does not have a lot of patients; he seems to spend a fair amount of time in the chemo department just chatting with people (which is nice - he's a nice guy). But I fell into a grey area as far as rads were concerned, and I was worried that he might be recommending rads just to have another patient. I did get a second opinion; I went to an NCI cancer center and informed the rad onc there that I had no intention of getting any treatment from her, I just wanted a second opinion from another rad onc. We had a great consult and she agreed that rads were very appropriate for me. Also the request for rads had to go to medical review with my insurance company, and they also approved it. So I knew then that my rad onc was truly recommending what was best for me.

I think most doctors do indeed care about their patients - I don't think they become doctors to make money for big healthcare companies. And I would think, even more so with oncology specialists. This is just my opinion, but I suspect it's too demanding a field, and too emotional, to go into solely for money. I do completely agree with you when you suggest anyone "on the fence" get a second opinion.

Wren44

Read "The Harm We Do". I think the author's name is Bradwell. He's an officer in the American Cancer Society. Pretty scary. I'm sure there are lots of docs who are not influenced by money, but being influenced by the bottom line is not rare.

1Athena1

Susan, you always being such interesting topics and I love how you don't take things lying down.

I really don't think doctors are any different from anyone else. I find it hard to believe that someone would put themselves through the hell of med school and a residency just to make loads of money. I mean, why not just go to Wall Street. English majors become traders all the time.

And yet people DO do that. They do put themselves through hell just for money. And there are doctors who really don't care. Indeed, this is preoccupying many medical schools. They are trying to change their admissions policies to a more "holistic review" way of seeing things. The old standard of relying on excellent grades and MCAT scores was producing a lot of good brains abut often hollow hearts.

And if I were one of those doctors will hollow hearts and lots of greed, I think I would consider oncology. Pots of cash, patients don't object to much or question much because they are so scared of cancer that they say yes easily. And society isn't going to punish a doctor for overtreating, because cancer seems to have this aura about it in which "more is better" in terms of treatment - if not scientifically so, at least in the purview of social acceptability.

Now then, whether this means that many oncologists are hollow is another question. I don't think their job is enviable by any means. Most people aren't sociopaths, and cancer is very depressing to have to deal with. It also has to be professionally demoralizing to be a doctor who can't cure many of his patients and often sees them progress from able bodied to dead. Much of the best treatments for large organ cancers are done by surgeons, not oncologists. Chemical treatments for large organ cancers have a frustratingly low success rate. So for an ambitious practitioner and one who wants to help, oncology has to be frustrating.

Other oncs might just be muddling through and persevering. Many also double as hematologists and, in some cases, as PCPs. They might get their money from cancer and their professional fulfillment from non cancer.

Maybe many oncologists, knowing that as cancer doctors they will have oodles of deaths, may tell themselves that someone has to do this thankless job and that society should be grateful. And I would have to agree with that... Just as undertakers, chimney sweeps and others render invaluable services that society desperately needs but wishes it didn't.

Conclusion: oncs, humans that they are, come in all shapes and sizes so generalizations would be absurd. The US health care economic system is the really broken party here, not the practice of medicine.

My onc? I think he is a good man who wants to help people. He was my second opinion. My first opinion struck me as an hysterical chemo booster and pinkwasher.

Finally, while oncology has lots of financial incentives, it isn't the most profitable of the specialties. There are others where doctors can earn more with less heartbreak. So for the truly greedy, it may not be enough. Although after so many deaths, I think I would want to be well paid too. There has to be something in it for me.

These disjointed thoughts are all I can offer.

As with everything cancer, lots and lots of nuance.

Wednesday brain droppings. :-)

Nurse_Lizzie

This is a fascinating discussion, and one that I debate with myself (and others) frequently.

I agree with much of what the previous posters have said.  There are good doctors and bad, doctors who are in it for the financial gain, and those who are in it for more altruistic goals.

However, oncology is a really really good example of the "perfect storm".  All doctors are taught to cure, and if they can't cure, they often feel like failures.  So they will continue to attempt to cure even when those attempts are futile.  It is the rare physician who specializes in palliative care, and will have a very honest conversation about the realities of treatment.

And, chemotherapy has its own really "special" issues.  Unlike many other treatments, chemo is not given like a prescription, where the patient leaves the MD office and picks up their med from another business. With chemotherapy, the physician office actually purchases the med from the drug company and administers it within their practice.  They make OODLES of money on some of these chemotherapeutic agents.  Oncology can be a very lucrative practice. Doctors know it, and their money people know it.  There are huge incentives to continue to treat, and the physicians can continue to work on the cure...

Absolutely there are some physicians who will only practice within their ethics, but with the economies of health care these days, they also aren't being paid for a lot of things, so there are huge pressures to provide those services that they can make good money on. I know of many physicians (not just oncologists) who left practices because they would not meet the productivity and income standards they were required to maintain.

Unfortunately we in the US do not necessarily make decisions about the best cancer treatments, and do not necessarily use evidence based care.  Insurance companies often make determinations about what they will pay for based solely on cost, which is just as ridiculous. 

The system that we have in the US is horribly flawed.  And we, the patients, get stuck in the middle. 

1Athena1

Nurse_Lizzie, you say:

Unfortunately we in the US do not necessarily make decisions about the best cancer treatments, and do not necessarily use evidence based care. Insurance companies often make determinations about what they will pay for based solely on cost, which is just as ridiculous.

Just wanted to reprint this part of your post because it is an excellent point. One very familiar to healthcare economists, medical school deans, science policy analysts and biomedical researchers. Sadly, the public still believes the opposite is true.

Anonymous

Thanks for chiming in.  I love reading everyone's various "brain droppings". (love that Athena)

For $hits and giggles, I did question her about whether she thought/knew there was a "cure" and if big pharma was hiding it from us because they'd lose money.  She did laugh (and semi-convincingly deny it). 

I suppose I like to believe that MOST doctors are ethical and not in it just for the money.  But I can't help but wonder if they even subconsciously err towards the side of more treatment because of the added financial benefit.

Though I completely agree that insurance companies make decisions based on costs.

Anonymous

Also interesting talk regarding the Oncologists administering the chemo within their own practice.  Never really thought about that.  Anything else they prescribe would go to an outside source (scans, hormonals, radiation, surgery).  So it would make sense that chemotherapeutic agents are their money makers.  Why did that not dawn on me until now? 

Wren44 ~ is the book you are talking about maybe called "How We Do Harm; A Doctor Breaks Rank About Being Sick in America", author Brawley.  From your description, I believe it's the same one you are talking about.  I just downloaded it to my Kindle.

Rdrunner

Interesting topic,  and I agree evidence based practice is a must.. but the onco type thing... hmmm the science is the way of the future for sure, but I have huge issues with this oncotype test and how it is being used right now.

Anonymous

Rdrunner ~ what are your issues with how the oncotype test is being used?

Rdrunner

Well, Im not sure I want to write it here the why and what of it, but my main concern is with reliabity and accuracy of the test. 

Anonymous

I suppose if you don't feel it is accurate or reliable, then you could decrease the amount of importance the results have in making a treatment decision... or forgo the test all together.

voraciousreader

The book mentioned earlier, How We Do Harm is written by Otis Brawley, MD. You can watch his SRO lecture on youtube given before a group of healthcare journalists. Extraordinary!



Worth spending 56 minutes watching!

fifthyear

Yes, How We Do Harm is an amazing book! I do agree that oncos are human and they come in all sizes and shapes, but I also think that it is a very hard and long road to become an oncologist. It must take more than $$ for someone to choose that path, I am hoping it is the desire to help others. Otherwise, go into cosmetic surgery and make tons of money, mostly CASH as well!

Anonymous

VR ~ Thanks for the tip on the SRO lecture, I will look that up.  I did download the book and look forward to reading it this weekend.  I 

voraciousreader

BTW.. Niece, bless her is a pediatric oncologist. When she finished her fellowship, many top ranked institutions, including Cleveland Clinic offered her jobs. She wanted private practice instead. Many private practices are being gobbled up by institutions making it difficult for doctors to give long appointments. Likewise, in private practice, there's that equal pressure of seeing a great number of patients. Dr. Brawley is critical of institutions, pharma, physicians and support charities. The book and his speech are very enlightening.





A good primer on how medicine can be fixed is written by Eric Topol,MD. In his visionary book, The Creative Destruction of Medicine, he describes how technology is and will improve medicine.



Both books rock! Really! I can't give them both enough accolades. Brawley tells us what's wrong and Topol tells us how to fix it!

MameMe

Roadrunner, I also have been very concerned about the way that the Oncotype Dx has taken over the market, and eclipsed the use of other indicators that are far less costly. When I mentioned my doubts about the Oncotype Dx being a heavily marketed product, the person to whom I was speaking said, "Oh, but its not a product, its diagnostic test. " I knew then that Genomic Health was doing a nice job of masking their gains and boosting profits through keeping the business end of things vague.

What were some of your concerns?

Anonymous

By the way, I finished "How We Do Harm".  Great book and very eye opening. Interesting seeing it from this doctor's perspective.  I still need to checkout the SRO lecture.

I was especially interested in his discussions about Prostate Cancer and his opinion about it being grossly over treated, leaving men needlessly incontinent and impotent.   It seems as though we (sometimes) get so emotionally blinded by the word "cancer" that we automatically assume "more is better", without rationally considering the real and serious side effects.  

It's also interesting how the author pointed out in an example of his friend dying from a complication that was a direct result of his radiation therapy for his prostate cancer.  (I can't remember what it was ~ maybe an infection?) Anyway.. the cause of death will say, "infection" or "heart attack" ...but not "death due to prostate cancer treatment".

In the end it really brought home that you have to be your own advocate.  You should not just blindly trust doctors without doing some homework/research yourself, asking questions, and have meaningful conversations with them about your treatment.

bevin

Really interesting.  I can tell you that I was informed by my Rads Doctor that some doctors recommend Mammosite radiation over regular external beam radiation as they get a LOT more money for it. hmmmm.

voraciousreader

Susan, I am glad you enjoyed reading Dr. Brawley's book, How We Do Harm. I thought the takeaway message was the need for "rational" medicine and how it is often hard to find in the din of competing voices....also recall how that one highly educated patient truly wasn't her own best advocate. The book is a terrific read and a cautionary tale...

marywh

My dads decline began with prostate cancer. They zapped him with so much rads, they completely ruined his bladder, he had to use a catheter  for the rest of his life. His quality of life really went downhill fast. Although he lived for 7 years after dx. his life was never the same and depression set in. very sad.

itsjustme10

My "moment" was with one of my surgical opinions.  Opinion #2, whom I did not choose, was only willing to do a BMX one breast at a time, and only if I used her plastic surgeon, who did not accept my medical plan.  She said she would not do the 2nd breast for at least 4 months.  She gave me no choice in the matter, it was her way, her plastics person, everything, or the highway.

Coincidentally, much later, and after my successful BMX, when I was speaking with surgeon #3, I mentioned this, and she told me what my friends and I suspected...their contract with my health insurer pays 1.5 times the fee for a BMX if done at the same time, but if you wait more than 4 months between breasts, they will consider it a second surgery and pay twice....

While I do understand and can empathize with the economic reality of having to pay a 6-figure malpractice insurance bill, along with everything else involved in running a business, hearing the confirmation made me really grateful that I chose not to use that woman.

MrsH

Justme, that's outrageous! I find it interesting that the majority of people don't consider that a lot of Dr's don't actually have their patients best interests in mind. I always feel a little like a crazy person when I try to suggest that chemo might benefit my Dr. more than it would me. This thread just confirms it.

warrrior3

Good morning ladies, this subject caught my attention and I had to give my opinion. I agree medicine is a business. I worked in an ENT office for over 15 years starting when insurance would pay for service, before HMO' s. The difference in reimbursements were unbelievable. Our senior physician who started the practice was not about money, but when he hired his 1st partner straight out of Medical school I noticed a huge difference. He wanted 2 new pts an hr and 4 follow up pts minimum. He became very involved in my job (billing, insurance), and yes did consider the way sx was reimbursed. 100% for the first procedure, 50% for the second procedure and 25% for the others. New office visits became consults, we started weighing pts just to build up a consult code. Medicine is a business.