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Medical Forum / General / General / September 2005

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online cash for docs

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fresh~horses - 21 Sep 2005 21:26 GMT
http://www2.epocrates.com/index.html

Check the "Honors" box on the left.
Howard McCollister - 22 Sep 2005 00:24 GMT
> http://www2.epocrates.com/index.html
>
> Check the "Honors" box on the left.

epocrates is generally small potatoes for honoraria, as are most of the
online offers. I, and most doctors I know, get such invitations by email and
regular mail at least a couple of times every week - fill out a survey by
phone or mail and get $100. Drug companies mostly, but some equipment
manufacturers and some marketing firms. Then, there are various other
consulting agreements, usually involving money plus travel expenses,
honoraria for speaking engagements....stuff like that. It's nothing
new...been going on for many years now.

HMc
Sbharris[atsign]ix.netcom.com - 22 Sep 2005 02:15 GMT
> > http://www2.epocrates.com/index.html
> >
[quoted text clipped - 10 lines]
>
> HMc

COMMENT:

What??  They've been offering ME only $35-- stuff in that range. I just
got one today in the mail.  And for half an hour of my time, I've been
too lazy to do it. I might, for $100.

I'm trying to figure out how having somebody pay me to tell them how
much of their advertising I listen to, causes harm to the world.

I suppose I could make a long complicated reasoned argument for a
causal chain, but at the end I wouldn't really believe it. No, the
answer is, I really am that lazy.

Back when I was an intern making $17,000 a year (which dates me,
because for a LONG time before that interns made quite a lot less, and
very shortly thereafter quite a lot more), some of these doctor opinion
thingies came with a $5 check enclosed. So then the moral problem was
do you cash the check and NOT do the survey?  They did make it clear it
was on the honor system, and I had no obligation to do the survey (and
of course no legal one either-- if somebody sends you a check in the
mail, it's yours).

Dilemas, dilemas. And of course doctors aren't the only people paid to
fill out marketting surveys. We just get paid a little more. ($100??
Really? That's obscene. Must be a surgical instrument deal).

SBH

PS. Hey, Howard, did you make your contribution to the Red Cross
Katrina fund, yet?  Good for you. Feel any better? Me, neither.

On future 1040's, it seems I'm due to make a major contribution to "The
War on Terror."  But I can't seem to find anybody in Washington who
doesn't understand that this is not the same as "The War on Iraq."
Anyway, they seem to have spent all the money earmarked for the one, on
the other, instead.  Not surprisingly, it doesn't seem to have worked
very well. If anything, a lot of people find the US just as terrifying
as ever. More so. So this is all very frustrating, too.

S.
fresh~horses - 22 Sep 2005 03:16 GMT
> > > http://www2.epocrates.com/index.html
> > >
[quoted text clipped - 51 lines]
>
> S.

You directed this latter to Howard...

You think only docs make donations?
Howard McCollister - 22 Sep 2005 06:31 GMT
>> > http://www2.epocrates.com/index.html
>> >
[quoted text clipped - 52 lines]
>
> S.

Yeh, surgical instruments are big. The technology moves so fast that early
adopters are often sought for preceptorships. My partner and I teach courses
in advanced laparoscopic techniques for 4 different companies. Or maybe it's
4 different divisions of the same company, or some combination in between. I
can never remember. The drug company stuff I just pitch....just too much
trouble. I've declared a personal moratorium on surveys. I carried it too
far when I didn't fill out the ubiquitous medical manpower survey the state
sends out with its medical license renewal forms and they held up my license
renewal until I did.

Yes. Thanks. No. Sigh...I volunteered to do medical support for Katrina
refugees at a military base close to here when they were going to send 5000
people. Then it was 3000, then it was 500. As it turns out, nobody is coming
to Minnesota from New Orleans. I can't figure out why so many Minnesotans
are surprised at that.... I also volunteered to go to Louisiana to do
coroner stuff (I'm Assistant County Coroner and death investigator here),
but Paul Brown didn't want me either. War on Terror, Katrina, now Rita...I
agree, very frustrating.

But hey!...at least we aren't living and practicing in Canada...

just kidding....really...

HMc
fresh~horses - 22 Sep 2005 03:14 GMT
> > http://www2.epocrates.com/index.html
> >
[quoted text clipped - 10 lines]
>
> HMc

It's nothing new been going on for years now...

That makes it ok?
Howard McCollister - 22 Sep 2005 06:32 GMT
>> > http://www2.epocrates.com/index.html
>> >
[quoted text clipped - 15 lines]
>
> That makes it ok?

No, that doesn't make it OK. I think it's intrinsically OK, all by itself.

HMc
fresh~horses - 22 Sep 2005 06:49 GMT
> >> > http://www2.epocrates.com/index.html
> >> >
[quoted text clipped - 19 lines]
>
> HMc

A couple questions related to a comment in your post to Harris ie)
"early adopters".

What does that mean?

And preceptorships...what does that mean?

And when you say teach ... do you mean teach for the pharma device
manufacturing company? Or teach for your surgery colleageus at Cayuna?

Zee
Howard McCollister - 23 Sep 2005 01:52 GMT
>> >> > http://www2.epocrates.com/index.html
>> >> >
[quoted text clipped - 33 lines]
> And when you say teach ... do you mean teach for the pharma device
> manufacturing company? Or teach for your surgery colleageus at Cayuna?

Surgery these days is increasingly technology-driven. In many cases, a
particular operation can't be done using minimally invasive techniques until
someone invents a tool make if safer, or to make it possible at all. The
days of being able to do modern surgery using the same tools that
Halsted/Halstead used are long gone, as of  1989, the day that Eddie Joe
Reddick did the first laparoscopic cholecystectomy in the US. There are all
kinds of technologies being invented, studied, FDA-approved, and then they
make their way into the medical market. Those companies then have to sell
the technology to surgeons.

My partners and I are committed laparoendoscopic surgeons. We tend to stay
at the leading edge of advanced laparoendoscopic technique and as such,
there are a number of operations we do that very few other surgeons around
our part of the country are doing. We evaluate the technologies that are out
there in order to find a better or safer way for us to do a particular
operation, and in some cases we participate in the development of those
technologies with a variety of different companies. We get paid for sharing
our expertise with those design teams. In cases where we have greater
experience with a particular operation than other surgeons, those surgeons
may come to our hospital and we will teach them (preceptorship). Most of
these companies have several other such teaching arrangements. In other
cases, we may be invited to speakand/or teach at other such training
courses. As I type this, I have my feet up on the balcony of a very nice
hotel overlooking the Hollywood hills in LA. I drove up this morning from
San Diego. Dinner at Spago tomorrow night.

Bear in mind that these companies with whom we have consulting agreements
have sought us out because we are already using their equipment - we didn't
start using their equipment because they gave us money. As an example, we
have a consulting agreement with one particular device company that makes
surgical staplers, and we teach surgeons how to do advanced laparoscopic
operations using those staplers. That same company makes an ultrasonic
scalpel and they would dearly love for us to buy it and use it in those
teaching courses. We don't, and use a competing company's ultrasonic scalpel
because we think it's better. It's a sore point with the first company, and
it creates a fair amount of friction in our relationship.

HMc
fresh~horses - 23 Sep 2005 03:19 GMT
> >> >> > http://www2.epocrates.com/index.html
> >> >> >
[quoted text clipped - 72 lines]
>
> HMc

I'm going to read this over, think about it carefully, and ponder on
how I can tell you why I disagree with you, in as unemotional a way as
possible. However, if I think *that* isn't possible...

...and it's been a couple days and I still haven't repsonded; send for
the Mounties.

<<sitting here with my feet up on a stool cause I have to be in flexion
to stop muscle spasms caused by the pedicle screws put in my spine
without my authorization; by a hotshot show-off who knew those screws
weren't ok'd for use in the spine at that time.>>

Butter tarts & espresso at the Farmers' Market tomorrow...

I hope you have a great weekend Howard. Truly I do.
Howard McCollister - 23 Sep 2005 08:15 GMT
> I'm going to read this over, think about it carefully, and ponder on
> how I can tell you why I disagree with you, in as unemotional a way as
> possible. However, if I think *that* isn't possible...

No offense meant, but I can't imagine that you understand the landscape and
the situation well enough to possibly be able to provide a meaningful
rebuttal to the concept.

HMc
fresh~horses - 23 Sep 2005 14:13 GMT
> > I'm going to read this over, think about it carefully, and ponder on
> > how I can tell you why I disagree with you, in as unemotional a way as
[quoted text clipped - 5 lines]
>
> HMc

If you think meaningful rebuttal can only come from your colleagues,
then you're right Howard.



Zee
Howard McCollister - 23 Sep 2005 08:22 GMT
> I'm going to read this over, think about it carefully, and ponder on
> how I can tell you why I disagree with you, in as unemotional a way as
> possible. However, if I think *that* isn't possible...

Hey Zee, you don't need to think about it - your arguments will certainly be
contained within this article:

http://www.nytimes.com/2005/09/22/business/22devices.html?pagewanted=4

HMc
fresh~horses - 23 Sep 2005 14:47 GMT
> > I'm going to read this over, think about it carefully, and ponder on
> > how I can tell you why I disagree with you, in as unemotional a way as
[quoted text clipped - 6 lines]
>
> HMc

Yes, some of my arguments may be there.

I have thought about it Howard. From your perspective now too, but for
some time as one who carries a device deployed in me in off-label use
by a surgeon who thought there was no need to ask my permission or tell
me I was part of an experiment.
Howard McCollister - 24 Sep 2005 07:26 GMT
>> > I'm going to read this over, think about it carefully, and ponder on
>> > how I can tell you why I disagree with you, in as unemotional a way as
[quoted text clipped - 14 lines]
> by a surgeon who thought there was no need to ask my permission or tell
> me I was part of an experiment.

Your situtation doesn't apply, Zee. I'm certainly not talking about
off-label use of ANY of these technologies.

HMc
Howard McCollister - 24 Sep 2005 07:26 GMT
>> > I'm going to read this over, think about it carefully, and ponder on
>> > how I can tell you why I disagree with you, in as unemotional a way as
[quoted text clipped - 14 lines]
> by a surgeon who thought there was no need to ask my permission or tell
> me I was part of an experiment.
Sbharris[atsign]ix.netcom.com - 22 Sep 2005 21:11 GMT
> > It's nothing new been going on for years now...
> >
[quoted text clipped - 3 lines]
>
> HMc

COMMENT:

Agree. One of the great reasons for decentralization of decision-making
is that it removes much of the incentive for bribery. This is as true
in politics as economics. One of the less-talked about bad things about
socialism and command economies isn't just that the commissars aren't
smart enough to decide how many widgets will be needed where, and when
(the sorts of horrors you saw with Katrina), but also there's the fact
that when decisions are made by a few on behalf of the many, there's
always corruption. That's bad enough even in Western-style democracies.
Republics are mandatory thing from the demands of information
processing, and if you have a republic, you will have junketing
politicos getting private donations for their private projects
(presidential libraries, whatever) who make doctors (ANY doctors) and
even many business people look more pure than Ceasar's wife.

What I don't understand is why anybody wants a system which encourages
this. Sure, somebody's always going to be doing complicated surgery
that nobody else can do. But there's really no reason to have many
drugs available only by prescription. Remember how long it took to get
Clariten and Prilosec over the counter?  This kind of thing is what
lead directly to drug company pressure on the few, when it could (and
would) be better diffused into the many. And thereby somewhat
detoxified. Who cares about direct to consumer advertising? If the
doctors aren't too biased, the intelligent consumer can always consult
them first.

I've long argued that the only drugs which should require a
prescription are those which are intrinsically destructive to society,
like some particularly nasty form of pollution. The only ones I can
think of in that category are antibiotics. Most of the narcotics are no
worse on their total effect on society than is alcohol. We deal with
alcohol without requiring it to be prescribed by doctors.

There are cases were people's lives are destroyed by drugs-- indeed by
alcohol. But in those cases, the decision of what to do about it should
not be left in the hands of doctors. That's a social decision. If
you're destroying your own life with alcohol or seem likely to destroy
somebody else's by your use of it, the judge or jury might decide in
such cases not to make alcohol illegal for everybody, but instead
illegal for YOU PERSONALLY for the next 5 years. Or the rest of your
life.  But again, such decisions are so personal and decentralized that
corruption would seem to be unlikely to be much of a problem. The
beer-makers might care if beer were outlawed altogether, but would not
give a fig if beer were outlawed for Joe Blow who wrecked his pickup
truck after drinking 2 six-packs after work on the way home. Indeed,
it's Joe who gives beer a bad name. Even the beer companies would
prefer he not partake.

Can doctors be bribed? Sure. Can juries be bribed?  Sure.  But fix the
system a little, and there's really no reason why the one shouldn't be
as rare as the other.

SBH
Frankie - 23 Sep 2005 18:24 GMT
Who cares about direct to consumer advertising?
If the doctors aren't too biased,
the intelligent consumer can always consult them first.

Sorry to butt in, but this struck a chord with me.

Re: Who cares about direct to consumer advertising?
It's unbalanced. The sun is shining, everyone is smiling
but the drug advertised has serious side effects, sometimes
life threatening and none of this is mentioned or is in fine
print that cannot be read on a TV screen.

Re: If the doctors aren't too biased...
That is a BIG "if"... many doctors are very biased.
Our doctor completely denied that Lipitor can cause
cognitive side effects, when there is clear evidence that
it can. In fact he was pretty darn snotty about it.
Walked out of the room in a huff, sent in the nurse to give
the in-office memory test, which my husband promptly
failed. Hubby's memory is much improved since off of
statins for over a year now.

Re: the intelligent consumer can always consult them (doctors) first.
Consumers might be intelligent but most are ill informed
and their doctors might be intelligent but many are ill informed
as well. Doctors are too mono-focused on "take this pill and you will
live a long health life".

Frankie
Sbharris[atsign]ix.netcom.com - 24 Sep 2005 05:17 GMT
> Who cares about direct to consumer advertising?
> If the doctors aren't too biased,
[quoted text clipped - 25 lines]
>
> Frankie

COMMENT:

Let me put it this way. It's a question of who is going to pay for
information-processing.

Imagine that I was in the market for a car, and wanted a mid-sized
sedan of some kind, painted red, and I wanted the best car I could get
for under $25,000.

But I don't know anything about cars.  So I ask  Joe Greasemonkey, a
mechanic and gearhead I know, to go buy me one. The "best" one.  I
offer him $500 to spend an afternoon shopping around, and with a phone
consult or two, finally I get the thing.

And I don't like it much. I don't like the way it handles. I don't like
the way it sounds. The switches are in the wrong place. I don't like
the power ash-trays. Joe suggested I'd have done a lot better going
with him to the dealers and listening some more about engines, but I'm
not interested in that stuff. Why else do I hire the guy?

While I'm mulling over my potential lemon, I find out more distressing
stuff, and it's becoming clear to be why I got the car I got. My bud
the mechanic guy has had deals and dealings with all kinds of car
manufacturers and parts makers for years, and he owns a couple of the
same kind of cars he just bought me!  Why, the very idea. I was paying
for a totally unbiased opinion. If that's not bad enough, I realize
that Joe spends half his time down at the local race track where
everything that is capable of motion is plastered with sponsor
stickers, and EVERYBODY developing everything has some connections with
companies that make car-stuff. I mean, really. Disgusting. How can his
mind not be totally polluted with spin and ad nonsense? Half of it's
buzz, and I can't tell which half. Anyway, I want to know what place
have Joe Greasemonkey's judgments and feelings about cars, which are
his life and his passion and certainly not his sober academic career,
got in this scientific issue of picking me out THE BEST CAR? The more I
think about it, the angrier I get.

But if you think that's bad, a few years later it's worse. I need
another car, having wrecked the first one (no fault of mine). But in
the meantime, the business of picking cars has been mostly taken over
by the government, which decided to remove all the commercialism and
corruption from it. Okay, that's a start. The problem is Joe the
mechanic has moved to some other country where they still actually have
a commercially sponsored racecar culture. He couldn't take my money
now, even if I wanted to pay him. So now I look around and realize I've
got few choices left. I'm left with Fred Friendly's Chain of Government
paid auto stores, instead, who get paid to pick my Best Car. They use
my taxes. If I want a better job of car picking, I have to go out of
the country for it. And the lines are pretty bad if I stay.

And you know what?  Even paid by my taxes and with less commercialism,
it's worse. At least Joe Greasemonkey knew his engines and was always
taking apart something or building something, and had some idea about
how the auto industry made progress.  He could tell you WHY brand X was
junk and company Y knew cars, and it wasn't just the stickers and
sponsor ads (though I'm sure they had some effect on his opinions). But
the Fred Friendly Government Guy seems to know only what they taught
him in government auto school about the stats, and that doesn't seem to
be much. It's just what opinions the government officially has about
what is the best car. But I'm I'm wondering where THOSE come from? Are
they cloned somewhere?  Government race track tests don't just spit out
the answer to what is the best car--- that's a value judgment. The
government has to be paying somebody and getting info from somebody.
And I know who. And I have the crawly feeling that some of the
companies that sponsor stuff at the track have been telling officials
somewhere about what cars are good and what cars are lemons. Not just
the drivers and mechanics, who can see from themselves. But this time,
it's all at a level where I can't even BEGIN to see the nuts and bolts
of it. The racetrack is gone. My gearhead guy is gone. The auto
developers have fled. I'm stuck in the government auto showroom with
the government-appointed and approved and trained salesman, and I'm
wondering about the nature of engineering. Where the hell DO good
expert opinions come from, anyway?  It's all very mysterious. The
government should be doing it, is all I know. And they're not.  The
people who invent cars and play with cars somehow still control it, out
there, somewhere. It's just not fair.

SBH
Frankie - 24 Sep 2005 06:36 GMT
Re: Let me put it this way.
It's a question of who is going to pay for information-processing.

Undoubtedly we all "pay for information-processing",
but the information many times is grossly manipulated.

And yes, "It's just not fair", but it also sucks, big time!

Frankie
 
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