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Rapid Responses: Rapid Responses published:
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Vested Interests and Medicine
- L-F Ng (4 June 2004)
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The most important editorial ever
- Jaiganesh.K. Viswambharan (7 June 2004)
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Financial incentives for doctors
- Selwyn D'Costa (7 June 2004)
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Financial incentives and disincentives for doctors:
- Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS (9 June 2004)
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Ethical Problems related to the new GP contract
- Philipp Conradi (17 June 2004)
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L-F Ng, Staff Medical Oncologist Ballarat Hospital, Ballarat, VIC 3350 Australia
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The creation of the NHS in the UK never eliminated the conflicts. Some doctors just became cleverer in identifying new ways of benefitting themselves and continue to be creative. The creation of completely separate private and public sectors in other countries, both developed and developing never solved the problem either. This challenge is global and there does not appear to be a simple solution for it. Present methods used include: 1. Using rank in the NHS and affliation to a private practice to subvert Trust policies in the use of drug protocols. I have worked in at least one Trust where a Clinical Director imposed an antiquated chemotherapy regime on NHS patients whilst practising 'state of the art' care in the private hospital despite clear published multidisciplinary team guidelines. Some thought for the Commission on Health Improvement (CHI) in plugging this! 2. The creation of long waiting lists. Well known common and even accepted practice in some places and plenty of challenges for administrators - remember they could real or manufactured. What amazes me is that people could tolerate it! 3. Peer pressure on the use of an unpublished (and thus non peer reviewed) clinical trial result (whether positive or negative) when there is a private practice component involved. For example, those of you in the CHI might wish to consider asking how many hospitals in the UK used the results of the MRC OEO2 Study in routine off-trial practice whilst awaiting its publication (lapse of nearly 4 years between trial closure and publication) 4. "Overservicing" or distorting the true intent of a clinical request in Radiological practice. 5. Surgical and screening procedures abound: despite lack of good quality evidence, some operate mostly on Level IV-land - because they think it saves lives or leads to marked benefits. 6. Part or major ownership in private clinics, laboratories or hospitals. Of course, if you go to one of these places and "get the best care" you will be given the full house, including the 200 point screening tests. One modern way is to own these through a nominee, at best not even a relative! 7. The age old practice of dichotomy (fee splitting) is still alive and kicking in many lands. The essential question might be how we actually choose our medical students and groom them to be "good ethical doctors" or have the bright rewards of the material world blinded some of us on the way? Or, is it that countries do not reward their doctors sufficiently for their level of training and experience? Or, is it the ever present sin of human greed? Competing interests: I come from a medical family, some of whom have shares in private hospitals in Asia, but, I am a full time public servant |
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Jaiganesh.K. Viswambharan, Nil Pondicherry
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EDITOR- I feel this is the most important editorial ever printed.This is because it deals with the core issues of doctor patient relationship,society,big money and ethics. However,it will not be appreciated by the majority of doctors since what they want is money,money and more money.They do not really care about their patients.If it were not for litigation by patients,patient care would have deteriorated to an all time low.But smart doctors still can manage to keep their records neat and orderly,preventing legal action and at the same time,cheating patients. Incidentally,Shaw's statement also reflects on the creation of false data base in evidence based medicine.'Publish or perish'is certainly not a good idea for EBM since the pressure to publish is so great that a whole lot of 'spin'or manufactured data is generated. However,doctors are not from outer space.They are the product of Society.Unless there is a spiritual and ethical revolution or reawakening the present state of affairs are not going to change.This effectively means that the editorial will remain a lament, and nothing else. Yours sincerely, Jaiganesh.K.V. Competing interests: None declared |
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Selwyn D'Costa, Consultant Paediatician DA2 8DA
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With financial incentives one has to put safeguards in place to prevent the noblest profession from becoming the oldest. Selwyn D'Costa Competing interests: None declared |
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Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS, Medical Director [A], Director, CME&R Postcode 2292, Buraidah Mental Health Hospital, Saudi Arabia
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Sir: Rodwin (1) and Lambert et al (2) have discussed the pros and cons of financial incentives and distinction awards for doctors and consultants. I strongly support the concept of financial incentives and distinction awards for doctors. Those doctors who excell in delivering the best health care services to the health consumers, do appropriate research at practice level and take active participation in education and training should be given financial benefits. The criteria for evaluation of doctors for financial incentives must include these three interrelated components, i.e., education, clinical services and research. On the contrary, there should be financial disincentives for those doctors who fail to meet the yet to develop criteria for excellent services, education and research. Otherwise dualism will prevail, i.e., one group of doctors will say let them work all because they are benefiting from financial incentives and distinction awards. This self- driven philosophy of not engaging in competitive work will harm the patients and award winning doctors who will bear the overall educational, research and clinical responsibilities. Finally, award committees must see that distinction awards and financial incentives and disincentives for doctors should not be decided on the basis of ethinicity and sex as found in this study (2). References: 1. Marc A Rodwin. Financial incentives for doctors BMJ 2004; 328: 1328-1329. 2. Trevor W Lambert, Michael J Goldacre, Elizabeth Vallance, and Netar Mallick. Characteristics of consultants who hold distinction awards in England and Wales: database analysis with particular reference to sex and ethnicity. BMJ 2004 328: 1347-0. Competing interests: None declared |
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Philipp Conradi, GP Locum Central Birmingham
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Rodwin writes an excellent article about the impact of financial incentives on medical decision making. He is however wrong to suggest that the NHS '...eliminates the need for practitioners to perform excessive medical procedures to achieve economic security...'(1) Since April of this year general practitioners in the UK receive payments for so called 'quality indicators'. These include treatments which are only marginally beneficial for the individual patient ( statin therapy for large patient groups <2>) or are known to have at least as many serious side effects to the patient than benefits ( HbA1c below 7.0 for more than 50% of the patient group <3>). I asked the GMC ( 'Protecting Patients, Guiding Doctors') for advice in this matter but I understand from their responses that they are neither interested in NHS policies nor in evidence based medicine. As a GP here in the UK I am in a dilemma since attainment of ' Quality indicators' is defined as good clinical practice as well as attracting income. I therefore have to adhaere to those targets and accordingly will receive financial inducements although I know that a substantial number of patients would not choose their treatment when informed about the absolute benefit those treatments confer (4). I do not know if and when this anomaly will be tested in the medicolegal field. In any case, the doctor patient relationship will suffer once our patients see behind the smoke screen. References 1) Rodwin M. Financial incentives for doctors.BMJ 2004;328:1328- 1329 (5 June) 2) Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high risk individuals: a randomised placebo controlled trial. Lancet 2002;360: 7-22.[CrossRef][ISI][Medline] 3) McCormack J, Greenhalgh T. Seeing what you want to see in randomised controlled trials: versions and perversions of UKPDS data. BMJ 2000;320: 1720-3.[Free Full Text] 4) Misselbrook D, Armstrong D. Patients' Responses To Risk Information About The Benefits Of Treating Hypertension Brit J Gen Pract 2001; 51: 276-279 Competing interests: interested in EBM |
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