1. Luxury Primary Care and Academic Medical Centers: The Erosion of Science and Professional Ethics Martin Donohoe

2. Academic Medical Centers Evidence-based medicine Evidence-based medicine Ethics Ethics Providers of last resort to poor and destitute, un- and under-insured Providers of last resort to poor and destitute, un- and under-insured Personal experience – university vs homeless clinic Personal experience – university vs homeless clinic

3. Financial Crisis: Responses Increasing links with pharmaceutical and biotech industries Increasing links with pharmaceutical and biotech industries Recruitment of wealthy, non-US citizens Recruitment of wealthy, non-US citizens Luxury primary care / executive health clinics Luxury primary care / executive health clinics

4. Luxury Primary Care/ Executive Health Clinics Most major academic medical centers Most major academic medical centers 2000-3500 visits per year 2000-3500 visits per year $1500 to $20,000/visit $1500 to $20,000/visit Avg. $2000-$4000 Avg. $2000-$4000

5. LPC Clinic Perks Same day appointments/tests, accompanied consults, vaccines Same day appointments/tests, accompanied consults, vaccines Shorter waiting times Shorter waiting times Low physician/patient ratios Low physician/patient ratios 24/7 access, house calls 24/7 access, house calls

6. Clients/Marketing Large corporations Large corporations Tobacco companies, environmental polluters, health insurers Tobacco companies, environmental polluters, health insurers Hope for contracts for institution/providers and/or corporate donations Hope for contracts for institution/providers and/or corporate donations Marketed to the “busy executive” Marketed to the “busy executive” Mostly white males Mostly white males

7. Unknowns Medical student/resident participation Medical student/resident participation Effects on physicians Effects on physicians Effects on old patients Effects on old patients How funded How funded Where profits go - ?cross- subsidization? Where profits go - ?cross- subsidization? Secrecy Secrecy

8. LPCs and the Erosion of Science Tests not clinically indicated or cost- effective Tests not clinically indicated or cost- effective CXRs – lung cancer CXRs – lung cancer CT scans/stress ECHOs – CAD CT scans/stress ECHOs – CAD Pelvic US – ovarian CA Pelvic US – ovarian CA Whole-body CT scans Whole-body CT scans radiation~Hiroshima, raise cancer risks radiation~Hiroshima, raise cancer risks

9. Consequences of Unnecessary Testing False positives → further testing, complications, anxiety, ↑ profits False positives → further testing, complications, anxiety, ↑ profits Diversion of limited resources – human and capital Diversion of limited resources – human and capital Erosion of evidence-based practice Erosion of evidence-based practice Unsound science Unsound science

10. LPCs and the Erosion of Professional Ethics General public subsidizes medical training General public subsidizes medical training Physicians limit practice to wealthy Physicians limit practice to wealthy Increasing differential of care between poor and wealthy Increasing differential of care between poor and wealthy Financial factors replace clinical judgment Financial factors replace clinical judgment

11. Contemporary Health Care ↑ wealth disparities ↑ wealth disparities 20-25% of US children live in poverty 20-25% of US children live in poverty ↑ environmental degradation (and related illnesses) ↑ environmental degradation (and related illnesses) ↓access to care ↓access to care 45 million uninsured in US, underinsured, dead end jobs, public hospitals closing 45 million uninsured in US, underinsured, dead end jobs, public hospitals closing Disparities by social class / race in access to and outcomes of care Disparities by social class / race in access to and outcomes of care Developing world brain drain; medical tourism Developing world brain drain; medical tourism

12. LPCs and the Erosion of Professional Ethics Workups, treatments based on ability to pay Workups, treatments based on ability to pay Ethics Ethics Rationing Rationing Acceptance of double standard Acceptance of double standard

13. LPCs and the Erosion of Professional Ethics Increasing cynicism/dissatisfaction among medical students/residents/practicing physicians and patients Increasing cynicism/dissatisfaction among medical students/residents/practicing physicians and patients More providers willing to “game the system” More providers willing to “game the system”

14. Solutions Renunciation of the measure of the marketplace as the dominant standard and value in health care Renunciation of the measure of the marketplace as the dominant standard and value in health care Equitable division of resources Equitable division of resources

15. Solutions: Medical Education and Ethics Training Increasing emphasis on social, cultural, economic and environmental contributors to health and illness Increasing emphasis on social, cultural, economic and environmental contributors to health and illness Health disparities, cultural competence, occupational and environmental illnesses (e.g., pesticide-related illnesses, air pollution and asthma) Health disparities, cultural competence, occupational and environmental illnesses (e.g., pesticide-related illnesses, air pollution and asthma)

16. Solutions: Medical Education and Ethics Training Heal schism between medicine and public health Heal schism between medicine and public health Service-oriented learning, research- based activist courses, volunteerism, political activism Service-oriented learning, research- based activist courses, volunteerism, political activism History, literature, role models/mentoring History, literature, role models/mentoring

17. Solutions: Public Policy ↑ education of public policymakers (business leaders, government representatives, and health care purchasers) ↑ education of public policymakers (business leaders, government representatives, and health care purchasers) ↑ public education ↑ public education

18. Solutions: Public Policy Deans, department chairs, division chiefs, ethicists, doctor-patient Deans, department chairs, division chiefs, ethicists, doctor-patient Ethicists quiet re LPCs Ethicists quiet re LPCs Outcome: ↑ funding for education, training, and care of the underserved by academic institutions Outcome: ↑ funding for education, training, and care of the underserved by academic institutions

19. References Donohoe MT. “Standard vs. luxury care,” in Ideological Debates in Family Medicine, S Buetow and T Kenealy, Eds. (New York, Nova Science Publishers, Inc., 2007). Available at http://phsj.org/?page_id=22 Donohoe MT. “Standard vs. luxury care,” in Ideological Debates in Family Medicine, S Buetow and T Kenealy, Eds. (New York, Nova Science Publishers, Inc., 2007). Available at http://phsj.org/?page_id=22 http://phsj.org/?page_id=22 Donohoe MT. Elements of professionalism for a physician considering the switch to a retainer practice. In Professionalism in Medicine: The Case-based Guide for Medical Students, Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge University Press, 2008, in press). Donohoe MT. Elements of professionalism for a physician considering the switch to a retainer practice. In Professionalism in Medicine: The Case-based Guide for Medical Students, Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge University Press, 2008, in press).

20. References Donohoe MT. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Int Med 2004;19:90- 94. Available at http://www.blackwell- synergy.com/doi/pdf/10.1111/j.1525- 1497.2004.20631.x Donohoe MT. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Int Med 2004;19:90- 94. Available at http://www.blackwell- synergy.com/doi/pdf/10.1111/j.1525- 1497.2004.20631.xhttp://www.blackwell- synergy.com/doi/pdf/10.1111/j.1525- 1497.2004.20631.xhttp://www.blackwell- synergy.com/doi/pdf/10.1111/j.1525- 1497.2004.20631.x Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical perspectives. American Medical Association Virtual Mentor 2004 (April);6(4). Available at http://www.ama- assn.org/ama/pub/category/12249.html Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical perspectives. American Medical Association Virtual Mentor 2004 (April);6(4). Available at http://www.ama- assn.org/ama/pub/category/12249.htmlhttp://www.ama- assn.org/ama/pub/category/12249.htmlhttp://www.ama- assn.org/ama/pub/category/12249.html

21. Contact Information Public Health and Social Justice Website http://www.phsj.org martindonohoe@phsj.org