Dangerous Idea: Becoming a Squeaky Clean Doctor

Every year as part of the College of Family Physicians of Canada's Family Medicine Forum (FMF), there is a call for abstracts for the Dangerous Ideas Soapbox.

This is the part of the conference during which physicians can share radical ideas for change in primary care. Four abstracts are chosen and presented. The successful ideas are later published in the Canadian Family Physician; see 2015's Dangerous Ideas.

This year, Alan Cassels and I submitted an idea, suggesting physicians completely divorce from pharmaceutical/device industry influence, particularly in medical education.

The idea was quite a dangerous one, particularly surprisingly because the CFP has come under fire (including from Alan) for their own conflict-of interest as far as taking industry money to fund physician continuing education. See: It's time to examine pharma funding of doctors' education - Healthy Debate, and Drug companies wine and dine family physicians - Toronto Star.

Our submission was not successful in the application for the Dangerous Ideas Soapbox, but we share an expanded version of it here for your consideration. 

Our idea: We propose that general practitioners should swear off attending any lectures, CME events, workshops or conferences which are funded, even partly, by those companies and organizations with ties to pharmaceutical and device manufacturers. Even events where the presenters have at least one tie to a pharmaceutical company within the last five years, or is supported by an association that receives funding by the pharma or device industry (including patient and disease groups), would be avoided.  Clinicians and researchers who are working or consulting for, owning shares or patents in, or carrying out speaking engagements on behalf of industry would not be invited to present content to general practitioners. 

How will this work? Physicians’ colleges, professional associations, and university-based continuing education programs would eliminate their dependency on industry-funded speakers, conferences, dinners, workshops and talks. Over time, physicians’ groups would develop their own conference content, invite only independent speakers, and collaborate with organizations that have the capacity for education, without the industry influences. CME credit would not be provided for events in which industry conflict of interest is present. Physicians will have to seek out independent and ‘clean’ sources of information about new drugs and treatments and will more likely rely on independent reviews produced by groups like the Cochrane Collaboration, La Revue Prescrire, and Up-to-Date which all have strict policies around conflict of interest.

Why does this matter? This would drastically change the landscape of prescribing and lead to better and more appropriate treatment, in the best interests of patients and outside the influence of the pharmaceutical industry. Significant harm has been done to patients because of overzealous marketing, off-label endorsement, and the lobbying “machine” of industry which has developed a condition for every medication. Ultimately, with a divorce from industry-tainted education, physicians will increasingly favour treatments that are well-evidenced and most appropriate for the goals of care of their patients. This is likely to be be less costly for patients and the system, and would place increasing emphasis on non-drug alternatives. Also, the image of physicians as “pushers” or “in the pocket of the drug companies” would be reduced over time, enhancing trust from the public.

Why is this dangerous? Physicians have long been part of a system that has allowed the adverse effects of pharmaceutical and device marketing to influence prescribing and patient care. Physician organizations claim they cannot provide education without funding from industry; industry lobbyists argue that interaction with physicians is the only way patients can discover and reap the benefit of new innovations. Some physicians, naive to evidence to the contrary, believe that they are justified in accepting education, meals, and gifts because they (alone) are somehow immune to industry influence. A divorce from industry is not a popular idea, as evinced by the number of physicians and organizations that still feel it is ethical to incorporate this funding into medical education.

The current system is harming patients, but it can be stopped. Those physicians who are concerned that their patients perceive them to be shaped by drug marketing can become “Squeaky Clean” and wear that badge proudly.  

Coccidiomycosis and other "Zebras" in Medicine; reconciling with Less is More

This is the first time I've had a peer-reviewed article published. Shortly after I wrote an email to the patient, the subject of this case report, to let him know, I was looking through my other emails and realized not only was it published, but that it had become the cover story for this of the British Columbia Medical Journal (BCMJ)!

Read the article here: A textbook case of coccidiomycosis (web version or a PDF version).

Ok, perhaps I shouldn't be so proud as it's not the Lancet or BMJ, but I think the BCMJ is pretty darn good and it was exciting for me to get to share this case in so doing, to make good on a promise to this patient to educate others about his diagnosis. It was also great to work with a friend, the very smart Dr Barlow!

I also liked the reflective exercise of thinking about how a "Less is More" kind of doctor could still diagnose exotic conditions.

The article is about an uncommon fungus (coccidiomycosis) that a patient I saw in on Vancouver Island had acquired. There's an expression in medicine:

"When you hear hoof-beats, think horses, not zebras."

One should never jump to the exotic diagnosis. However,  occasionally, people do have exotic diagnoses.

Even though I had to order some specialized tests to find out for sure what he had, this practice is still consistent with the "Less is More" philosophy. The idea is that in avoiding all the unnecessary stuff, we can use our time and resources wisely to order the RIGHT tests and treatments. It also helps immensely when patients are aware of their own health and can tell us their story clearly.

It all worked out because we had:

- A clear patient, advocating for himself, open-minded & contributing to my assessment and plan
- A doctor with time to hear the patient's story, medical knowledge appropriate for the situation
- Judicious ordering of tests (wrong test for most people, the RIGHT test for him)
- Confirmation of a suspicion gained from the history and reviewing the labs/xray that were already available

This was a highly satisfying case. I'm rarely clever, and rarely have a patient who is as good a historian as he. It's a wonderful illustration of a working acute care system, the benefits of being a patient who takes ownership for his health, and that some obscure knowledge is tucked away in my brain which will sometimes emerge when needed!