by Kate Atkinson, MD
Six years ago, I organized a group of female healthcare practitioners for a women’s medical journal club. A multidisciplinary team of doctors and NPs from primary care and sub-specialties regularly attended monthly dinners. Invited speakers presented on a variety of topics and over the course of a meeting we exchanged insights while challenging each other on how best to manage our challenging patients.
Our group grew close enough to provide some much needed emotional support – something, any physician can use but more so for women providers who try to juggle work and family issues. Ultimately, we became more skilled at our craft, helping patients, while building strong working relationships with colleagues from across the community. To the surprise of some, these meetings would not have been possible without industry support. The cost of dinner and a babysitter priced many of us out once we lost that support and our group has dwindled sadly since the ban.
This is the so-called ‘wining and dining’ that is slowly being eliminated by heavy-handed conflict of interest policies being promulgated by academic medical centers (AMC) and by misguided “gift bans” being enacted by state legislatures. AMC’s purport that severing industry ties will ensure a more “pure” clinical environment (Note: no claim is made about improving patient care). And legislators have been convinced that inhibiting interactions between pharmaceutical companies and physicians will control spiraling health care costs, a myth deftly debunked by Drs. Tom Lee and James Mongan in Chaos and Organization in Health Care (neither of whom could be considered industry shills).
Although their stated goals differ, the consequences of such policies and laws are the same: Productive interactions supported by those marketing products as well as those discovering and developing products, are quickly becoming extinct.
With the rapid advances in medicine and skyrocketing health care costs, there could not be a worse time for “bans” that choke off opportunities for clinicians to gather new scientific information (even pharmaceutical marketing material must pass FDA review for scientific content and balance) and exchange real-world clinical information. Primary care, considered the bedrock of a strong health care system, is already in dire condition and cannot afford to have partially informed clinicians. Cost-effective care truly depends on access to information, whether the source is biased towards new therapies (industry) or biased towards cheap therapies (insurers and academic detailers), clinicians need all of the available information.
Primary care already suffers from low reimbursement rates relative to the value of care provided, high medical school debt-to-income ratios, and excessive insurer paperwork burdens that diminish valuable time with patients. It is no surprise that few physicians-in-training are choosing primary care and many current practitioners are choosing early retirement or are simply abandoning medicine altogether.
I can attest that running a small primary care practice is a Herculean feat and additional barriers to my success, like bans, do little to “bend the curve” of primary care decline. Like many of the other clinicians that attend our meetings, I run my own practice, and see ~100 patients per week. I also have four school-aged children. And as much as our meetings allowed us to learn about the latest products or get new information on older products, they were also about interacting with fellow colleagues. They provided a forum for mutual education and support. They also fostered detailed case discussions, sharing of medical pearls on clinical management and even tips on how to better interact with male colleagues.
We averaged 15-20 providers at each of our dinners and often hosted medical students and residents, modeling interdisciplinary work in a small town setting. (And I would challenge almost any small town to demonstrate such an vital educational group with such staying power over the years.) We also invited a highly selective group of clinicians to lecture on topics that we otherwise may not have found the time to learn by simply wading through the medical literature. In fact, in one six-month span we heard on topics including hormone-therapy, EMRs, ophthalmology, osteoporosis, alternative medicine and pain management topics. We even had a sex therapist talk which was most illuminating to many of us. In exchange for hosting our Journal Club the pharmaceutical representative used to be entitled to one talk to our group each year and we had say over who the speaker was and the topic.
Since our State enacted its “gift ban,” we have been unable to find a sponsor for our meetings. The medical society outright declined our request because our meetings were not considered sufficiently inclusive (i.e., females only). Post-“ban” we have limped along paying our own way but the truth is medical practice is demanding and chaotic for us all, and possibly even more so for women with families – the logistics alone have stymied us. We are not close to an academic teaching hospital and even our community hospital is a 40-minute drive for me and many of my colleagues. Therefore, there are no other resources of this quality and nature in our community. And if we tried to host the meetings in our homes our family members would pose a distraction. A once staunchly loyal group of 15-20 now often sees 5-6 women attending.
We limped along this past year despite immediately losing all of our NP’s and more recently losing most of our primary care doctors as well. (Sad but true that the cost of a dinner was prohibitive.) It has been painful to watch such a dynamic and supportive group dwindle over the past year. We had something truly special. In the past many people wanted to join our group – even male doctors – and we frequently received unsolicited requests from individuals interested in presenting to the group.
When the “gift ban” was passed, it seemed as if the vote was influenced exclusively by those with access to the big teaching hospitals (which ironically, according to a recent report by the Massachusetts Attorney General, we now know they are the real cost-drivers in the state)–they even wrote it so that their grand rounds could still be subsidized by pharmaceutical companies– and that there was little understanding of what we, the practitioners beyond the Boston “medical Mecca” needed. The ‘country doctors’ were not even consulted.
Many recognize that it is hard to practice primary care. And most recognize that it is particularly hard to practice in our State. What few appreciate is that it is even harder to practice in a rural area of our State, where access to resources is more limited. We had a solution that made us both better clinicians and better equipped to survive another day as clinicians for our patients – two things our nation and Massachusetts desperately need – yet politics prevailed and took this solution from our community and its patients.
Kate Atkinson is a family physician in Massachusetts.
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{ 15 comments }
Yet billions of dollars can be spent on capitol hill every year by lobbyist to sway votes.
I believe it has been repealed, after local businesses has complained of lost revenue.
May I suggest UpToDate as an important instant resource for learning. If there is any specialty practices in the area a practitioner may be very happy to come to a meeting and share their expertise on selected topics. I’m sure you can think of other ideas without using slanted information. Turning to the pharmaceutical industry is not wise in the face of more objective learning possibilities. Doesn’t your local hospital supply any CME?
Nicely stated, Dr. Atkinson. At the surface, the issue is the right of businesses to practice effective marketing methods to develop goodwill and to keep practitioners informed of the state of the art — business practices that are absolutely acceptable in other industries (as well as the government).
However, it goes even deeper than that. Your post made me sense the existence of an oppressor who effectively compromises my autonomy, my freedom to associate with colleagues, who expresses a generic mistrust of my professional integrity, or who believes me to be too weak-minded to keep a proper perspective about my patients’ needs.
Now it’s time to consider the bigger picture. I wonder, Doctor, if you are willing to write as eloquently about our government’s attempt to take over our profession through “universal” health care? The issue you write about is so small compared to what is imminently about to happen to us.
I understand that you lost a source of revenue and sympathize with that, but I think that source of revenue was not the right source that should have funded your group.
Who would want to have you meet and be emotionally supported? I would think that patients. I would look for a patient organization that could help. Patients might not be organized enough yet, but some of us would pay more money to get better care.
I’m not saying this is easy or that you have time for this, but moaning about what we lost by losing the drug companies funding is not constructive. The drug companies pay these out of our money for medication anyway. We need to break the vicious cycle somehow.
If only we had a Jaqueline Novogratz for healthcare.
Dr. Green, I also have uptodate, although it is 400 dollars a year, so if people are short on cash, it’s a pretty big expense
I’m a specialist and I don’t think I could foot the bill for 16 doctors/NPs at a restaurant. what’s that bill going to be maybe 1500 too 1600 dollars…
also I think that the point of the letter was that the meetings were more for social and information sharing or practice than about the drug sponsor and without this funding source the meeting goes away.
I wonder occasionally about my fp comrades in the community, if they don’t go to the hospital and they are solo practice how do they ever get interaction with other docs. I guess you could join the county medical society, ours only costs a thousand a year, that’s a pretty big bill for me..
When the women in my industry want to meet – we get together at one of our homes on a rotating basis, pot luck style. There are about 20 of us. It doesn’t require a large cash outlay – buying our own food (even pre-made – as many of us don’t have the time for home cooking) and BYOB. Babysitting can be expensive, but we manage to keep those costs down by getting a consensus on the timing for our next meeting. With enough lead time, husbands (even ex-husbands) can be scheduled for babysitting duty. Other women in other professions manage to meet and support each other and learn from each other – we even get guest speakers. Seems you could do it, too. Just because you’ve become accustomed to someone else picking up the tab, doesn’t mean you can’t find workable solutions to this challenge. Can’t really cry over this on your behalf. It just doesn’t wash.
To ANM: I suspect that your ‘industry’ isnt primary care medicine. Just the time involved in organizing a potluck is prohibitive to me at this point in my career. weeks go by with mail remaining unread in our household for want of time and energy. I have piles of medical journals next’ to my desk at the office and my bed at home which i struggle to read before my patients are quoting them to me. This journal club was one of the few professional things i did that was just for me. We DO continue the meetings paying our own ways (and dividing the cost of the speaker and students) but–as i mentioned in the article–all the NPs have been priced out, the retired doctors and many of the primary care docs as well.But it was more than paying for the meal which was lost–it was someone organizing the venue and the overhead projector, doing setup etc. most of the doctors would run in late from the office and have this great talk and interaction and then home to tuck kids in . It is not possible to explain to someone who isnt in primary care medicine how many pulls there are for us–this week i had a 50yo die suddenly, a 92 yo break her hip and 3 calls from families needing home visits due to change in medical condition. Each of these prompted a myriad of phone calls from family members needing to speak directly to me . I n addition to seeing 100 patients a week and making sure that all 4 kids have rides to their prospective camps, is enough to drive me over the edge some weeks. I am constantly trying to be all things to all people and NOT to burn out and to pay the bills, and remember to leave a check for the babysitter and the plumber. .. our local hospital is a 40 minute drive for me and the meetings they have are on days when i dont have childcare. I am not ‘crying’; clearly i am not wounded by this, simply saddened. I have a great job and a great family but not enough hours in the day to do it all. My point in sharing this experience was to point out that those of us in rural areas have been hit the hardest and our needs NOT even considered in the process. THis legislations was not just about pens and pads from drug companies. Insurance companies promote certain medications to us, often using misinformation in order to try to save themselves money. Pharmaceutical companies do the same in order to make us order their medicines. I like to believe that i am an educated professional who takes BOTH of these inputs into consideration and ultimately decides what is best for the patient, not what is best for me or the drug rep OR the insurance company.
I am also a primary care physician and am keenly aware of the challenges (emotionally, physically, and personally) posed by having such a job. It *is* exhausting, and I completely understand that even organizing a pot-luck seems impossible. But rather than placing blame on a change in regulations that has taken away one of your stress-relief mechanisms, the blame should be on a system that so devalues primary care as to make our lives as miserable as they are.
I do think that you can find a way to make it work; if each member commits to coordinating one meeting per year, by finding someone interested in speaking about a topic and organizing the pot-luck and child care, you might be able to get what you need.
why does one person have to foot the bill?
everyone can pay for themselves, and i’m sure they selected reasonable restaurants. $100/ mo seems like it would do it. less if they stopped bringing in speakers and did the education themselves.
it’s a lot of money but not a lot for that kind of emotional support and camraderie. i have a hard time buying that it is too expensive to maintain, but i certainly can understand if people have priorities that are more pressing. sometimes these meetings fade away, even with support. and sometimes if the only way they can survive is with external support, it speaks to the commitment level of all the participants (which may not match those of the organizers, who i am sure tried very hard to make it work).
I agree with A.N. above. I meet with a similar group of doctors about once a month for journal club. It’s pot-luck, the location rotates among different houses, and those who can’t make baby-sitting arrangements bring their children and they generally manage to occupy themselves in another room (the babies stay out front, and there’s generally a good mix of ages of children so that a few can be trusted to keep an eye on the others). The best part is that we are beholden to nobody, and it really is do-able for everyone if they make an effort.
Those “gifts” were helping us while they were hurting our patients. It’s time to move on and find new ways to take care of ourselves and our patients.
Maybe you could find a couple of daycare teachers who would be willing to watch a big group of kids at a more reasonable price than individual sitters for every participant?
For fun, from the excellent Thank You for Smoking:
Senator Orlotan Finistirre: Mr. Naylor, who provides the financial background for the Academy of Tobacco Studies?
Nick Naylor: Conglomerated Tobacco.
Senator: That’s the cigarette companies.
Naylor: For the most part, yes.
Senator: Do you think that might affect their priorities?
Naylor: No. Just as, I’m sure, campaign contributions don’t affect yours.
I remember not too long ago in residency we had a lot of drug sponsored dinners and CME, in addition to the weekly ‘grand round’ which was usually sponsored by a drug rep.
usually this consisted of a few free pens, some other type of trinket, and a 5 minute lecture on why their drug ws the best for a particular condition.
Pretty much all of us took this for what it was, an advertisement, but we did appreciate the efort involved in bringing us food, and taking the time to let us know about their product. As highly intelligent college grads, our residency director pretty much assumed that we would be able to understand the advetising for what it was.
Fast forward 4 years now I am in a small group practice, in a hospital system. my income this year is down 40+ percent. my group does not give out CME money, and the hospital has only limited grand round and CME available, none of it in my specialty. I miss the collegial ‘grand rounds’, which are really only possible with outside drug money. This year, I have had zero CME. dont have the income to do ‘cme conferences’ anymore, hell, dont even have the spare cash to join the specialty national organization this year.
I sympathise with your plight, dr atkinson, and please keep us updated as to the grand social experiment taking place in mass.
I agree wholeheartedly with Kate. I have done solo rural family medicine for 30 +years. My best learning experiences have been in pharma dinner meetings with leading speakers. Not by attending CME events, nor by reading other people’s opinion. but rather these small quiet very small group sessions where I could pick the brains of front wave thinkers. In no other venue is this possible. There is no method available now for this to happen. NONE.
The absolute neglect by bigger centers with lots of resources, of those of us who chose to look after that segment of the population that is not big city centered, is a crime. We are overloaded and the ease of some of the suggestions is showing the lack on insight into our daily world. Unfortuatley I am becoming more and more bitter to “the one solution fits all approach” by my peers. And this from family medicine where working with each patient as an individual is our speciality.
Sorry for the rant.
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