Who’s my doctor? The total transparency manifesto

Our health care system is broken and in dire need of reform. We all know the statistics: the U.S. spends $2.7 trillion on healthcare30% of which is waste in the form of unnecessary tests and unnecessary treatments. Conflicts of interest are rampant, with 94% of doctors reporting an affiliation with a pharmaceutical or device manufacturing company, and many more insidious influences including salaries being tied to productivity. Dozens of studies have shown that these conflicts of interest have a real impact on care, and are a major driver of excessive cost and avoidable harm.

On my recent book tour, I discovered an even bigger problem than the cost of care. There is a rampant and growing epidemic that we seldom discuss — the epidemic of fear. It’s understandable why patients are scared when they come to us. They’re not feeling well. They’re scared of what might happen.

But there’s another layer of fear, one that begins and ends with trust. When my mother was diagnosed with metastatic cancer, it took her months to find an oncologist she liked. One day, while trying to locate his office number online, she found a listing for him as a highly-paid consultant and speaker for a drug — the same chemotherapy drug that he’d put her on. This might have still been the right treatment for her, but it made her wonder, and it made her scared.

Traditionally, medicine has maintained a certain mystique. While there has always been information asymmetry, patients and doctors established longstanding relationships, and patients trusted that doctors had their best interests at heart. However, today’s medical landscape is very different. Few patients have longstanding relationships with their doctors. They have little to go on when deciding who to trust with their health, then are kept in the dark on matters ranging from cost of care to doctors’ motivations to necessity of tests and treatments.

In a time when they are already vulnerable and scared, patients have become even more afraid that they may not be receiving the right care for the right reasons. Doctors, too, have become afraid of their patients; much has been written about the fear of malpractice leading to hiding mistakes and practicing defensive medicine.

This mutual fear has led to distrust, disconnection and poor medical care. The driver of fear is secrecy and shame, and the antidote is honesty and transparency. Doctors are public servants whose duty is to be accountable to our patients. We need to break through the barrier of fear by sharing with our patients and the public who we are.

This is why I’m starting a new campaign, “Who’s My Doctor? The Total Transparency Manifesto.” Participating doctors produce a voluntary, public disclosure statement that includes the following: revenue streams of all payments, salary contribution and how salary is determined (i.e. hourly, RVU system, incentive/bonus), paid and unpaid board membership, investments, volunteer activities, professional interests, hobbies, and philosophy of practice.

Doctors already disclose much of this information when they apply for jobs and when they submit to medical journals. So why shouldn’t this information also be available to the public? Our patients have a right to know what influences their doctors may have that affect their care. It holds doctors accountable to our patients while at the same time humanizing us and reinforcing our role as socially responsible public servants.

Many patients may well decide that this information is irrelevant and never look at it. However, it should be available in a public, easily searchable database for those who do think it matters. Patients then have the option of identifying a doctor whose philosophies match their own. They can also help to encourage their doctor to participate in this project.

Many doctors may have qualms about their information being available in such a public forum. However, in the era of Google and social media, much of this information can already be found online, and having a voluntary disclosure gives more control to the doctor. Also, experience with other transparency pilots such as OpenNotes has demonstrated that openness leads to better communication, more trust, and better care, and it only follows that a more open relationship with our patients leads to less fear and less malpractice.

I believe that this form of radical transparency is paradigm changing. It is changing the culture of medicine from one of secrecy and mystery to one that is totally open to patients. It is a public demonstration that patient interests are primary, that reaffirms the reasons why each of us went into medicine. Every time I tell my patient about my decision to be a totally transparent doctor, every time I share my Total Transparency Manifesto, I are saying, I’m your doctor. I’m looking out for you. I’m free of influence that could affect you. Don’t be afraid of me; trust me. I’ll be vulnerable with you.

Over the last few weeks, I’ve been discussing this idea with my colleagues and my patients. So far, I have myself and 10 other doctors who are willing to be totally transparent doctors. I’d love to have doctors of all specialties to participate, to say, I’m doing what I can to restore professionalism and break down the barrier of fear.

I’d love to have you join us. What you need to commit to is to write a Total Transparency Manifesto for the website (full website TBA; see more information and my manifesto on my webpage), tell your patients about it, and share your experience with me and the readers on this blog. How did it make you feel. Scared? Uncomfortable? Defensive? Liberated? And how did your patients respond?

And patients — what do you think? Please post your responses. Over the next few months, I’ll be posting my own experiences as well as the experiences of my fellow transparent doctors and our patients. Please join us in this new mission to counter fear and restore trust.

Leana Wen is an emergency physician who blogs at The Doctor is Listening. She is the co-author of When Doctors Don’t Listen: How to Prevent Misdiagnosis and Unnecessary Tests.  She can also be reached on Twitter @drleanawen.

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  • doc99

    I wish I got some of these “revenue streams” folks write about. In exchange, I’d have no problem whatsoever with disclosure.

  • Ron Smith

    Hi, Leana. You stated the following:

    “Conflicts of interest are rampant, with 94% of doctors reporting an affiliation with a pharmaceutical or device manufacturing company, and many more insidious influences including salaries being tied to productivity.”

    By the sheer way you quote that from the study you inject your apparent opinion that any associations are bad associations. How can you honestly make that conclusion?

    It seems to me that you are being self-serving and deceptive from the start of your post. It makes everything else in your article suspect. Here’s why I think that personally.

    I’m a solo Pediatrician. We have a company that comes to the office with their nebulizers. They bring them and leave them in the office. When I have a patient who comes in wheezing and my evaluation concludes they need a nebulizer, our staff collects the information that the company needs on their form, without any guarantee of payment from the third party provider. This is a great resource for which I am thankful because it helps my patients.

    Yet they often will leave the nursing staff a small supply of various candies as a courtesy and a way they can say ‘thank you.’ That would be considered an ‘association’ I believe by your and the NEJM’s standards.

    Here’s another even more apropos example. I have for thirty years treated children for ADD. Drug manufacturers will not uncommonly provide lunch in my office so that I can have time to discuss their medications. It is quality time because, unlike many rude physicians that I’ve heard about, I personally am there talking with them, instead of hidden back in my office just consuming the food.

    I see all representatives equally and have no endearment to any one product. ADD is one of those problems where there are limited treatments, and I have and do use them all at various times out of necessity. The kids need a working pharmaceutical solution and I’m determined to do everything that I can to get the best effect with the least amount of symptoms.

    These representatives provide not only information, they often also provide special cards that we can give to patients to reduce their medication costs at the pharmacy. I can discuss problems and issues that I’m having. My eyes are open to the fact that they are also hawking their product, but I’m there representing my patients. I take the time to engage on their behalf.

    Is the lunch that they provide me and my staff an ‘association’ by the NEJM’s study? Probably. Is it inappropriate? Absolutely not. It is essential that I get the best for my patients. The lunch means that I get to eat that day while still doing that.

    Physicians in general understand medicine, but they do not understand the ‘business’ of medicine. My Father was a natural gas pipeline in Arkansas when I was growing up. That meant that he dug ditches for a living.

    He understood the ‘business’ of doing ‘business.’ In high school, I drove for him in the summers. He at one point had thirteen crews across Arkansas, Louisiana, and Texas. Numerous times we drove 4 to 5 hours and more from Arkansas to the job sites in those other states only to spend maybe 15 minutes with a gas company executive to whom he was responsible. All 8 or 10 hours of driving that day was focused on that 15 minutes.

    How often he told me how important that 15 minutes was. Those gas companies knew my Father cared enough to take care of his ‘business.’

    Let me state that I think there are two kinds of ‘business’ in medicine. There are the physicians who are doing things like creating ‘companies’ that run patients through like cattle to extract the highest dollar per pound. The other kind of physician knows and understands that to provide his patients with the best care he can, will have to be that representative for them in the medical ‘business.’

    Just because a physician says he doesn’t have ‘associations’ with pharmaceutical or other paramedical entities does not mean he is somehow better or ‘transparent.’ It may more likely mean he doesn’t understand my Father’s ’15 minute rule’ within the business of medicine.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • PrimaryCareDoc

    I am just…at a loss.

    When I became a physician, I don’t recall taking an oath of poverty. I certainly never agreed to have “total transparency.” Why the heck should anyone know about my investments (or lack thereof, as the case may be)? Why should anyone know my salary? I’m not a public servant. My money is gained legally and ethically, and the amount is basically between me, my husband, my employer, and the IRS.

    • EE Smith

      Your patients absolutely have the right to know what your personal hobbies are. If, say, you collect first edition My Little Pony figurines, your patients have the right to know that and to consequently refuse to let you treat their high blood pressure or corns. Because, TRANSPARENCY.

      /s

    • Leana Wen MD

      Who’s My Doctor doesn’t ask for your salary amount, just for your revenue streams. It is potentially relevant to your patients if you are receiving money for things that may affect them.

  • guest

    It’s hard to even know where to start here, but I am going to try. In the first place, it would be interesting to know what constitutes a “conflict of interest” that 94% of practicing physicians would be found to have. 94% seems extremely high, unless one counts all physicians who occasionally get some take-out food brought in by a drug rep, in which case, it’s hard to get very worked up about the supposed “conflict of interest.”
    In the second place, it would be interesting to know the basis on which Dr. Wen is claiming that doctors are “public servants.” Doctors fund their own education privately, at great personal expense, and the vast majority of them are not government employees, but work for private entities such patients or private healthcare organizations. To say that doctors are public servants makes no more sense than to say that engineers or lawyers are public servants.

    In the third place, it seems to me to be a little bit of a conflict of interest that Dr. Wen is discussing with her patients a patient advocacy “movement” that she has created, which is currently posted on a website on which she is advertising a book she has written and her services as a paid speaker.
    Tricky stuff, indeed.

  • Shirie Leng, MD

    Yeah the public servant comment probably doesn’t fly. However, limited transparency isn’t a terrible idea. No one needs to know what I make, but anyone who has presented in any conference knows you have to disclose financial interests you have in ay products you discuss. There’s no reason patients can’t know the same. I thinks that’s fair.

    • guest

      I have absolutely no problem at all with disclosure of significant financial relationships. What I have a problem with is the idea that my name should end up on some website along with those who do have significant conflicts of interest because I happen to, once a month, go to a staff meeting where a drug rep has brought in takeout food which I eat while internally rolling my eyes at their sales spiel.

      A lot of my patients are not in the position to differentiate between me and my lunch and the high-level academic who is working with pharma as a “consultant.” And yet the differential in conflict of interest from those two very different activities is at least several orders of magnitude. It would be nice if the people who are pushing “full disclosure” could at least be somewhat sophisticated about it and find a way to differentiate between significant and insignificant conflicts.

      • Leana Wen MD

        You’re right; there may be a difference. Your information will be on a public website anyway as part of the Physician Sunshine Act as of Oct 2014, so Who’s My Doctor allows you the opportunity to explain what you are doing specifically.

  • Tiredoc

    Just financial transparency? Since you’re advocating full disclosure, why not post a board about your emotional and physical health? Slap on a monitor and post how much sleep you’ve had the night before. Rate your relationships for the day, 0 for a death in the family, 10 for bliss. Rate how compliant you are with your medications. Make sure you note how much coffee you had, too.

    If it would make you feel better, post a sign in you waiting room. State unequivocally that you are human. You don’t work for free. You aren’t a computer, so sometimes your decisions don’t match exactly the treatment algorithm. You get tired, bored, angry, sad. You spend more time talking with people you like than with people you don’t.

    You are advocating a voluntary financial colonoscopy as a solution to the problem of medical care provided outside of the bounds of published guidelines and the fear of patients that their doctors make decisions in part on their ties to pharmaceutical companies.

    I have a greater fear. That fear is that my ability to order the tests, treatments and medications I believe are appropriate for my patients will be taken away by bureaucrats in lab coats, aided by misguided Quislings eager to demonstrate their moral purity.

    For every complex problem, there is a simple solution. A simple solution that is wrong.

    • PrimaryCareDoc

      Financial colonoscopy. Spot on.

      And bonus points for teaching me a new word- “Quisling.”

  • EE Smith

    I want to live in a world where there are still doctors, when I am old and gray. You know?

    While I agree with disclosing major conflicts of interest, by the time you get into demanding that physicians publish their full “investments, volunteer activities, professional interests, hobbies” &cetera, you are getting to a place where you are basically saying that doctors can have no private lives outside of their practice, and I think that’s going too far. I don’t need to know that my doctor has an investment home in Maui or that she helps run her Synagogue’s youth group and supports the World Wildlife Federation and the Coalition for Home Schooling or that she collects Precious Moments figurines. I just don’t, and I don’t see why physicians should have to give away that much of their private lives to all and sundry on the world wide web.

  • guest

    In other news, I notice that on Dr. Wen’s Total Transparency Manifesto, she lists herself as “Board certified/board eligible: yes.” Most physicians who are board certified don’t bother to include the “board eligible,” since it basically just means that you have completed your residency. This gives rise to the question–is Dr. Wen board certified or not? And if not, why is she not being a little more straightforward about it on her Total Transparency Manifesto?

    • Leana Wen MD

      The language used in emergency medicine (my field) is board certified/board eligible, so that is the language used on my website. You can see that it is the same for all the doctors listed on http://www.whosmydoctor.com.

      • guest

        The language is the same in all fields. The ABEM is no different from any other specialty. It is true that it did recently allow graduates who have not taken their boards to refer to themselves as “board-eligible” for a period of five years after completing residency training. However, if you are board-certified, you don’t use the term “board eligible” to refer to yourself, since by definition “board-eligible” means that you have not taken (or passed) the boards.

        You may want to check with someone about this, if you really are under the impression that you should refer to yourself as “board-certified/board-eligible” after becoming board certified.

  • Deceased MD

    She may be an ER doc but she does not seem to think. Does she think it will solve anything being transparent? Will that solve the HC crisis?

  • Leana Wen MD

    Thanks to everyone for your replies.

    I’ll respond to individual comments below. Some comments to general themes raised:

    #1: About drug companies and doctors: the NEJM study quoted citing 94% of doctors have affiliation with drug and medical device companies includes all affiliations, which includes a lunch, pen, and other gifts. Dozens of other studies have shown that even small gifts affect physicians’ prescribing habits, and that doctors suffer from the “you but not me” phenomenon—where we believe our own prescription habits aren’t affected (which implies that pharma is somehow wasting their marketing efforts, a contention we know is not true).

    Some have raised the point that drug reps are helpful for educational purposes, or that they need the lunch to get through their day. I find it offensive to think that I need to be “educated” by someone with a marketing background, when there are plenty of unbiased and free sources of information out there. Ample studies also that samples, while they may seem to help patients, actually increases cost for patients in the longterm.

    All that said, there *might* be a difference between doctors accepting money to be a “key opinion leader” for a drug and leading a multi-site clinical trial. There are multiple websites where doctors’ affiliations with drug companies are already out in the open: ProPublica has a website, and also Accountable Care Act will have a public website in Oct 2014. Who’s My Doctor allows doctors the opportunity to explain the degree of
    interaction with drug companies. If you as a doctor think that your interaction with drug companies is good for you and your patients, then you have a chance to explain why.

    Ultimately, the point is not to say that doctors who associate with drug companies (or that have investments or other specific revenue streams) are bad, but rather that our patients should know about it. Perhaps it could even be seen as a good thing that, as an oncologist, you lead
    large pharma-funded research studies. Just as we disclose our conflicts of interest to each other in journals and conferences, we should disclose them to patients. If we are doing something that we are ashamed of letting our patients know, perhaps it’s not something we should be doing.

  • Leana Wen MD

    #2: About social accountability: medical students face heavy debt, but our medical education is still heavily subsidized by taxpayers. Every student interviewing for medical school understands that our job is to be socially accountable to our patients and our society. We swear a Hippocratic Oath where we place patients as our first priority. I argue that it very much is our patients’ business how we get paid, because it affects their healthcare directly. Even if you don’t believe that doctors are public servants and are just responsible to themselves, remember that disclosure is standard business practice, i.e. lawyers have to disclose their conflicts to every potential client.

    • PrimaryCareDoc

      Ah, the old canard about out medical education being tax-payer subsidized.

      Here’s the thing- Medicare may fund GME, but residents do plenty to earn that money. They are not sitting around at classes and in conferences. Working 80 hours a week for what amounts to well less than minimum wage is certainly not a free ride from the US taxpayers. Hospitals are getting highly skilled workers for a pittance.

      Anything that I obtained from the US taxpayers for funding of my medical education was paid back in spades.

      On a similar note, one might suggest that everyone who has ever taken out ANY educational loan, be it a Stafford loan or Sallie Mae, has had their education heavily subsidized by taxpayers.

      • EmilyAnon

        “Anything that I obtained from the US taxpayers for funding of my medical education was paid back in spades.”

        Yes, but paid back in spades to the hospital, not the taxpayer. It’s the hospitals that “are getting highly skilled workers for a pittance” but have no problem billing the patient 10 times what they are paying you. And don’t forget it’s these same taxpayers that become free practice patients necessary for your training.

        • PrimaryCareDoc

          Is that really what you would consider patients at the finest teaching institutions of the country? Practice patients?

          Don’t forget that a first year intern still has more training than an NP right out of school, who is being set loose to practice without supervision in many states.

          • EmilyAnon

            I don’t see anything wrong with the term “practice” patient. Don’t doctors “practice” medicine. If I am being treated by inexperienced students or interns who are honing their skills on me, then yes, they are practicing on me until someone deems them accomplished enough to practice (there’s that word again) on their own.

            That being said, the necessity of training on real patients is obvious, and I personally don’t have an issue about being in their care because I have always felt my participation was appreciated.

        • guest

          Actually, the original deal with CMS (Medicare and Medicaid) was that hospitals would accept discounted rates for caring for those patients, and the care would be provided by trainees, whose salaries would be subsidized by CMS. The taxpayers are paying for charity care to be provided to the poor and the elderly. The subsidy was never intended to be a subsidy for training. As mentioned above, the trainees pay for their training in spades, by basically being hospital slaves for several years during residency.

  • Leana Wen MD

    #3: While there are no doubt other problems in our medical system that require other solutions, including malpractice and high cost of care, transparency is one way for us as physicians to say to our patients that
    we want to do our part to counter fear and reinstill professionalism. (The
    opposite is also true: if we are hiding from our patients our financial
    incentives when we order a test or procedure, that further leads to lack of
    trust and lack of professionalism.) This is not the only solution to the vast problems in healthcare. However, we also cannot say that just because there are huge problems, that we should not do our best to do some small things that may have positive impacts.

  • Leana Wen MD

    #4: Financial transparency is part of radical transparency. Other parts include who we are, which includes our hobbies, volunteer activities, languages spoken, age, research interests, philosophy of practice, etc. We need to change the paradigm from one where the doctor decides what
    information is relevant for patients to know to one where patients decide what information is relevant for them. Doctors can decide how much to disclose, but it shouldn’t be up to us to say that my hobbies or financial conflicts aren’t relevant to our patients—that’s up to our patients to decide.

  • Leana Wen MD

    #5: One final point I’ll add is that disclosure is happening, with or without participation of doctors. Info about us is getting out there, about “ratings”, “quality”, “patient satisfaction”, etc. We may not like this—and we may not even like the disclosures that are getting put out there about us. But since it’s out there, why not have a website where doctors can control some of that information, and add our own philosophies of practice and who we are? Who’s My Doctor is an attempt to take back that control and put it back into the individual doctor’s hands to say, this is who I am, this is why I do what I do, and I am telling you this because I have nothing to hide–everything I do is in my patients’ best interests.

    Thanks, everyone, for reading. If you are interested in joining Who’s My Doctor, please contact me and visit http://www.whosmydoctor.com.

  • Mike

    This is a voluntary program Dr. Wen is advocating. I understand why some doctors might not want to participate in it, but I also understand why some doctors see it as a positive move. But Dr. Wen makes it pretty clear that “total transparency” only applies to those doctors who choose to participate

    As long as no one is being compelled to make such disclosures over and above those which are legally mandated, what’s the problem? As the (admittedly overused) expression goes, “It’s a free country!” Let Dr. Wen and those who chose to join her be free to practice this “total transparency”, and let doctors who do not wish to participate be free to stick with the status quo. And let the patients decide how much value they place on physician transparency.

    • guest

      I think everyone is aware that it’s a voluntary program. What I personally find off-putting (and maybe others do, too) is that this is an example of something all too common in medicine these days: a young physician, with limited clinical responsibilities in an academic setting which protects him or her from the worst stressors of medical practice these days (I am an academic physician, so I know what I’m talking about), decides to earn money not by taking care of patients, but by telling the rest of us what we should be doing to improve care.

      If you’re not in the trenches being a full-time provider of medical services, you really aren’t in a position to be that informed about what’s really wrong with our healthcare system.

      Also, if you’re not board-certified, you should be upfront about it in your “disclosures.”

      • Mike

        You explain your points well. I have a better understanding of some peoples’ objections now, thank you for taking the time to respond.

        • guest

          You are welcome. Without these explanations, I know that we doctors can sometimes come across as grumpy and arrogant (and of course there are some arrogant doctors out there and an increasing supply of grumpy ones, too). I do think it’s important for us to fully explain what the basis is for our objections to some of the suggestions that people make; hopefully we can all have a better understanding of where others are coming from, doctors and patients alike.

          • Leana Wen MD

            Thanks for your explanation–it helps to understand your objection. I also agree that it is critical for doctors to provide excellent medical services; we just have to be up front about what it is we are doing, and who pays for it. If I, as a patient, am being recommended a procedure, I would want to know if my doctor is being paid to do it, or if my doctor is salaried and therefore doesn’t benefit from either ordering it or not ordering it. That’s part of informed consent.

            As for my own revenue streams and disclosures, I started Who’s My Doctor entirely voluntarily, because I believe it is the right thing to do, not because I will have some personal gain from it. It is not a profit-making entity, nor will it ever be. My medical school is not a tenure-track institution so I personally do not gain financially or academically from this program (if anything, with the objections from so many doctors, I am putting myself out there at significant professional jeopardy). At the moment, I volunteer my time at least 20 hours a week to this project because I believe it is important for our patients. I hope this also helps to add some additional nuance to Who’s My Doctor.

          • guest

            Well, good luck. I would encourage you to consider pursuing full-time clinical practice for a few years, if you can manage to make it fit with your personal life. In my opinion, that is really the best way to obtain real insight into what’s going on in medicine these days. Plus, it gives you more street cred with real doctors once you decide to get involved with policy matters.

          • Leana Wen MD

            Thanks for your advice. You’re right; that’s why I do practice full-time: I work 2-3 full-time shifts a week clinically, in addition to teaching medical students and conducting research in patient-physician communication. I love my work and love being a physician–and, indeed, it is what gives me insight into what is going on with medicine.

          • guest

            You know, I think some of this is a generational thing. For you, full-time work is doing 2-3 ED shifts a week, teaching med students (unclear whether than means giving lectures or having them shadow you) and doing research.

            But for me, and a lot of other (older) doctors, full-time clinical work means that you see patients 40-60 hours a week. IN ADDITION TO THAT, I do both clinical and didactic teaching of residents as well as medical students, do research with a mandated goal to publish within a year (I do get two days a month of protected time for this) and sit on the boards of two statewide medical organizations. That’s in addition to the various journal clubs, case conferences, committee meetings, residency applicant interviews etc, etc that one must do if one is on the faculty of a training program. It’s a matter of routine for me to be paged several times for clinical emergencies during the course of my weekly lecture to the residents. The idea that my clinical work could be contained to 2-3 defined shifts per week sounds unbelievably luxurious. I can’t even imagine how nice it would be to have that sort of flexibility.

            But in having that flexibility and good work-life balance, you give up something else, which is the ability to speak with any real authority on how others, who are working more demanding schedules, should best do their work. It’s just human nature. People don’t take well to directions offered by those they don’t respect. And respect is earned by doing the same work as others and proving that you can do it well under the same circumstances as anyone else.

          • PrimaryCareDoc

            Bravo. I almost snarfed my coffee when I read that she does practice full time- 2 to 3 whole shifts a week!

            I spend about 50 hours a week in the office. Plus volunteer positions at the hospital, serving on my state medical society, and other various committees.

            Plus raising a family.

            I think that people who are not in medicine don’t realize how damn insulting it is to be lectured to by someone who is four whole months out of residency.

          • guest

            Oh, right, I forgot to mention that. Single mother of three as well.

            This is really a topic that interests me, since we had a recent faculty development lecture on the care and feeding of the Millennial, which is the generation that Dr. Wen appears to be from. Apparently this is a generation which prizes life-work balance and so they will not accept the kind of work hours that we have traditionally taken for granted as part of our jobs. In addition, they are accustomed to more “affiliative” relationships with authority figures, so are very comfortable offering feedback and advice to their elders.

            As I pointed out in the seminar, however, there’s a tricky part to all of this, which is that in medicine, if you have a crop of workers who are declining to do a certain amount of the work, that work then has to be done by….us, the older workers. So when the residents decide that they need to sleep while on call and that admissions should get capped, guess who has to take telephone call in the middle of the night to give phone orders on post-cap admission? The senior attending on call. This is all fine (maybe) but then don’t be telling us how to do the work, after we were up all night actually doing it while you slept.

          • Suzi Q 38

            Don’t things change and evolve over time?
            Cut her a “break.”
            I am sure she is not the only doctor with such a schedule.
            We could also compare your schedule to physicians who loved their patients and work so much that they worked 24/7 and chose never to marry or have children.
            My point is that you are all

          • Jess

            “I do practice full-time: I work 2-3 full-time shifts a week”

            What is a “full-time shift”? A normal shift, I would assume. And if you’re only doing 2 or sometimes 3 shifts a week, you’re not practicing “full-time”.
            Unless this is some new definition of “full-time practice” that I’ve never heard of.

            Would you consider your local doctor’s office open “full time” if it were only open in Tuesdays and Fridays? Would you hire a “full-time nanny” who only showed up on Wednesdays, Thursdays, and sometimes Saturday mornings? I often look after my brother’s kids on weekends and school holidays. This does not make me a “full time parent”, nor does it give me enough insight into the world of full-time parenting to go around lecturing people who actually DO that.

            Working a couple of shifts a week is not being in full-time practice. It’s being a hobbyist. And more importantly, it doesn’t actually give you a lot of insight into the worlds of doctors who actually DO practice full time.

          • Leana Wen MD

            Actually, 2-3 shifts is full-time for emergency medicine–in both academics and (for many places) community practice. I encourage you to look into this more if you are interested.

            I also encourage us to come back to the core issue at hand, which is transparency and the need for disclosure. You are welcome to add in your transparency manifesto how much you yourself work, and how you are getting paid.

  • rbthe4th2

    Wow! It seems like a lot of docs are attacking Dr. Wen. I think what she is trying to do (reading into it) is striking a balance between disclosures that may affect a patients’ treatment and ones that won’t. From what I read, I don’t think she’s looking for disclosures if someone likes art or history. If they want to, fine. I think the disclosures would be more financial pointed where in you have $10K invested in Novartis, rather than if you just had $10K invested in large company stocks. Financial in you own a lab and make $$$ off of doing bloodwork.

    The idea being, are we going to gel/mesh as patient and doctor, do we have the same outlook on life and how we want to solve issues relating to health?

    I think disclosures that would be helpful to patients, truly is your outlook on medicine itself. Do you practice evidence based medicine? Do you welcome a patient bringing in medical literature and asking how does it affect them or their treatment? Or do I have X disease? Do you believe in doing testing first and then solving a problem, or do you just give a pill and that’s it? What other types of issues have you encountered that you are experienced to deal with? If you’re an ER physician, I’d want to know if you can deal with a lot of gunshot wounds, maybe. If you’re an internist, what criteria do you use to refer to other docs?

    Those types of things are actually going to help us pick our docs better, we’re all going to be happier in the end.

    I just got the impression from what was posted below that physicians think we want to be in your private life. Quite honestly, I see docs posting they’re married with 2 kids or something, they have dogs, cats, etc. As a patient, that’s well and good, but whether or not you want a patient who is going to ask questions, one who will write some notes for the patient because their older & need the ‘memory jogs’ (a friend of mine’s parents are like that), those types of things are what I want to know about you personally before any kids/dogs/vacations stuff.

    Yes, the above financial disclosures, in the vein I put above, that would be helpful.

    Next, doctors are paid during internship/residency/grad med. education by the govt. Correct me if that’s wrong. I think that is what she’s referring to. If you also take Medicaid or Medicare, then you are taking taxpayer/govt. funding.

    I think she’s been above board about what she is doing and her interests with her book and all.

    Frankly, I would be concerned about a doc without a stable home life. It only distracts them. I would want them to sleep well, eat well, and spend time with family or doing hobbies, vs. their life be nothing but medicine. Burned out docs do NO one any good. I think the point being made is that the person has a job as a physician but can disconnect and be a human being off work hours. That is healthy for both the physician AND the patient. I’ve seen too many docs who REALLY needed a vacation AND to get a life outside of medicine. They learn what life is like for us patients. If they understood or got a glimpse of what its like trying to juggle copays, doctor visits, time off work, drug copays, I think there would be better understanding of why patients were “non compliant”.

    One last item, “If you’re not in the trenches being a full-time provider of medical services, you really aren’t in a position to be that informed about what’s really wrong with our healthcare system.”. Let me tell you, if you aren’t a patient, then I don’t know how much you can comment on it either. I’ve been told by specialist X that I’m to go back to my PCP because they would run Y test. PCP says I don’t do that, go back to your Specialist. I’ve had specialist X say eat this particular diet (say vegetarian) and then specialist Y say eat paleo. Or that specialist Z should run X test and specialist Z says we don’t do that. I have tons of those stories.
    At least Dr. Wen is trying to help a main issue in healthcare and that is the loss of trust in the healthcare profession. Its not just because of financial interests, but the inability of patients to get doctors to police their own, and we see time and again doctors who really shouldn’t be ‘in the game’ left in, well, docs can be their own worst enemy.
    Randy

    • PrimaryCareDoc

      Why would you think that a doctor knows nothing about juggling copays and drug copays and doctor visits and time off work? Do you think we never get sick? Never have to take a medication? Never have to see a doctor?

      Or do you think there is some special doctor clinic that we all go to that is free and open at all hours for our convenience? There isn’t, you know. When I had to have hand surgery last year I took time off and paid out of pocket because I have a high deductible plan. Just like anyone else.

      • rbthe4th2

        On our salary? Do you make $31K a year? Drive a 13 year old car? Live in the rough side of town? Can you get “curbside consults” that we can’t? I end up taking off for 1-2 hours for a checkup. You may not have to go see a doc because you have figured out what’s wrong with you and can take OTC stuff. I have to take that time off and pay it.
        There’s a difference between trying to pay for a $150 ER copay + 20% balance on $31K a year at $650 or so take home pay year/biweekly, compared to $150K at least, $75K take home, even after $1-2K a month for school bills. I’m in my 50′s, by the time one of you reach the 50′s, your loans will be paid off.
        I understood you all eat free in the cafeteria. I don’t get that benefit. So if I have to stop off, that cup of coffee or a sandwich isn’t free on my $31K a year salary that it is on your $150+ a year one.

        • PrimaryCareDoc

          No, I make more than $31,000. But I’m also the sole breadwinner of my family of five, and yes, I am paying off my loans (still) and will be putting 3 kids through college. My loans will not be paid off until I am 61.

          I have to take 1-2 hours off of work to see a doctor, also. And I try not to treat myself. I would be a fool to try to do that.

          And no, I don’t get free food in the hospital cafeteria. Never have, not even as a resident. Not even a cup of coffee.

          • rbthe4th2

            You’ve got a lot more tax deductions than I have also. Do you have a spouse that can work or doesn’t because they don’t have to due to your salary? How about a mortgage deduction?
            That’s a big difference. You can raise a family on at least $150K a year. I know lots that are doing it on less than that and getting along quite well. They can afford more than I do.
            Bottom line if we put our tax docs out to an accountant, bottom line you will outmake me.
            In this area, the docs get free food at all but one of the hospitals I know. I haven’t checked that hospital though.
            Btw, my parents didn’t help me but once for college tuition. There is no rule that says you have to pay for your kids college.

    • guest

      Actually most of my comments and thoughts about what is wrong with our healthcare system are informed by (unfortunately) a lot of bad experiences being a patient (and the mother of patients). Unlike others, I have tried to keep from being bitter and resentful, even when I have felt that I or my children got less than optimal care from physicians who easily outearn me. It helps that as a physician, I have myself experienced all of the stressors that keep doctors from being able to provide optimal medical care. Unfortunately, there’s absolutely no way that most patients can ever truly appreciate those stressors.

      The closest I ever came was when an “efficiency expert” came to shadow me during a typical day at my job in order to make recommendations about how I could work more effectively. After about three hours, she said “This is an unbelievably chaotic work environment, I have no idea how you are able to function. I have a splitting headache and I have to leave now.” We never heard from her again.

      • rbthe4th2

        Unfortunately mine are the result of quite a few bad experiences also. The reason most I’ve met are bitter, is because they’ve trusted docs, and were let down. It wasn’t the system, it was doctors. Ones who made treatment decisions without us, and we’ve had to live with it. Ones who made wrong decisions and we’re suffering for the fallout. Ones made because other doctors passed on their wrong decisions on a patient and it ruined their health care.

        As someone who tried to help a few docs out, and was “bitten” by them for it, you can’t expect someone not to be bitter. It was the PHYSICIANS choice to do what they did, and perpetuate things that were incorrect to save their own hide: not their patients.

        You can’t blame the system for that, especially when one isn’t looking to sue but to get things fixed.

        Randy

        • guest

          I am sorry that you have had bad experiences with doctors. I wish you luck in getting your medical problems addressed in more helpful and positive way.

          • rbthe4th2

            Thank you. I find I have a few doctors who are evidence based medicine and are very thorough. I make sure that their admin knows that their care is outstanding, and I pass on their information to other patients. I have found that lack of knowledge and inability to deal with complex issues makes a difference. I’ve been much more pointed in my questions, and although it is not always appreciated, I believe that getting the appropriate experience and education for more complex problems tends to save time and money for everyone.

  • rbthe4th2

    I did that. They got angry with me and refused to answer. So did the hospital when I asked. I never asked about the hobbies, but I did care whether or not there was a conflict due to the financial acceptance.

  • Suzi Q 38

    I thought her article was very interesting especially the part where her mother was put on a drug that her mother’s physician was promoting and being paid to promote

    • guest

      Yes, I agree that that is highly unfortunate and should never happen. I always cringe when I see doctors helping drug companies promote medications.

  • Suzi Q 38

    I think it’s a great idea to look up your doctors big Pharma payouts on record. I looked up all of my doctors on the website.
    I was pleased to find that 50% of them didn’t receive any money from big Pharma and the other 50% had. Not bad.
    Of the physicians that did receive money from big Pharma the money was not a whole lot.
    Son this case transparency was probably a good thing.
    I know I would feel differently if the total amount per year received from big Pharma I was say $20,000.00 or more.
    That would be a red flag for me.

    • Leana Wen MD

      Thanks for the comment. Research shows that small gifts–even a pen or a lunch–can influence doctors as much as large gift. That’s why all disclosures are important.

      • guest

        I think it might be interesting for you to cite the research that establishes that a doctor who gets an occasional lunch supplied by a drug rep is as likely to show influence on prescribing patterns as a physician who is getting substantial remuneration from a drug company. In my personal experience, that’s not at all true, and I would be quite surprised to see any methodologically valid study that proved otherwise.
        By the way, this is why an issue is being made about your level of experience. People are not discussing it just to be mean to you. It’s being discussed because you are presenting yourself as an expert who is in a position to make judgments and policy recommendations about how patients and doctors communicate when the fact is that you are not communicating yourself with patients on a full-time basis.
        Full-time clinical practice is stressful, and no one, least of all me, who worked part-time for six years after I finished my residency so I could raise children, would ever consider criticizing a doctor who decided to do part-time clinical work. But I used the other part of my time to take care of my children, and I accepted a part-time salary during those years. I would never have considered myself qualified to be paid to be an “expert” on anything having to do with clinical practice, let alone advise others on how they could improve their relationships with their patients while I was, as other doctors put it at the time “kind of working as a hobby.”. That would have seemed unacceptably presumptuous to me.

        • Leana Wen MD

          Thanks for your explanation. There are some excellent research articles on the topic–many citations in Dr. Marcia Angell’s book, The Truth About Drug Companies. Great links also here: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0040150

          I also want to clarify a misunderstanding. I do not profess to represent doctors. Quite the opposite; I think that for too long, we have had a hierarchical structure that is doctor-centered and not patient-centered. I represent myself as a doctor and patient and caregiver. We need to hear the voices of more patients and caregivers–people who don’t have “titles” or “legitimacy” as traditionally defined, but who have extremely valuable opinions when it comes to their health.

          It is to understand what people want from their healthcare that drives me to do what I do every day. You don’t need an MD or many years of full-time clinical experience to speak on healthcare issues. In fact, the most important voices, the ones that aren’t being heard, are the ones that represent those who may have had just one–but a very critical one–experience with healthcare.

      • Suzi Q 38

        You’re so right I used to be a pharmaceutical sales rep in the 80s and 90s. We used to take doctors out to lunch we gave them so many free things I don’t remember all of free things we said to give them we stood by their family gifts we would give them honorariums to speak in our territories food flight them out from other states to have them speak in our territories

  • azmd

    I am personally very much in favor of transparency where it pertains to financial conflicts of interest as well as training and professional background. That’s why I find it hilarious (although a little sad) that the “Total Transparency Manifesto” is structured to allow doctors to be opaque about the gold standard of professional achievement in our profession: board certification.

    By lumping “board certified” and “board eligible” into one yes/no category, the website makes it impossible to know whether your doctor is board certified or not. Speaking as a patient, that’s one of the most critical pieces of information I want to have about a doctor. Knowing what the doctor’s “practice philosophy” is, not so much. It’s like the medical school admission essay, anyone can write anything they like about themselves, it does not necessarily have any basis in reality…

    • Leana Wen MD

      This is a great point. I will work on changing this on our website; thank you.