How the Massachusetts gift ban hurts primary care doctors

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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