Ideological Sorting of Physicians in Both Geography and the Workplace.

CONTEXT: The distribution of physicians across geography and employers has important implications for the delivery of medical services. This study examines how the political beliefs of physicians influence their decisions about where to live and work. METHODS: Physician relocation and employment patterns are analyzed with a panel constructed from the National Provider Identifier directory. Data on political donations are used to measure the political preferences of physicians. FINDINGS: The "ideological fit" between a physician and his or her community is a key predictor of both relocation and employment decisions. A Democratic physician in a predominantly Republican area is twice as likely to relocate as a Republican counterpart living there; the reverse is also true for Republicans living in Democratic areas. Physicians who do not share the political orientation of their colleagues are more likely to change workplaces within the same geographic area. CONCLUSIONS: Physicians are actively sorting along political lines. Younger physicians have trended sharply to the left and are increasingly drawn to urban areas with physician surpluses and away from rural areas suffering from physician shortages. The findings also help explain why physician shortages are more prevalent among left-leaning specialties such as psychiatry.

Bringing Transparency to Medicine: Exploring Physicians' Views and Experiences of the Sunshine Act.

The Physician Payments Sunshine Act (PPSA) requires health care product manufacturers to report to the federal government payments more than $10 to physicians. Bringing unprecedented transparency to medicine, PPSA holds great potential for enabling medical stakeholders to manage conflicts of interest (COI) and build patient trust-crucial responsibilities of medical professionalism. The authors conducted six focus groups with 42 physicians in Chicago, IL, San Francisco, CA, and Washington, DC, to explore attitudes and experiences around PPSA. Participants valued the concept of transparency but were wary of the law's design and consequences. They downplayed PPSA's potential and felt it undermined public trust. Showing broad unawareness of COI, they dismissed the notion of industry influence and welcomed company "perks." Misapprehensions may leave physicians unprepared to advance the opportunities PPSA holds for professionalism. The authors offer recommendations for government and medicine to improve physicians' and other stakeholders' understandings and use of the data.

Medical communication companies and industry grants.

IMPORTANCE: Medical communication companies (MCCs) are among the most significant health care stakeholders, supported mainly by drug and device companies. How MCCs share or protect physicians' personal data requires greater transparency. OBJECTIVE: To explore the financial relationships between MCCs and drug and device companies, to describe the characteristics of the large MCCs, and to explore whether they accurately represent themselves to physicians. DESIGN: We combined data from the 2010 grant registries of 14 pharmaceutical and device companies; grouped recipients into categories such as MCCs, academic medical centers, disease-targeted advocacy organizations, and professional associations; and created a master list of 19,272 grants. MAIN OUTCOMES AND MEASURES: Determine the distribution of funds from drug and device companies to various entities and assess the characteristics of large MCCs. RESULTS: Of the 6493 recipients of more than $657 million grant awards from drug and device companies, 18 of 363 MCCs received 26%, academic medical centers received 21%, and disease-targeted organizations received 15%. For-profit MCCs received 77% of funds (208 of 363). Among the top 5% of MCCs, 14 of 18 were for-profit. All 18 offered continuing medical education: 14 offered live and 17 offered online CME courses. All required physicians to provide personal data. Ten stated that they shared information with unnamed third parties. Eight stated they did not share information, but almost all added exceptions. None required explicit physician consent to their sharing policies. CONCLUSIONS AND RELEVANCE: Medical communication companies receive substantial support from drug and device companies. Physicians who interact with MCCs should be aware that all require personal data from the physician and some share these data with unnamed third parties.

Olfactory Changes After Military Deployment Are Associated With Emotional Distress but Not With Mild Traumatic Brain Injury History.

OBJECTIVE: The aim of the study was to identify the impact of mild traumatic brain injury history and current emotional status on olfactory functioning. DESIGN: This was a cross-sectional study of 49 predominantly male, military veterans, reservists, and active duty service members with Operations Enduring Freedom, Iraqi Freedom, and New Dawn deployments and varying mild traumatic brain injury histories. RESULTS: Those with a positive history of mild traumatic brain injury (n = 32) endorsed significantly higher rates of self-reported olfactory disturbance. However, there were no differences between the mild traumatic brain injury and no mild traumatic brain injury groups for rates of objective odor identification dysfunction (none vs. microsmia or more severe) or overall accuracy of odor identification. In keeping with this, self-reported olfactory disturbance also failed to associate with odor identification dysfunction. In both groups, those self-reporting olfactory disturbance reported significantly greater emotional distress, severity of posttraumatic stress symptoms, and attentional impulsivity. However, self-reported olfactory disturbance was not associated with other behavioral factors frequently attributed to TBI, such as aggression, motor impulsiveness, poor planning, and cognitive flexibility. CONCLUSIONS: These findings indicate mild traumatic brain injury is not a risk factor for postacute microsomia among Operations Enduring Freedom, Iraqi Freedom, and New Dawn military veterans. Higher observed rates of self-reported olfactory disturbance in patients with mild traumatic brain injury may be a function of emotional distress rather than organic brain injury.

Health advocacy organizations and the pharmaceutical industry: an analysis of disclosure practices.

Health advocacy organizations (HAOs) are influential stakeholders in health policy. Although their advocacy tends to closely correspond with the pharmaceutical industry's marketing aims, the financial relationships between HAOs and the pharmaceutical industry have rarely been analyzed. We used Eli Lilly and Company's grant registry to examine its grant-giving policies. We also examined HAO Web sites to determine their grant-disclosure patterns. Only 25% of HAOs that received Lilly grants acknowledged Lilly's contributions on their Web sites, and only 10% acknowledged Lilly as a grant event sponsor. No HAO disclosed the exact amount of a Lilly grant. As highly trusted organizations, HAOs should disclose all corporate grants, including the purpose and the amount. Absent this disclosure, legislators, regulators, and the public cannot evaluate possible conflicts of interest or biases in HAO advocacy.

Medical Professionalism In An Organizational Age: Challenges And Opportunities.

The structure of medical practice is undergoing an extraordinary transformation. The percentage of physicians salaried and employed by hospitals and health care groups has increased dramatically. Growing numbers of patients are using health information technologies that facilitate transparency and enable patients to use the internet and health tracking devices to better manage their health care. This article aims to start a dialogue on how these changes may affect the key responsibilities of medical professionalism: putting patient interests first, maintaining and enhancing physicians' medical competence, and sustaining trust in the doctor-patient relationship. We identify several potentially effective strategies. They include policies to promote an institutional culture committed to professionalism and to enlarge physicians' role in institutional leadership. We also address how the principles of professionalism might guide physician compensation formulas, policies governing transparency, and best practices for strengthening the relationships between physicians and newly empowered patients.

Marketing HPV vaccine: implications for adolescent health and medical professionalism.

The new vaccine against 4 types of human papillomavirus (HPV), Gardasil, like other immunizations appears to be a cost-effective intervention with the potential to enhance both adolescent health and the quality of their adult lives. However, the messages and the methods by which the vaccine was marketed present important challenges to physician practice and medical professionalism. By making the vaccine's target disease cervical cancer, the sexual transmission of HPV was minimized, the threat of cervical cancer to adolescents was maximized, and the subpopulations most at risk practically ignored. The vaccine manufacturer also provided educational grants to professional medical associations (PMAs) concerned with adolescent and women's health and oncology. The funding encouraged many PMAs to create educational programs and product-specific speakers' bureaus to promote vaccine use. However, much of the material did not address the full complexity of the issues surrounding the vaccine and did not provide balanced recommendations on risks and benefits. As important and appropriate as it is for PMAs to advocate for vaccination as a public good, their recommendations must be consistent with appropriate and cost-effective use.

Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest.

Professional medical associations (PMAs) play an essential role in defining and advancing health care standards. Their conferences, continuing medical education courses, practice guidelines, definitions of ethical norms, and public advocacy positions carry great weight with physicians and the public. Because many PMAs receive extensive funding from pharmaceutical and device companies, it is crucial that their guidelines manage both real and perceived conflict of interests. Any threat to the integrity of PMAs must be thoroughly and effectively resolved. Current PMA policies, however, are not uniform and often lack stringency. To address this situation, the authors first identified and analyzed conflicts of interest that may affect the activities, leadership, and members of PMAs. The authors then went on to formulate guidelines, both short-term and long-term, to prevent the appearance or reality of undue industry influence. The recommendations are rigorous and would require many PMAs to transform their mode of operation and perhaps, to forgo valuable activities. To maintain integrity, sacrifice may be required. Nevertheless, these changes are in the best interest of the PMAs, the profession, their members, and the larger society.

Physician activism in American politics: The opposition to the Price nomination.

Although a substantial literature considers physician advocacy fundamental to medical professionalism, only a minority of physicians actually pursue it. We analyze the characteristics of 6,402 physicians who engaged in political advocacy by signing the Clinician Action Network's 2016 petition objecting to the American Medical Association's endorsement of the nomination of Tom Price as Secretary of Health and Human Services. These physicians were matched to the NPI (all physicians) and PECOS (largely Medicare payment recipients) directories. Physicians in the directories were matched to publicly disclosed campaign contributions. Contributions are used to measure political preferences expressed on a liberal-conservative scale. We document a pronounced generational realignment in the politics of the medical profession, with recent graduates trending sharply Democratic. Petition signing vs. non-signing is responsive to gender, specialty, geographic location, personal liberal-conservative preferences and year of graduation from medical school. Petition signers were more likely to be women (62% of signers versus 34% of non-signers), recent medical school graduates (58% of signers versus 42% of non-signers), and in lower-paying specialties (27% of signers versus 12% of non-signers). The changing face of physician advocacy has important implications for understanding how the medical profession is likely to influence health care policy in coming decades.

New York City's initiatives on diabetes and HIV/AIDS: implications for patient care, public health, and medical professionalism.

Two recent New York City Department of Health and Mental Hygiene initiatives expanded the mission and scope of public health, with implications for both New York and the nation. The programs target diabetes and HIV/AIDS for greater systemic and expanded reporting, surveillance, and intervention. These initiatives do not balance heightened surveillance and intervention with the provision of meaningful safeguards or resources for prevention and treatment. The programs intrude on the doctor-patient relationship and may alienate the very patients and health professionals they aim to serve. Better models are available to achieve their intended goals. These initiatives should be reconsidered so that such an expansion of public health authority in New York City does not become part of a national trend.

Evidence-Based Medicine and State Health Care Coverage: The Washington Health Technology Assessment Program.

OBJECTIVE: To evaluate the Washington State Health Technology Assessment Program (WHTAP). STUDY SETTING: Washington State Health Technology Assessment Program proceedings in Seattle, Washington. DATA COLLECTION AND STUDY DESIGN: We assessed the program through observation of its proceedings over a 5-year period, 2009-2014. We conducted detailed analyses of the documents it produced and reviewed relevant literature. PRINCIPAL FINDINGS: Washington State Health Technology Assessment Program is unique compared to other state and federal programs. It has successfully applied evidence-based medicine to health care decision making, limited by the strength of available data. It claims cost savings, but they are not substantiated. CONCLUSIONS: Washington State Health Technology Assessment Program is a useful model for other states considering implementation of technology assessment programs. We provide key lessons for improving WHTAP's process.

Physicians and drug representatives: exploring the dynamics of the relationship.

BACKGROUND: Interactions between physicians and drug representatives are common, even though research shows that physicians understand the conflict of interest between marketing and patient care. Little is known about how physicians resolve this contradiction. OBJECTIVE: To determine physicians' techniques for managing cognitive inconsistencies within their relationships with drug representatives. DESIGN, SETTING, AND PARTICIPANTS: Six focus groups were conducted with 32 academic and community physicians in San Diego, Atlanta, and Chicago. MEASUREMENTS: Qualitative analysis of focus group transcripts to determine physicians' attitudes towards conflict of interest and detailing, their beliefs about the quality of information conveyed and the impact on prescribing, and their resolution of the conflict between detailers' desire to sell product and patient care. RESULTS: Physicians understood the concept of conflict of interest and applied it to relationships with detailers. However, they maintained favorable views of physician-detailer exchanges. Holding these mutually contradictory attitudes, physicians were in a position of cognitive dissonance. To resolve the dissonance, they used a variety of denials and rationalizations: They avoided thinking about the conflict of interest, they disagreed that industry relationships affected physician behavior, they denied responsibility for the problem, they enumerated techniques for remaining impartial, and they reasoned that meetings with detailers were educational and benefited patients. CONCLUSIONS: Although physicians understood the concept of conflict of interest, relationships with detailers set up psychological dynamics that influenced their reasoning. Our findings suggest that voluntary guidelines, like those proposed by most major medical societies, are inadequate. It may be that only the prohibition of physician-detailer interactions will be effective.

Health industry practices that create conflicts of interest: a policy proposal for academic medical centers.

Conflicts of interest between physicians' commitment to patient care and the desire of pharmaceutical companies and their representatives to sell their products pose challenges to the principles of medical professionalism. These conflicts occur when physicians have motives or are in situations for which reasonable observers could conclude that the moral requirements of the physician's roles are or will be compromised. Although physician groups, the manufacturers, and the federal government have instituted self-regulation of marketing, research in the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts. We propose a policy under which academic medical centers would take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry.