The Covert Rationing Blog

Another Sign of the End-Times for the Doctor-Patient Relationship

January 16th, 2008 by DrRich

A feel-good story in the Philadelphia Inquirer does not make DrRich feel good.

The story extols a local (to Philadelphia) start-up company called Verilogue. Verilogue places digital audio recorders in the offices of physicians, and “captures every word” of the doctor-patient encounter. Verilogue then processes these conversations, appropriately scrubbing them of identifiers, and places them into a searchable digitized database. Verilogue’s clients - consisting, so far, of nine large but publicly unidentified drug companies - then pay to get access to that data for the express purpose of doing market research. According to the Inquirer, “Verilogue’s technology allows pharmaceutical and biotech firms to hear first-hand from customers, get a glimpse of the patient’s state of mind, progression of disease, and what is said about the company’s medications - or a competitor’s drug.” So, thanks to Verilogue, drug companies for the first time will be able to design marketing materials according to what actually takes place between doctors and patients behind those closed doors.

Drug companies will certainly find this kind of information useful, and (what with docs today having to cram all that P4P and other mandatory whatnot into their 7.5 minutes per patient encounter) eye-opening. The pharmaceutical marketing experts undoubtedly will learn that what they’ve got to do in order to encourage doctors to sell their drugs in this environment is to distill their marketing messages down to less than 10 seconds of utterly compelling prose. All that excessive verbiage they’re able to include in their luxuriously sedate and drawn-out TV commercials (warning about priapism with Cialis, for instance), will need to be cut out. Perhaps details like this can be packaged into an attractive pamphlet, which docs can toss at their patients as they process them through the efficient office experience (shoving them back out into the hall, bundle of clothing in hand).

Specific doctors are targeted for the Verilogue opportunity according to the needs of the company’s pharmaceutical clients. That is, which drugs are their clients interested in moving, and which doctors are most likely to see patients eligible for those drugs? Doctors who agree to record their patient encounters are, according to the company, paid an amount “similar to stipends paid to medical investigators in other clinical research.”

To witness the process in action, the Inquirer reporter helpfully visited the office of one Nathan Zankman, pediatrician. When a 4-year-old boy with asthma (one of the targeted diseases) came in, Dr. Zankman asked the boy’s mother for permission “to have their conversation recorded for use in medical research.” She agreed, later telling the reporter, “I look at it as helping medical research. . . .I’m a firm believer in science and technology. If companies could learn something from conversations about my son’s condition, maybe it could help someone else.”

So what’s not to like here? Allow DrRich:

1) Coersion. When their doctors ask to record the office visit, patients - already reduced to mere supplicants, seeking to have their medical needs fulfilled by doctors whose life work depends on keeping third party payers satisfied - are immediately placed into an untenable position. It would be very difficult for patients to refuse this request. In the Inquirer article for instance, Dr. Zankman allows that he has never had a patient turn down a request to record an office visit.

2) Wasting precious time. To whatever extent the doctor takes the necessary care to fully inform the patient as to the real purpose for the recordings, the time taken to do so is likely subtracted from the strictly limited office visit. Of course, the wasting of time can be minimized by not informing patients of what’s actually going on (see item 3).

3) Misinformation. DrRich suspects the Inquirer reporter was witnessing a pretty typical example of the Verilogue process. (Generally what happens when a reporter wants to showcase a new medical technology is that he/she contacts the company, which suggests a “model” physician for the interview.) At least in this case, it appears the patient’s mother was sadly misinformed as to what was actually going on. She was apparently led to believe the recording would be used explicitly for medical research, that is, would presumably advance the state of the medical art, and would potentially help future patients. But that wasn’t the case at all. The recording was being made only for market research. This is a purely commercial endeavor; it has nothing whatever to do with scientific or medical advancement, and everything to do with marketing advancement (specifically, to tailor marketing messages in order to optimize drug sales). So at the end of the day the patient and her little son were unwittingly drafted into a particularly sophisticated focus group.

4) Mal-compensation. Traditionally, participants in market research focus groups are paid for their efforts. Since in this case the patient is at least as much a participant in the generation of marketable data as is the doctor, the patient undeniably deserves his/her fair share of the proceeds. The cut should be at least a 50%, or preferably more since it is the patient whose personal medical information is being risked in a private, for-sale-to-whomever, corporate-controlled database. There’s no indication that the patients are being informed that this is a money-generating endeavor, let alone being offered their fair share in compensation for their participation and their personal risk.

There’s nothing about the Verilogue business model that’s inherently bad or unethical. There’s nothing here that couldn’t be fixed with sufficient disclosure, full transparency and appropriate compensation. In DrRich’s view, the two founders of this company - who come from a pharmaceutical market research background, and whose sense of propriety thus may have been professionally altered - should have established fairer processes. The reporter for the Inquirer should have discerned the problems with what she witnessed and subsequently wrote about. But at the very least, the doctors working with Verilogue ought to be taking pains to protect the rights and welfare of their own patients.

That they apparently do not may simply reflect thoughtlessness and greed. On the other hand, it may reflect the extent to which the doctor-patient relationship has been systematically destroyed. Once you have succeeded in destroying that relationship, all sorts of new business opportunities will open themselves up. Apparently these will be blithely accepted (if not celebrated) by all parties involved, and will even be subjects of ain’t-it-wonderful feature stories.

Posted in General Rationing Issues, Primary Care in America

5 Responses to “Another Sign of the End-Times for the Doctor-Patient Relationship”

1. Dr. Val wrote on 01/17/08 at 8:16 am :

   “There’s nothing about the Verilogue business model that’s inherently bad or unethical.”

   I’m not sure that full disclosure makes this kind of activity ok. Sermo offers full disclosure of its monetization strategy (big Pharma and Wall St. speculators are paying to watch your private MD to MD conversations and to try to influence your prescription patterns outside of EBM) and I think that it undermines physician community and the ethics of EBM. Just because we know how we’re being influenced/harmed doesn’t mean we should sign up for it or even turn a blind eye to how its affecting our peers. I think we should take a stronger stand against sliminess when we see it.

   My 2 cents.

2. DrRich wrote on 01/17/08 at 12:24 pm :

   Val,

   I am sympathetic toward your 2 cents, but I am probably a bit to the right of you on the libertarian scale on this one. I think if doctors want to spout off on Sermo while the drug companies listen in, then as long as they understand the implications, let them.

   And while I really do think that the Verilogue business model is not inherently bad, what I mean by “inherent” is a pretty stiff standard. “Inherently bad” to me is completely, fully, unredeemeably, unsalvageably, inarguably evil in every way. Not all that many varieties of human activities meet this standard; even God listed only ten.

   While the Verilogue model is not inherently bad, in my view it would take a pretty monumental effort to make it OK - that is, to assure that patients understood the real implications of what they were agreeing to. Indeed, adequately protecting the patients’ right to make a fully informed decision here, and adequately compensating them for their risk, would probably make the effort (and this business model) impracticable altogether.

   As the former chair of a busy IRB, I’ve seen plenty of medical research projects (as opposed to market research projects) that suffer from the same problem - if patients were truly informed about the research, it’s likely none would participate. In these cases, when I told the investigators what they would need to tell research subjects in order to be allowed to enroll them, most grumblingly bailed out, and opted to expend their efforts on more productive projects. (It’s one of the reasons that a good IRB chair has an average “life expectancy” of 5 years or less.)

   Rich

3. Dr. Val wrote on 01/17/08 at 7:29 pm :

   Heh. Did you make it the full 5? The continued onslaught of mischievousness (cf. this week’s NEJM grand reveal of pharma companies witholding negative studies on anti-depressants) is so tiresome. There are so many ways that we are deceived and manipulated. How can one maintain faith in positive reform and scientific ideals in the midst of the harsh realities of life? How do YOU do it? I know it’s not anti-depressants because apparently they don’t do much.

4. Dr. Wes wrote on 01/20/08 at 11:20 pm :

   Did Nixon use this service? Just asking.

   Great post, as usual.

5. Dan wrote on 06/5/08 at 7:41 am :

   Who Would Not Want To Be A Doctor Today?

   Lately in the media, others have said and expressed concern about the apparent shortage of primary care doctors, most notably. Typically, the main reason stated for this shortage is lack of pay of this particular specialty compared with other specialties chosen by potential physicians.
   Yet considering the additional attention of shortages of students in some medical schools, one may ask the question as to whether or not people want to be any type of doctor in the first place in the United States. About one third of their lives are spent achieving the requirements of this profession. Reasons for not choosing to enter this profession are several and valid.
   There is the issue of long hours- with primary care in particular because of the apparent lack of doctors of this specialty. Such doctors may be over-worked without an expected pay reflecting the work they do. Furthermore, those doctors employed by health care systems are required to see a certain number of patients a day, and receive a monetary bonus if this expectation is exceeded. It seems that most doctors are members of such health care systems. So burnout certainly may occur. And I consider such a requirement mandated by health care systems demeaning to this profession, and leave the doctor without the control that the doctor is entitled to due to their training and experience.
   However, the recent increases in hospitalists, who are those doctors that are usually Internal Medicine doctors who specialize in patients presently under hospital care, and they have lessened the load for all doctor specialties for the work they do that the admitting doctors would have to do without their presence. This in itself makes a doctor possibly more effective and efficient in their practice outside of the medical institution.
   All doctors, I presume, face a high degree of emotional and physical stress associated with their profession, as stated in the previous paragraph, for example. And this is not to mention the incredible stress associated with patient care in the first place, with some patient cases causing more stress than others
   Doctors, due to the changes that have occurred recently in the U.S. health care system, not only have the issue of money to deal with, but also a loss of autonomy regarding patient care combined with loss of respect that may be due in large part to others dictating on how they practice medicine. Ironically and often, these others are not as qualified as the doctor in the first place. This is complicated by the perception that the public, with some who view doctors as having the easy life with their pay and profession, which does not seem to be the case presently.
   There are also reasons of malpractice insurance, which is why doctors choose to join health care systems, it is believed, to pick up the tab for this necessity, along with eliminating the concerns of running a practice in a private manner, which historically has been the case, as their offices are owned by the health care system as well.
   Up to 90 percent of malpractice cases against a doctor are baseless and without merit, so they are unsuccessful for the plaintiff, yet this still affects the rate the doctor has to pay for malpractice insurance. I understand that simply filing a lawsuit against a doctor, as frivolous as it may be, still increases the malpractice premium of that doctor. This is combined with the amount the doctor has to spend to defend themselves in such cases, which approaches about 100,000 dollars over the course of about 4 years for such cases. A tort reform in Texas in 2004 resulted in annual malpractice premiums reduced by about a third of what they were. Soon afterwards, claims against doctors remarkably dropped by about 50 percent. Some specialties of doctors pay more premiums for malpractice than others. For example, OB/GYN doctors have been known to pay around 300 thousand dollars a year for this insurance. Certain types of surgeons experience a similar high rate of malpractice premiums. Malpractice flaws are catalysts for doctors to practice defensive medicine to avoid potential litigation, which is a waste of health care resources and unneeded patient methods or procedures.
   Also, about a third of the U.S. is insured by Medicare, which progressively has lowered what they will reimburse a doctor for regarding the care they give a patient they treat. This fact is recognized by other insurance companies who will eventually follow the recommendations of Medicare, usually, regarding the reimbursement issue, so it seems. This will lead to a doctor having to see even more patients in order to make it financially with their profession, as this has resulted in the overall income of a doctor experiencing a decline of about 10 percent over the last decade.
   Furthermore, doctors normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training. About 20 years ago, that debt was only about a fifth of what it is today. Paying this debt off is typically about 2 thousand dollars a month that doctors on average have to pay in order to eliminate this debt in a timely fashion.
   There are some who believe that doctors in the U.S. are over-paid. This may be true, but they are not absent of financial concerns as with any other profession.
   Most doctors do not recommend their profession to others for such reasons stated in this article presently, and perhaps other reasons not mentioned. This is somewhat understandable, yet extremely unfortunate for the health of the public in the future, especially. There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall.
   No all doctors are dieties. Like others, some are greedy and corrupt, which complicates others in this profession. Personally, I believe that the intentions of most physicians are bonafide. Yet in time, due to the nature of the current health care system, doctors frequently become cynical, demoralized and apathetic. This may be considered a significant concern to the well-being of those in need of restoration of their health, understandably.
   Not long ago, the medical profession that has been discussed had overt honor and a clear element of nobility. Such traits are not as visible anymore, which saddens many intimate with the profession needed by many.
   “In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero
   Dan Abshear

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