Listen to Who's My Doctor on NPR's TED Radio Hour

Since my TEDMED talk on the importance of transparency in medicine was featured on TED.com last month, I have had an overwhelming number of responses. The majority were very positive. Hundreds of people encouraged us to keep going, and a lot wanted to know how they could participate: as transparent doctors and as patients. 

Many asked about how they could find a transparent doctor in their area. Our website is not robust enough for a geographical search function, and it contains a small fraction of the doctors who have signed the Total Transparency Manifesto. We are open to working with nonprofits and developers on improving Who’s My Doctor to make it more user-friendly.

In the meantime, Who’s My Doctor is fortunate to have captured the attention of someone who I’ve secretly admired for a long time: NPR radio host Guy Raz. You may have heard of Guy’s work as host of All Things Considered. Since March 2014, he has been the host of NPR’s TED Radio Hour. As a TED nerd and NPR faithful, I download these excellent podcasts every week. Some of my recent favorites have been the Source of Creativity featuring (among others) Sting and Overcoming.

I had the privilege of meeting Guy at TEDMED; he is as energetic and charismatic in person as he is on air. I was flattered when he invited me to be interviewed on TED Radio hour—but quite astounded and not a little bit embarrassed when he revealed that the topic of this session was “courage”. The other people interviewed in this episode are war journalist Janine Di Giovanni, human rights litigator Kimberley Motley, former CEO Margaret Heffernan.

TED Radio Hour: Courage

What we’ve done in Who’s My Doctor is important, but hardly courageous! Having been a patient and caregiver, I know how frightening it is to be in the position of extreme vulnerable, when you or a loved one are ill. Dealing with these stressful situations is what takes real courage; Who’s My Doctor is our attempt to level the playing field.

Whatever your thoughts are on transparency in medicine, I hope you will listen to Guy’s masterful interview, where he created a narrative out of my story and the stories of Janine, Kimberley, and Margaret. I look forward to your comments.

Who’s My Doctor on TED.com!

I am thrilled that TED has picked up on Who’s My Doctor and our efforts to improve transparency in medicine. 

Click here for link to TED talk 

TED prohibits “selling from the stage” and apparently my call to action at the end was too much of a “sell”. Here is the intended conclusion of my original TEDMED talk.

"Radical transparency won’t be easy. There will be many critics, some who have ulterior motives and have something to hide, and others who are just scared of changing the status quo. But if it’s anywhere we can unlock our imaginations, any place where we dare to speak up, with anyone who can make the impossible a reality, it’s here at TEDMED, with all of you.

I call upon everyone here—anyone who will ever be a patient or family member of a patient—to sign the total transparency manifesto. I call upon doctors, nurses, physical therapists, nutritionists, and all healthcare providers to take off our white coats and show our patients who we are. 

I’m taking the leap. This, today, is my pledge. Will you join me?"

The talk is here. I'd love to hear what you think.

Open Payments: Will Transparency Hurt Or Help Patients?

Today, I was interviewed on CBS This Morning about whether the government’s Open Payments website should be delayed. This is part of the Physician Payment Sunshine Act that will provide public access to payments made to physicians by pharmaceutical and medical device companies.

Over the years, I have become increasingly concerned about the harmful effects of financial conflicts of interest on patient care. Dozens of studies have shown that financial relationships between doctors and drug/medical device companies influence physician prescription practices.

My research on patient-centered care also shows that patients are concerned about these potential conflicts of interest and how they may affect their care. Our patients deserve to know how their doctors are paid and whether this may affect them. The Sunshine Act will provide much-needed, critical tools for increasing transparency and accountability, and will help exert pressure to prevent inappropriate financial relationships between doctors and industry in the future.

The Open Payments website that will display the payments to doctors has already been delayed by more than a year. Now, in light of some technical problems, physician groups including the American Medical Association are arguing that there should be another six-month waiting period. While it is important to provide doctors an opportunity to review and dispute payments to them, this should not delay timely release of physician payments data to the public.

The American Medical Association argues that inaccurate information could undermine trust. If physicians want to improve trust, they can take a proactive approach and begin conversations with patients. They can send out an email or letter clarifying their affiliations with drug companies. They can participate in Who’s My Doctor and explain their philosophy publicly, online. They can have one-on-one conversations with those who have questions. Such openness will only improve the doctor-patient relationship, improve trust, and increase accountability.

For those doctors who truly are ashamed of their payment history, perhaps they can reevaluate their financial relationships. As former Supreme Court Justice William O. Douglas said, “Sunlight is the best disinfectant.” The sunlight is available now. Physicians and patients alike should embrace it, now.

Parts of this post were part of an open letter I sent to Ms. Marilyn Tavenner, CMS administrator, on May 27^th 2014 with the subject of “Revision of a currently approved collection; Title of Information Collection: Registration, Attestation, Dispute & Resolution, Assumptions Document and Data Retention Requirements for Open Payments (CMS-10495).”

TEDMED!

This week, TEDMED announced its final speakers for the dual San Francisco-Washington, D.C. event. 

 

TEDMED 2014

I am excited and honored to be part of this list, along with a phenomenal group of healthcare leaders & entrepreneurs including Abraham Verghese, Thomas Goetz, Danielle Ofri, Betsy Nabel, and many more.

My talk will be on radical transparency in medicine. More to come soon--and please join us at the Kennedy Center in September!

Guest Post: My Total Transparency Manifesto

In this guest post, I am honored to host Dr. Elizabeth (Liz) Phillips, a resident physician in emergency medicine at George Washington University. She wrote this statement as part of her Total Transparency Manifesto on Who’s My Doctor. It was so moving that I asked her for permission to post it here. Thank you, Liz, for your inspiration and your humanity.

I am a physician and therefore a servant of others but I am also a human being. I believe in the importance of humanity in medicine and the danger of losing our capacity to have valuable and true human connections. Undeterred by the warnings from my mother who is a nurse and therefore all too familiar with the dysfunction of the health care system, I pursued a career in medicine because I consider it to be one of the most privileged professions. Not because of the academic prestige or the potential reimbursement but for the corporal, intense and deeply personal relationships that physicians have with patients.

My first real encounter with the ugly side of medicine was in college when I volunteered in a nursing home. Despite my attempts to mentally prepare myself for visits at the Erwin Gardens, every week I would find myself aghast of the poorly lit rooms, dirty floors and slight odor of urine that filled the air. Mrs. J was a Medicaid patient with little to no control over the quality of her care. Three times a week she would awake at 4 a.m. to be taken to the hospital for dialysis only to return hours later, face sunken and stomach growling with no one who really cared. My visits with Mrs. J were part of a service-in-learning course on Death and Dying but the interactions that I experienced at her nursing home exposed me to much more than the dubious and gradual process of dying. It was apparent to me that my spirited conversations with Mrs. J were a weak anesthetic to the constant sting of the poor quality of life, depression and lack of options that plagued her mind.

Patients like Mrs. J have been salient examples of the complex ethical dilemmas that confront physicians and our health care system every day. My experiences with her put a human face on the issues surrounding end of life care, insurance, medical costs, quality of life and health disparities. Mrs. J poignantly reminded me that physicians are demanded to work in an environment that ethically challenges them both as professionals and individuals. The emergency room is a place where many of these issues are highlighted as physicians struggle to care for patients who are underserved or unable access care efficiently through other venues. 

My philosophy of practice is deeply impacted by my clinical and educational background. I completed a masters in bioethics in medical school because it was essential for me to practice medicine with a constant awareness of patients as individuals and not illnesses. I am participating in the Who’s My Doctor campaign because it is important that patients know that I accept no money from drug companies or device companies. I am not making money from ordering more tests or pushing you as a patient to make certain medical decisions. I understand that I am a stranger with whom your share the most personal information and I consider this a privilege.

I see the need for physicians to serve as patient advocates. I have also witnessed the increasing demand for considerate and professional physicians whose integrity and dedication can withstand the turbulent changes that continue to confront health care in this country and around the world. I hope to utilize my unique background by serving as a competent and skilled practicing physician who also participates in changing policy to make our health care system one that better serves patients and reinvigorates our focus on comprehensive, preventive and compassionate care. Mrs. J would expect nothing less than my most valiant attempt to ameliorate the health care system that failed her in so many ways. I am constantly striving to make her proud.

Please join us in the joint patient-provider partnership for transparency.

Featured in British Medical Journal's Editor's Choice!

British Medical Journal has just featured Who’s My Doctor in their Editor’s Choice!

“As a physician in Washington, DC, [Dr. Wen] has become increasingly troubled by conflicts of interest that are apparent to doctors but hidden from patients. She sees full transparency as part of “a renewed professionalism.” This should extend beyond payments from industry, she says; doctors should also make clear to patients how they are reimbursed. Payment structures such as fees for services (or, in the UK, the Quality and Outcomes Framework) incentivise doctors to order tests or to provide specific treatments. Patients need to be able to ask whether tests and treatments are being prescribed because they are in their best interests or because they benefit the doctor, she says….

…Not everyone will welcome such moves with open arms. Wen reports extreme hostility to her initiative from some doctors [see link to article], and McCartney and colleagues acknowledge that being required to declare sources of income will concern some. But declarations of interest are now standard practice for publication in medical journals. The same should be true for our dealings with patients.”

Please join us in our campaign for transparency.

Seeking Your Help to Call for Total Transparency in Medical Care

I received many responses to my NPR article on Who’s My Doctor. Many have asked what they can do. Here is a joint provider-patient petition to call for honesty and transparency in medical care. Your thoughts? If you agree, please sign here!
 

We are patients and providers who believe that doctors need to be honest, transparent, and accountable.

When we go to the doctor, we are vulnerable and need to trust that our doctors have our best interests at heart.

Doctors have to tell each other at conferences if they are paid by drug companies or medical device companies; they should also tell their patients about these potential conflicts of interest. They need to be open with patients if their employers pay them more to do more, or to do less. These incentives directly affect patient care.

We believe that informed consent isn't complete without doctors' disclosure of how their financial incentives align with their treatment recommendations.

We also believe that patients have a right to know our doctors’ views on healthcare issues such as preventive health, integrative medicine, shared decision-making, end-of-life care, and women’s health. Such beliefs can have an important impact on the provider-patient relationship, and patients need ready access to this information to be empowered to choose the right doctor for us.

Those of us who are doctors, nurses, healthcare providers, and providers-in-training affirm through Who’s My Doctor and this Total Transparency Manifesto that our patients' best interests are our best interests. We know that patients come to us at a time of vulnerability, so we will be vulnerable too. This is a partnership; we are in this together.

With this pledge, we are coming together as patients, doctors, and healthcare providers to rebuild our healthcare system into one that upholds professionalism, prioritizes patient values, and respects human dignity.

On NPR This Weekend!

My NPR op-ed about Who’s My Doctor and the need for transparency came out this weekend!

http://www.npr.org/blogs/health/2013/12/14/250714833/before-the-prescription-ask-about-your-doctors-finances

There has been an outpouring of comments on the NPR site and on Facebook.

More thoughts and reflections to come soon. For now, let me share wise words from my long-time mentor, Dr. Fitzhugh Mullan:

"Who can be against transparency? Surely not physicians. Our job is to treat, heal, and provide succor to our patients. Is there disagreement here? 

If we have interests, limitations, or preoccupations that would compromise or confuse that mission, shouldn’t we disclose that? As a patient (which we all are), I would hope so. 

Dr. Leana Wen’s campaign is one we should all embrace.  If any of us have trouble signing on, perhaps it is time to pause for a Hippocratic gut check. If not, let’s make Total Transparency our practice mantra."

--Fitzhugh Mullan, MD, Murdock Health Professor of Medicine and Health Policy, Professor of Pediatrics, George Washington University

To the Doctors: A Response (Part 2 of 2)

This is my second blog in response to some comments that were posted after my new transparency campaign, Who’s My Doctor, was featured on KevinMD and Medscape. As with the first blog, the responses from dissenting doctors are divided into three themes. I have listed these themes, followed by direct quotes and my responses. 

Theme #3: There are many other problems in healthcare to tackle. It’s stupid to tackle this issue. 

“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?”

“This is totally absurd. I am way too busy taking care of my patients who need my service as a physician, to spend my time defending myself against some media manufactured crap.”

“Should I tell the psychotic patient "yes, you're correct. Those voices in your head telling you to kill your mother are not your imagination". Of course not. Why? Because that patient is insane. As insane as our government manipulated medical system. Most ideas that I read about are just tinkering with an insane system. Insanity is making a medical insurance company pay for routine care. Does your auto insurance provide coverage for every ding and scratch of paint, oil changes, brake pads? Of course not. Government meddling, the purpose being for power and control of the citizen is what it's all about. Plain and simple. Boiled down to its raison d'etre.”

“Senators, Congress members and managers across every major industry accept gifts, business incentives, and informative handouts from their vendors - this is called free market, and any information exchange is protected by the 1st amendment. You fixers, like the meddling Dr. Wen, will be unpleasantly surprised to awaken to NO DOCTORS WILLING TO PRACTICE MEDIVINE (sic) UNDER HYPER-REGULATED GOVERNMENT CONTROL!” 

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.)

There is evidence to show that disclosure improves trust, and that patients want trust. In a recent study, “Most (patient) agreed that disclosure of competing interests by doctors is important (84%), believing this disclosure would help patients make better informed treatment decisions (78%). Eighty per cent of patients stated that they would have more confidence in their doctor's decisions if interests were fully disclosed, with strong support for verbal disclosure during the consultation (78%).” While some people may not wish to know about their doctors’ disclosures, many people—the majority—do. Having a voluntary disclosure by doctors gives interested patients that opportunity to find out.

One final point I’ll add to the doctors who really don’t like the idea of transparency is that disclosure is happening, with or without doctors’ participation. Info about doctors is increasingly out there, about “ratings”, “quality”, “patient satisfaction”, etc. Doctors 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. 

To be sure, 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. 

Theme #4: All of this information is irrelevant to patients. It’s not their business, and I wouldn’t want to know this about my doctor. 

“I think Dr. Goody 2 Shoes is not a strong enough title for Dr. Wen. Pretty soon we will have disclose where we buy our lab coats from, and what toilet paper we use. NO, this type of idiocy must stop. If this is allowed to proceed I envision my gas station attendant disclosing his investments in the Oil Company he works for, and my Server telling me that she came up with the recipe for the hot sauce on the table BEFORE getting to the specials. C'mon, wake up! Stupidity Outrageicus (sic)!!”

“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."

“'Ballroom dancing', 'will never smoke a cigarette'. Please!! What will be next, 'I have never stalked anyone', 'I don't see porn'” 

Research shows that patients are more likely to comply with recommendations when they come from a doctor whose world view aligns more closely with their own. Who’s My Doctor offers the opportunity to find doctors who have particular expertise and interest in certain fields, such as preventive health, alternative medicine, women’s health, etc. This information is voluntary, so doctors don’t have to discuss their personal views on these issues. Some doctors choose to disclose personal stories and views, because we believe it humanizes us, and that sharing the stories allow patients insight into who we are and how we think.

We don’t presume that all information is relevant to every patient. Some patients may not wish to know their doctor’s revenue streams; others may not want to know their doctors’ personal information. However, some patients will want to know this information when making a decision about which doctor to choose. Rather than having doctors deciding what information is important, we prefer to give that choice to patients.

All of this is in the context that participation is voluntary, and doctors can choose what information they would like to disclose. Some doctors wish to only disclose potential conflicts of interest; others wish to have more personal information including their philosophy of practice of preventive care, women’s healthcare, end of life choices, etc, available for their patients to see. 

Theme #5: You pretend to represent doctors, but you can’t because you’re too [young, inexperienced, female, foreign, Asian, “socialist”, “fascist”, “anti-American”, stupid, etc]. Besides, you have personal gain, aren’t you making money from this thing? 

(The comments on the original sites related to this theme are not suitable for posting on this blog—if you’d like to read them yourself, please see links above.) 

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, putting myself out there could result in significant professional jeopardy).

At the moment, I volunteer my time at least 20-30 hours a week to this project because I believe it is important for our patients. I reiterate that I do not make any money from Who's My Doctor at all, and in fact volunteer my time to this cause that aims to bring together doctors and patients to the cause of transparency, service, and professionalism. 

I also do not profess to represent all doctors, all patients, or the healthcare system. 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 some title in a hospital to speak on healthcare issues. In fact, the most important voices are the ones that aren't being heard.

Thanks, everyone, for reading. I'd love to know what you think; please comment below. If you are interested in joining Who’s My Doctor, please visit www.whosmydoctor.com and our Facebook page.

Guest Post: When Not Knowing Price of Medications Costs Lives, by Dr. Ali Khoshnevis

I'm pleased to welcome this article by Ali Khoshnevis. Ali is an optometrist and CEO of WeRx.org, a pharmacy price comparison site and app with the goal of helping patients find the lowest cost medications in their neighborhood. Please read on for another take on transparency.

My brother and I, both optometrists, had a heart-to-heart discussion about the loss of one of our patients. We realized he was not taking his medications, which was leading to vision loss. When pressed, the patient said he had a choice of eating, supporting his family, or purchasing his medication.  

He was under the impression that the $150 price for his generic cholesterol-lowering medication was "about the same" at any nearby pharmacy. We later realized that some of those nearby pharmacies charged from $11 to $25 for the same medication. Our studies revealed this type of discrepancy existed for almost all of his medications.

Our patient lost his life after suffering a stroke.  This was a bitter pill to swallow, but his loss led us to a period of discovery and determination to prevent this from happening again.

His life could have been saved with the knowledge of the vast price differences at retail pharmacies. That's when my brother and I began our mission to promote transparency in retail drug pricing. I have left the practice of optometry to dedicate my career to addressing this problem. 

This is when we met Sumanah, a 26-year-old event planner in New York City suddenly diagnosed with congestive heart failure. Sumanah was like many typical 26-year olds, without health insurance and no savings capable of paying for her medical bills. Taking 10 medications for her condition, Sumanah was paying full price at what she “thought” was the cheapest pharmacy. After she discovered that not only were some pharmacies cheaper for the same exact medication, she learned that some pharmacies could be upwards of 16 times more expensive than another pharmacy right across the street. Using this information, Sumanah was able to price shop for the right pharmacy and save a lot on her prescription costs. This story, although not uncommon, shows how important shopping around for medications can be.

In their May issue, Consumer Reports published an article confirming the experience Sumanah and many others have each time they go to fill a prescription. The study focuses on five of the most prescribed medications in the U.S. and reviews more than 200 pharmacies for price comparisons. The findings show the details of each pharmacy and drug researched as well as the overall discrepancy between the lowest cost pharmacy and the highest cost pharmacy. For the same prescriptions, the difference was a whopping $749 per month or 447% between the highest and lowest cost options.

Price shopping prescriptions from one pharmacy to another can dramatically reduce out-of-pocket costs for patients without changing medications. The cost savings can be vast and can help those unable to afford medication in the past, be able to consider options at a low cost pharmacy. The current lack of pharmaceutical price transparency causes many patients to simply stop taking their medication because it is too expensive for them to afford, which is a truly dangerous option for patients to consider.

Currently, medication non-adherence is cited by The IMS Institute of Healthcare Informatics as the largest contributor to healthcare costs in their June, 2013 study, “Avoidable Costs in U.S. Healthcare.” The study shows that a patient’s inability to stay on a prescribed medication is estimated to cause over $100 billion in avoidable healthcare costs due to the resulting health complications, hospital visits, and additional advanced treatment

Many patients, and their healthcare providers, assume medications at different local pharmacies are about the same price. We’ve been operating solely in our roles as care providers for too long, and have been oblivious to changes in other parts of the healthcare system. While we work to keep patients healthy, parts of our healthcare system try to maximize profits at the expense of our patients and the entire system.

We invite you to join us on a mission to improve healthcare and save lives.

Guest Post: Trust First, by Dr. Aaron Stupple

In this guest post, I am thrilled to host Dr. Aaron Stupple, a resident physician in internal medicine at Beth Israel Deaconness Medical Center. He is a founding member of Who’s My Doctor and an excellent humanist and doctor. Follow @astupple.

Leana Wen’s Who’s My Doctor? campaign is an important step to help health care. Detailed on her blog as well as recently on KevinMD, she endorses a total transparency manifesto where physicians can describe their sources of revenue and other potential conflicts of interest. It’s an effort to build trust.

We can’t fix health care without patients’ help. A quick look at the numbers for chronic disease are compelling enough—half of Americans have at least one chronic disease, and it accounts for 75% of all health care costs. If we don’t make an impact there, we really won’t make an impact at all.

The trouble with chronic disease is that it depends so heavily on behavior—eat well, exercise, don’t smoke, and take your meds every day. Until we can truly engage patients, we will struggle.

How do we engage patients? How do we get them to literally restructure how they live their lives? How do we get them to agree that they have a disease, that they need to swallow pills every day and risk the side effects, that they need to fit in time for exercise, that they need to arrange with family and friends and coworkers different ways to eat, to not smoke? If we truly want them to get better, we’re truly asking the world. We’re asking them to adopt our world, on our say so. Doctor’s orders.

We simply can’t do it if they don’t trust us.

If we have an obligation, a professional and moral contract with society, to which we swore an oath, and for which society has granted us privileged knowledge at great personal and civic cost, then we need to demonstrate our trustworthiness to our patients.

There’s no one way to do this. But Leana Wen has offered an excellent place to start: declare, openly and publicly, the totality of our agenda. The truth is, we don’t have to be a foot soldier for a pharmaceutical company to have an agenda. 

A patient came to see me the other day, and I was in a fantastic rush. I was behind in my clinic schedule, and I was set to deliver a lecture to our medical students in five minutes. Thankfully, my last patient only needed a tuberculosis skin test. As I hurried about setting things up, he mentioned he was having a lot of stress. I asked him if it was impairing his ability to live and work, and he said no. The calculator in my head told me that the stress in this otherwise healthy young man’s life couldn’t be thoroughly addressed in this one visit, that he’d get his day’s value with the skin test, and I could make it to my presentation on time.

Watching my vigorous preparations, he apologized for taking up my time.

I realized that I had allowed my own desire to be an important teaching figure to supersede his need for health care. Apologizing for my rush, I sat down and listened to him tell me about the causes of his stress. We had a long chat, and afterward I gave him some perspective that he genuinely took to heart. I emailed my powerpoint to the med students.

In the busy life of medicine, establishing trust is hard. The forces that inform our priorities as physicians are often subtle. If nothing else, Dr. Wen’s transparency campaign offers us an opportunity to reflect on those forces. Rather than a threat, I see it as one of many tools that I can use make patients comfortable with what I’m asking them to do.

To the Doctors: A Response (Part 1 of 2)

Last week, KevinMD published my article calling for participation in the new transparency campaign, Who’s My Doctor, on his highly trafficked website. Medscape also highlighted the campaign in an report. The articles drew many responses, including from some doctors who were not thrilled with the concept of transparency.

My next two blogs will report the five major themes and direct quotes, and my responses.

First is Theme 1.  If you don’t want to read the (rather entertaining) quotes, here’s the general idea: “Doctors need drug companies. We’re not influenced by them. They just pay for lunches, and I need to eat. Bedsides, it’s not my patients’ business what I do.”

“If I get some pizza from a drug rep, I'm not going to use that med for every patient regardless of need, and I don't think the patient needs to know that.”

“Do people really think I will change how I treat my patients if I am given a pen or a pizza, GOD forbid, a lunch? This whole thing is insulting to physicians and shortsighted.”

“I don’t have money or time to buy my lunch. Drug companies know that. I get food and learn some stuff, so what’s wrong with that?”

“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.”

“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.”

“Is the lunch that they provide me and my staff an 'association' by the NEJM's study (I had quoted a New England of Journal Medicine study that 94% of doctors have some affiliation with a drug or medical device company)? 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.”

“I implore all physicians to defend the freedoms of the American way of life and to do everything possible to defend the individual patient. If helping an individual patient involves learning about a new medication from a Pharmaceutical Representative, then never be ashamed to do it. Take advantage of all options, as that is the American way. Your patients deserve it.”

“The USA is still a free market society and sometimes that's how business is conducted.”

“Maybe Dr. Winn (sic) needs to move to Russia or Cuba where she can practice her style of medicine!”

Dozens of 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. As a physician who invested over 14 years of my life in medical training, I find it offensive and disingenuous for doctors to say that we are interacting with drug reps "for our education". There are many free, impartial sources of information to learn evidence-based guidelines on new protocols and treatments. Drug companies are beholden not to providers, or patients, but to their stakeholders, and we as professionals (making plenty of money to buy our own lunches!), and we need to uphold our professional duties to do what's best for patients.

(For more information, there has been excellent work done in this field. See information about Healthy Skepticism, No Free Lunch, American Medical Student Association, Dr. Peter Mansfield, Dr. Joel Lexchin, Dr. Marcial Angell, Dr. Ben Goldacre, among others.)

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 goal is not to point fingers and 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 pharmaceutical-funded research studies. We need this transparency. Just as doctors disclose our conflicts of interest to each other in journals and conferences, we should disclose them to patients.

Finally, there is the issue of whether our patients should know what we are doing. The next question answers this from the standpoint of social accountability, but here’s some food for thought directly on the question of drug-company sponsorship: if doctors are taking money for something that we are ashamed of letting their patients know about perhaps it’s not something they should be doing.

Theme #2: Doctors aren’t accountable to society. We are just private citizens conducting business.

“When I became a physician, I don't recall taking an oath of poverty… Why the heck should anyone know about my investments?”

“I find it an invasion of my privacy to disclose where my income comes from. My patients don't disclose their incomes to me.”

“I'm not a public servant.”

"Maybe we can talk about accountability when all my debt has been paid off.”

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

“The individual's right of privacy is in the constitution. The "sunshine act" violates this right. Therefore the "sunshine act" is unconstitutional.”

I cite from an article for the Lancet that some colleagues and I wrote about social accountability in medicine:

“Service is the highest calling for all health professionals and, upon beginning our studies, each of us enters into social contract between our profession and the public to serve in the public’s best interest. Using physicians as a specific example, the World Health Organization defines social accountability in training as ‘the obligation to direct their education, research and service of activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve.’”

Here is an excellent article about the role of physician-as-citizen.

If we are to use an economic argument, though medical students face heavy debt, 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. They choose to enter medicine willingly, and to take the debt and our obligation willingly. 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.

In addition, 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.

Questions and comments? Please post below; I’d love to hear from you! Also, please visit our new website (open while under construction): www.whosmydoctor.com and our Facebook page.