The California Biotech Law Blog wrote a blog posting on March 21st about legislation under consideration which would require doctors to disclose the acceptance of gifts from drug companies and we addressed the issue of whether doctors should have an ethical duty to disclose potential conflicts to patients; however, a column today by Peter Huber in Forbes.com looks at a new angle to this debate: whether the public should really be concerned about doctor bias against drug companies?

The crux of Huber’s argument  is that some doctors out there are biased against the drug companies because if drug companies churn out drugs that are too good, doctors will lose business.  Huber writes as follows:

Brilliant doctors often work closely with big drug companies, and they seem to like their corporate partners just fine. Too fine, say their vocal critics–no doctor can have objective views about Lipitor when he takes Pfizer‘s money to develop or test it. But when the critics are doctors themselves, as they quite often are, keep in mind that there’s a deeper conflict in play here that the critics never acknowledge or discuss. By working at the cutting edge of pharmacology in close collaboration with Big Pharma, top-tier doctors are taking over the whole medical show. It’s because of their work that so many of their less able colleagues are destined to provide doc-in-a-box services at Wal-Mart, at cut-rate prices prescribed by Big Insurance or Big Government. . . .

In the old way of looking at things, drugs are just extensions of the physician’s wise hands, like stethoscopes and sutures. But when Big Pharma’s products get good enough, they displace a whole lot of hands-on doctoring. A pregnancy test used to be an office visit and a lab analysis; now it’s a remarkably smart dipstick sold over the counter. Diagnosis used to be almost all doctor; now it’s almost all lab–and the lab technicians rely on higher-caliber dipsticks, assays and reagents developed and mass-produced by the same teams of top-tier doctors, research hospitals and big drug companies.

When drugs get good enough, they displace hours of ineffectual (but remunerative) human monitoring and palliative care. Drugs displace doctors, nurses and hospital beds because they really work and because they often work long before bad chemistry morphs into clots, plaques, lumps and other symptoms that require scalpels and beds. In the first half of the 20th century almost all medically supplied gains in health and life expectancy came from germ-killing vaccines and antibiotics. All the important gains since have come from arrays of drugs that target clogged arteries, strokes, cancer and other diseases rooted in our own human chemistry. Human eyes can’t see and human hands can’t handle most of the things that make us sick–bacteria, viruses, white blood cells, antibodies, proteins, enzymes, fats and genes.

At first glance the argument seems a bit ludicrous.  Isn’t there a doctor shortage in many places?  Aren’t we having to import doctors from overseas? Isn’t there talk about the fact that the baby boomers growing older means we need more doctors than medical schools are already churning out?  Why would doctors be concerned about losing work? Or at least work that is the most profitable?

But on further consideration, you have to admit that there may just  be a glimmer of truth in the argument.  Coming from a medical family myself, I know that the real money for a physician is in specialization–becoming board certified in a particular field.  This is not so different than in the legal field.  You specialize to become an expert on a particular field, since experts can stand out in the profession and potentially make more money. 

In the medical profession, patients go to specialists when they have an illness that seems to need the attention of an expert in that field.  However, if a miracle drug exists that eradicates the illness, would that patient ever need to go to the specialist?  The patient might never get past the primary care physician.  Or, if the the patient did go to the specialist, at the very least the physician wouldn’t see the patient very often. The patient would take the drug and not really need a specialist unless the drug stopped working, which in the case of the miracle drug perhaps wouldn’t happen.  Perhaps the specialty wouldn’t really be that profitable any more.

Sounds crazy?  Maybe.  But it does happen in the legal profession.  Specialties become unprofitable all the time.  Lawyers get asked to leave law firms, or they just gradually realize that they need to switch specialties if they intend to have a profitable practice.  Isn’t it just possible that the same could happen to specialist physicians?

I think the answer is yes: it can and probably will happen to some physician specialties.  Perhaps not as quickly as a legal specialty becomes unprofitable, but just like certain jobs are getting phased out due to technological advances, the same probably will happen to certain physician specialties over time as biotechnological advances make certain specialties unprofitable.  Look what is happening in the medical profession: the same consolidation that has happened in the legal industry is increasingly happening among medical practices.  With consolidation comes the reality that practices and specialties will be viewed through the eyes of the business on their overall profitability to that business.

So, back to the argument–is it just possible that there is a bias by some doctors against pharma due to a fear that  pharma may be doing its job too well?  Perhaps. I’ve certainly seen things written by lawyers worrying that technology will cause us to be able to do our job too efficiently.  Why wouldn’t doctors have similar worries?  Can’t those worries cause a conflict?  Of course, they could.  I would be concerned if the practice I had built was looking like it might not have a future–or at least a very profitable future. That’s only natural. 

How concerned should we the public really be about this?

Well, I think we should keep it all in perspective.

In the end, technological advances benefit society and our professions at large.  Doctors, like lawyers and other professionals, will inevitably develop new expertise as the need for various specialities changes with those advances–we all have to adapt in this world to survive.  So, any damage to a practice that might be caused by those advances will likely be temporary.  Savvy doctors will develop new expertise just like savvy lawyers and other professionals have to do to change with the times.  In my opinion, the majority of doctors will recognize this reality and not let fear get the better of them. 

Nevertheless, Huber makes some interesting points, which are definitely worth considering in parallel as Congress considers legislating that doctors disclose potential conflicts with drug companies.  Should we perhaps be taking another logical step and asking if Congress should really be legislating on doctor conflicts?  Or should we perhaps consider other possible doctor conflicts in tandem to what Congress has been proposing?   Is focusing in on doctor conflicts arising from receiving gifts from drug companies too narrow a focus for the legislation?  I think that these are all valid questions to consider as Congress moves forward and addresses this issue.