2003 Health Care Symposium:                            

Case 1

You’re the hospitalist who is taking care of a 50-year-old woman who was admitted through the Emergency Room with an upper GI bleed.  The bleeding has stopped, so that her emergency medical condition has been stabilized.  You’re planning a GI endoscopy and definitive therapy to treat the source of the bleeding. 

A.  You receive a call from hospital utilization review telling you that the patient is uninsured and the hospital would like you to transfer the patient to a County hospital for treatment.

Does your professional duty create an obligation to treat the patient in spite of the hospital’s request?

Does it matter that you believe your hospital’s endoscopist is superior to the County’s? 

Would it matter if this were a procedure that was not available at the County hospital?

Does it matter that neither you, nor the endoscopist, nor your hospital will be paid if the patient stays in your hospital?

B.                   You receive a call from Insurance Co/HMO X saying that this is an insured patient of theirs, and that they are requesting that you transfer the patient to the hospital down the street, because they have a contract with that facility and not with your hospital.

Is your obligation to the patient any different than in A? 

C.                  You receive a call from the physician Medical Director of your own medical group who tells you that this is a capitated patient in your medical group, and that the group’s guideline, based on the medical literature, is endoscopy is indicated only if there is a repeat bleed. 

Is your professional duty compromised if you believe the guideline is flawed, but you comply with it?

Does it matter if your medical group, directly, and you, indirectly, will make more money if fewer endoscopies are performed?

Does making this request compromise the Medical Director’s professional duty?

Case 2 

Two companies make a drug to treat prostate cancer.  They are similar in reported efficacy, however drug A is 30% more expensive than drug B.  What level of inducement by the company that makes drug A would persuade you to prescribe it preferentially over drug B, if any:

A.     Detailing visits by the salesman showing how drug A is really better tolerated by patients, accompanied by educational materials.

B.     Lunch for residents and students accompanied by educational materials.

C.     Free tickets and a trip to the Super Bowl.

D.     Unrestricted gift to your research and educational fund comparable to the difference in drug price.

E.      Free samples that you can sell in your office comparable to the difference in drug price.

Which of these are acceptable practices, if any?

Would it make any difference if the company that makes drug B were doing these?

Case 3

Patients with lung cancer and one site of spread are generally considered by community standards to be unresectable and are treated with palliative care.  The University oncology department, however, has the technology to evaluate these patients with PET scan to ensure that there is no more than one metastasis and treat those patients with an investigational protocol of surgery and chemotherapy.  Only a very small percentage of patients will be found actually to have a single site of spread.  Preliminary data suggests that about 10-15% of patients with a single metastasis will have 12-18 months prolongation of life with treatment.  You understand that resources are limited and that doing one PET scan may lead to a whole new series of costly tests, surgeries, and treatments.  If you have a patient with lung cancer, should there be any restrictions on your ability to refer a patient for this protocol?  If so, who and under what circumstances? 

Case 4

 A patient comes into your primary care clinic with a severe community-acquired upper respiratory tract infection.  He is a self-described physician-phobic who never seeks medical attention unless his symptoms become more than he can bear.  You wish to develop a long-standing relationship with him as you learn that he suffers from multiple chronic diseases including severe hypertension and diabetes that require regular monitoring and long-term treatment.  The patient, however, is at the office for one reason only: to get a prescription for the new purple polka-dotted pill that he saw advertised on television to treat his infection.  [The purple polka-dotted pill is being marketed to the public by Drug Company X as a new and improved version of their blue pill which is about to lose its patent and become generic]  You are hesitant to prescribe the requested medication because you know that it offers minimal additional benefit for your patient’s particular condition at a higher cost.  You are also concerned about the drug because you have been reading about increasing resistance to this drug. 

Does your responsibility lie with patient and your long-term relationship with him or with the greater community who ultimately bear the economic burden of expensive therapies and who, in the far future, may suffer from wide-spread drug-resistant bacterial infections?

Case 5

A researcher at an academic medical center is investigating an experimental cardiovascular therapy in a controlled, double-blind study. His research is being funded in part by a large biotechnology company for which he holds significant shares of stock.  Is this an unacceptable conflict of interest?  If not completely unacceptable, what requirements should be placed on such an investigator that would ensure human subject protection?

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