Separating Doctors from Industry: A Never-Ending Struggle?

           “Separate doctors from industry”: So read the headline of an Aug. 16 op-ed in the Boston Globe.  Few realize the headline could have appeared 180 years ago.

          David S. Brown and Dr. Stephen Tosi, executives of the University of Massachusetts Memorial Health Care, began their Globe article by praising Harvard Medical School for imposing in July restrictions on ‘relationships between its faculty and the pharmaceutical and medical device industries.’  

           They note a survey in the Journal of the American Medical Association of medical school department chairs ‘revealed that 60 percent reported some form of personal relationship with industry, including as a consultant, paid speaker, officer, founder, or member of a board.’

          After describing others’ concerns about such relationships, including lawmakers’, they describe their system’s vendor relations restrictions and apparent success.

           In the 1830s, these industries did not exist as we know them today.  Nonetheless, financial relationships between doctors and the pharmacists who made up drugs and nostrums was of major concern to medical reformers.  The conflict of interest was obvious.

           George Eliot made this reform a major theme in Middlemarch (1872), the greatest novel, I think, on social change in English.  She wrote about 1832, a year that resonates in British history as ‘the Sixties’ do in US history.  Everything changed.

           In this subplot, her protagonist, Tertius Lydgate, received his medical education on the Continent and returned to England determined to change how medicine was practiced and prescriptions dispensed,

 …for since professional practice chiefly consisted in giving a great many drugs, the public inferred that it might be better off with more drugs still, if they could only be got cheaply, and hence swallowed large cubic measures of physic prescribed by unscrupulous ignorance which had taken no degrees.  Considering that statistics had not yet embraced a calculation as to the number of ignorant or canting doctors which absolutely must exist in the teeth of all changes, it seemed to Lydgate that a change in the units was the most direct mode of changing the numbers.  He meant to be a unit who would make a certain amount of difference towards that spreading change which would one day tell appreciably upon the averages….  (Chapter 15)

   Then in words many social investors could cite, Eliot describes one of Lydgate’s aspirations:

             …On one point he may fairly claim approval at this particular stage of his career: he did not mean to imitate those philanthropic models who make a profit out of poisonous pickles to support themselves while they are exposing adulteration, or hold shares in a gambling-hell that they may have leisure to represent the cause of public morality.  He intended to begin in his own case some particular reforms which were quite certainly within his reach….  One of these reforms was to … simply prescribe, without dispensing drugs or taking percentage from druggists. This was an innovation for one who had chosen to adopt the style of general practitioner in a country town, and would be felt as offensive criticism by his professional brethren. But Lydgate … was wise enough to see that the best security for his practising honestly according to his belief was to get rid of systematic temptations to the contrary.  (Emphasis added.)  (Chapter 15)

           By his own standards – if not others’ – Lydgate fails.  Why is one of the tragedies of Eliot’s magnificent novel.

           For responsible investors and reformers of all stripes, Eliot illuminates how often the same battles must be fought.  The contexts will be different – as different as a country pharmacist in the 1830s is from a multi-national pharmaceutical corporation in the 2010s – but not the nature of the struggles.

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N.B.:  A shorter version of this post appeared on the Risk Metrics blog on August 31.

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