Medicine and industry are bound together by mutual needs. The de-velopment and utilization of new drugs and medical devices requires both the scientific and clinical expertise of physicians, and the resources and entrepreneurial ethos of business. The medicine-industry partnership has contributed to dramatic improvements in medical care. The increasing influence of the pharmaceutical and medical equipment industry in medicine has, however, raised concerns about costs and regulation, as well as about medicine's traditional independence and objectivity. Some critics feel that the fundamental obligation of business to provide profit for shareholders conflicts with physicians' traditional role as disinterested advocates of patients' interests. Nonetheless, with about 15% of the U.S. economy now devoted to health care, an ongoing and ro-bust relation between business and medicine seems inevitable. A mutually productive relationship between medicine and industry is essential for continued innovation and improvement in health care. Continuous and open dialogue, such as that in the following articles, is necessary to resolve conflicts and achieve this goal.
Professional medical societies have become increasingly dependent on pharmaceutical, device, and biotechnology companies for ongoing support of their programs, but the internal influence of this financial largesse on medical societies' practices is well hidden. Many examples exist in which societies' educational products, including clinical practice guidelines and professional publications, have been tainted by involvement by industry-paid individuals. These examples show that professional judgments of organizations can be affected in ways that are not in the best interests of our patients. Society leaders should develop policies that leave critical decisions, especially those that affect patient care, in the hands of members without financial ties to industry. Society leaders should not accept funds designated for specific industry-recommended projects unless such programs are already part of their planned agenda. These leaders, who typically serve for only a year or two, should delve into arrangements that salaried society executives make with industry, and insure that no promises are made that compromise an organization's professional goals. Professional societies should also find ways of reducing the vast, embarrassing industry involvement at their national meetings, especially the vulgar circus-like displays and the drug company-sponsored symposia. We must reduce commercialism and restore professionalism to our medical meetings.
The use of ghostwriters by industry is subject to increasing public attention and scrutiny. This article addresses the practice and ethics of scientific ghostwriting. We focus on the type of ghostwriting that involves a pharmaceutical company hiring a medical education and communications company to write a paper favorable of their product, who then hires a well-known academic to publish it under his or her name without disclosing the paper's true origins. We argue that this practice is harmful both to the public and to the institutions of science and that it is not justified by an analogy to accepted scientific authorship practices. Finally, we consider ways to discourage the practice.
Interactions with industry begin early in medical training, and attitudes toward these interactions among students and trainees are permissive, which is not surprising given the "informal curriculum" received from peers and role models. Though the Accreditation Council on Graduate Medical Education has recommended explicit policies on interactions between trainees and industry, past studies have shown that most schools and training programs do not have such policies. Given that accep-tance of gifts from industry can create conflicts of interest, that promotional information may be biased, and that non-promotional sources of prescribing information are readily available, medical schools and training programs should develop and implement explicit policies restricting interactions between trainees and industry representatives.
Lesser, Eugene A.
Megerian, J. Thomas.
Gozani, Shai N.
Nerve conduction studies (NCS) and needle electromyography are useful and established diagnostic procedures for evaluating patients with signs and symptoms of neuromuscular disease. Although technological advances have occurred since the introduction of commercial electromyography instrumentation in the 1950s, most improvements have been evolutionary and were designed to benefit traditional users—neurologists and physiatrists specializing in electromyography. In the past seven years, instruments have been introduced that automate NCS and thereby enable a broader group of physicians, including internists and orthopedic surgeons, to perform these studies and utilize electromyographic data in the care of their patients. Automated NCS devices are an example of what Clayton Christensen terms a "disruptive innovation." In this article, automated NCS is contrasted with traditional electromyography, and the challenges and opposition to its widespread adoption are explored.
Medicine -- Research -- Moral and ethical aspects.
Conflict of interests.
The free market, which includes most practicing physicians, publicly supported biomedical researchers, and private drug and device companies, has succeeded spectacularly in delivering new medical technologies to the public. Increased interactions between doctors (physicians and biomedical researchers), epitomized by the founding of the biotechnology revolution, have and can continue to accelerate this delivery. A powerful anti-commercial advocacy movement that has blossomed over the past 20 years threatens this momentum. This movement has succeeded in inverting reality by demonizing the market and by promoting distorted and damaging views of professionalism and of science. Most ominously, it has imposed onerous and counterproductive regulations on medical education and translational research.
Conflicts of interest are rife in all areas of human endeavor, including medicine. Dealing with them is often difficult, because various disclosure remedies are sometimes too weak, while explicit prohibitions against participation in certain forms of research could block the needed synergies between scientists who work in universities, government, and industry. The situation is made still more difficult, because any effort to control one set of conflicts will necessarily generate another in its stead, as is well captured in Juvenal's famous question, "Who will guard the guardians?" That problem is more acute today, because many of our social watchdogs are in fact complex organizations that are rife with their own internal conflicts of interest. The problem is acute for the FDA, for example, which so fears the release of harmful drugs that it often keeps beneficial ones off the market. The problem can also arise in connection with the review of medical research by major journals, which is well illustrated by the recent effort of the New England Journal of Medicine to attack a Vioxx study it published in order to protect its own reputation.
Thyroid hormone (TH) elicits an extraordinary multiplicity of biochemical, cellular, and physiological responses in the simplest to the most complex organisms. The diverse actions of the biologically active thyroid hormone, L-triiodothyronine (T3), can be divided into two groups: growth and development, and regulation of metabolism. A large number of mechanisms, some mutually contradictory, have been proposed to explain the actions of this hormone. A chronological examination of the mechanisms of action of TH and other hormones reflects the rapid increase in our knowledge of biological regulatory processes. The discovery in the 1980s that the two TH receptors, TRa and TRb, share the same modular structure as other members of the large nuclear receptor multigene family of transcription factors focused attention on transcriptional regulation by TH. TH receptors function together with co-activators and co-repressors in multi-protein complexes, which are organized along with hormonal target genes into the structure of chromatin. Many new facets of TH action are beginning to attract our attention, so that investigators will still be busy attempting to explain the mechanism of its action for decades to come.
The ethics of anatomy bears on the ways in which we present and behold human bodies and human remains, as well as on the duties we have with regard to the persons whose bodies or body parts are presented. Anatomy is also a mode of thought and of social organization. Following Merleau-Ponty's assertion that the human body belongs both to the particular and to the metaphysical, I contend that art's ways of rendering of the particular in human anatomy often bring into relief metaphysical and ethical insights relevant to clinical medicine. This paper discusses the art of Gideon Gechtman, Mary Ellen Mark, Shari Zolla, and Christine Borland. It considers the relationship of these artists to earlier artistic traditions and the implications of their work for contemporary medicine and the biopsychosocial paradigm. Andrew Wyeth, the Visible Male Project, the Isenheim Altarpiece by Grünewald, and an anonymous Dutch Baroque portrait are also discussed.
Both leading scientific journals and the popular press now regularly report the convincing evidence of massive environmental degradation and decline. Yet despite the seriousness of the problems, despite their anthropogenic nature, and despite their profound implications for present and future population health, such topics are rarely discussed in the leading public health journals. When these issues are mentioned, they are examined in the same limited framework as other questions in public health—questions of models and tests of independent causal associations dominate. This approach will not suffice, for both scientific and ethical reasons. If public health scientists wish to sustain human health in the face of such crises, and to retain our integrity as scholars who speak truthfully about public health matters, we will have to broaden the notions of "health" and "community" to include nonhumans. I draw on recent scholarship in moral philosophy and in the philosophy of science to support my argument. Scholars in the health professions must take seriously the words of theologian Andrew Linzey, who states that the attempt to place human well-being in a special and absolute category of its own is perhaps the primary cause of our ecological travail.
"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type—that is, professional culture—may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.