That clinicians practice in an ever-changing, more complex environment that increasingly exposes them to multiple factors that may influence care is a cliché—and an understatement. A clinician’s behavior can be influenced by many factors that range from indirect approaches to direct financial compensation.
At a very basic level, patients attempt to influence our behavior. For instance, strong patient preferences and the right to refuse treatment are conscious efforts directed at changing a recommendation that may not be liked. Transference, a psychodynamic construct generated by unconscious forces, may also result in patient attempts to change the physician’s behavior. Clinicians are familiar with these doctor-patient forces in the relationship.
External forces also exist. For example, doctors view advertisements, navigate financially sensitive formularies, and try to manage insurance requirements. These tactics do not involve direct monetary arrangements, but they influence physicians’ decisions and may have macroeconomic consequences. Moreover, some clinicians receive direct compensation from the medical industry for participating in activities such as advisory boards, research trials, and promotional talks.
By nature, physicians are strong-willed and make recommendations based on the Hippocratic principle and with their patients’ best interests at heart. Despite this, payments to physicians have been a concern because the doctor’s judgment may be biased toward the source of remuneration.1,2 The field of ADHD has been singled out in the controversy, in particular as it relates to whether the condition is being overdiagnosed and consequently overtreated.3,4 A regulatory response to this issue, applicable to all physicians and conditions, is the Sunshine Act, which mandates that the industry post a list with the names of doctors who receive payments and the amounts paid.5,6
A back-to-basics approach
Physicians wield great power over individual lives as well as the financial outcome of medical products. The following case vignettes illustrate potential challenges that physicians confront in day-to-day practice and offer a rationale to help resolve influencing forces.
Married to a public school teacher, Mrs B, a 46-year-old stay-at-home mom, complained of lifelong distractibility. Her husband was emotionally supportive, calm, and well organized. The couple had 2 boys, aged 8 and 5. Mrs B explained that she had had a very successful career and had done very well financially. This money allowed her to stop working when her first son was born and for the family to enjoy a very comfortable lifestyle. She reported having concentration problems since early childhood and that she had been accident prone until she reached puberty. Her school performance was poor, but with a lot of effort she managed to graduate from high school. She was often referred to as “being in her own world.”
Her father experienced alcohol-induced violent episodes. Both her brothers had been treated for ADHD during childhood and did not do well as adults. Despite her difficult upbringing, Mrs B was very ambitious and completed an associate’s degree. A bubbly personality and a desire to advance helped her land a job with an Internet start-up. Her work required frequent travel. Mrs B’s contributions were instrumental to the success of the start-up, and she made a small fortune by selling her stock after the company went public.
Although she had never received a formal diagnosis of ADHD, several features point to the condition. As a child, she had problems with concentration and was overactive. A career in sales, working in the field rather than in an office setting, and a spouse who could help her set complex schedules are typical examples of compensating strategies for adults with ADHD.7 A strong family history of ADHD further validated that Mrs B met criteria for the condition.
Mrs B was not looking for diagnostic accuracy when she requested a consultation. After all, she had known that there was something wrong with her cognition for a long time and she was aware of her brothers’ diagnoses. She had successfully dealt with her problems on her own up until now, but a change in circumstances motivated her to seek treatment. Because a recent financial crisis had depleted the family’s savings, Mrs B needed to begin earning income again. She wanted to remain very involved with child care, so she decided to start a business locally to avoid traveling. She attempted to write a plan, put together financials, and study the relevant regulations, but she found it impossible. She could not concentrate on the many documents she needed to review and had difficulty in keeping a schedule without her husband’s help. She was getting confused about appointment times, was unable to help her sons with schoolwork, and was leaving pans on the lit stove. She had tried to improve her organization by using scheduling software and getting help from friends, but these methods had only minimal impact.
Dr Kaplan is Clinical Associate Professor of Psychiatry at Rutgers New Jersey Medical School in Newark. He is a consultant for Ogilvy CommonHealth.
1. Harris G, Carey B. Researchers fail to reveal full drug pay. New York Times. June 8, 2008. http://www.nytimes.com/2008/06/08/us/08conflict.html?pagewanted=all&_r=0. Accessed May 13, 2014.
2. Carey B, Harris G. Psychiatric group faces scrutiny over drug industry ties. New York Times. July 12, 2008. http://www.nytimes.com/2008/07/12/washington/12psych.html?pagewanted=print. Accessed May 13, 2014.
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