Going after the Wrong Doctors

A recent ProPublica expose co-published with the Boston Globe typifies a growing gotcha genre of health journalism that portrays doctors as the enemy in a struggle for honesty and openness in medicine.

These reports make unfounded leaps in their efforts to subject doctors to levels of skepticism once reserved for politicians and lawyers. They’re going to end up doing patients a disservice.

For this particular hunting expedition ProPublica set its sights on Dr. Yoav Golan, an infectious diseases specialist caring for patients at Tufts Medical Center in Boston who also works with pharmaceutical companies developing antibiotics.

But in its zeal to argue how physicians like Golan are corrupting medicine through their industry partnerships, ProPublica went to press without an iota of evidence Golan is corrupt.

A close look at Golan’s impressive career suggests quite the contrary and raises questions about ProPublica’s claim to objectivity.

Yoav Golan is a remarkably bad choice for anyone who hopes to use him as a poster boy of pharma-physician malfeasance.

As Tufts said in a statement in response to the ProPublica story, Golan enjoys international respect in the infectious diseases community and has assisted the development of “two important antibiotics, including the first antibiotic developed in the past 25 years to treat the growing threat of deadly C. difficile.”

(Disclosure: I held an academic appointment at Tufts for one year when I was practicing in Boston, but in another department and I never met Golan before this story.)

That antibiotic, fidaxomicin, is pricey, and you’d think an industry shill would liberally advise its use. Yet Golan and his team advised a Tufts committee setting internal standards for its use that the hospital should heavily restrict the drug. “We were very active in making sure it’s not used in pathways where it’s not cost effective,” Golan told me.

Golan’s colleagues all have access to the details of his industry relationships, and all patients enrolling in his trials are provided the dollar amounts too. Golan is sought after on the grand rounds speaker circuit precisely because of his work in developing conservative decision matrices that emphasize cost effectiveness and responsible antibiotic stewardship.

One of Golan’s more influential studies, published in the top-shelf journal Annals of Internal Medicine, recommended a drug transitioning to generic, fluconazole, instead of a newer more expensive agent, caspofungin, when ICU patients are thought to be suffering from severe fungal infections.

The analysis hinged on cost effectiveness. The study is similar to a trend in recent industry-funded antibiotic research; most studies, which are double-blinded such that no party can influence the outcome, find the new drug isn’t superior.

This isn’t the first time national media has highlighted Golan’s industry work for the wrong reasons; in both cases journalists seemed to have little understanding of their subject’s contributions to medicine, or indeed the precise details of the moral crime they allege he committed.

Last fall the New York Times implied Golan is exempt from Tufts’ conflict-of-interest (COI) regulations because he’s not a staff physician there. To the contrary Golan started as a Tufts fellow in 1999 and has been an attending physician employed directly by the medical center since 2002. During that time he’s never run afoul of any of the hospital’s extensive COI policies, which include a well-structured program involving senior physicians and administrators that monitor all physician-industry relationships.

“We very much value productive collaboration and we have safeguards in place to ensure the work is done ethically and to the benefit of patients and medicine,” the medical center told me.

Dr. Daniel Carlat, director of the prescription project at The Pew Charitable Trusts, a leading organization promoting transparency of physician-industry interactions, told me he also thought Golan was an odd subject for such media scrutiny.

A Pew task force charged with advising medical centers on how best to manage their industry relationships recently issued a comprehensive slate of recommendations.  ”We support appropriate relationships with industry,” Carlat told me.“Financial relationships that are related to research are completely appropriate.”

Describing Pew’s recommendations for academic medical centers like Tufts, Carlat says they “do not preclude appropriate research relationships.” Carlat holds an academic appointment with the Tufts department of psychiatry.

For ProPublica’s part, sloppy data leads to sloppy analysis. It claims Golan received $9,062 for his research and was paid an additional $29,750 for speaking and consulting, all from Pfizer. Golan did speak and consult for Pfizer but he says the research grant was made by Wyeth, which was subsequently acquired by Pfizer, and his speaking and consulting for Pfizer had nothing to do with the Wyeth research.

Such facts don’t neatly support ProPublica’s thesis that speaking and consulting serve as industry’s mechanism to garner additional influence with physicians. The numbers often deserve further explanation, as Golan himself didn’t receive that research money. For example in 2012, $12,050 from Merck went directly to Tufts for administrative expenses on a planned trial. Golan himself actually received no payments for the trial in that year.

This disregard for the details carries on to the strange selection of Golan as a subject at all. Golan was merely an example in a piece that really speaks to the lax policies of Tufts Medical Center, ProPublica’s Charlie Ornstein told me about his article, which featured a large picture of Yoav Golan, not Tufts Medical Center.

“Other prestigious centers like Harvard found that they can’t manage these relationships well, why does Tufts think it can,” he said. That Tufts made a very considered decision to carefully navigate these funding sources means little to ProPublica since other top medical centers have decided differently, barring or heavily restricting the level of industry collaboration Tufts engages in.

Yet the NIH encourages private industry collaboration. Researchers trying to determine appropriate antibiotic treatment populations for patented antibiotics are referred to the companies that hold the patents. There is woefully insufficient public money for all the antibiotic research we need, and indeed the NIH and similar European agencies are now actively pursuing public-private partnerships that harness the profit-seeking motives of private corporations for public good, while crafting deals that let the public share in the commercial upside of successful new antibiotic development.

ProPublica reveals some of its bias when trying to drive home how much money Golan makes. Any money he earns through industry collaboration “is on top of what he earns for treating patients,” ProPublica states, failing to understand that physicians enjoy the right do additional work for additional compensation just as any high level professional might in any other field.

“They obviously think physicians should do nothing but charity work,” says Dr. George Bakris, professor of medicine at the University of Chicago and editor of the American Journal of Nephrology, where Golan published work last year about challenges tackling clostridium difficile infections in chronic kidney disease patients.

(Golan does in fact do substantial charity work: he’s spent 13 years donating care to Boston prisoners infected with HIV.)

Golan’s work is “above board and beyond reproach,” says Bakris. Dr. Sherwood Gorbach, editor of the journal Clinical Infectious Diseases, where Golan has published 10 articles, describes him as the journal’s “go-to” peer reviewer for studies in immunocompromised patients, and has never heard a negative word about Golan’s work.

ProPublica’s reporting techniques are better suited to the world of politics. There, a clearer relationship can often be drawn between donations and political outcomes. In medicine and the pharmaceutical industry, the flow of money in and of itself can not so easily be characterized as an exercise of influence; rather it is the lifeblood of research and the development of new treatments.

That’s not to say that ProPublica’s concerns aren’t legitimate: There are no doubt specific cases of malfeasance out there awaiting discovery. Many institutions have put up more barriers than Tufts, and it’s reasonable to ask why Tufts made the decision it did.

Tufts has answered that question. The past is riddled with clear cases of abuse, including companies that paid doctors generously as consultants when the doctors weren’t actually contributing anything of value to the enterprise. That type of graft no longer exists in responsible pharmaceutical companies.

Many observers don’t understand accepting company money to give academic lectures, and while I wouldn’t speak for company money, I certainly wouldn’t focus a high profile media expose on anyone in particular unless I had clear evidence they’ve been corrupted.

I’d want to know that the physician gave biased lectures in exchange for the money, conducted biased research or accepted a sinecure consulting gig.

ProPublica has no such evidence when it comes to Yoav Golan, though they’d have little trouble finding other physicians who have essentially become pharma salespeople. Traveling to speak is an expensive enterprise that takes time away from reimbursed clinical work.

There’s a legitimate argument for paying physician speakers. What about Ornstein’s point that Tufts isn’t Harvard? Each institution can set the policies it thinks best serve its mission, and Pew’s recommendations are a good place to start. Golan is working by the rules at his institution, which contain numerous safeguards and strong similarities to Pew’s recommendations, which allow for industry funding of research and scientific consulting relationships, and recommend against “promotional” speaking.

The way ProPublica handled Yoav Golan should remind us that the organization isn’t print’s answer to NPR or PBS. Last year I wrote about how ProPublica used a Medicare prescription database to unfairly malign an Oklahoma psychiatrist. That reporting, too, erred by failing to understand the actual work and practice of a physician committed to the care of vulnerable populations.

ProPublica is an advocacy campaign whose unwavering commitment to the concept that medicine and industry shall not intertwine involves enlisting legacy media brands like the Boston Globe in their effort to steamroll the reputations of good doctors. They hope for an impossible world in which potential COIs aren’t managed as carefully as Golan manages his, because other interests simply don’t exist.

Research is to be the reserve of scientific clerics or uninspired automatons who don’t navigate the real world. ProPublica’s absolutist pursuit of this new public policy threatens the innovation engine we all rely on for our next cure.

I asked Golan what he thought about the fact that people who know nothing about him will now be weighing ProPublica’s report when they Google him.

With a sigh, he says “the most important thing for me is whether I draw right conclusion or not, or benefit people or not.”Golan’s patients and the field of infectious diseases benefit precisely because of how he manages his priorities.

We’re lucky they’re funded.

Ford Vox, MD (@fordvox) is a staff physician at the nationally-ranked Shepherd Center caring for inpatient and outpatient survivors of acquired brain injuries. His writing can be found  in The Atlantic, Bloomberg View and Forbes, where this post originally appeared.

13 replies »

  1. Dialogue is cheap at the end of the day, deeds are what are valued.

    Health care is now near fully politicized, so yes, to rectify the damage, the cause had to be corrected by eliminating the disruption.

    But, I think a great many here are so partisan and lost, the opportunity for healthy and substantial change is unlikely. My premise is fairly simple at the end of the day: we are ruled by narcicists, antisocials, and blatant cretins, who have an entrenched mob to insulate this corrupt leadership.

    So, healthy and responsible dialogue is gone.

    Otherwise, why hasn’t effective change occurred?

  2. If I understand the argument being made by Dr. Hassman, it is that he will engage in productive conversation when there are fewer incompetent politicians in office.

    Political incompetency stems not only from the conflicts of interest we are discussing here, but also bombast out of proportion to substance, so this amounts to saying one is not committed to engaging in productive conversation. Ever. Or at least until someone else fixes a problem.

    I don’t demonize this behavior, since that sort of invective would be counterproductive in the exact fashion I decry, but it is sad to lose a physician to such philosophical dead end.

  3. Sites like this have the usual suspects clamoring for “productive conversation” and then tries to demonize those who are fed up with the pervasive and disrupting profit oriented agendas that typify too much in the health care process.

    Well, it’s been over 4 years since Obamacare was signed into law, more than enough time for invested and concerned citizens and politicians to read the damn thing to some level of competency, and yet it is obvious the law is not well written nor interested in assisting care interventions, just playing the shell game with money and control.

    Frankly, having been raised to be the “mensch” always sounded nice and was well intended and respected by those who were equally appropriate, responsible, and respectful, but with the players who are cronies, crooks, and incompetents, they have no interest to dialogue honestly with the mensches of the world. In fact, they use the mensch mentality against one who is trying to do right and responsible.

    So, to your “productive conversation starts with us” ending, my retort is start with ending the reign of incompetent and corrupt incumbents in office, irregardless of “party” affiliation, pay attention to the deeds and not just the words of candidates, and maybe, just maybe, realize that after the 5 plus years of poor choices, actions, and agendas by the Left, they don’t get it and don’t deserve the endless passes most give that party agenda here.

    But, I have no respect nor admiration for the Right/Conservatives/Republicans either, so it really is time to leave the Republocrat world and start seeking honest and invested third party or independent thinkers and providers.

    “Productive conversation” at these threads overall, what a joke!

  4. Conversations here and in person are more productive if we avoid all good/all bad beliefs.

    True evil is rare. I doubt anyone seriously – anyone serious – thinks the half of the country that leans left is actually “vile,” “perverse,” “corrupt” or otherwise so categorically different from the other half of the country.

    Disagreements are common, and usually arise from differential understanding and prioritization of issues and values. If we come at the conversation with that understanding, and with some modesty about the perfection of our own views, we are more likely to find some common ground as well as respect for our differences.

    Thus in this example, medicine has a conflict of interest problem. I do not hear a disagreement about that issue. A more informed and nuanced understanding of a complex thing like medicine also reviews that incredible compassion and motivation to make the world a better place also characterize medicine and its practitioners. Statements like “almost all the people give value only for money but not for ethical values” are not only factually inaccurate, they likely inflame people and are less likely to lead to an adult productive conversation.

    Similarly, less on point but a great example of the issue afflicting public commentary now and directly leading to political stasis, characterizing all of Massachusetts or the half of the country that leans left as evil likely is fun to write but unlikely to lead to shared understanding.

    Life isn’t that simple. Dr. Vox isn’t all good, but he sounds like an admirable guy to me. At the same time, were he at another institution his industry ties would run afoul of conflict of interest policies. Likewise, medicine is both admirable and flawed. Obamacare, a compromise created by political stasis (see above), is good in that it newly insures millions of poor people, but it clearly has many flaws. Massachusetts? Great place to live, but man those people can’t drive. The left? Lots of nice principled people driven by values such as justice, concern for the poor, equal rights. The right? Ditto.

    Productive conversation starts with us.

  5. It is truly incredible how some of the most vile and offensive commentary demeaning physicians comes from the left/progressive/Democrat machinery that, oh, is also promoting Obamacare as the second coming of the messiah.

    Frankly, as I have said before, now, and to come, if you as a physician support this travesty of ruining the health care system of America, good luck looking for support from responsible and attentive colleagues when it burns you.

    God, the state of Massachusetts devours not only their own, but just look at the latest poster child of Justina Pelletier who is not even a resident of that corrupt state to begin with.

    How do you practice honest, caring, standards of care medicine in Massachusetts with how the academic and media heads control the information? Oh, my mistake, the blueprint for Obamacare in the first place!

    Wow, another example of the Left’s perverse efforts to twist tolerance into hate and ostracizing. And 30 to 40% of voters will vote for such behaviors just as reflexively as they sit on a toilet to expel waste.

    At least they are consistent!!!

  6. It is easy to find extreme examples of physicians who run afoul of industry conflicts of interest. Similarly, drug companies have a history of currying physician influence with both overt and subtle bribes.

    This means journalistic inquiry into the physician conflict of interest in industry relationships makes sense, as Dr. Vox writes. The quality of such reporting by ProPublica and others though will influence its impact. Reporting ultimately judged a smear campaign runs the risk of undermining the agenda that likely prompted it in the first place.

    Much of Dr. Golan’s work is uncontroversially admirable, but we should admit that some is more controversial. Dr. Golan is an important contributor to his field, and receipt industry funding for research is in no way unethical. To imply otherwise misunderstands how antibiotics and many drugs are and have been developed for the benefit of all of us for decades. On the other hand, I do think physician acceptance of industry support for public speaking engagements is ethically dicier. It can be understood by patients and colleagues as advertising for industry interests, and this risks credibility. Further, speaking on behalf of an organization risks undue influence on the speaker even if they take steps to mitigate that influence.

    Dr. Vox argues convincingly that Dr. Golan’s behavior does not suggest he is the drug industry shill the original article makes him out to be. Concerns are reasonable to raise, and – as Dr. Vox asserts – the question of why one institution would allow behavior another would prohibit in its ethics policy is worth debate. To my mind, the best way for a leader in the field to retain credibility is to avoid all entanglements that could give even the appearance of conflict of interest. Being a “thought leader” crosses this line for me, but not all would agree and thus ongoing dialog is healthy.

    Reputation is a two way street. Dr. Golan could protect his own reputation more assiduously by hewing only to uncontroversially appropriate interactions with industry, such as the conduct of research. ProPublica, on their part, should exercise standard journalistic concern for the reputations of upstanding physicians they investigate, and thus not make Dr. Golan out to be a devil he is not.

    We too can contribute to a meaningful resolution of this societal issue by making balanced comments.

  7. Maybe the Supreme Court can exempt doctors from scrutiny as they have done for politicians. After all “corruption”, as they see it, is only quid pro quo, not the corruption of the system.

  8. Reporting on conflicts of interest in medicine is a legitimate line of inquiry for the media and Pro Publica has done it very well. The U.S. healthcare system is all about money, and the more the public understands this, the better.

  9. Well, considering physicians seem to be the whipping post for much of the Health-related media these days, I’m not surprised.

  10. The ProPublica scrutiny of Dr. Golan is not unexpected from people who eat, sleep, and breathe righteous indignation. The reasons they do it are: 1) because they can; 2) the media, thanks to the First Amendment, is the only industry in America in which exclamations (except for yelling “Fire” in a crowded place) can be successfully shorn from maturity, responsibility, and depth not just without penalty but with social approval; and 3) being stupid and shallow attracts readers, which is what attracts funders. In the end, it’s all about money, which is the case they’re trying build against Dr. Golan.

    There is an unfortunate tendency to think that the media are objective protectors of the public good. In some rare cases they are, but they are mostly people with an agenda (just like the rest of us) only they don’t feel obligated to be transparent, which is their lofty standard for everyone else.

    If ProPublica really wanted to do a public service, they might look into physicians like this one, who brags about having generated $300,000 in income in one year by using his imaging facility as a revenue generator. http://www.aaos.org/news/aaosnow/mar09/managing1.asp. Notice that he does not utter a word about whether the imaging was necessary, appropriate, or ultimately clinically valuable. It’s all about the Benjamins. Physicians like this ARE the problem, not doctors like Dr. Golan, whose relationships with industry are, by comparison, a very modest entanglement.

  11. much media coverage of doctors is a classic love/hate/envy relationship

    journalists see themselves as going into their fields as a public service , it offends their sense of right and wrong and that others should do something similar and be richly rewarded

    and they’re right — they should be paid more – but that doesn’t justify it …