Doctoring Health Care Health Care Reform

Kentucky’s back problems

“John…Why are you going out in the cold?”

“I need some stuff for work.”


“Pens…those cool felt tip ones that write really dark and bold.”  I like it when the ‘Electrophysiology’ note stands out in the chart—like John Hancock’s signature did.

Until a few months ago, a pacemaker company used to give out nifty plastic pens.  They were awesome: brightly colored, lightweight (cyclists like everything to be lightweight), and they wrote smoothly. You couldn’t leave them laying around; they’d be snatched up in no time.

But these instruments of proclamation have gone the way of the narrative-only non-EMR patient letter. Vanished.  You see, plastic pens with industry-logos represent far too much temptation, far too much potential conflict of interest for doctors. They had to go, the all-knowing pen-banners proclaimed.

However, I, like most masters of the obvious, know that the notion that a 99 cent plastic pen could influence a doctor’s decision is a bit like a pre-teen believing in Santa.  They want to believe, but can’t because of reality.

The subliminal message of a plastic pen with an industry logo just doesn’t rate high enough on the influence scale to change a doctor’s behavior. It’s true and obvious; don’t over think it.

And for proof of their wrongness of scale, the pen-banners need only read yesterday’s front page WSJ article in which the excesses of the now (in)famous Norton Hospital (Louisville, KY) spine surgeons are chronicled in gory detail.  Granted, Kentucky has its problems with obesity and sedentarism, but who knew that there was this much spinal disease in our medium-sized midwestern city.  So much so that a 640-bed hospital would rank third in America in spinal fusion surgery.

Sure the 1000 dollar screws are eye-grabbing, but clearly the most striking feature of the article was the hard-to-fathom size of the royalties paid by Medtronic. For their “intellectual contributions” to product development, each of the five Louisville spine surgeons were paid 1.38 million in 2010.  (And this was only for the first three quarters of 2010.)

That’s a lot of pens! And just a little conflict.

As a doctor, it’s incredibly sad for me to read about such tomfoolery.  For most readers, it would be easy to conclude that such excess are a representative sample of doctors as a whole.  Although compelling, this conclusion would be dead wrong.  Rather, this story is similar to the saga of the one unruly kid who caused the whole class to loose recess. But in this case it would be that that one bad-boy made the whole school miss recess.

Ok, Ok… John….That’s a lot of words to say that a few doctors and hospitals reaping huge rewards from medical device surgery are not representative of doctors as a whole.

Is their anything else?  Any other lesson, message, conclusion?

Here’s my summary…

  • Doctors are humans and when humans are involved, so is human-nature.  This means greed is always in play.  That ain’t ever changing.
  • Doctors are not vigorous in their self-policing.  (Perhaps this is because of human nature too.)
  • Medical device companies benefit from 1000$ screws.
  • Hospitals benefit from the large volume of cases.  

From 2004 to 2008, Medicare paid Norton Hospital $48 million for the 2,475 spinal fusions it performed on Medicare patients during those five years, according to the Journal analysis.

  • Finally, the biggest reason that these rare but well-publicized cases occur is that in our present compensation system, doctors are paid according to ‘how much’ they do, rather than ‘how well’ they do it. 

The problem for masters of the obvious, is that we see the farcical regulations, like pen-banning, as distractions to the greater problems at hand, like a distorted compensation system that rewards quantity of care not quality of care. 


Oh, and one more thing, I never felt very conflicted about eating a pharma-bought bagel or sandwich, and I sure don’t now.

5 replies on “Kentucky’s back problems”

John, I'm a big fan who admires your posts but I have to say I couldn't disagree more with you about this topic.

Your logic here seems to be that compared to these guys who were making millions, accepting a sandwich or even a pen is laughably minor. And there is a slight suggestion that because others are SO much more corrupt, just a tiny bit of corruption is ok. Why is it that you "never felt very conflicted" (the "very" is telling) before but that you "sure don't now" after reading about your colleagues? Just because Madoff stole billions doesn't mean it's suddenly acceptable to steal hundreds, or even a few pennies from the even a newspaper from the newsstand.

I forget the details but there was a recent study showing that factors like medical school debt can influence physicians acceptance of industry "largesse." And in the past you've written quite poignantly and accurately about how "they" are trying to take all the fun out of medicine, but these unpleasant aspects of contemporary medical practice are no justification for accepting (even very small) gifts.

To be clear, resentment, and perhaps some envy, over the very large gifts accepted by these spineless spine surgeons is no excuse for accepting smaller gifts. The scale may be entirely different but the concept is exactly the same. In fact, I would guess the ROI of the sandwiches and pens is actually much higher than the millions in kickbacks given to the surgeons. And of course industry marketers know this. Which is why they keep doing it, of course.


I think you might have missed the master-of-the-obvious logic here. First of all, using a free pen isn't analogous to stealing a few pennies or a newspaper. The pen is free.

Second, and more important, the pens are material gifts but they aren't enough to influence a doc's decision regarding care. In other words, they are immaterial.

Therefore, banning them is a symbolic waste of time. Worse yet, the pen banners will likely tout their inane efforts as something real. "Look how serious we are about conflicts of interest. We even ban pens!" The implication being that "If we ban pens, you know we ban the really bad stuff."

I'd guess that's not true.

So I say, nix the symbolic pen banning and focus the reform effort on things that matter.

Put simply, master the obvious.



Thanks for your thoughtful comment. It's OK to disagree. You made me think, and talk to a bunch of other doctors–my wife included.

As background, I am old enough to have lived through times that would have induced severe arrhythmias in the pen-banners. A free medical-device-sponsored Charlie Daniels concert at a NASPE meeting (now HRS) comes to mind. There are many others, but most smart doctors my age have expunged these memories.

In the literal sense a gift is a gift, a rule a rule…etc. But I like to use the example of the 4 AM red light in the middle of nowhere. Sure, the law says stop and sit there, and at any other time, those with sense would stop and wait. At 4 AM though, masters of the obvious look around, assess and then go. Why? Because no one is harmed. Going through the red-light is inconsequential–in fact not idling mindlessly is environmentally friendly. This is how I (like RDB) view the 99-cent pens and bagels–as inconsequential.

In the EP lab, I use ablation catheters that I feel are the best; I implant devices that I would implant in my family, and prescribe drugs that I would take myself. No sandwich–no matter how good–would change that. But that doesn't mean I don't think about the potential conflicts when I eat the sandwich or admire the boldness of the ink pen. I do. However, like the driver who doesn't wait at the 4 AM light, I assess the immaterialness of the conflict and move on.

I may be naive, perhaps because I lived in Indiana for seven years, but it is clear to me that 1.38 million in royalties is corrupting, whereas a turkey sandwich is not. I believe the scale does matter.

Gosh, not all that industry touts is bad. Carvedilol was once Coreg. Metoprolol was Toprol XL. Enalapril was Vasotec. These drugs are now staples of heart disease management. Minneapolis classrooms in education centers of medical device companies taught me a bunch about pacemakers and ICDs. Do the M and M-cookies negate that experience? What about those incredibly useful ECHO conferences Thursdays at noon at IU. I remember Dr Harvey Feigenbaum's lessons to this day. The industry-provided food didn't negate these positives.

I understand and acknowledge the conflicts. The Multaq example is highly illustrative.

There must be a middle ground. One in which common sense dominates.


I was the recipient of one of Norton’s infamous spinal fusion surgeries during the period stated. Not only did my company get dropped by the hmo the very next year, I have developed very annoying and painful peripheral neuropathy as a result (the surgeon said “sometimes that happens” and shrugged it off); not only, my back is no better and possibly worse since. Thanks.

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