Bigotry Against the Obese by Leaders of Massachusetts General Hospital and Blue Cross and Blue Shield of Massachusetts?

I am amplifying a post by Roy Poses entitled "Why Pretend An Advertising Executive and Chamber of Commerce Leader Are Public Health Experts?".

In that post, Dr. Poses noted a lack of relevant professional credentials in executives making profoundly misinformed and indeed cruel statements about the obese:

Obesity as a public health problem has been the subject of considerable discussion. So that luminaries from the prestigious Partners Healthcare system and Massachusetts Blue Cross Blue Shield would weigh in on the issue at a public meeting should surprise no one. But see this report by the Boston Herald:

When asked about rising health-care costs, Jack Connors - chairman of the Partners chain, which includes Mass. General and Brigham and Women’s hospitals - said yesterday, 'Taking care of yourself starts at home.'

'What happened to individual responsibility?' Connors said at a Greater Boston Chamber of Commerce breakfast at the Westin Boston Waterfront. 'Why is obesity such an epidemic (when) we all know that a big part of being healthy is exercising and eating the right food?'

Blue Cross Blue Shield Chairman Paul Guzzi echoed Connors’ attitude yesterday.

'What is the responsibility of the individual?' said Guzzi, who as the chamber’s chief executive hosted Senate President Therese Murray’s speech on health care yesterday, despite his dual role as Blue Cross chairman.

Dr. Poses then went on to point out the lack of these executives' appropriate credentials to be making such statements.

In a Dec. 2009 post I'd addressed related issues:

Diversity Nightmare And Federal Antidiscrimination Laws: Cleveland Clinic CEO Delos M. Cosgrove Would Proudly Discriminate Against Fat People

The following stunning quote appeared in the Nov. 27, 2009 Newsweek article "The Hospital That Could Cure Health Care" about the Cleveland Clinic:

[Cleveland Clinic president and CEO Dr. Delos M. Cosgrove, a former cardiac surgeon] has even taken on the most intractable driver of American health-care costs: Americans. Having already banned the hiring of smokers (a dictate enforced by urine tests for nicotine), Cosgrove declared this year that if it weren't illegal under federal law, he would refuse to hire fat people as well. The resulting outcry led him to apologize for "hurtful" comments. But he has not backed down from his belief that obesity is a failure of willpower, which can be attacked by the same weapons used to combat smoking: public education, economic incentives, and sheer exhortation.

My thoughts come from the perspective of a former fitness-for-duty evaluator and drug testing officer (Medical Review Officer) for the regional transit authority in a very large city, and a hiring manager in the hospital and pharmaceutical sectors. I find a profoundly discriminatory statement that a hospital CEO would "refuse to hire fat people" if he could get away with it, and that he refuses to hire smokers and forces people (presumably candidates) to take a urine nicotine test, totalitarian and highly abhorrent.

The attitudes of these executives show a near-complete ignorance of this disease and its causes and treatment.

The attitudes also seem to show simple bigotry.

In Connors' case, his statements also show ignorance of his own hospital, Mass General.

From the website of the MGH Weight Center, realistic and compassionate attitudes about obesity:

Obesity, or excess body fat, is a serious medical problem now affecting one-third of all American adults and 20% of American children and adolescents. Even mild obesity increases a person's risk of having diabetes, heart disease, respiratory disorders, liver disease, arthritis, certain cancers, and other medical conditions. Overweight people have tried hundreds of ways to lose weight, from expensive commercial programs and risky drugs to unusual diets and exercise regimens.

"Recent discoveries about the genetic and physiological causes of obesity, along with the rapid development of pharmacological opportunities, have generated hope and excitement among patients and their families, their physicians and the scientific community. Massachusetts General Hospital has assembled the resources and outstanding professionals so that we can provide state-of-the-art treatment and work to find a cure for this challenging medical problem."

Lee M. Kaplan, MD, PhD Director

Overweight and obesity, like many other chronic medical problems, require specialized treatment. We believe that weight disorders must be treated by compassionate and knowledgeable professionals who take advantage of the latest scientific developments and tailor treatment to each patient's individual needs.

In that regard, I wrote Dr. Kaplan an email:

Sent: Wednesday, May 12, 2010 7:52 AM
To: kaplan@helix.mgh.harvard.edu
Cc: Miriam@cswd.org; Lynn@cswd.org; billfabrey@amplestuff.com

Re:  Bay State hospital and insurance heavies blames
fat-slob consumers for heath problems

Dear Dr. Kaplan,

I am a physician and advocate for the best healthcare, in my case through excellence in health IT. However, I am also an advocate for another cause - antidiscrimination against the obese.

As my colleague Roy Poses of Brown wrote at the blog of the Foundation for Integrity and Responsibility in Medicine, Heathcare Renewal:

Why Pretend An Advertising Executive and Chamber of Commerce Leader Are Public Health Experts?

Obesity as a public health problem has been the subject of considerable discussion. So that luminaries from the prestigious Partners Healthcare system and Massachusetts Blue Cross Blue Shield would weigh in on the issue at a public meeting should surprise no one. But see this report by the Boston Herald:

When asked about rising health-care costs, Jack Connors - chairman of the Partners chain, which includes Mass. General and Brigham and Women’s hospitals - said yesterday, 'Taking care of yourself starts at home.'

'What happened to individual responsibility?' Connors said at a Greater Boston Chamber of Commerce breakfast at the Westin Boston Waterfront. 'Why is obesity such an epidemic (when) we all know that a big part of being healthy is exercising and eating the right food?'

Blue Cross Blue Shield Chairman Paul Guzzi echoed Connors’ attitude yesterday.

'What is the responsibility of the individual?' said Guzzi, who as the chamber’s chief executive hosted Senate President Therese Murray’s speech on health care yesterday, despite his dual role as Blue Cross chairman.

It seems Connors and Guzzi are calling obese people irresponsible, in effect, lazy slobs. Roy also noted that both your Chairman Connors and Guzzi lack healthcare credentials and therefore any understanding of the causes and challenges of treating obesity.

I had addressed this issue in a Healthcare Renewal post of my own, in my Dec. 2009 post "Diversity Nightmare And Federal Antidiscrimination Laws: Cleveland Clinic CEO Delos M. Cosgrove Would Proudly Discriminate Against Fat People"

As a physician who has been up and down the scale myself, and discriminated against when on the heavy side, I am quite tired of such attitudes.

I note more realistic attitudes at http://www.weightcenter.org/ .

I believe a statement from you on this matter would be appropriate.

I am CC'ing this message to cswd.org and amplestuff.com, two groups with whom I communicated in the past.

It is a sad day indeed when the Chairman of one of the finest hospitals in the world, Massachusetts General, talks stupidly and discriminatorily out of the distal gastrointestinal orifice about how much people put in the proximal end of their GI tracts.

-- SS

Post Title → Bigotry Against the Obese by Leaders of Massachusetts General Hospital and Blue Cross and Blue Shield of Massachusetts?

Spun Silly: Academic Medical Center Cancer Treatment Advertising in the Era of Hype and Flim-Flam

Over the weekend, the New York Times reported on how prestigious academic medical centers advertise cancer care.  Here are some examples,

Prostate Cancer Surgery at Mount Sinai

A print advertisement for prostate cancer surgery at Mount Sinai Medical Center in Manhattan is typical of the way many elite research and teaching hospitals sell hope to the public.

'Our newest prostate specialist, Dr. David Samadi, has pioneered a minimally invasive approach that allows him to retain the highest cancer cure rates with the lowest risk of side effects,' says the ad.

Highest cure rates. Lowest risk. What evidence does the medical center have to back up such superlatives?

The ad’s claims are based on the successful results of Dr. Samadi’s operations and testimonials from his patients, said Jane Zimmerman, Mount Sinai’s chief marketing officer.

However, the article noted that the hospital could provide no studies that showed that its or Dr Samadi's results were superior to those of other hospitals or other surgeons.

... the ad with the superlative prostate cancer claims ... was later revised to say that Dr. Samadi’s approach gives 'high rates of success coupled with lowered risks of side effects.' Ms. Zimmerman said Dr. Samadi was not available to be interviewed.

Also,the people who concocted the advertisement said it was not really meant to tell prospective patients that the surgeon had better results than all others:

But marketing executives defend their approach, saying cancer treatment ads tend to play more heavily on emotion than on medical statistics because the ads are not intended to inform people who already have the disease. They are meant to make an impression on future patients, who may decide on treatments years after they have seen an ad, or to sway influential people who might advise a future patient.

'This isn’t retail advertising,' said Ellis Verdi, president of the DeVito/Verdi Agency in Manhattan.

The agency produced the Mount Sinai ad, which ran in The New York Times, and has created cancer ads for other hospital clients. 'This is reputation advertising,' Mr. Verdi said. 'There is a very big difference.'

But the advertisement said that the hospital's prostate cancer specialist had the highest survival and lowest adverse event rates.  How would a patient with prostate cancer realize that the advertisement was only meant to enhance the hospital's reputation, but not meant to speak to him?  

Radiation for Brain Tumors at Massachusetts General Hospital

'We gave Nick something he couldn’t find anywhere else in the Northeast. Life without cancer.'

That was the text of a print ad last year by the Massachusetts General Hospital Cancer Center in Boston, promoting its $50 million center for proton beam therapy, a kind of high-energy radiation to treat brain tumors and other cancers.

The hospital was the only medical center in the region with a proton therapy center, the ad said, enabling doctors there to successfully treat the brain tumor of a young man named Nick.

The ad’s concept was that Nick had a greater chance of survival because the precise proton beam could destroy malignant brain tissue while leaving surrounding healthy brain tissue intact, said Jodie Justofin, the marketing director at Mass General’s cancer center.

Dr. Thomas F. DeLaney, the medical director of the Francis H. Burr Proton Therapy Center at Mass General, said he had no involvement in the ad and did not have any information about Nick.

However, the article also noted that "no rigorous studies have shown that proton beam therapy has higher brain-cancer cure rates than other treatment methods, said Dr. [John D] Birkmeyer of Michigan [a professor at the University of Michigan and cancer outcomes researcher]. 'The ad might be accurate that they are the only hospital in the Northeast with this particular widget,' he said. 'But it could be misleading that the availability of this particular widget gave this patient better odds of survival.'"

Again, the advertisement said that the patient got "life without cancer," something he could not get anywhere else in the Northeast.  How would a patient with a brain tumor realize that the advertisement was merely based on a "concept," rather than scientific evidence that his  or her only hope for "life without cancer" could come from proton beam therapy at the Massachusetts General Hospital?

Surgery for Cervical Cancer at Memorial Sloan-Kettering Cancer Center

'Cancer, You said I’d never bear children,' reads the handwritten letter, held out by a pretty, healthy-looking woman, as a toddler peeks from behind the paper. 'My daughter says you’re wrong.'

That recent print ad from Memorial Sloan-Kettering Cancer Center in Manhattan tells the story of Michelle Rogala, a patient with cervical cancer.

Ms. Rogala’s hospital in New Jersey could offer her only a hysterectomy, an operation that would have left her unable to have children. Instead, she went to Memorial Sloan-Kettering, where she entered a clinical trial that was studying less invasive surgery. Ms. Rogala now has a little girl named Maddie.

Ellen Miller-Sonet, vice president for marketing at Memorial Sloan-Kettering, said consumers seeing the ads realizes that these were individual stories. 'They know that no two people are the same,' she said.

However, Ms Rogala told the NY Times, "hers had indeed been a special case. She had early-stage cervical cancer, she said, making her eligible for a novel operation that has now become a standard treatment at the center. After her operation, doctors told her she would need fertility treatments to conceive. But she said she turned out to be one of the few patients in the study who did not need radiation — which can cause fertility problems. She later became pregnant without medical intervention."

Again, why "consumers," much less patients with cervical cancer, would realize that the advertisement was just an "individual story," not a promise that the hospital's treatment of cervical cancer would not prevent future pregnancies, was entirely obscure.

Summary

The three advertisements described in the NY Times article had some features in common. All seemed to promise exceptional results. None were based on clear scientific evidence. All seemed to have been products of marketers and advertising agencies working without input from the physicians who actually provide the treatments they were advertising. All the marketers defended their work by saying that the advertisements did not actually mean what they appeared to mean.

My most obvious comment is that hospitals, even the most prestigious teaching hospitals, now seem to be willing to market their services like the used car salespeople seen on late night television.  Such advertisements, of course, are unseemly and undignified coming from such august institutions.  Worse, they seem to promise more than what these or any hospitals can be proved to deliver, and the only defense of the marketers who produced the advertisements were that they did not mean what they seemed to mean.

This shows the sad, and ultimately deceptive and unethical effects of turning the leadership of our best medical institutions over to businesspeople with little knowledge or understanding of the values of  health care.

It also shows what has happened to health care in an age of hype, scam, sham, spin and flim-flam.  It all seems part of what Frank Rich just wrote about in the NY Times:

If there’s been a consistent narrative to this year and every other in this decade, it’s that most of us, Bernanke included, have been so easily bamboozled. The men who played us for suckers, whether at Citigroup or Fannie Mae, at the White House or Ted Haggard’s megachurch, are the real movers and shakers of this century’s history so far. That’s why the obvious person of the year is Tiger Woods. His sham beatific image, questioned by almost no one until it collapsed, is nothing if not the farcical reductio ad absurdum of the decade’s flimflams, from the cancerous (the subprime mortgage) to the inane (balloon boy).

What makes the golfing superstar’s tale compelling, after all, is not that he’s another celebrity in trouble or another fallen athletic 'role model' in a decade lousy with them. His scandal has nothing to tell us about race, and nothing new to say about hypocrisy. The conflict between Tiger’s picture-perfect family life and his marathon womanizing is the oldest of morality tales.

What’s striking instead is the exceptional, Enron-sized gap between this golfer’s public image as a paragon of businesslike discipline and focus and the maniacally reckless life we now know he led. What’s equally striking, if not shocking, is that the American establishment and news media — all of it, not just golf writers or celebrity tabloids — fell for the Woods myth as hard as any fan and actively helped sustain and enhance it.

People wanted to believe what they wanted to believe. Tiger’s off-the-links elusiveness was no more questioned than Enron’s impenetrable balance sheets, with their 'special-purpose entities' named after 'Star Wars' characters. Fortune magazine named Enron as America’s 'most innovative company' six years in a row. In the January issue of Golf Digest, still on the stands, some of the best and most hardheaded writers in America offer 'tips Obama can take from Tiger,' who is typically characterized as so without human frailties that he 'never does anything that would make him look ridiculous.'

I would note that the health care precursor to all this was how the former CEO of the Allegheny Health Education and Research Foundation (AHERF), the biggest health care system in Pennsylvania in the 1990s, was hailed as a visionary in the medical press and scholarly literature, which later ignored AHERF's bankruptcy and its former CEOs criminal conviction (see post here.)  So my one disagreement with Mr Rich is that the problems are much older than the 21st century.
Rich concluded,

after a decade of being spun silly, Americans can’t be blamed for being cynical about any leader trying to sell anything. As we say goodbye to the year of Tiger Woods, it is the country, sad to say, that is left mired in a sand trap with no obvious way out.

The way out of our sand trap in health care, of course, is to refuse to be spun any more. We need to stop believing the hype propogated by all the clever marketers, and all the self-interested CEOs who hire them.

Meanwhile, I would suggest to any cancer patient who failed to get the wonderful results promised by some slick hospital advertisement, there may be some lawyers who with whom you ought to speak.

Post Title → Spun Silly: Academic Medical Center Cancer Treatment Advertising in the Era of Hype and Flim-Flam

What Me Worry? - Academic Leaders Blissfully Unaware of the Commercial Purposes of their Research Center

A few weeks ago, the Boston Globe published an investigative report on differences in reimbursements insurers and managed care organizations provide to different hospitals and hospital systems. One major bullet point was that the Partners HealthCare system, whose flagship hospitals include the Massachusetts General Hospital and the Brigham and Womens Hospital, received higher reimbursement rates than other well-known hospital and health care systems. A second was by some measures of quality, the major Partners teaching hospitals did not do better than other Boston hospitals.

In the resulting debate in the blogsphere (for example, see these posts and accompanying comments, on the Running a Hospital blog, and on the Movin' Meat blog,) some argued perhaps Partners really did deserve the extra payment. After all, the Massachusetts General Hospital and the Brigham and Womens Hospital are two of the most prestigious hospitals in the US, and indeed, the world. It is not implausible that this prestige arose from some real quality advantages. Furthermore, as we and others have argued, the available measures of quality, including those proposed to govern so-called "pay for performance" (P4P) in health care, are deeply flawed. For example, because of the Massachusetts General Hospital's reputation, it may attract the most difficult and complex patients, and these patients' severity and complexity of illness may have caused the hospital to have high mortality rates, despite the best of care.

Thus, at the time, the extra reimbursement going to Partners hospitals did not seem an issue for Health Care Renewal. But this week another series of stories came out about "Man's Best Hospital," (as it was called in "Samuel Shem's" House of God).... And they suggested that the Partners system may have quality problems of another kind.

Revelations about a research center at the Massachusetts General Hospital, and the renowned psychiatrist who ran it resulted from discovery legal proceedings. Lawsuits against several drug companies claimed that children were injured by atypical anti-psychotic drugs produced by several companies. The plaintiffs asserted that Dr Joseph Biederman's research was "crucial to the widespread acceptance of pediatric uses of antipsychotic medicines," (per Gardiner Harris reporting in the New York Times). The Massachusetts General Hospital's web-site notes that Dr Biederman is "Chief of the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at the Massachusetts General Hospital, and Professor of Psychiatry at the Harvard Medical School."

According to the NY Times article, Dr Biederman pressured Johnson & Johnson, the manufacturer of Risperdal (risperidone), an atypical antipsychotic drug, to finance a research center at Massachusetts General Hospital,

E-mail messages and internal documents from Johnson & Johnson made public in a court filing reveal that Dr. Biederman pushed the company to finance a research center at Massachusetts General Hospital, in Boston, with a goal to 'move forward the commercial goals of J.& J.'

Furthermore,

A series of documents described the goals behind establishing the Johnson & Johnson Center for the study of pediatric psychopathology, where Dr. Biederman serves as chief.

A 2002 annual report for the center said its research must satisfy three criteria: improve psychiatric care for children, have high standards and 'move forward the commercial goals of J.& J.,' court documents said.

A February 2002 e-mail message from Georges Gharabawi, a Johnson & Johnson executive, said Dr. Biederman approached the company 'multiple times to propose the creation' of the center. 'The rationale of this center,” the message stated, “is to generate and disseminate data supporting the use of risperidone in' children and adolescents.

Furthermore, David Armstrong, writing for the Wall Street Journal, noted

Internal J&J records that are part of the plaintiffs' filing indicate that Janssen (Johnson & Johnson subsidiary) paid, or was requested to make payments, of $500,000 to help start up the center in 2002, another $200,000 for operating funds in 2003 and an additional $250,000 for 2004 activities. Janssen declined to comment on those figures.

Dr. Biederman was receiving direct compensation from J&J during those years, according to records obtained by Sen. Charles Grassley, who has been investigating drug-company payments to the Harvard researcher at others at academic medical centers. In 2001, Dr. Biederman was paid $58,169 by J&J although he reported to Harvard that he was only paid $3,5000, according to Sen. Grassley. In all, Dr. Biederman received more than $1.6 million between 2000 and 2007 from drug companies while reporting to Harvard receiving only several hundred thousand, Sen. Grassley's documents show.

Also, per the WSJ,

The emails also suggest that the company's marketing staff were involved in creating the institute and that company officials helped to write and vet research work done by Dr. Biederman and his associates.

Officials from Massachusetts General Hospital denied that they knew what was really going on at the Center. Per an article in the Boston Globe,

Massachusetts General Hospital issued a statement yesterday saying that the center, the MGH-Johnson & Johnson Center for the Study of Pediatric Psychopathology, existed from 2002 to 2006 and gave many researchers 'the infrastructure necessary to complete projects related to the psychiatric care of children in an efficient, expeditious, and integrated manner.'

The hospital controlled the center's programs, it said, and, 'The grant agreements stated that the center was for scientific and educational purposes only and not for purposes of promoting, directly or indirectly, the products of Johnson & Johnson and its affiliates.'

The allegations in the Risperdal case 'have raised significant questions and concerns about the implementation of those agreements,' the statement said. 'The MGH takes these allegations very seriously and intends to investigate these issues thoroughly.'

Meanwhile, Harvard University denied any direct involvement. Per an article in Bloomberg News,

David Cameron, a spokesman for Boston-based Harvard Medical School, said Harvard isn’t involved with the J&J Center at Massachusetts General, a Harvard teaching hospital.

'Harvard Medical School does not ‘own’ any of its teaching hospitals,' Cameron said in an e-mail. 'While we are affiliated with them through academic appointments, all teaching hospitals are individually governed.'

A major theme of this blog has been how the leadership of ever larger and more dominant health care organization have forsaken their missions, and instead acted to threaten physicians' and other health professionals' core values. For example, a leader of academic medicine asserted that faculty were judged more for their ability to bring in money, to be "taxpayers," in his words, but not to teach, do research, or take care of patients. This occurred while health care organizations were increasingly run by people from the business world who had little experience in or knowledge of the care of patients, or of biomedical or clinical science.

The sorry tale of Dr Joseph Biederman now adds to the evidence that at even the most elite academic medical institutions commercial purposes may outweigh the academic or clinical mission. The remarkable feature of this story is that the leaders of the particular institutions involved seemed blissfully unaware of what was going on.

At best, the leaders of Massachusetts General Hospital did not seem to know what the purposes of their own so-called research units were. Although Harvard Medical School has long been identified with its prestigious teaching hospitals, and vica versa, now the Medical School says it was "not involved" in the hospitals' and its own faculty's research activities. It all has the smell of "plausible deniability." Maybe the leadership of ostensibly academic institutions no longer want to know too much about their institutions' academic activities, presumably as long as those activities brought in enough money to be good "taxpayers."

But if academic leaders claim to know nothing about and have no involvement in their organizations' academic activities, what sort of leaders are they, and what really are their missions?

Meanwhile, all too many medical academics cloak themselves in the mantles of their academic respectability while helping to hawk drugs and devices, while claiming to be perfectly uninfluenced by the tens or hundreds of thousands or more dollars they are making on the side, and uninfluenced by how the huge grants their sponsors hand to their institutions promote their careers, making their academic cloaks all the more showy.

For additional comment on this case, see this post in the Clinical Psychology and Psychiatry Blog, this one on the Alison Bass blog, and this one on the University Diaries blog.

ADDENDUM (1 December, 2008) - Also see this post on the Carlat Psychiatry Blog.

Post Title → What Me Worry? - Academic Leaders Blissfully Unaware of the Commercial Purposes of their Research Center