The article “Patient views on financial relationships between surgeons and surgical device manufacturers”1 has caught my attention as few articles have in a very long time! The subject is particularly relevant today, not only because it has an important bearing on the cost of government-sponsored health care, but also because it delves into an aspect of health care delivery that is so seldom examined by the profession while at the same time having the most phenomenal import on the quality of care that we physicians and surgeons believe we are delivering to trusting patients.
Given the importance of the proposed study, I am disappointed that a convenience sampling was resorted to. I am not implying collusion, but convenience sampling, also known as “accidental,” “grab,” or “opportunity sampling,” is an inadequate instrument in the search for factual conclusion and truth. It is a nonprobability sampling from a population close at hand, readily available and within too close a network to be unbiased — a network difficult to distance from those involved, either geographically or on a professional level of doctor–patient interaction.
It would be naive on my part to think that the subject could be competently dealt with in a letter to the editor, but we must at least display the fact that these issues that question the integrity of the industry have been generously covered in American courts, with fines and reparation claims to the industry reaching billions of dollars. Class actions against Bard, Ethicon and Boston Scientific have peppered the news, revealing a justice system that is losing patience with the industry through multimillion dollar court-ordered decisions and settlements in favour of patients, including substantial punitive fines for “lying in court.”
The extent of the cooperation by the “collaborative faculty,” the term referring to surgeons who work closely with the industry, was highlighted in an editorial directed at the American Hernia Society when 60% of the speakers at their annual conference had 1 or more financial connections with the manufacturers of hernia devices and implements.2
The choice of one’s own patients to carry out the present study is, to my thinking, not a well thought-out design. Is it far-fetched to think that a patient in one’s own clinic may be intimidated? Would the patients find it difficult to be objective? Can such a patient assess the quality of treatment and the integrity of a surgeon? Of an industry? Of a financial interaction between the last 2 entities? Can a patient not be concerned of a possibility of retribution in the quality of care? Not only is it not a multivariate proposal, but also one bordering on psychological testing, which has been difficult of late to duplicate with any accuracy.
It may be of interest to add that the US Food and Drug Administration itself is facing its own set of conflicts of interests, abundantly covered in the lay press. Dr. Jeff Shuren (a lawyer and physician), who is in charge of the devices division that vets various polypropylene and other gadgets in hernia and other surgeries, is married to a lawyer who is an established lobbyist for the industry that manufactures the very items that her husband has to approve or reject!
The assistant chief to Shuren recently proposed by President Obama is Robert M. Califf, a former “Big Pharma” mega-lobbyist who received millions in funding and salary support.”3
Despite the honest intent of the University of Toronto group, their dutiful call on the ethical teams and sundry support from their venerable institution, I find it difficult to believe their conclusions, and without malice I must quote the insightful Scottish poet Andrew Lang: “politicians use statistics in the same way that a drunk uses lamp-posts — for support rather than illumination.”