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To the Editors:

In a recent article (Wickersham P, Golz D, West SG. Clinical academic rheumatology: getting more than you pay for. Arthritis Rheum 2005;53:149–54) Wickersham and colleagues noted that academic rheumatologists generate downstream income for their institutions by ordering tests, procedures, and therapies. They believe that academic rheumatologists should be compensated for this. In their discussion, they did not consider the possibility that this may present a conflict of interest.

The authors comment that physicians in private practice can augment their incomes with office-based infusions, radiologic procedures, and laboratory tests. This is not always a good thing; it may encourage the use of tests, procedures, and therapies that have limited benefit, while engendering cost and possible risk to patients. In the studies presented, more than 40% of the downstream revenue was generated by the prescription of intravenous gamma globulin (IVIG). If our salaries were dependent on this revenue, would there not be an incentive to increase the use of IVIG, which currently has limited therapeutic use in rheumatic diseases and which carries considerable cost and some risk?

The authors suggest that rheumatologists should preferentially see patients with inflammatory diseases rather than patients with fibromyalgia. This plan is proposed not because it might best utilize the expertise of rheumatologists but because “although these patients are typically more complicated and take longer for the rheumatologist to evaluate, the downstream revenue generated for the academic medical center hospital and physician practice plan more than compensates for the additional time.” If other subspecialties can generate more downstream revenue than we do, should their patients replace ours?

Wickersham et al raise important issues regarding inadequate compensation for teaching in academic medicine and the difficulty of offsetting this through a clinical practice for which compensation is relatively low. There are, however, professional problems, with the concluding suggestion that “administrators and division heads should consider the relative contributions of downstream revenue generation when determining compensation levels.”

For further consideration of these issues and others, I recommend the book On the Take by Dr. Jerome Kassirer, even though he, and not I, may profit from the purchase.

William E. Seaman MD*, * University of California at San Francisco.