Wednesday, January 22, 2014

Time to fire somebody

Regular readers know that I tend to operate in a no-blame mode, i.e., be hard on the problem and soft on the people.  But when someone has violated the public trust in an institution to support the commercial goals of a private company, they have shown such poor judgment that consideration must be given to terminating their employment.

Today's example is the following advertisement, which appeared in the New York Times Magazine this past weekend.

So far so good: A hospital is bragging about a technology it has in place to serve its customers.  This happens all the time.  While we might question the efficacy of an advertisement for the University of Illinois in attracting customers from across the United States, that is less a question of ethics than one of business judgement.

But, now let's look at the bottom part of the ad:

Perhaps you have trouble seeing the small print, but the tag line is that the copyright on this advertisement is held by Intuitive Surgical, Inc., the manufacturer of the daVinci robot.  Just above that we have a disclosure that "some surgeons who appear in this ad have received compensation from the company for providing educational services to other surgeons and patients."

Wait a second.  Whose ad is this?  If it is an ad paid for by the University of Illinois, why doesn't the University hold the copyright?  If the ad is paid for by Intuitive Surgical, Inc., how can the University allow its name to be used for commercial purposes?

According to its website, "The University of Illinois is the state's best and most comprehensive public university."  Hmm, a public university, presumably supported by tax revenues.  The University has a Code of Conduct, which provides, in part:

Those acting on behalf of the University have a general duty to conduct themselves in a manner that will maintain and strengthen the public's trust and confidence in the integrity of the University and take no actions incompatible with their obligations to the University.

With regard to professional conduct, those acting on behalf of the University should practice:
  • Integrity by maintaining an ongoing dedication to honesty and responsibility;
  • Trustworthiness by acting in a reliable and dependable manner;
  • Evenhandedness by treating others with impartiality;
  • Respect by treating others with civility and decency;
  • Stewardship by exercising custodial responsibility for University property and resources;
  • Compliance by following State and Federal laws and regulations and University policies related to their duties and responsibilities.
Let's consider how this Code has been violated by this advertisement:

1)  The University has allowed its reputation to be used in a nationally distributed advertisement produced and owned by a private party, in benefit to that party's commercial objectives.  This is not consistent with "exercising custodial responsibility for University property and resources."

2)  The information presented under the University's imprimatur is not "reliable and dependable" and therefore undermines the trustworthiness of the institution.  I refer especially to the assertion:  "See facts and clinical data at"  This website does not contain the results of objective peer-reviewed, case-controlled data comparing robotic surgery to manual laparoscopic surgery--the expected research standard for academic medical centers.  Instead, the site leads to a document that asserts: "Over the past decade, hundreds of studies have been published on the use of the daVinci Surgical system demonstrating improved surgical outcomes when compared to open surgery."  Imagine the disciplinary action that would follow if a professor in the university had attempted to publish such self-serving information in support of his or her scientific hypotheses and label it as "facts."

3)  The inclusion of a surgery technician and nurses in the photograph raises concern about the idea of "treating others with civility and decency."  What was the process by which those people were invited to participate in the ad?  While it might be based on affection and respect for them as part of the surgical team, were they given a choice? Were they inserted in the picture to give an impression of greater gender and ethnic diversity?  If some of the participants in the photograph have received compensation for their commercial activities, were these staff members treated equally?

4)  On the compensation issue, there is no disclosure as to which surgeons have been compensated by Intuitive Surgical, Inc., the nature of the work they did to receive that money, and the amount of money involved.  Again, the issue of trustworthiness arises.

So, who should be fired for these violations?   Simple: I would choose the highest-rank administrator and clinician who gave permission for this advertisement to be published.


Barry Carol said...

I remember when Warren Buffett temporarily took over as CEO of Salomon Brothers in 1990 after a Treasury bond bidding scandal; he told the employees (paraphrasing) that if you lose money for the Firm, I’ll be very understanding. If you lose reputation, I’ll be ruthless. That sounds like the appropriate approach to me for this situation too.

Anonymous said...

Welcome to Illinois where it's politics as usual. Where students who also do not deserve scholarships receive them because their parents know someone, supported someone...

Paul Levy said...

Hmm, beyond my expertise, but, if so, some reporter would love to know that.

Bobby Franklin said...

That is a great quote Barry Carol.

medicine for real said...

The Da Vinci people have been very aggressive in their ad campaigns. I tried to get a Da Vinci rep to comment on some recent negative publicity with regard to robotic surgery and he is "not allowed to comment." This ad is only the most recent example of the company's use of hospitals and surgeons to tout their wares.

Anonymous said...

When I finally took a close look at this ad, I realized what bothers me most - saying "We believe in" a surgical tool is an oxymoron. That's the whole problem with this robot - it has built a belief system in place of evidence.

nonlocal MD

e-Patient Dave said...

Paul, on Facebook this is getting new eyes. I note that in this particular post you're not talking about a frequent previous subject of yours, the lack of good evidence of benefits of robotic surgery.

A friend was surprised and sent this link to this article.

It's limited to precision of knee replacements done on cadavers.) Thoughts?

Anyone know what Da Vinci says on the subject of evidence?

Medical Quack said...

One of the issues that popped up and here and popping up everywhere as we buy in to what is called "Quantitated justification" as you are shown numbers and stats and my bud Charlie says in the video we are sucker for math and the old saying goes if you want to make a sale, throw numbers at them..but indeed we need accurate numbers I agree:)

Don't get mad when you read the post and look at the last video..I know you just wrote your book and this is no time to say "I could have had a V8" and yes I am being funny and satirical here at once but see how many books he wrote and put on sale at Amazon.

Also keep in mind this is what the editors at papers are looking at too, the jounobot and Charlie has a new book in teh works for the journobot too, very scary bot stuff, but it's out there and the other day I caught a couple reporters on Twitter talking about the jobs list that someone created saying edtitor was #5 on the list so they know and and are a bit unsettled.

You know it's like pay for performance with doctors, they get paid and judged on clicks and reads, too, Forbes is trying to sell their bot that does some of the automated articles as it feeds ad revenue.

So coming back around here to the point, see what we were fed with quantitated justifications...this is really a big deal all over the place and the answers is to straighten out the math and code, that's where it starts.

So who did the math selling and who bought in to allow the second part you illustrated here to happen:) Somebody got duped along the line:) Algo Duping is what I call it.

James Falasco said...

When I was on the faculty of the University of Illinois Medical Center in Chicago we could not even accept a free lunch from a supplier . I guess sports teams aren't the only groups cutting commercial deals . How long before the staffs of major medical centers get their own shoe commercials ?

Thomas said...

I agree with your post. As part of that, the University should run a “correction” ad explaining why the first ad was wrong in the first place.

Anonymous said...

According to the university web page, one of the 'team' members (Ms. Nita) is the "Media and Administrative Contact" yet she is wearing a lab coat. Must have needed more balance in the photo.

Paul Levy said...

Oh my. Well, if you are going to be deceptive, you might as well go all the way!

Paul Levy said...

Proof if you want it: Here's that website:

james a carlin jr said...

any procedure economicaly tied to institutions doctors or personal using that procedure is suspect because it is difficult to be objective
conflicts of interest are common
science driven by profit is often compomised
but I state the obvious

Brad said...

I see this type of hospital practice every day. I am also sick to death of MM's such as Parallon.... who refuse to order better products that the doctors beg for....then Parallon charges reps to have access to the hospital !

Unknown said...

This is especially bothersome in that the ad came from a public university with people who are on a public payroll. Your suggestion, on who to fire, bolstered by the first comment quoting Buffett is certainly appropriate. I also like Thomas' suggestion that U of I publish a retraction.

Dr Frank Ervolino said...

Excellent Article. No one knows what the heck is going on behind the curtain of hospitals these days. The most stressful position in a hospital these days is the Nurse/Case mgr. whose job it is to keep patients in the hospital until the money runs out then get them out unless the CMO intervenes.

Anonymous said...

Paul, thanks for raising these important ethical issues. You see things with a clarity that many of us miss.

By the way, I just bought your "How to Negotiate" job offer book for my niece who is a college senior. She loves it! Thanks for taking the time to put together such a great resource for these students.

Michael J Katz MD said...

I have mixed feelings about your article. I understand your feelings about public and private domain and I agree. We give our medical students a gift of a superior stethoscope as a gift from alumni and faculty just so that they are sheltered from the "dark side" for a little longer. Nevertheless, Davinci is an amazing technology. It has revolutionized Prostatic surgery and the concept is needed in Orthopedic Surgery. The most outstanding faculty with the most outstanding fellows in the United States reported that only half of the cups in total hip replacement were placed in the accepted range. That is very scary. Davinci and other robotic technology is changing that.

Anonymous said...

The odds are high that the robot was originally developed at University of Illinois and that they or licensed the intellectual property rights/patent to the company who then commercialized it. This is how most universities operate with patentable inventions made with university money or using university owned property/equipment.

Stanford has one of the more well developed programs commercializing faculty discoveries/inventions. They even partner with venture capital firms and invest themselves in the venture fund syndicates that fund the companies created to commercialize the product. Stanford makes a lot of money doing this. Of course that money is generally funneled back into scientific research, the endowment, student fellowships, etc.

All this being said, if in fact this is the case, it would have been good to note that in the fine print as well. The conflicts of interest noted could be explained this kind of tech development too. After all if they university is getting royalties it would be to there advantage to help the company in any way possible to be successful.

facelessbooking said...

As a 70-year old patient dealing ever increasing interactions with healthcare providers and institutions, I am extremely sceptical that MY best interests are being served.
Most doctor's have found ways to get paid multiple times for the identical activity by sending me through the maze of as many facilities in which they have a vested interest.
First I go to a doctor's office and fill the forms for medications, history, etc. Next, I go to a specialist cohort in the practice and provide the same information on another form. Then the lab to give much of the same information. Then the outpatient facility where the same information needs to be provided. Sometimes many of the operations are in the same building owned by the very same doctors. Over several days 4 charges, and as if adding insult to injury, the outpatient clinic asked for same information in during a 30 minute phone call.
A colonoscopy, which 20 years ago was performed in my primary physician's office by the doctor without anesthesia with only a nurse in attendence now involves multiple people in multiple facilities.
The procedure, performed in a surgical suite, involved contact with 4 nurses, 2 anesthesiologists vying for the opportunity to sedate me, 2 orderlies, and 2 front desk clerks. And that's not counting any supervisors/managers behind the scenes. Besides the suite, I was in the lobby, the prep room, a recovery room, and a waiting room prior to being picked up.
And I can't fail to mention the heated socks with no-slip soles (although I was not allowed to stand) and a heated blanket.
I wonder how much the 4 ounce post-procedure apple juice cost.
Little wonder that univetsity/hospital administrators want to push ethics aside in order to cash in for their institutions and possibly themselves.

John Sherman said...

As a past Patient of robotic liver surgery at UoW Seattle WA; as a result, out of hospital in two days, less abdominal wall area injury as result of this robotic need for small access area and I could raise myself up and out of hospital bed without mechanical overhead bar assistance or others to help me out; therefore, there is some truth in the claim: I believe and "WE BELIEVE IN DA VINCI SURGERY BECAUSE OUR PATIENTS BENEFIT".

So where is the Patent discussion related to this article?

Anonymous said...

Mazor Robotics is all former Da Vinci people and is taking the same marketing approach whether public or private institution.

SPUBOL said...

Thanks for calling this out Paul.

As the old adage states, "A picture is worth a thousand words". Yet the adolescents of today, and future payers for Obamacare, barely master a 300 word vocabulary, leaving the "image" as their sole means of communication. The image of the white-coats labeled as University endorsed medical care is appalling. However, it will live in infamy and infinity on the internet because it cannot be deleted no matter how many retractions are attempted. By its mere existence it now becomes "fact" to the majority of those who will be seeking medical care in the next decade.

It doesn't surprise that the University is asleep at the switch. It seems all of Illinois is asleep at the switch in allowing their government to bankrupt both their moral systems and pocketbooks. i.e., "the likes of "Rod", "Barry", etc."

I could not agree with you more! Those in authority associated with this ad in any way should be sacked immediately. They are probably already remodeling the waiting rooms to accommodate slot machines!


Turquoise said...

Patients want less invasive surgery and this Da Vinci robot seems to supply that need. As someone who got majorly hacked by a surgeon in 2012, and is still recovering, something less invasive would be a win win situation for all patients.

No so sure about the doctors mind you. I think that surgeons will still be required but I personally would have liked a less invasive surgery, and the Da Vinci seems to give us this.

I'm not sure what the argument is here. I don't think it is time to fire anybody, but it is high time that patients got more choices when it comes to treatment.

I would much rather have had the choice for smaller incisions and shorter recovery time. But alas, I live in California, and this device wasn't being used at my hospital..

Please keep the end in mind. Better outcomes for patients. I think that this Da Vinci device just might be the next better thing in surgery.

Anonymous said...

Paul, you are phenomenal!!! Thank you for bringing this up. It' disgusting. If only you knew what's going on out there. The practice you have uncovered is just kid's stuff. Also, try to send this to the code of conduct office out there and they may well laugh at you. On the other side, Intuitive has lost almost everything and those guys are the only ones willing to do this kind of stuff "Italian style"

Unknown said...

Yikes! I guess I'm not surprised that wellness companies don't have a monopoly on lying, which is basically what this is. If you "believe" in something (which by the way in the case of prostate surgery doesn't work), you don't have to be paid to say it. When the collection plate comes around people put money in. They don't take money out.

DrMole said...

This is not confined to DaVinci. GE, Siemens, Varian, Elekta, proton machine makers, Depuy, etc all have cooperative advertising they push when their equipment is installed in a hospital or physicians' office. They provide the copy and there is a cost-sharinig agreement to pay for it. A pervasive problem. The old "build it (and advertise it) and they will come.

Anonymous said...

To the patients commenting on 'less invasive' surgery with the robot: The robot is being compared to laparoscopic surgery, another minimally invasive technique. It is not being compared to open ( a big incision) surgery. But if you use the robot instead of laparoscopy, it costs a whole lot more. The question is, what does the robot offer that laparoscopic surgery doesn't, for all that extra money. Not to mention reports of perhaps unique complications which are starting to appear.

That's what the argument is here. But the bigger argument right now is the ethics of this advertisement, which seems quasi-religious.

nonlocal MD

Anonymous said...

Definitely not all patients are as naive as the ones who posted above here (certainly I am not!). But the ones who are are definitely the ones at whom this nefarious ad is targeted.

ultrasound1 said...

This is nothing new. It happens all the time. I can give you plenty of examples in my area. Medicine is populated with what I call "the Spreadsheet users". They will do anything for a buck. No wonder why there are so many empty hospital beds everyday in many towns and cities but hospitals keep building new facilities. Imagine all that wasted money could go towards giving care to less fortunate amongst our population.

We used to have a hospital sponsored bill board in our town touting purchase of a new laser system for GYN surgeries. It was taken of after a few serious complications from use of laser!! Now it is for Neurosurgery!!

Anonymous said...

Anon 4:21, people can't be called naive if they are being downright hornswoggled. We used to have trust in our doctors, and it's sad that now that is called naive. But it's the doctors' fault for violating that trust, not the patients'. That's the entire point of Paul's post, and right he is.


Anonymous said...

The state of Illinois in general, and Chicago in particular, are well known for the pervasive corruption and disonesty. What has been clearly identified in his blog by Dr. Levy is another classic example.
Dr. Giulianotti was a semi unknown surgeon in Italy who was using the DaVinci robot and had very strong economic ties with Intuitive. He was brought to the University of Illinois in Chicago a few years ago as an "international expert". What made him an expert? Contrary to many other foreign medical graduates he never had to pass any test such as the USLME. Contrary to many other foreign medical graduates he did not have to repeat a residency in general surgery. Finally he never set for the examination of the American Board of Surgery. At the present time, he is performing not only robotic general surgery, but also thoracic surgery, vascular surgery, urologic surgery and gynecological surgery. How was he granted these privileges at UIC?
There is no question that he has "very strong personal economic ties" with Intuitive and it is a scandal that UIC allowed that ad to be published. In reality he is the only person performing complex cases at UIC with the DaVinci robot, others do only simple operations, and some of the people in the picture, despite the white coats, are not even physicians.
UIC is a great state University. This episode affects the reputation of the University. It needs to be brought to the attention of the UIC President and local newspapers. And I agree with Dr. Levy, the top admistrator and the top clinician shouls be fired.

Anonymous said...

Not a defense, but an observation...

Physicians have historically been held to a high moral standard, and Dr. Levy is implying that the standard should be applicable to this situation.

American business has always been allowed considerable leeway concerning "truthiness", transparency, duty to the customer (caveat emptor) and responsibility/liability for products and services.

These two philosophical positions are in direct conflict with each other, which is why, up until the last 30 years or so, every society in the world has forbidden the corporate practice of medicine.

American government is now actively seeking to corporatize medicine, and it's a virtual certainty that the people in the photograph are either employed directly by UIC or are contractors dependent upon UIC for their jobs.

Dr. Levy's assertion that someone should be fired is directly oppositional to the business ethics of UIC (or any other business), and is unfair to professionals whose professional lives are put at risk by the necessities of maintaining "at will" employment by the hospital.

If you're going to be soft on the people but hard on the problem, let's make sure we address the root cause of the problem - the corporatization of American medicine.

Paul Levy said...

I'm not a doctor.

Anonymous said...

Dear anon 7:16;

I do not know the 'rules' regarding international specialists who come to this country to practice; there may be some sort of exception for those of a certain stature/qualifications. If one believes what is on Google regarding this surgeon, he is a general surgeon with fellowships in thoracic/vascular and digestive surgery, which would cover some of the surgeries you allege. However - urologic and gynecological?? That would be a pretty serious violation of scope of privileges; I hope your information is accurate. Perhaps he is deemed a 'surgical consultant' for the robot to the appropriately privileged urologist or ob-gyn who is the primary surgeon on the case. I certainly hope so, else the hospital really does have a problem on its hands.

nonlocal MD

Anonymous said...

People like Dr. Giulianotti and UIC have ridiculed the American College of Surgeons, the American Board of Surgery and the American educational system in general. In the United States to be a general surgeon requires 4 years of college, 4 years of medical school and at least 5 years of residency. In addition, to become a Fellow of the American College of Surgeons it is required to pass a written and an oral exam. How can somebody with very limited credential and uncertain qualities come form abroad as an expert? This betrays the trust of our American patients who do not have the proper information about the background of the so called "expert".
The practice of the different types of procedures performed robotically, form urology to gynecology, form vascular to thoracic surgery, is unethical. These procedures are usually performed by specialists who have completed dedicated training and passed the appropriate qualifying exams. This is fraud, and considering that many of the UIC patients have either Medicaid or Medicare, it constitutes a Federal offense. This should be investigated accordingly by the Federal Bureau of Investigation.

Anonymous said...

Of Course it is well known that Giulianotti is owned by Intuitive, at least here in Chicago. What is missing in this entire list of comments relates to the COST of using the robot. UIC draws a huge percentage of patients who are uninsured or covered by medicaid. How can UIC justify the expense of using a robot to lose money on most of their cases? Patients get sucked into the "technology" but is there ANY study showing better results with a robot? Their only references compare the robotic procedure to an open procedure. WHAT???? How many open chole's occur today? Not many. So what benefit is a robotic chole over a lap chole? I am so sick of the hypocracy used in the hospital board room. We need a mountain of basic surgical instrumentation but go years without, so we can add another one of these weights that suck the profit out of the OR...all to have a billboard on the freeway. Can someone make sense of this for me?

Anonymous said...

There's more to this story. All of the senior surgeons in the University of Illinois at Chicago department of general surgery depicted in the photo are Italian born immigrants. This is an example of flagrant nepotism and unfair hiring practices as well.

Paul Levy said...

I don't think it is fair to draw that kind of conclusion.

Anonymous said...

As an American educated physician who is Board certified and employed by UIC, I am also disgusted by the robotic program at UIC. There is so much more to this story... There is a loop-hole in the licensing requirements at the State level that allow foreign trained physicians to have full privledges at academic institutions like UIC without undergoing the same training & certification as American graduates. I defy the University administration to reveal the financial losses associated with this program!