Medical Education
Aug 2006
A proposal to accept funding for dermatology residencies by the pharmaceutical and medical device industries has been before the officers and board of directors of the American Academy of Dermatology for possible action for the past two years. A pilot program is already under way [1].
For the purposes of discussion, I will assume that a real shortage of dermatologists exists in the United States. This conclusion is not clear-cut, since as recently as 1994 a projected excess of physicians—particularly specialists—on the order of 165,000 was predicted [2, 3]. At least one study has produced evidence that a shortage of dermatologists now exists [4]. There are concerns that the study may be flawed, but it is in part the basis for the proposal now being presented to the academy.
The funding for residency programs draws upon the resources of individual departments of dermatology and the federal government. The specific formula is derived from Medicare payments to teaching institutions. Federal aid is limited and, hence, so are the number of residency slots that a specialty department can afford.
The perceived shortage of physicians has led medical educators to look beyond the government for additional funding for more residency slots. The question then becomes whether funding of residencies—in dermatology or any specialty—by pharmaceutical and medical device companies presents a conflict of interest. The question should be a matter of concern to residency program directors, dermatologists and all physicians throughout the country.
The ethical practice of medicine in the United States is founded on the following familiar principles: non-maleficence, beneficence, distributive justice and respect for autonomy. Here, I would define respect for autonomy as a physician's responsibility to the individual patient. As a corollary, no third party, whether an employer, a commercial entity or a governmental agency should interfere with the patient-physician relationship, which must remain pure.
In my view, no commercial pharmaceutical or medical device company can be expected to fund any enterprise unless it will reap a benefit from that sponsorship. Whatever safeguards are put into place—such as pooling industry resources so that recipients are not indebted to a single, known funder—are unlikely to overcome the overt or covert influence that the pharmaceutical and medical device industries will exert on the teaching and research activities of any participating department of dermatology that accepts their funds.
I believe that there must be a firewall between industry and dermatology. If the public thinks dermatology is for sale, we will lose the trust of the most important individual in a sacred relationship—the patient.
It seems to me that society should assume the financial burden for the postdoctoral training of physicians. If this means additional allocations of funding by the governmental route or from private sources that do not create a potential conflict of interest, we will all benefit. To put into jeopardy collective trust from the public we serve is a price I do not wish us to have to pay.
No one can serve two masters. Dermatology must reinforce its belief in autonomy as a cornerstone of the ethical practice of medicine.
References
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Crosdale M. Innovative funding opens new residency slots. Am Med News. January 30, 2006. Available at: http://www.ama-assn.org/amednews/2006/01/30/prl20130.htm. Accessed June 15, 2006.
- Weiner JP. Forecasting the effect of health reform on US physicians workforce requirement. Evidence from HMO staffing patterns. JAMA. 1994;272(3):222-230.
- Blumenthal D. New steam from an old cauldron—the physician supply debate. N Engl J Med. 2004;350(17):1780-1787.
- Resneck J Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol. 2004;50(1):50-54.
