Seeking balance, not purity, in medicine and drug development

Medical equipment by Dikiiy / Shutterstock.com

As convenient as it may be to imagine medicine or medical product research as fundamentally driven by either altruism or greed, most participants I know seem to be motivated by a complicated mixture of the two, which can result in great achievement yet also create unusual challenges.

Medicine

Most doctors, I believe, feel deeply committed to providing the very best care for their patients, and explicitly do not see themselves as out to maximize profit (otherwise, as they like to say, they'd have gone to business school).  Yet... med students tend to be drawn to the most lucrative specialties and subspecialties, while practicing physicians often (some would say reliably) behave in ways that tend to increase their income.

Cheery as it might be to imagine that the absorption of solo or small fee-for-service practices into larger health systems (where physicians are salaried) will lead to a change in profit-oriented-behavior, I suspect that unless the approach to reimbursement changes fundamentally, as Dave Chase describes, rather than cosmetically, as many others fear, there will be continued efforts - at the care-system level - to maximize activity-based compensation.   And even if we do evolve to a true value-based approach to reimbursement, many providers and hospital executives will continuously strive to game the system.

I've heard a number of senior hospital officials describe their care network as essentially a huge funnel for the revenue-generating specialists; similarly, it's disappointing but hardly surprising that hospital systems such as Cedars Sinai cut back on services such as psychiatry (Disclosure: one of my brothers used to work there) perceived to contribute little if anything to the bottom line, while continuing to erect shiny new buildings focused on highly profitable proceduralists.

The challenge experienced by many physicians is simultaneously sustaining two very different belief systems - a commitment to putting patients first, which I know most truly believe, and a reflexive response to economic self-interest, which is how an objective observer might describe much of their actual behavior.

Medical Products

Many similar issues arise in the development of medical products, where participants are motivated by both a passion to change the world and a desire to be paid for doing so.  In my view, the opportunity to make money from medical innovation drives progress far more powerfully than if the profit motive wasn't present.

If you have a disease, I suspect you are much more likely to see it cured if someone thinks they can make money by doing it. Moreover, if you want to actually see an idea translated into a real-world medical product solution, this almost inevitably is going to happen in industry, as many academic scientists ultimately discover - see this (admittedly gauzy) profile of former Yale professor Ira Mellman, now VP of Research Oncology at Genentech.

The co-existence of contrasting motivations is occasionally difficult, as I was reminded yesterday in a valuable but uncomfortable twitter exchange with noted industry columnist Adam Feuerstein, of TheStreet.com.

In anticipation of an upcoming announcement regarding the success of a clinical study that Celgene conducted in patients with pancreatic cancer, Feuerstein tweeted to his 34,000+ followers, "Let's hear your guesses for $CELG Abraxane survival benefit. Data at 6 pm ET. What say you?"

Having lost an uncle to this terrible disease (see here and here), I asked Feuerstein whether it seemed vulgar to make a game out of the survival of cancer patients.  He responded, "No. When are you going to understand that I write about biotech stocks and investing? Get w/ the program."

But surely, I pressed, it should be possible to write informatively about the industry (as he does) and still not treat cancer survival "as a parlor game."  His response, "You'd be wrong."

Here (obviously) is where I struggle.

On the one hand, I think it's terrific that investors care about drugs for terrible diseases such as pancreatic cancer, and it's a great thing that innovators who develop meaningful treatments for pancreatic cancer stand to reap significant financial rewards.  I am glad to see such alignment of incentives, and believe it's in the best interest of patients.

I also realize that most investors in Celgene (the company in Adam Feuerstein's example) are looking for returns, exactly the same way they would if they invested in Coca-Cola or Walmart, and that success is measured by clinical trial results.

At the same time, I fundamentally can't get comfortable with viewing a clinical trial of a drug for pancreatic cancer like a sporting event, or like a scene in Trading Places where investors place bets on the future price of coffee, wheat, or pork bellies ("which is used to make bacon, which you might find in a ‘bacon and lettuce and tomato' sandwich").

I also struggle, in a slightly different way, when I think about the reformulation plays that are so popular right now in the industry (e.g. liquid Ritalin, inhaled dihydroergotamine; you might even include colchicine in this category).  I suspect a remarkable amount of current activity within the industry is focused on this sort of reformulation work, for a simple reason: you take a ton of risk off the table, and it can be a great business decision.  According to Bijan Salehizadeh via twitter, the VC backers of MAP Pharmaceuticals (who created the reformulated dihyroergotamine), just acquired by Allergan, did very well - despite the fact that the underlying drug was originally approved, according to Bruce Booth (also via twitter), in 1946.

I also agree that reformulated products may provide substantial benefit to patients (certainly more than some critics contend), and can lead to improved adherence, and the possibility of better outcomes.

The question here is how would you feel being a member of a team developing one of these products?  My guess is very different than the feeling experienced by members of the Novartis team that developed Gleevec, or the Vertex team responsible for Kalydeco.

On the other hand, new mechanisms are notoriously risky; members of the team responsible for liquid ritalin presumably at least enjoy the satisfaction of getting a drug on the market, an experience most teams targeting new oncology mechanisms will never share.  It's not surprising that (surviving) life science investors often look so favorably on new formulation opportunities.

Closing Thoughts

At the end of the day, I suppose everyone in medicine and in medical product development - and I assume in most other disciplines as well - must find a way to balance and come to terms with the many conflicting influences that in total serve to catalyze constructive innovation for society, but which can feel disorienting at the level of the individual.

Our professional success and personal happiness is presumably determined by the extent to which we are able to identify a point of equilibrium - and by how much we enjoy the journey.

 

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About the Author

 

David
Shaywitz
  • Dr. Shaywitz trained in internal medicine and endocrinology at MGH, and conducted his post-doctoral research in the Melton lab at Harvard. He gained experience in early clinical drug development in the Department of Experimental Medicine at Merck, then joined the Boston Consulting Group’s Healthcare and Corporate Development practices, where he focused on strategy and organizational design. He is currently Director of Strategic and Commercial Planning at Theravance, a publicly-held drug development company in South San Francisco. He recently wrote Tech Tonics: Can Passionate Entreprenuers Heal Healthcare With Technology? 

  • Email: davidshaywitz.aei@gmail.com

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