The unspoken rules of politics and medicine


This Wednesday, many Americans were glued to the coverage of Michael Cohen’s testimony to Congress. The political fallout of this hearing remains to be seen, but there was one part of the testimony I found particularly interesting on its own. 

Many times during the hearing, Cohen said that Trump did not directly tell him to lie, but the way Trump talked to him made it clear that he wanted Cohen to lie. For example:

“In conversations we had during the campaign, at the same time I was actively negotiating in Russia for him, he would look me in the eye and tell me there‚Äôs no business in Russia and then go out and lie to the American people by saying the same thing. In his way, he was telling me to lie.”

What a shrewd way of speaking, I thought. By stating lies as truth over and over, one creates the expectation of others to adopt these lies, without incriminating themselves directly.

Cohen’s anecdote reminded me of the way unethical behavior can occur in our health care system. In many cases, clinicians or administrators are not directly told to commit unethical acts, but they are given information indirectly (or information is strategically omitted) that points them toward a path, making it clear what they are expected to do.

For example, employees at Universal Health Services, America’s largest psychiatric hospital chain, were not told explicitly to lock up patients without their consent. But administrators kept track of employee inpatient conversion rates “as if they were car salesman” and chastised employees when they gave new patients “too much information” about the evaluation process. All of this created the clear expectation for employees that their job was “to get patients,” while UHS officials maintain the position that they only admit patients based on clinical need, not financial considerations. 

Another example is seen in industry funding of clinical trial research. When an investigator is asked to author a paper funded by the pharmaceutical industry, researchers are not explicitly told that they must get a positive result in exchange for authorship. However, being an author on an industry-funded trial can offer many benefits, including research funding and publication in a high-impact journal. In a survey of authors of industry-sponsored trial, 41% reported that funding was a benefit of the project. Although the rule remains unspoken, authors know that if the trial isn’t positive, industry can take their funding for future projects elsewhere. 

Adherence to this tacit rule may affect how we conduct research, even subconsciously. In a recent blog about the ways in which clinical trial data can be manipulated, Dr. Milton Packer ends with these thoughts:

Investigators who engage in misdirection may not actually be consciously trying to mislead people. Amazingly, they are often the ones who are being misled. All too often, investigators are susceptible to self-deception — especially if they do not know the rules of proper analysis and are inclined to find a way to show that the intervention works (even if it does not). 

We have to keep looking at the culture that exists in health care institutions as well as the written rules. Do hospital administrators mention over and over to clinicians the importance of referrals to specialists at the hospital? Are the doctors who perform the highest-reimbursing procedures given the most accolades? Do journals have written rules with strict outcome reporting requirements, but create different expectations through unwritten rules? Whether in politics or in health care, unspoken expectations can create a toxic culture that paves the road to corruption.