When a cancer center is not one

I don't know who the author of this blog is, but s/he has a thoughtful view of the "business plans" that seem to characterize a lot of cancer centers being set up by hospitals across the country.  It's called, "Your cancer center is just a box."  Here's the excerpt:

I had the opportunity to discuss the idea for a new cancer center with a healthcare system. The team consisted of the CFO and COO, a couple of the medical directors, several VP’s from service lines, and the marketing team.

Everyone had their list of all the inputs that they feel needs to be a part of the new cancer center. The technology, the specialists, the types of treatments. They even had a preliminary design that they had worked through with an expert architecture firm.

My honest opinion is that I have NOT seen anything in this presentation that shows you understand how families, businesses, patients, and consumers of cancer services want to use your “stuff.”

The room went silent. I could tell I hit a nerve. I told them that what they have is very manageable, but it isn’t anything special. It’s a box. It has a bunch of things in it. Yet it is still a box. I don’t do boxes.

The beauty comes when you know why people walk through your front door. . . . It comes in having an intimacy in understanding how they think, feel, react, and what they expect from your services. It comes in anticipating their needs before it even comes up and delivering the content in a manner that is easy, simple, and available.

If that is what you want, then I suggest you scrap what you think you know, and begin with the people that matter the most, those that live in your community.

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Robotic surgery: The Sequel?

The first time was such a hit, why not do it again?  I refer, of course, to the marketing ploy used by Intuitive Surgical, Inc. when it introduced robotic surgery in the prostatectomy scene.  Go with direct-to-consumer advertising to give the impression that the results from robotic surgery are better than from manual laparoscopic surgery.  Make sure the early-adopter surgeons are on board and publicly proclaiming their great results.  When it comes to men and the functioning of their penises, you can predict the result.  Who can argue with that kind of success?  The stock market rewarded the company handsomely.

But now the market for prostate surgery is saturated, so it's time to move to another type of surgery that raises anxiety, this one for women.  Hysterectomies are the target.  Again, let's use the heartfelt comments of patients to support the cause, while being soft on scientifically valid clinical studies.

Further, give the impression that there is extensive use of the machine for hysterectomies by saying, "100% of the top 50 cancer hospitals in the United States use the da Vinci Surgical system."  While true, this statement omits what I surmise to be the actual case, that the vast majority of those machines are used for prostate surgery, not for hysterectomies.

Here, though, the professionals have spoken, and the words are not good for the company.  Look at these comments by James T. Breeden, president of ACOG:

Many women today are hearing about the claimed advantages of robotic surgery for hysterectomy, thanks to widespread marketing and advertising. Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.

At a time when there is a demand for more fiscal responsibility and transparency in health care, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes. 

At a price of more than $1.7 million per robot, $125,000 in annual maintenance costs, and up to $2,000 per surgery for the cost of single-use instruments, robotic surgery is the most expensive approach. . . . A study of over 264,000 hysterectomy patients in 441 hospitals also found that robotics added an average of $2,000 per procedure without any demonstrable benefit.  

Aggressive direct-to-consumer marketing of the latest medical technologies may mislead the public into believing that they are the best choice. Our patients deserve and need factual information about all of their treatment options, including costs, so that they can make truly informed health care decisions. Patients should be advised that robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated.

Who will prevail in the court of public opinion, the company or the professionals?  In light of the dearth of coverage of this issue by the medical press, I would ordinarily put my money on Intuitive. On the other hand, some Wall Street analysts now seem less sanguine. Suraj Kalia at Northland Capital Markets noted yesterday:

Intuitive now has to engage in lengthier discussions on price negotiations, both on capital sales & instruments. This is a shift over the last 6 - 9 months. Capital sales continue to be tough, and it is unclear to us what turns this tide around.

It seems some hospitals are asking for discounts (10% and more) on instruments and a global risk sharing program. Part of this discussion is compounded by an unused capacity of about 30% or so in U.S. hospitals. 

More importantly, it seems hospitals are asking Intuitive Surgical to be a "partner" in their robotic surgery practices, rather than engage in aggressive marketing & pricing. Some hospitals, as was explained to us, have asked Intuitive to help in "rationalizing" procedures in order to "optimize" outcomes. Optimizing outcomes would have the benefit of making robotic surgery look cost-effective and clinically better, albeit at the expense of "weeding" out extra procedures giving the industry a bad rap.

Lowering prices in order to meet quotas results in margins being squeezed. Don't lower prices and you have a situation where hospitals perforce have to cut back on procedures or capital sales in order to justify economic viability.

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Huddling in New York City

It's National Patient Safety Week, and I was honored to be invited to Metropolitan Hospital Center in New York City to give a talk on clinical process improvement.  Before that, I had a chance to visit parts of the hospital to see some of their initiatives. 

Led by Chief of Service Gregory Almond, the Emergency Department has been looking at many of their processes.  One of the simplest and most effective steps was a decision to conduct huddles, not just once per day, but every two hours.  These might last only two or three minutes, but everyone is involved, including the security folks as well as clinicians.  Problems are identified, assignments are given, and follow-ups occur regularly.  The whole process is documented on a white board in real time, providing a visual cue to everyone on the floor as they walk by.

You see some of the protagonists above, including Irene Quinones, Patient Safety Associate; Jean-Paul Menoscal, Associate Chief of Service for Emergency Medicine; and Samrina Kahlon, the hospital's Patient Safety Officer.  (I'm pleased to report, too, that Samrina is an alumna of the 2012 Telluride Patient Safety Camp!  It's great to see her progress to such a position of responsiblility in a hospital.)

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My kind of town, Chicago is.

For those of us in the rest of the country, Chicago has always set a certain standard when it comes to conflicts of interest, and why should health care there be any different?  You've been reading about such concerns at the University of Illinois.  Now, check out this recent story by Kristen Schorsch and Andrew Wang at Crain's Chicago Business.  Does this meet the smell test in your view?  An excerpt:

For at least 15 years, Cook County Circuit Court Judge Lynn Egan has sat on the boards governing a south suburban hospital while it regularly has hired her brother's law firm. 

Chicago-based Pretzel & Stouffer has represented Palos Community Hospital in almost half of the 170 cases involving the hospital filed over that period in the law division of the circuit court, according to a Crain's review of court records. From 2011 to 2013, Matthew Egan, a partner in the firm, represented Palos in at least 15 cases before his sister's judicial colleagues, most of them involving medical malpractice or personal injury.

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Lessons from the Aga Khan in Canada

One of the world's great leaders is not the head of a national government. He is the leader of a religious faith.  The Aga Khan is the spiritual head of the Ismaili Muslims, a Shia sect reaching back to the days of the Prophet Mohamed.  In this role, and through the Aga Khan Development Network (AKDN), he has addressed issues of the elimination of poverty, access to education, and social peace in a pluralist environment.  He was recently recognized for this and other accomplishments by being invited to address the Canadian Parliament.

The speech is a remarkable exposition of the potential power of pluralism in a deeply disturbed world.  It also helps us non-Muslims understand a bit more about the history and divisions and commonalities in this faith, something seldom covered in the mainstream media.  It is on this latter topic that I present some excerpts, as I found it a fascinating and helpful discussion for my understanding of the world:

First then, a few personal words. I was born into a Muslim family, linked by heredity to the Prophet Muhammad (may peace be upon him and his family). My education blended Islamic and Western traditions, and I was studying at Harvard . . . when I became the 49th hereditary Imam of the Shia Imami Ismaili Muslims.

The Ismaili Imamat is a supra-national entity, representing the succession of Imams since the time of the Prophet. But let me clarify something more about the history of that role, in both the Sunni and Shia interpretations of the Muslim faith.

The Sunni position is that the Prophet nominated no successor, and that spiritual-moral authority belongs to those who are learned in matters of religious law. As a result, there are many Sunni imams in a given time and place. But others believed that the Prophet had designated his cousin and son-in-law, Ali, as his successor. From that early division, a host of further distinctions grew up — but the question of rightful leadership remains central. In time, the Shia were also sub-divided over this question, so that today the Ismailis are the only Shia community who, throughout history, have been led by a living, hereditary Imam in direct descent from the Prophet.

The role of the Ismaili Imam is a spiritual one; his authority is that of religious interpretation. It is not a political role. I do not govern any land. At the same time, Islam believes fundamentally that the spiritual and material worlds are inextricably connected. Faith does not remove Muslims — or their Imams — from daily, practical matters in family life, in business, in community affairs.

Faith, rather, is a force that should deepen our concern for our worldly habitat, for embracing its challenges, and for improving the quality of human life.

---

Our work has always been people-driven. It grows out of the age-old Islamic ethic, committed to goals with universal relevance: the elimination of poverty, access to education, and social peace in a pluralist environment. The AKDN’s fundamental objective is to improve the quality of human life.

Amongst the great common denominators of the human race is a shared aspiration, a common hope, for a better quality of life. I was struck a few years ago to read about a UNDP survey of 18 South American states where the majority of the people were less interested in their forms of government, than in the quality of their lives. Even autocratic governments that improved their quality of life would be more acceptable for most of those polled than ineffective democratic governments.

But the sad fact behind so much instability in our world today is that governments are seen to be inadequate to these challenges.

--

Against this background, let me move on to the broad international sphere, including the role of relations between the countries and cultures of Islam — what we call the Ummah — and non-Islamic societies. It is central to the shape of global affairs in our time.

I would begin by emphasising a central point about the Ummah often unseen elsewhere: the fundamental fact of its immense diversity. Muslim demography has expanded dramatically in recent years, and Muslims today have highly differing views on many questions.

Essential among them is that they do not share some common, overarching impression of the West. It has become commonplace for some to talk about an inevitable clash of the industrial West and Islamic civilizations. But Muslims don’t see things in this way. Those whose words and deeds feed into that point of view are a small and extreme minority. For most of us, it is simply not true. We find singularly little in our theological interpretations that would clash with the other Abrahamic faiths — with Christianity and Judaism. Indeed, there is much that is in profound harmony.

When the clashes of modern times have come, they have most often grown out of particular political circumstances, the twists and turns of power relationships and economic ambitions, rather than deep theological divides. Yet sadly, what is highly abnormal in the Islamic world gets mistaken for what is normal. Of course, media perceptions of our world in recent years have often been conveyed through a lens of war. But that is all the more reason to shape global conversation in a more informed direction.

The complexity of the Ummah has a long history. Some of the most glorious chapters in Islamic history were purposefully built on the principle of inclusiveness — it was a matter of state policy to pursue excellence through pluralism.

This was true from the time of the Abbasids in Baghdad and the Fatimids in Cairo over 1,000 years ago. It was true in Afghanistan and Timbuktu in Mali, and later with the Safavids in Iran, the Mughals in India, the Uzbeks in Bukhara, and Ottomans in Turkey. From the 8th to the 16th century, al-Andalus thrived on the Iberian Peninsula — under Muslim aegis — but also deeply welcoming to Christian and Jewish peoples.

Today, these Islamic traditions have been obscured in many places, from Muslims and non-Muslims alike.

Perhaps the most important area of incomprehension, outside the Ummah, is the conflict between Sunni and Shia interpretations of Islam and the consequences for the Sunni and Shia peoples.
This powerful tension is sometimes even more profound than conflicts between Muslims and other faiths. It has increased massively in scope and intensity recently, and has been further exacerbated by external interventions. In Pakistan and Malaysia, in Iraq and Syria, in Lebanon and Bahrain, in Yemen and Somalia and Afghanistan it is becoming a disaster.

It is important, therefore, for non-Muslims who are dealing with the Ummah to communicate with both Sunni and Shia voices. To be oblivious to this reality would be like ignoring over many centuries that there were differences between Catholics and Protestants, or trying to resolve the civil war in Northern Ireland without engaging both Christian communities.

What would have been the consequences if the Protestant-Catholic struggle in Ireland had spread throughout the Christian world, as is happening today between Shia and Sunni Muslims in more than nine countries? It is of the highest priority that these dangerous trends be well understood and resisted, and that the fundamental legitimacy of pluralistic outlooks be honoured in all aspects of our lives together — including matters of faith.

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In memoriam: Robert C. Moellering, Jr.

This announcement arrived from Harvard Medical School:

Dr. Robert C. Moellering, the HMS Shields Warren-Mallinckrodt Professor of Medical Research and a renowned infectious disease researcher, was physician-in-chief and chair of the Department of Medicine at Beth Israel Deaconess Medical Center from 1981 to 2005. He died on Feb. 24, 2014, at the age of 77.

Dr. Moellering made major advances in the investigation, treatment and prevention of infectious diseases, in particular studying the mechanisms of antibiotic action and bacterial resistance to antimicrobial agents. His work led to the development of laboratory tests that are now used worldwide. He was also the first to show the clinical effectiveness of penicillin-gentamicin combination therapy for enterococcal endocarditis, now the standard of care for this infection.

A dedicated teacher, researcher and clinician who trained generations of clinicians and academic physicians, Dr. Moellering’s career spanned more than four decades at HMS.

All true, but I'd like to add some more.

When I arrived as CEO of BIDMC in 2002, there was a lot of turmoil, but at the center of things stood a person of great integrity, calmness, and kindness.  He was not only Chief of Medicine, but he was also head of the faculty practice plan.  He had been Chief at New England Deaconess and was one of a very view "Deac" people to be asked to serve in a senior capacity in the newly merged hospital.  The reason for this was clear: Few people were as highly respected on "both sides of the aisle" as Bob.

I enjoyed working with him.  He was honest and clear, and his commitment to clinical care, research, and teaching were unmistakable.  Although he was in a leadership position, that position was not important to his self-image.  In an academic environment known for ego, he was remarkably unegotistical.  Perhaps that is why is was such a good teacher.  I remember attending a grand rounds session he taught about MRSA one day: In 45 minutes I learned more about the subject than I imagined possible. The talk was lucid, well organized, approachable regardless of your level of knowledge, and full of good humor and modesty about what was understood and what was still unknown.  That is was a substantive tour de force was no surprise given Bob's expertise. That it was a pedagogical tour de force was something else still.  I talked about it for days afterward.

As told on another blog:

I wanted to share two quotes from Dr. Moellering and a final one from Dr. Jerome Groopman delivered on the occasion of Dr. Moellering stepping down as Chair of Medicine.

“I served for the better part of 24 years as chairman of the department and also ran the faculty practice plan here. But I view administration as nothing more than a means to an end--a means to create more effective clinical and teaching programs in the department, and a way to ensure that I could have an impact on the training of physicians and the internal medicine house staff.”

“Teaching is the most important thing we do. Imparting knowledge to the next generation of physicians is incredibly important. It’s a privilege we are given in the academic setting. Not only does it give you a tremendous sense of satisfaction in that you’ve done something worthwhile, but it gives you some immediate gratification because you can watch students who go on to successful careers.”

Dr. Jerome Groopman: "How many of us has he supported on his shoulders? How many of us has he helped to move forward when we felt we didn't have the energy or endurance to continue? Those shoulders have carried enormous burdens, carried with a quiet confidence, through all the difficult times, the growth of the department, the merger…. Bob is loved because beyond his intellect, beyond his knowledge, beyond his hard work, he is filled with a unique form of kindness. Bob has true generosity of spirit. He sees your success as his success. This is his legacy."

At that same stepping-down party in June of 2005, Bob quoted a poem, and I asked if he would mind sending it to me.  He did, and I have saved the letter all these years:

Dear Paul:

The poem I quoted last Thursday evening was entitled "Ithaca," and was written by Constantine Cavafy.

"Hope the way is long.
May there be many summer mornings when,
With what pleasure, with what joy,
You shall enter first-seen harbors...

Keep Ithaca always in your mind.
Arriving there is what has been ordained for you.
But do not hurry the journey at all.
Better if it lasts many years;
And you dock an old man on the island,
Rich with all you’ve gained on the way,
Not expecting Ithaca to give you wealth.

Ithaca gave you the beautiful journey.
Without her you would not have set out.
She has nothing more to give you."

Bob entered many first-seen harbors, and some of us were lucky to travel with him for a portion of the voyage.

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A matter of public trust

Several weeks ago, I raised the issue of whether it was appropriate for the Dean of the College of Medicine at the University of Illinois to be on the Board of Novartis, a major biomedical corporation. My concern was quickly slapped down by a University spokesperson, who said, in part:

The University of Illinois views Dean Azar’s service on the Board of Director of Novartis as appropriate, given that the conflict of interest and commitment is well-managed. The UIC leadership and Dean Azar have commendable records of integrity and in dealing with conflict of interest issues associated with external activities."

I wonder if the University did any research into this matter before giving this response.  I'm going to present some of my own research, derived solely from public sources.  In so doing, please understand that I in no way seek to denigrate the exceptional scientific and clinic record of the Dean.  I merely seek to present facts and context that, in my mind, again raise the issue of governance and propriety--both for the University and for a company that has itself faced questions of ethics and governance:  How can this person exercise a proper duty of care and loyalty to both institutions, not only in terms of time commitment, but also in terms of the overlapping scientific research and clinical interests of the two organizations?  I raise this issue not to accuse anyone of misbehavior, or engaging in conflicts of interest that result in personal gain, but as a matter of public trust.

As noted by Joan Miller, Chief and Chair of Ophthalmology at Massachusetts Eye and Ear Infirmary:

As we try to sort through COI and the relationship between industry and academe, we want to do what is in the best interest of our patients and the public good. We want to maintain the positive advantages of collaboration and philanthropy, especially in educational grants and research, while holding ourselves free from possible bias. We must treasure and ensure the public’s trust. No one can do it better than we can. 

The Novartis business plan

How did Dmitri Azar end up on the Board of Novartis?

In April 2011, Novartis announced its acquisition of Alcon for $51.6 billion:

“With Alcon, we will add eye care as a fifth growth platform alongside innovative pharmaceuticals, generics, vaccines and diagnostics, and consumer health,” said Dr. Daniel Vasella, Chairman of Novartis. “The strong Novartis presence around the world, including in emerging markets, will open new growth prospects for the combined businesses. Novartis and Alcon can be expected to profit from the combination of complementary research and development activities and ultimately benefit patients suffering from eye diseases worldwide.”

“The new Alcon Division will cover more than 70 percent of the eye care segment with more than USD 9 billion in annual revenue,” said Joseph Jimenez, CEO of Novartis.

Less than a year later, in February 2012, Dr. Azar was elected to the Board.  Clearly his credentials in the field could not be questioned and would be of value to the company as it pursued its new line of business:

Dr. Azar, a US citizen, is Dean of the College of Medicine and Professor of Ophthalmology, Bioengineering, and Pharmacology of the University of Illinois at Chicago, USA. He holds a medical degree from the American University of Beirut, Lebanon, an Honorary MA from Harvard University and an Executive MBA from the University of Chicago, Booth School of Business. Dr. Azar is an internationally recognized ophthalmic surgeon and prolific researcher. He has been named one of The Best Doctors in America and one of the Castle Connolly Top Doctors in America annually since 1994. He holds multiple committee positions with the American Academy of Ophthalmology, is a member of the American Ophthalmological Association, and sits on the Board of Trustees of the Chicago Ophthalmological Society and the Association of Research in Vision and Ophthalmology. He has received multiple leadership awards, including the 2009 Lans Distinguished Award from the International Society of Refractive Surgery.

Dr. Azar was well known at Alcon.  After joining the faculty at the University in 2006 as Head of the Department of Ophthalmology & Visual Sciences, he received, in 2007, an Alcon Research Institute award, "represent[ing] a unique example of industry support by identifying exceptional ophthalmic scientists and awarding each with $100,000 unrestricted grants to further their research endeavors."

The relationship grew. In the Illinois Statement of Economic Interests submissions dated 2008, 2009, 2010, 2011, 2012, and 2013, he reported receiving over $5000 for each of the previous years as a consultant to the company as well as getting honoraria in excess of $500.

University purchases of Novartis equipment and supplies

And the relationship has grown in both directions.  Three phacoemulsification machines (for cataract surgery) were purchased from Alcon.  I do not have information about the timing of this purchase decision. If it occurred during his tenure, did Dr. Azar recuse himself from this issue, given his relationship with Alcon? There are competing companies for this type of equipment.  Was the original purchase of equipment a sole source purchase, or were competitive proposals received?  I note that University purchases from around this time were criticized in a report from the State Auditor General--"The University did not review and approve sole source justification forms as required by University Policy."--but it is not clear whether that criticism was directed at this specific purchase.

This kind of decision regarding capital equipment has long-term financial ramifications.  After purchasing the three phacoemulsification machines from Alcon, the University was locked into buying the supplies for these machines from the same company.  For example, in 2009, it entered into a sole source purchase for such supplies.

Purchase of intraocular lens implants, probes, drapes, crescent knives and retractors for Alcon Phaco machines for the period of July 1, 2009 through June 30, 2011. 

Cost:  $1.1 million

This purchase is a sole source because the items are patented and compatible with existing equipment from the only manufacturer. Currently the Hospital owns three Alcon Phaco machines that are used to soften, shatter and remove cataracts. Alcon equipment is a standard in the industry for removal of cataracts in cataract surgery. The supplies are required for the operations of these machines. 

Likewise, in 2013, the University entered into a similar sole source purchase:

The University awarded a contract for PHACO System Packs to Alcon Laboratories, Fort Worth, TX, for an estimated $2,925,000.

Purchase from Alcon Labs their Infinity and Constellation PHACO system packs for the 3 Alcon Phaco machines (a Phaco Machine is a ultrasonic device used to soften, shatted and remove cataracts) currently used in the Hospital Operating Room.

The University has determined that this purchase is only economically available from this source because the item or service is copyrighted or patented and is not available except from the holder of the copyright or patent. 

The same equipment was purchased for the Millennium Park Eye Center, the site where Dr. Azar sees patients.

Leading edge technology purchases

In 2012, the University acquired a new LenSX laser for cataract surgery from Alcon, among the first in the Midwest.  Did Dr. Azar recuse himself from this issue, given his relationship with Novartis?  The Alcon femtosecond laser is not the only one on the market.  Again, I do not have documentation as to whether the purchase was a sole source procurement, or whether a competitive process was used.  But this article suggests that the former was the case, quoting a member of Dr. Azar's faculty, who (as I discuss below) receives financial support from Alcon:

Another consideration for Dr. de la Cruz in choosing the LenSx Laser was the university's prior experience with Alcon. "The technology fits well in our operating room, because we already have the Infiniti phaco system," Dr. de la Cruz says. "We were confident the company would provide good support and maintenance."

While it is common for academic centers to invest in state-of-the-art technology for research purposes, it is still appropriate to ask if purchase of this machine was a good business choice for the University.  Did such a conversation take place among University officials?  If so, did Dr. Azar recuse himself from the discussion of this issue, given his relationship with Novartis?  Under whose authority did the purchase take place? According to this 2011 article, the cost-effectiveness of this approach is not yet proven:

The final discussion point for FLACS is cost. These laser machines with integrated OCT or Scheimpflug technology will add considerable cost to a currently standard procedure. The final cost -benefit analysis will be more complete once long-term data on the laser systems is available. Because the size of the laser platforms is quite large, many surgery centers may require an extra step of moving a patient from the preoperative laser suite to the operating room. This will also be an extra cost in both time and efficiency.

A Medscape article also found:

Femtosecond laser-assisted cataract surgery (FLACS) represents a potential paradigm shift in cataract surgery, but it is not without controversy. Advocates of the technology herald FLACS as a revolution that promises superior outcomes and an improved safety profile for patients. Conversely, detractors point to the large financial costs involved and claim that similar results are achievable with conventional small-incision phacoemulsification. . . . While in its infancy, FLACS sets out the exciting possibility of a new level of precision in cataract surgery. However, further work in the form of large scale, phase 3 randomised controlled trials are required to demonstrate whether its theoretical benefits are significant in practice and worthy of the necessary huge financial investment and system overhaul. Whether it gains widespread acceptance is likely to be influenced by a complex interplay of scientific and socio-economic factors in years to come. 

Use of this equipment was not covered by Medicare at the time of purchase by the University:

[P]reliminary published research has not been scientifically powerful enough to persuade private insurers or Medicare -- which pays for about 8 of every 10 conventional cataract procedures in the United States -- to compensate providers for the extra cost of using femtosecond lasers in cataract surgery. Practitioners are prohibited from billing Medicare beneficiaries for costs that the federal insurance program will not pay.  

"[But] in truth, you can't add femtosecond surgery [to your practice]," William W. Culbertson, MD, a professor of ophthalmology at Bascom Palmer Eye Institute in Miami, Florida, said. "You would lose money on every procedure." 

Or, as summarized here:

The use of a femtosecond laser during cataract surgery is a new and exciting option but an extremely expensive one. It raises important questions about reimbursement as well as the technology’s potential. 

There have also been concerns raised about training residents and fellows on this equipment.  At the University of Illinous, this became the topic of a research study:

Ophthalmology residents and fellows at the University of Illinois at Chicago performed a retrospective study comparing their experiences performing cataract surgery with and without the femtosecond laser. The 6-month results were reported at the 2013 meeting of the Association for Research in Vision and Ophthalmology.

The researchers concluded that resident surgeons on the initial learning curve for cataract surgery are capable of safely learning standard phacoemulsification techniques along with use of the LenSx Laser system. In addition, the LenSx Laser system appears to allow cataract extraction with less energy, which may result in improved long-term outcomes.

Was Alcon involved in sponsoring this research?  As noted in this February 2014 advertising supplement, Dr. de la Cruz--the lead faculty author for the research project--has received funding from the company (although his 2013 Statement of Economic Interests contains no hint of that.  Perhaps it will be included in the 2014 report.)

Did Dr. Azar recuse himself from any involvement in the decision to conduct the research or any aspects of it, given his relationship with Novartis?

Alcon involvement in University education programs

Beyond these matters, it is well documented and disclosed that Alcon supports continuing medical education programs at the University. Here's one example:

As Joan Miller notes in her comment above, this is not unusual and--properly disclosed--can be of value to all.  That's not the issue at the University of Illinois.  The issue at UIC is whether there is anything about the dual positions held by Dr. Azar that lead to his involvement in the decision to invite or include Alcon--particularly in preference to other ophthalmic equipment suppliers--to be the sponsor of such programs.

Conclusion

I for one believe it would take a superhuman effort on the part of the Dean to recuse himself from every financial analysis, purchase decision, research decision, and educational decision at the University of Illinois that has the potential to involve Novartis or its competitors.  As noted, I am in no way asserting or implying that this superb physician and researcher has improperly benefited or that he has failed to disclose under state law or University policy.  What I am saying is that both institutions require a person to exercise a proper duty of care and loyalty to each of them.  It is inconceivable to me that this is possible in this case, not only in terms of time commitment, but also in terms of the overlapping scientific research and clinical interests of the two organizations.

It is this matter that faces the Trustees of the University of Illinois.  It is this matter of public trust.

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