NSHEN has developed this educational resource called Featured Articles. We will be choosing articles from recent health ethics  literature that we think will be of interest to ethics committee members as well as others working in our health care system.

We will create a summary of each article we feature for those too busy to read it in its entirety.

New Summary

Industry Technicians Embedded in Clinical teams: Impacts on Medical Knowledge

by Howard, M. and K Hutchinson (2022) Industry Technicians Embedded in Clinical teams: Impacts on Medical Knowledge. The Hastings center Report; 52 (2):41-48.

Short summary

In this article, Howard and Hutchinson discuss the ethical issues associated with industry technicians, also referred to as ‘industry employed allied professionals’ (IEAP), working as part of a medical team in the hospital setting. Dialogical practice, where all members of the health care team work together towards a common goal, is essential for clinical communities, as it is a way of sharing knowledge and identifying gaps in that knowledge that are relevant to patient care. The authors argue that by mediating expertise about medical devices on behalf of the manufacturer while also working as part of the health care team, IEAPs potentially limit opportunities for independent learning and for dialogical education practices. In keeping with their role, IEAPs are protecting the commercial interests of the medical device manufacturer, and true knowledge exchange is therefore limited. This may negatively affect clinical knowledge and patient outcomes.

Introduction

Advances in development of implantable medical devices, increases the dependence on IEAPs to provide service, support and training to health care team members. Embedding IEAPs in the clinical team as non-physician members of the team is associated with conflict of interest. In this paper, Howard and Hutchinson demonstrate how the claim that IEAPs disrupt medical knowledge is based on epistemology. They describe how the reliance on IEAPs to provide service, support and training can negatively impact or even undermine the norms of clinical knowledge sharing.

 Key discussion points

 Clinical knowledge and epistemic communities

Clinical learning and knowledge derive from physicians and/or interdisciplinary health care teams working together toward shared understanding of diagnoses or shared decisions around treatment. As such, the clinical knowledge system relies on collaboration between members of the clinical community communicating and sharing their expertise in a transparent and open manner. The knowledge sharing may be disrupted if some of the members within the clinical community attain unwarranted epistemic privilege. Medical device manufacturers have commercial interest in protecting knowledge about their products, and IEAPs are essentially functioning as a gatekeeper for medical teams or health care professionals to access this knowledge. The paper argues that this way of controlling knowledge for commercial benefits is an example how IEAPs exploit clinical hierarchies.

  •  Impact of IEAPs on Clinical Epistemic Communities

The technological complexity of some implantable medical devices increases the demand for IEAPs in hospitals. Moreover, IEAPs are often relied on to alleviate the clinical knowledge gap created by rapid technological advances. This means that the IEAPs may have more knowledge about a medical device than the surgeon who is using it. The role of IEAPs can vary depending on the situation, and can include primarily sales-oriented activities, training in use of devices, proctors to train others, support to use equipment and/or provision of technical support. In these roles the medical device manufacturers and IEAP are in a position of power to practice knowledge management, for example by controlling training resources, technical information, and the like. Physicians may be entirely dependent on IEAPs to gain knowledge and expertise with new equipment if no independent training option or knowledge source about new devices is available. The paper notes that many members of the health care community underestimate the impact the presence of IEAPs has on decision-making, which is a problem. It  argues that more attention should be paid to the fact that decisions around purchasing and use of medical devices are often made without adequate independence from those who stand to profit from their use.

  • Industry Employees, the Knowledge Economy, and Clinical Knowledge

IEAPs are often the  to knowledge about whether, when and how to use specific medical devices. This is for example often the case with implantable medical devices. The authors argue that industry-based training and education provided by IEAPs contribute to shaping epistemic communities in the clinic, and that this is a concern because they may provide suboptimal training. The knowledge offered by IEAPs is specific to the medical device/devices produced by the company they work for. Irrespective of the IEAP’s good intentions, it is a fact that the knowledge that the IEAP has is provided by the company, and that this knowledge is generated for the sake of profiting from the product.  IEAPs are therefore not able to provide comparable knowledge around medical devices produced by competing companies.

  • Competing Norms of Exchange in the Clinic

Influence on knowledge production and sharing is not limited to individual clinics. Knowledge exchange is also affected at a broader system level, as hospitals engage with IEAPs in purchasing practices. The authors flag the importance of paying attention to how medical device companies interact with health care institutions and use knowledge management procedures at this level. Norms of knowledge exchange in public institutions and/or clinics are fundamentally different from those of the medical device industry. The former is founded on knowledge sharing, whereas the latter builds on commercial interest. That means that for IEAPs ,patient needs in hospitals are secondary to industrial profit, and may in some cases be overridden by the IEAPs’ primary goal. Howard and Hutchinson flag the importance of paying attention to the difference in interests and highlight that the IEAPs’ advice first and foremost is provided to service commercial interests. IEAPs’ knowledge and advice is product specific, which limits the IEAPs ability to provide advice around which device would be best for a specific type of surgery or in a specific patient case. Moreover, it may skew recommendations in situations where the medical team is seeking advice around whether to proceed with a device-based versus a non-device-based intervention.

Conclusion

The authors conclude that IEAPs placement on medical teams contribute to undermine the norms of clinical knowledge sharing.

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