To sleep, perchance to dream- ay, there’s the rub.

Lisa Rosenbaum, in a well argued article (NEJM) about financial and industry bias and physicians, recalls:

I would like to say I was just following the guidelines, that I’d read the many trials addressing the optimal approach to reperfusion under these circumstances and was thinking only about the patient. But deep down, I know my assessment may have been clouded by a secondary interest, and it wasn’t stock in the manufacturer of a fibrinolytic agent. Rather, it was sleep — an area where my own best interests were clear. If the patient received fibrinolytics and reperfusion was successful, I could admit him when he arrived and then go to bed; catheterization could wait until the next day. If, instead, he was transferred for PCI, by the time he was reperfused, settled in the coronary care unit, and I had pulled the catheter sheath as required a few hours after the procedure, the night would be over.

Sleep. This rings true to me. Much as I am suspicious of pharma advertising, doctors own motivations may be a bigger problem — and in any case, doctors are downstream of pharma, and therefore in a position to correct any wrong. Large amounts of health care expenditure reflect variations in practice linked — not to sleep, as in this example — but money.