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The Medical Professionalism Blog

What’s All the Fuss about Conflict of Interest in Medical Care?

A couple of weeks ago, the New York Times published a story entitled I Disclose…Nothing by Elisabeth Rosenthal. The premise of the article dealt with conflicts of interests in several professions, including those in medicine. It got me thinking about whether or not the concept of disclosure can successfully manage conflicts of interest in medicine as much as people expect it to.

The conclusion I came up with, in short, was no.

In health care, disclosure is an attempt to manage conflicts of interest through the transparency of financial arrangements between drug and device companies, and pharmaceuticals and physicians. But disclosures don’t guarantee there won’t be any conflicts of interest in medical care. It simply provides transparency with the hope that exposure will alter undesired behaviors.

With a focus on such transparency as a means to mitigate conflicts of interest, the Physician Payment Sunshine Act (enacted as part of the Affordable Care Act) requires pharmaceutical companies to disclose their financial relationships with physicians. While it might not address conflicts of interest in particular, it could:

  • Bolster the trust of the profession by the public. The public might buy that disclosure is adequate to build trust.
  • Decrease costs of care through the broader use of generic drugs. Providing disclosures may decrease the use of brand-name drugs that have an equivalent generic and have a higher cost with small marginal benefit. This, of course, depends on whether information is provided comparing generic and brand equivalents head-to-head on effectiveness, efficacy and costs. PCORI is designed to do that but I doubt that enough such comparisons will be made to make a significant difference.
  • Decrease distortions in medical decision-making that sub-optimizes effective and efficient health care. The Sunshine Act will not, in my estimation, achieve a decrease in distortions in medical decision-making without a standard of what are acceptable and unacceptable financial relationships.

Instead of focusing on disclosure as a means to an end to conflicts of interest, I would prefer to see renewed efforts to set standards for relationships between the pharmaceutical and the device industries. Other entities such as the Association of American Medical Colleges, the Institute of Medicine and the Council of Medical Specialty Societies have recommended such standards.

In 2004, a committee sponsored by the ABIM Foundation and Institute of Medicine as a Profession, recommended in a 2008 JAMA article that no gifts of pharmaceutical companies to physicians of any size be allowed. It did so based on evidence from neuroscience that determined that gifts of any size influences behavior of physicians. Disclosure will not touch that distortion.

Until definitive lines are drawn in the form of set standards, medicine will still be plagued by conflicts of interest among all parties involved, transparent or not.

What do you think should be the focus of government’s conflict of interest policy?

6 Comments to What’s All the Fuss about Conflict of Interest in Medical Care?

  • February 15, 2012 at 3:53 pm | Permalink

    The government, and academic institutions ought to focus on the most severe conflicts of interest. An example of these appeared in the evidence presented at the abruptly ended Texas TMAP trial.

    The example was of Dr Shon, the Texas director of mental health who was paid by a Janssen, a drug company, to market its products in the guise of his professional role. (See this blog post on Health Care Renewal for further discussion: http://hcrenewal.blogspot.com/2012/02/texas-tmap-trials-as-illustration-of.html)

    Instead, academic institutions tend to focus on much less severe conflicts of interest, and use them to argue that conflicts in general can be easily “managed,” mainly by disclosure.

    The Institute of Medicine report on conflicts of interest defined them as “a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.” The report, and indeed much of the discussion of conflicts of interest in health care assumes that most secondary interests are “-within limits – legitimate and even desirable goals.” For example, an academic physician who also was a basic scientist could be paid by a pharmaceutical company to do a specific assay on samples used in research. In that case, the payments could conceivably create a risk that the academic’s professional judgment in a clinical setting would be unduly favorable to the products of the company. However, the relationship hardly seems intended to cause such a bias. Notions that conflicts of interest are “inevitable” but “manageable” may stem from consideration of conflicts of interest like this.

    However, conflicts of interest deliberately created as perverse incentives may be much more consequential, and as this example shows, perhaps not rare. It appears that Janssen paid Dr Shon not to do some task that was unrelated to how he fulfilled his primary entrusted responsibilities as director of mental health, but in order to influence how he fulfilled them. We have noted previous examples in which corporate marketers consider paid key opinion leaders as sales people (see posts http://hcrenewal.blogspot.com/2008/06/key-opinion-leaders-were-sales-people.html and http://hcrenewal.blogspot.com/2010/10/not-best-and-brightest-drug-marketers.html). Such conflicts are deliberately created so that the recipient of payments uses his or her entrusted responsibilities to serve the vested interests of the payer may be deceptive, as noted above. Furthermore, by being intended to induce changes in how the payee performs his or her primary responsibilities, these conflicts are particularly likely to lead to abuse of these entrusted responsibilities. Given that the Transparency International definition of corruption is abuse of entrusted power for private gain, we need a new and more incisive term to described this variety of conflicts of interest. We also need to consider banning such conflicts entirely.

  • February 23, 2012 at 5:07 pm | Permalink

    Perhaps I did not make myself clear.

    I did not advocate ONLY going after the most egregious violations. I advocated going after them FIRST.

    At the moment, we seem to be very far from banning the sort of egregious conflicts I mentioned above. Instead, what efforts there have been to do more than simply require disclosure of conflicts seem to have mainly focused on the most minor, least egregious conflicts.

    For example, in 2006, we discussed how Stanford banned residents from receiving coffee mugs with a pharmaceutical company logo, but allowed that rule to be enforced by a faculty leader who also was on the board of directors of that pharmaceutical company.

    http://hcrenewal.blogspot.com/2006/09/stanfords-new-conflict-of-interest.html

  • Marc S Frager's Gravatar Marc S Frager
    March 4, 2012 at 12:24 pm | Permalink

    I think it is time for ABIM to show its own professionalism and discuss how its fees for MOC fund this blog and the ABIM foundation. To be truly professional the ABIM should disclose how much it could lower its fees to participate in MOC if funding for the ABIM foundation were reduced or eliminated. This ABIM conflict of interest seems to me to be much more serious than a physician accepting a pen from a pharma rep.

    • admin's Gravatar admin
      March 6, 2012 at 3:17 pm | Permalink

      Dear Dr. Frager,

      Thanks for your comment. The Medical Professionalism Blog is sponsored by the ABIM Foundation, not ABIM. We have shared your comments with ABIM.

  • John Benson's Gravatar John Benson
    March 11, 2012 at 8:39 pm | Permalink

    Daniel, I suggest that a greater long-term yield will come from stringent policies within academic health centers and hospitals, as suggested by the original paper. Isn’t better to “bend the twig” by example to students and residents, let alone faculty? I suspect a survey would disclose that such has been both common and effective since that paper.
    I’d rather see curbing such conflicts as a professional obligation/initiative than a governmental edict/threat.
    John.

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