Stop trivializing conflict of interest

“I’m sorry, Doctor, but we can’t have you give that talk; you have a conflict of interest since you’ve been paid to do research on that medicine.”

“Well, Senator, it’s a conflict of interest for a doctor to sell those crutches in his office.”

“It is the opinion of this newspaper that physicians should declare to each patient any ownership interest they might have in a surgery center so that the patient is aware of any conflict of interest.”

And on and on the drums beat, droning incessantly and insistently about the dreaded conflict of interest.

In a world now run by the terminally attention deficited, with multi-tasking and synergy-seeking all the rage, we apparently have one domain in which nothing but the purest, most antiseptic, monastic and single-minded devotion to a single task and goal is acceptable: the provision of health care in America. Think about it … the simple existence of other interests is de facto evidence of some nefarious conflict of interest.

The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this?

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. I bought pens last month for the first time in my professional career (I graduated from med school in 1986). It was weird. Who knew that there was a place called OfficeMax and that this huge store had not one but two aisles of pens to peruse?!I think it was Bics in a Kmart the last time I bought a pen. Somehow this fact means that I have been making decisions for my patients based on all those pens I didn’t buy all these years. There’s only one problem with that: I don’t remember a single thing about even one of those pens.

And yet somehow accepting those pens is a conflict of interest. Seriously.

Why is it that if I somehow get something from someone, big or small, even if I perform some service or even buy something from them, that it’s a conflict of interest if some company or other might make money from what I do for my patient? Why is every peripheral interest that exists around the little silo in which I practice medicine–a space occupied by me, my staff, and my patient–why is that automatically a conflict of interest with some sort of negative connotation? That I must be doing something bad? Why not just another interest? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us?

Listen, I get it. There have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. I’m reviewing a med-mal case right now where the plaintiff had an eye problem which resulted in cataract surgery. The cataract surgeons are not being sued, but I looked over the surgical record and saw that they put an inferior lens implant in this guy’s eye, and I know they did that because they own the surgery center and that lens is dirt cheap. That’s a conflict of interest. But for every surgery center owner like this putz I know 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is that a conflict of interest?

It’s not.

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or the one that left a couple pen lights in the office? Tell me, how and why is this a conflict of interest?

This trivialization of the concept of conflict of interest is actually weakening the protections that we should have against real conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene consulting agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients.

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these conflicts of interest. Who will replace them? Will the ascete cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by specialists who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients?

Here’s my bid: a true conflict of interest is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician. Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. We should stop this silliness; stop trivializing the concept of conflict of interest through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.

We should be allowed to seek a convergence of interests.

Darrell White is an ophthalmologist who blogs at Random Thoughts from a Restless Mind.

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  • http://twitter.com/nerdherd0005 Sherry Christy Loyd

    Very whiney.  No sympathy here.

    • http://twitter.com/nerdherd0005 Sherry Christy Loyd

      Dr. White,

      Let me make a disclosure and offer some very specific feedback to what you have
      written. First, I would like to disclose that I work as a staff member in a
      large hospital system coordinating the COI disclosure process. I’ve also
      worked, previously, as a med mal paralegal.

      It appears
      that you are an ophthalmologist from Ohio, and a business person.  You started your own brand of eye care
      clinics.  Source:  http://www.skyvisioncenters.com/corporate_become.asp
      You have stated you review charts for
      litigation. 

      There are
      lots of things that can qualify as a conflict of interest, that is, a conflict with
      a physician’s duty to his/her patient.  Transparency
      of those conflicts to those persons owed a fiduciary duty should be a minimal
      expectation.

      Conflicts exist
      in everyone’s life.  It isn’t “negative”,
      it just “is”.  How hard is it for a
      surgeon to inform a patient that (s)he is an owner of the surgery center he or
      she will have an *invasion medical procedure* performed upon him or herself,
      where the surgeon will also receive payment for the services rendered at the
      center (in addition to the surgeon’s fees)? 

      Conflicts,
      actual or perceived, need to be mitigated. 
      Mitigation doesn’t always mean you must be 100% removed (recused) from the matters
      at hand.  Management interventions can be
      sufficient.  Of course, if there are truly
      legal issues like anti-kick back, fraud, or Stark matters, a lawyer needs to be in the
      conversation. 

      I’m afraid
      that your arguments (pens, disclosing ownership) just don’t convince me that
      you have taken this matter very seriously. 
      Your situation of the 3 equally efficacious drugs can have a very simple
      answer or answers:  (1) patient choice
      (what is on your formulary?) or (2) rotate prescriptions if they are truly
      equally efficacious.  Even more
      significantly, is there a generic available? 

      Just my opinion.

      Sherry

      • http://twitter.com/DarrellWhite Darrell White

        All wonderful points Sherry, and the disclosures you suggest are more than reasonable if for no other reason than they protect a doc/owner from a patient who for whatever reason feels they should have known about an ownership relationship. You’ve actually helped me make my point, though, by setting a ‘threshold’ of potential conflict that might apply, might reasonably cause a physician to act in his own interests at the expense of a patient (my implant example applies, no?). You are arguing that there is moral equivalency between lunch from Jimmy Johns and disclosure of ownership in a surgery center? There is no difference, and we should be equally vigilant with labelled pens as we should with medical device consulting contracts that run into the hundreds of thousands of $$? Really?

        Rest assured that I take this very seriously. Indeed, some of the most important educators in my world are resigning their educational posts in favor of their consulting posts because the educational institutions are insisting on no PERCEIVED  or POSSIBLE conflicts of interest. Indeed, it can be hard to take the issue seriously when supposedly serious people write legislation banning trivial stuff like pens and post-it notes. Real conflicts where there is the real possibility of conflicting interests must be mitigated. In my opinion the other stuff is trivial and creates an atmosphere of suspicion and accusation where neither is necessary.

        Seriously.

        • http://twitter.com/nerdherd0005 Sherry Christy Loyd

          What you have presented are situations which may be in conflict because of a physician’s fiduciary duty to his/her patient, and a sales rep’s fiduciary duty to the company and its stakeholders. Because these are situations (and not accusations), integrity is not the cure. I’m not making moral statements (morality is extremely variable). 
          Processes (management plans) can resolve many conflicts. So can avoidance.  I haven’t said that healthcare/industry relationships shouldn’t exist.  I am as aware as you are that collaboration is needed to bring new products to market.  However, the relationships cannot be too cozy (sometimes they are).  Management plans can “firewall” the competing interests with just a little bit of effort. 

          Regarding the trivial gifts, it is true that some institutions can take a very strict view of total avoidance.  Some of those environments require strong separation, because as Jonathan Marcus notes above, it is not about the pens or the lunch but the contact.  The trivial gifts are the foot in the door.  Both pharma and the device industry have voluntary codes of conduct for interacting with HCPs.  Without knowing the context of the situtations you site as trivial, what does the pertinent code say about those interactions? 

          The bigger issues – yes, those require much more attention, and the first step is transparency, which is coming quickly with healthcare reform (the “Sunshine Act”).

  • Anonymous

    What you’re describing is the pendulum swinging back the other way. For too many decades, according to doctors who are studying this, doctors didn’t believe friendly drug reps did in fact influence their decisions. THAT is the problem.

    If the medications are – as you say - equivalent and pennies apart in price, and you do not benefit, then somebody does. Would that be the company that bought lunch for you and your staff?

    It doesn’t always matter whether or not YOU benefit, you are targeted because your actions benefit others – and those others try to influence you. and your profession has turned a blind eye for a very long time and FAILED to police itself.

    So bear with the rest of us as a necessary correction takes place. I’m pretty sure you can afford pens.

    • http://twitter.com/DarrellWhite Darrell White

      How, then, to decide which of the three companies I should prescribe? 

      Sorry, I believe you’ve missed the forest here. Of COURSE someone benefits. The thousands of people who work for whatever company makes the med. The stockholders of the company. If all three companies make a “me-too” product that costs the same, should I draw straws?

      There is no moral equivalence here I’m afraid. 

  • Anonymous

    Great Job!!! You are so right all this noise just trivializes the term and makes everyone feel guilty for doing their jobs.   I miss those pens too, and have no idea where they were from, just that they worked.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Are you doing anything about those surgeons who used cheap lens implants? Is there a process by which members of the profession are routinely expeling those few bad apples from their midst?
    If not, you will have to continue buying pens, which is a terribly inadequate solution to a problem that you are best equipped to solve.

    • http://twitter.com/DarrellWhite Darrell White

      Ah…the implants fulfill the “standard of care” test so there is no ground upon which to stand. My beef with the eye surgeons is that they accepted an ADDITIONAL payment from the patient for a premium service (vision w/out glasses after surgery by treating astigmatism), but did not go the full way and provide the full premium service. They were petty, and to someone who knows the details it was tawdry. 

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        So is there anything that you can do to single out, and perhaps get rid of, those petty and not so good apples?
        I think the “public” is stepping in because a vacuum has been created, and the “public” comes in with a hammer because it does not have either the understanding or the visibility that you have. If your board or association, would have historically regulated excess and improper behavior of its own members, I suspect we would not be having this conversation.

  • http://twitter.com/PorterOnSurg Chris Porter

    Dr White,

    Three comments:

    1) Marketing works. It rings naive to talk of pens as bagatelles.

    2) While a sponsored lunch may be a small conflict of interest, it is a nevertheless a *clear* conflict of interest. If you think the rep has something important to teach you and your staff, sponsor the lunch yourself. Easy solution, no conflict.

    3) You suggest that true conflict of interest in one in which there is an essential tension…Who judges whether that tension exists?

    • http://twitter.com/DarrellWhite Darrell White

      Chris, I never said that marketing DIDN”T work, only that marketing per se does not create a conflict of interest that reaches a level of moral or ethical danger. There are conflicts that are real and frankly repugnant; other “conflicts” are trivial and do not rise to a level of any sort of relevance. eg. pens. 

      Regarding “tension” there is obviously a gray area somewhere, and the level of tension will vary based on one’s frame of reference. I think this is a fair question. Why, though, are all docs lumped in with the few bad apples who have abused this, who have gone past the gray zone to the dark side? Trivializing the concept of “conflict of interest” by making all possible conflicts (all determined by some outside “expert” at that) equally heinous is, quite simply, wrong-headed and makes our/my job all the more difficult and for whatever it’s worth, less pleasant. 

      I appreciate your thoughts and your cordial approach. Thanks.

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    If a human being is in a position of privilege with the power to enact arbitrary laws that other people are forced to obey (at the threat of being arrested and thrown in locked custody if they don’t), and if that human being takes exorbitant sums of “campaign money” from corporations and special interest groups, is there a remote chance that this could result in conflict of interest? Maybe just a teeny chance?

  • http://www.facebook.com/jonathan.marcus.ca Jonathan Marcus

    It’s too bad that the author probably didn’t read the extensively available ‘influence’ literature before writing this particularly uninformed blog, starting with Cialdini’s, ‘Influence, the Psychology of Persuasion’.  Seriously, Kevin needs to get a bit more careful choosing bloggers.  In the meantime, this author should stick to less ‘random thoughts’ and write on what he hopefully knows something about, ophthalmology.

    • http://twitter.com/DarrellWhite Darrell White

      Help me out Jonathan…I’ve made no comment about influence, only about the trivialization of the concept of “conflict or interest” in medicine. How might your expertise and knowledge on ‘influence’ shed light on the topic on which I wrote? While it is not germane enough to this post to have added it I have actually read extensively on the topic of influence and my reading informs my opinion: pens and lunches are trivial WRT patient care because the “conflict” between what is best for the patient and what is best for the doctor is below any reasonable threshold wherein the doctor will deviate toward himself, away from the patient. The “influence” of higher profit by choosing a lower quality/lowest cost implant would rise to that threshold.

      • http://www.facebook.com/jonathan.marcus.ca Jonathan Marcus

        Those pens are just a foot in the door.  One of the most effective influence techniques is for pharma reps to become the doctor’s ‘buddy’.  Visits and small gifts are ways to make inroads.  Food is next and has been shown to have a larger proportionate influence for each dollar spent than any other gift.

        I think it’s all a conflict of interest.  IMO we doctors don’t NEED any contact with reps.  We don’t deal with TV reps when we buy TVs… we don’t deal with grocery reps when we buy groceries….etc.

        We could easily be getting much better quality education without them.  They could mail us the samples.  Why get buddy-buddy at all?… that’s the conflict of interest.  It’s gradual and insidiously increased as we hardly see it ramping up.

        • http://twitter.com/DarrellWhite Darrell White

          Jonathan, you’ve essentially made my point. “Influence” is necessary to achieve a situation in which a conflict of interest could take place. In order for a conflict of interest to exist there must, by definition, be some forced choice made by the conflicted in which the “victim” will suffer some maladie secondary to the choice. If I have a patiet who must be treated with compound “X”, and compound “X” is made only by company Z, please identify the conflict present if a rep from company Z drops off a couple of pens. Indeed, if compound “X” is safe and effective, where is the conflict in prescribing it (assuming that the patient needs it) regardless of ANY benefit provided to the doc?

          One can opine, as you have done, that physicians should be quarantined from any and all commerce, that our continuing ed should be funded by some source that is not commercial (pharma, etc.). All well and good, and certainly worthy of a post from someone and comments to follow, but that’s not the subject of my post. Your opinion that all addtional benefits accruing to a physician constute equal conflicts of interest, all of which are equally dangerous and harmful, is wrong in my opinion for all of the reasons in my post. There is no moral equivalence between a ham sandwich and a consulting agreement that prompts a surgeon to use inferior or dangerous implants.

          We’ll have to agree to disagree.

          • http://www.facebook.com/jonathan.marcus.ca Jonathan Marcus

            Appreciate your viewpoint Darrell.  Yes, let’s agree to disagree.  Nice that Kevin has provided us with this excellent forum to discuss issues.  All the best.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Hospital employed physicians receiving payment and compensation from a hospital health system  trying to meet length of stay goals are a conflict of interest. I do not hear any government agency questioning length of stay now on hip fractures as opposed to ten year ago and the increased cost of more readmissions with todays shorter stay?  We talk about pens and lunches instead . On a separate thread on this blog we talked about the lost CPC conference with postmortem evidence presented for teaching purposes. Those conferences have disappeared for numerous reasons including their cost and the cost of the compiling the data was usually funded by pharmaceutical companies and is now considered a conflict of interest.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I’m glad you mentioned the shorter stays. There is a tremendous buzz right now about improving transitions and coordination, with the goal of reducing readmissions, but strangely, I have not seen any mention of shorter stay (and I’ve been looking). Do you know of any studies connecting the two? I would very much like to see some real evidence.

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        Recent article last twelve months in either ACP  or JAMA on reduction in length of stay for hip fractures and increased readmissions and costs and mortality in shorter stay patients

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