Conflicts of Interest Ad Infinitum

This review from the New England Journal of medicine gives perspective on the issue of conflict of interest in medicine. Written in 1993, it is still relevant and timely.

There are numerous aspects to these conflicts. Belief based conflicts of interest in medical care were recently discussed in the 2/8/07 Post.

“In the survey of 1,144 doctors nationwide, 8 percent said they had no obligation to present all possible options to patients, and 18 percent said they did not have to tell patients about other doctors who provide care they found objectionable.”

“Based on the findings, the researchers estimate that more than 40 million Americans may be seeing physicians who do not believe that they are obligated to disclose information about legal treatments the doctor objects to, and 100 million have doctors who do not feel the need to refer patients to another provider.”

“Male doctors and those who described themselves as religious were the most likely to feel that doctors could tell patients about their objections and less likely to believe doctors must present all options or offer a referral.”

Researchers are often on the payroll of interested parties. Here too. This excerpt is from an article in the Washington Monthly:

“Lots of eminent people took great offense at being accused of being influenced,” Relman told me recently. “‘What an insulting thing to say. I value my reputation; doctors and scientists know best. Trust us.’ I spent the first 25 years of my career doing clinical research and being one of them, and I know the feeling.” As Harvey Lodish, professor of biology at MIT, huffed to Technology Review in 1984, when Relman first required disclosure at the Journal, “Scientists have all kinds of private consulting arrangements with biotechnology companies and many own stock in these companies, but that’s nobody’s business. It has nothing to do with the quality of their research.”

Practicing physician’s conflicts include receipt of gifts from suppliers, use of pharmaceutical samples, attending drug company sponsored continuing medical education, receiving funds for physician and even family travel, speakers bureaus, ghostwriting articles by the physician, and being paid for consulting and research.  Some even accept very significant payments for enrolling patients in drug company run clinical trials. 

Another aspect of conflicts of practicing physicians is the arrangement with insurance companies to restrict provision information regarding treatment options to patients, receiving money from insurers for cost containment.

There is also the conflict that the physician’s decisions directly influence his/her income. See this and this about Cancer specialists. For what it’s worth, you could make the same observations about all physicians who do procedures or authorize them. (Medicynical disclosure–I am a retired oncologist)

While I don’t believe that improving one’s income has a tremendous influence (see Angell’s comment below) on the choice of treatment, the patient’s ability to pay for whatever is being recommended certainly is a factor.  Private groups in a for-profit health care system do not, and indeed cannot, provide costly therapy without reimbursement. These patients may qualify for medicaid, VA care or treatment in a public supported clinic and receive treatment in that fashion. Others may be offered less expensive and perhaps less effective approaches. Still others are simply out of luck and have to defer whatever they need. In part, some of the allure of unproven and mostly ineffective so called “alternative” therapies is that they are less expensive. So to some degree, in our non system of care, treatment is tailored to the ability to pay and whether we admit it or not, money influences choices.

Also from the Washington Monthly:

“They actually believe that they aren’t influenced,” says Angell. Aside from the fact that it’s not in physicians’ self-interest to acknowledge the effects of corporate money, they may have a hard time seeing the problem for the same reason fish don’t know they’re swimming in water: Doctors are surrounded by conflicts of interest almost from the moment they arrive at medical school. Pharmaceutical companies begin wooing young doctors with small tokens at first, pens and coffee mugs emblazoned with drug logos, then escalating to pizza night for medical residents, dinners at expensive restaurants and tickets to sporting events. Most schools offer a class in medical ethics, but there’s no requirement that they discuss conflict of interest. Besides, a few lectures can’t outweigh the message young doctors absorb every day, as they watch the icons in their profession–their professors, visiting lecturers, heads of departments–taking gifts, speaking on behalf of companies, flying first-class to medical meetings in Paris and Honolulu. By the time medical residents enter private practice or the lab, the gifts from industry no longer seem like gifts, but entitlements”just another way to be compensated for all those brutal, slogging years of lousy pay and long nights.”

We’re not the only ones with this problem. See this in Australia.

12 Billion dollars is spent yearly on marketing to physicians. If one includes all marketing costs for pharmaceutical companies, the total exceeds big Pharma’s research costs. This needs to change–this may help.

More on conflicts of interest in medicine in: On the Take: How Medicine’s Complicity with Big Business can Endanger Your Health by Jerome Kassirer

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