JAMA Takes Sweeping Aim at Conflicts of Interest in Medicine

Diana Swift

May 02, 2017

In a wide-ranging multifaceted review, the current edition of JAMA, published online May 2, explores the complex landscape of physician conflicts of interest (COIs) and suggests remedial solutions.

As healthcare expenditure, transparency, patient-centered medicine, and physician–patient trust take center stage, the 44-page, 23-essay review offers opinions and strategies from medical specialists as well as ethicists, public policy advocates, health economists, and experts in decision-making behavior.

"This issue has been an important one in medicine for well over a decade," said JAMA Editor-in-Chief Howard C. Bauchner, MD, a professor of pediatrics at Boston University School of Medicine in Massachusetts, in an interview with Medscape Medical News. "[COI] is critical to the health and well-being of the medical profession because the profession relies on trust. We have to get this right."

In planning since last fall, the series talking points were selected to cover a wide swath of medicine, including the COI pressures inherent in fee-for-service reimbursement, medical education, disclosure to patients, and payments from industry. Dr Bauchner said no medicine-related setting in which secondary interests may cloud judgment, threaten independence, or affect decisions escaped the microscope. These included the consulting room, clinical research, schools of medicine and public health, continuing education, scholarly publishing, professional associations, practice guideline committees, hospitals, and interactions with industry.

"Every year, JAMA selects a special theme to focus on, and for this year, we felt that COI would be broadly appealing to doctors and other people interested in health care," Dr Bauchner said. He added that the topic choice was not influenced by the current political focus on COI in Washington.

With the care and well-being of patients the first responsibility of physicians and the primary driver of their decisions, internist William W. Stead, MD, a professor of medicine at Vanderbilt University in Nashville, Tennessee, explained in an editorial that COI exists at one end of a spectrum, with bias in the middle and dishonesty at the distal end.

Whereas few professionals are intentionally dishonest, he notes, all have COIs. These may be internal, such as a desire to advance career and reputation, or external, such as ownership in a for-profit medical enterprise. "Recognition that each physician has COIs and that COIs and dishonesty are at different ends of the spectrum is the first step in a thoughtful conversation about how to protect professional judgment and integrity," Dr Stead writes.

"The aim, throughout, is to preserve and protect public trust in the independence and objectivity of physicians involved in the exercise in question," adds Harvey V. Fineberg, MD, PhD, from the Gordon and Betty Moore Foundation in Palo Alto, California, in an overview article.

And forget about "potential" COIs — there are none, as secondary interests are ever-present and ready to bias judgment, according to a thoughtful essay by medical ethicists Matthew S. McCoy, PhD, and Ezekiel J. Emanuel, MD, PhD, both from the Perelman School of Medicine at the University of Pennsylvania, Philadelphia. "The notion of a potential COI reflects the mistaken view that a COI exists only when bias or harm actually occurs," they write.

According to Arthur L. Caplan, PhD, a professor of medical ethics at New York University's Langone Medical Center in New York City, the challenge is not to eliminate COIs — you can't — but to manage them. "If, for example, you're in vaccine research, you have to interact with the drug companies because they're the major players. There's very little academic presence in vaccines," he told Medscape Medical News.

For Dr Caplan, the most novel essay in the series is that by Ian Larkin, PhD, from the University of California, Los Angeles, and George Loewenstein, PhD, from Carnegie Mellon University in Pittsburgh, Pennsylvania. They describe COI resulting from incentives for overusing interventions in the fee-for-service setting and suggest a move to salaried compensation as a possible remedy. "There's been a lot of talk about this, but not much had been written," Dr Caplan said.

Among the mix of viewpoints, Dr Bauchner was particularly surprised by four viewpoints that address the emerging issue of COI reporting to patients, including the one highlighted by Dr Caplan. "What percolated up in these was the individual [COIs] some physicians have and when it is their obligation to talk to patients about them, and when it is not," he said.

Such competing concerns may include, for example, referral to an offsite radiology suite in which the physician has ownership or, again, the decision to use procedures in a compensation system based on volume of service. Despite their prevalence and influence, such business model-related COIs have received little scrutiny, write Dr Larkin and Dr Lowenstein.

"We don't understand much about what doctors should say to patients, and we know very little about how patients use this information," Dr Bauchner said. As Abigail Zuger, MD, an infectious disease specialist at Mount Sinai St Luke's Hospital and Mount Sinai West Hospital in New York City, reflects in her article, "[W]hether the modern decision to reveal some of these relationships preemptively will make any real difference to the average patient is still unclear."

Dr Bauchner believes, however, that disclosure discussions will open up a much-needed ethical conversation about how much physicians are obligated to tell to patients. "It may create more work for physicians, but in a time of evolving transparency, this is an issue that is likely to be debated, and it should not be an issue you hear about for the first time as you enter residency or practice."

Whereas Dr Bauchner emphasized the need for more research in the area of patient reaction to COI reporting, Dr Caplan took a different view: "Studies suggest that most patients say they don't care if their doctor is getting payments from a drug company," he said.

Another important component in this JAMA issue, according to Dr Bauchner, is a study by Dr Larkin and colleagues on how interaction with pharmaceutical sales representatives influences prescribing practices in favor of brand-name drugs.

Although medicine is already held to a higher ethical standard than professions such as business or law, in Dr Bauchner's view, the evolution of COI and disclosure policies will continue to apply needed pressure in this area.

However, according to Dr Caplan, who called the viewpoint series "extraordinary, very thorough, and long overdue in a journal," there's a hard core of COI skeptics who will not be influenced. "Some doctors are dismissive and won't be moved. They say, 'I don't care how much evidence accumulates, I am not swayed in what I do by incentives or gifts large or small from pharmaceutical or biotech companies,' " he said.

"But it's a proven principle of anthropology that giving a gift induces feelings of a need to reciprocate," he continued. "Even small gifts make a difference. If they didn't work, companies wouldn't do it."

Many of the authors contributing viewpoints disclosed financial relationships with industry.

JAMA. Published online May 2, 2017. Journal issue

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