Medical Conflicts of Interest are Double-Edged (2013 Jun)

by Barry A. Liebling

When you see a physician for a check up, for expert advice, or for treatment you expect that the physician’s interests are consistent with yours. Ideally, the physician is motivated to use her best judgement to help you preserve and improve your health.

But there are some circumstances where the interests of the patient and the physician may be at variance. Outside incentives could discourage a physician from doing what is best for the patient. Here we are in the realm of conflicts of interest – both actual and potential.

Recently Robert M Pearl, director and CEO of the Permanente Medical Group, wrote an article describing his concerns.
Dr Pearl applauds the “Physician Payment Sunshine Act, which requires pharmaceutical and medical-device companies to disclose payments they make to doctors, hospitals and other health-care providers.” Its intention is to “reduce potential conflicts of interest for physicians or teaching hospitals that may have financial relationships with these for-profit companies.”

According to Dr Pearl physicians who have financial relationships with for-profit companies will be incentivized to curry favor with these companies – at the expense of their patients’ interests. Financial relationships include being a paid consultant, attending conferences at “resort destinations,” and accepting “extravagant dinners.” He believes that this can lead physicians to recommend expensive treatments that fuel the income of private companies – rather than prudent, optimal treatments – to their colleagues and patients. The solution to the “problem” at the Permanente Medical Group is to prohibit all member physicians from “accepting anything of value from … drug and device companies.”

Dr Pearl asserts that the Physician Payment Sunshine Act is a step in the right direction, but it does not go far enough. He would like to see it “supplemented with a requirement that physicians provide full disclosure regarding potential conflicts of interest to any patient they treat.”

Certainly people are influenced by incentives, and there is always the possibility that a physician might be discouraged from doing what is right for the patient. But physicians of good character will recognize potential conflicts of interest and take actions to minimize them. It is not obvious how often a medical professional’s judgement is being tainted by a relationship with a drug or device company. But whatever the incidence is of corruption, it is only part of the story.

Assume that Dr Pearl has a valid point that health care professionals can be discouraged from acting properly. Physicians may be compensated or rewarded to do things that are not advantageous to their patients. Dr Pearl focuses on drug and device manufacturers, but he does not consider other institutions that can deter a physician from working in the interests of patients. Could this oversight be due to a general antipathy toward private, for-profit companies?

Also, Dr Pearl is concerned with the error of over treating – recommending procedures that are extravagant and really not needed. But he neglects the other type of error – physicians who are excessively cautious, stingy, and motivated to minimize expenditures even if it means a decrease in medical effectiveness. If patients who are inappropriately over treated are at risk, certainly patients who are under treated are in peril.

It is often said that physicians who consult for pharmaceutical or device manufacturers have a built-in bias to tout their clients’ products. They will not be invited to consult again if they are hypercritical of the company. Critics assert that their judgement is clouded because they have a financial stake in pleasing their client.

But consider physicians who consult for a governmental agency, especially the FDA. They get no special reward if their investigation shows that a new drug is safe, but they are celebrated as heroes if they convincingly argue that it is dangerous. Everyone knows that introducing an unsafe drug can harm patients, but it is also true that patients can suffer if a useful drug is kept out of the market. If a physician’s judgment can be tainted by a profit-making company then it can likewise be sullied by a government that pays for advice. Conversely, if a health care professional can demonstrate integrity and do the right thing while being paid by the government she can also act appropriately if her client is a drug or device company.

Many large medical groups have a mandate to economize. Member physicians are encouraged to perform less expensive procedures, to prescribe drugs that are on the official formulary of the institution, to use generics instead of branded drugs. Medical groups keep meticulous statistics on their physicians’ actions. Sometimes the best recommendation and treatment for the patient is expensive, and being frugal does not serve the patient’s interest. If a medical practitioner knows that she will be evaluated – getting a raise or promotion – on the basis of her thriftiness will this discourage her from doing the best for her patients? If you believe good sense can be derailed by payments from an outside profit-making company you must concede that sound judgement is equally vulnerable to the nudging of a medical group or hospital.

Dr Pearl has a keen interest in minimizing conflicts of interest between physicians and their patients. He argues that when a medical professional accepts payments from a drug or device company there is a potential conflict. If so, the same problem materializes when a physician is paid by any outside entity different from the patient. The way to assure that physicians are incentivized properly is to have all payments come directly from patients – in cash, through medical savings accounts, or through some other mechanism where the patient is the real customer.

The suggestion that “physicians provide full disclosure regarding potential conflicts of interest to any patient they treat” has some merit. And if it is taken seriously medical professionals would not only disclose their involvement with drug and device companies, they would also explain to patients how their affiliation with governmental agencies, medical groups, and insurance companies might influence their decisions.

If you are sincere about aligning the interests of physicians and patients you cannot restrict your critical attention to for-profit companies. You have to take all potential conflicts into account.

*** See other entries at in “Monthly Columns.” ***

Comments are closed.