Monday, December 8, 2008

Physician Conflict of Interest

The NY Times, Dec 3, 2008, has a story on the Cleveland Clinic’s new policy requiring disclosure by its physicians of potential conflicts of interest; it is on page 1 – of the Business section. Entitled “Doctors Disclose Their Hand” (cute!), it indicates that the Clinic will begin disclosing all ties its 1,800 doctors have with drug and device makers, and that “It appears to be the first such step by a major medical center to disclose the industry relationships of individual doctors.“ It is about time. As in the case of issues recently addressed on this page (such as universal health care and “not getting what we pay for”) this has been a concern that has been raised by those within, and outside, the profession for many years, but has been stonewalled and “pooh-pooh”ed not only by the doctors receiving the gifts, but also the institutions that employ them and are afraid of losing high-status and high-dollar researchers if they implement restrictions. The Cleveland Clinic is to be congratulated for implementing such standards, and every single medical school, medical center, and hospital should immediately emulate them or be ashamed. It should not have to take Congressional action: “Senator Charles E. Grassley, Republican of Iowa, has brought Congressional scrutiny to the issue and introduced legislation that would require drug and device makers to divulge the payments they make to doctors. In a statement, Senator Grassley praised the clinic’s move, citing it as evidence of change. ‘Patients deserve easy access to information about their doctors’ relationships with drug companies,’ he said, ‘and the Cleveland Clinic is making that possible.’”

There are reasonable arguments in favor of physicians in academic medical centers having relationships with manufacturers of drugs and devices. The most important is that most of the original research done to develop new drugs and devices is done in such centers by such scientists, usually sponsored in the initial phases by the National Institutes of Health, a federal taxpayer supported agency (contrary to the marketing claims of manufacturers that they support most research and development). When the new compound is promising enough to need industry support for further development and manufacture, it is good that the physicians and scientists involved in development, and the institutions that employ them, get credit and even financial payment. The argument in support of physicians as speakers for drug or device companies (“flaks”) is much less reasonable. There can be no reasonable argument for non-disclosure; indeed, to the extent that such relationships are ethical, there should be no hesitancy on the part of physicians and institutions to disclose. Can’t have it both ways, guys – can’t say it is OK to do, but you would be embarrassed to have your patients and the public and the media know about it.

The Times reports that Guy Chisolm, chair of the Cleveland Clinic’s conflict-of-interest committee, says “῾Disclosure is a minimum,’…The current disclosure simply lists the companies for whom the consulting takes place. He said the group was planning to improve the clinic’s ability to audit the information it received from doctors, because the clinic must now rely on doctors’ self-reporting to find potential conflicts.” and I absolutely agree. When you have scandals such as that of Emory University’s “…Dr. Charles B. Nemeroff, [who] drew criticism in October for failing to disclose at least $1 million in consulting fees from drug makers,” it is clear that self-disclosure is insufficient.

Then there is the question of whether the disclosures will make any difference to patients. “Some experts wonder how useful the industry disclosures actually are to patients when they are told of a doctor’s industry ties before agreeing to take part in a research trial. A patient, they argue, may not know what to make of such information.” Well, that is the doctor’s job. Ethically, it is part of informed consent. It is not only the doctor’s job to be able to not only explain clearly why s/he thinks that this is a good idea (which is obvious); s/he needs to make the counter-arguments him/herself, and direct the patient to places where they can find informed alternate, independent, and even opposed information. This is the responsibility of the academic medical center to enforce. Beyond the direct effect on patients, it is only through such disclosure that the colleagues of a particular physician or scientist will know of these potential conflicts, know that independent information will be needed by patients, and be in a position to exert peer influence and policing in excessive cases.

Finally, the Times quotes Dr. Delos M. Cosgrove, a cardiothoracic surgeon who is the Cleveland Clinic’s chief executive. He “…acknowledges that the environment has changed significantly in recent years as doctors’ industry relationships have come under scrutiny. In fact, he considers some of that scrutiny to be excessive. `You can’t get a coffee mug from a drug company,’ Dr. Cosgrove said.”

While quite a different issue from the big-dollar relationships that the Cleveland Clinic is addressing, and probably worthy of at least another blog entry, the question that comes to mind is: Why would Dr. Cosgrove, who presumably makes a good living and can afford his own coffee mugs, want one from a drug company? Why would any doctor? Why compromise yourself for coffee mugs, pens, sticky pads, calendars, and donuts? While not worth thousands in themselves, these “small” gifts have a big impact. The individual physician may not think much of using a pen with a drug company logo to write a on a note pad with a drug company logo while sitting under a poster or calendar or clock with a drug company logo, but patients notice these things, and understandably might think that the doctor is endorsing these products.

The American Medical Association position is that small gifts are ok, but large gifts are not. Fortunately, many academic medical centers are restricting even small gifts, for both the “appearance of propriety” and for the good reasons noted above. Essentially, gifts to physicians are a form of graft, in that they are given to one person (a physician, a politician) to encourage them to spend money on the company’s product – but not their own money – someone else’s (in the politician’s case, the public’s; in the physician’s case, the patient’s.) Arguing that small amounts of graft are OK is not a position I would care to defend.

Of course, most physicians would argue that their prescribing habits are not affected by gifts, large or small, or dinners. While that always could be true for a particular individual, it is clearly not true for the universe of doctors or the pharmaceutical companies wouldn’t spend so much money doing it! For those who are interested in how what is in one’s financial self-interest is seen, often subconsciously, as “coincidentally” the “fair” or “right” thing, I strongly recommend the article “A Social Science Perspective on Gifts to Physicians From Industry” by Dana and Loewenstein (JAMA.2003; 290: 252-255). While directed to the topic at hand, it is actually very useful in understanding a variety of self-justifying behaviors.

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