Trust and Conflicts of Interest

I have been thinking a lot about the “trust” that needs to exist between the public and institutions, and what the repercussions of losing that trust are.

After the Enron scandal, public trust was lost in corporations and the accounting industry (which in turn had a negative effect on the financial markets). To ensure the situation didn’t happen again, the government passed the Sarbanes-Oxley Act, the purpose of which is to hold corporate governance accountable for disclosing accurate financial information. The law even goes so far as to define specific codes of conduct companies must comply with, including disclosing conflicts of interest and individual corporate officers’ financial transactions.

When I read Susan Chimonas et al.’s recently released study, Managing Conflicts of interest in Clinical Care: The “Race to the Middle” at U.S Medical Schools, I thought about Enron and started wondering what the effects of loss of public trust would have on the medical profession.

Dr. Chimonas is one of the leading experts in conflicts of interest. She worked on a past JAMA paper that called for no gifts of any size from pharmaceutical companies and made recommendations on honoraria, CME funding, ghostwriting and others. ABIM Foundation and Institute of Medicine as a Profession were the sponsors of that earlier study.

Chimonas’ recent study presents good news and not-so-good news.  Per the authors’ findings, there has been significant progress in managing conflicts of interest thanks to efforts made by the profession, the Association of American Medical Colleges, Institute of Medicine and the Council of Medical Specialty Societies:

• The frequency of “stringent policies” increased in all areas, with the greatest increases occurring in honoraria (385%), speakers’ bureaus (355%), travel (244%) and scholarships (215%), for an overall increase of 178%.

However, there is still a long way to go, particularly in some areas, and gaps still to close:

• The lowest frequencies of stringent policies were in consulting (3%), honoraria (6%), CME (13%) and vendor access (17%).
• The frequency of “no policy” in 2011 was greatest for ghostwriting (30%), honoraria (29%) and speakers’ bureaus (24%).

In medicine, conflicts of interest are inexorably linked to overtreatment and misuse of resources. They can distort good clinical judgment that should be based on sound clinical evidence rather than influenced by outside relationships. They also shake the core of the public trust in the profession. When the media focuses on isolated incidents of physician greed (e.g., unnecessary colonoscopies and stents), the public believes that the profession is self-serving and not putting patients’ interests above their economic interest, a core tenet of the Physician Charter.

Government has already felt the need to help maintain the public trust in the medical profession. The Sunshine Act, passed this year, calls for transparency regarding all transactions between pharmaceutical companies and physicians. The message is clear: If physicians cannot be relied on to mitigate conflicts of interest themselves, the government will step in and do it for them in the form of regulatory measures and the like. I can only hope we don’t have to go to such extremes.

The Physician Charter’s principle on the Primacy of Patient Welfare states: “Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.” Individual physicians must remind themselves of this principle, before the profession loses is precious “self-regulated” status and becomes another institution that lost the public’s trust due to greed and self-interests.

Daniel B. Wolfson
EVP and COO, ABIM Foundation