Convergence of Interest – Not Conflict of Interest

Given all the recent coverage of the proposed regulations implementing the Physician Payments Sunshine Act (Section 6002 of the Affordable Care Act), there has been an increasing focus on the issue of “conflicts of interest” that may arise from physicians who collaborate with industry.  A recent blog post addressed this issue and correctly asserted that people should “stop trivializing conflicts of interest.” 

The blog post, written by ophthalmologist Darrell White noted that given all the other potential for conflicts of interest in other industries in America today, it seems a bit surprising that people expect the provision of health care in America to be so “pure”—that is free from industry.  

For some, the simple existence of other interests is de facto evidence of some nefarious conflict of interest.  The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this? 

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. For example, he noted that recently Dr. White had to purchase his own pens for the first time since he graduated from medical school in 1986.  He noted how some people believe these “pens” influence physician decision making and lead to the use of high cost drugs that are risky or even unnecessary.  There’s only one problem with that assertion according to Dr. White: he doesn’t remember a single thing about even one of those pens.  And yet somehow accepting those pens is a conflict of interest. 

Why is it that if a doctor somehow gets something from someone, big or small, even if they perform some service or even buy something from them, that it’s a conflict of interest if some company or other might make money from what the doctor does for their patient?  Why is every peripheral interest that exists around the little silo in which a physician practices medicine automatically a conflict of interest with some sort of negative connotation? That the physician must be doing something bad? 

Why not just another interest? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us? 

While there have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. In fact, Dr. White noted how he is reviewing a medical malpractice case in which a cataract surgeon clearly had a conflict of interest for putting in an inferior lens inplant.  But he noted that for every surgery center owner like this one, he knows 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is that a conflict of interest?

Dr. White said, “It’s not.” 

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or the one that left a couple pen lights in the office? Tell me, how and why is this a conflict of interest? 

This trivialization of the concept of conflict of interest is actually weakening the protections that we should have against real conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene consulting agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients. 

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these conflicts of interest. Who will replace them? Will the ascetic cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by specialists who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients? 

Ultimately, Dr. White asserted that, “a true conflict of interest is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician.” Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. 

He maintained that, “We should stop this silliness; stop trivializing the concept of conflict of interest through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.” 

We should be allowed to seek a convergence of interests.