Posted by Bill Sandweg on 23 December 2019.
One of the very first of the ethical rules promulgated by the American Medical Association requires doctors to place the welfare of the patient ahead of the doctor’s own self-interest or obligations to others. As life grows ever more complicated, doctors are under greater and greater pressure to violate this most important of rules.
Physician conflicts of interest can arise in many ways. The cartoon above illustrates just one of the conflicts that can arise based on a doctor’s relationship with a pharmaceutical company. Pharmaceutical companies employ virtual armies of representatives whose sole job it is to develop relationships with doctors who might prescribe their company’s drugs. These representatives regularly visit doctors’ offices. They leave behind product samples, knik-knaks and gifts of value. They sponsor lunches, brunches, and breakfasts. They take doctors out to dinner. They don’t do these things out of the goodness of their hearts. They expect and hope that these things will cause the doctor to look favorably on their company and its products.
Sometimes, the transaction is even more rewarding for the doctor. Pharmaceutical and device companies sometimes hire doctors to give talks at conferences in an attempt to sway other doctors. They hire doctors to give them advice about their products. They commission doctors to participate in studies funded by the drug or device company. Although doctors who write articles following such studies are supposed to disclose any conflicts of interest, not all do so. Drug and device companies spend big money on these activities in the hope that they will affect the way doctors treat their patients and improve their bottom line.
Doctors may own laboratories and send their patients to those labs for testing. Or they may do some of the testing in their own offices and charge the patients for it. Or the doctor may own a company that supplies surgical parts and supplies he or she will use on their patients. When a doctor can make money by ordering a test or using a product, there is an incentive to put the doctor’s self-interest ahead of the welfare of the patient.
More and more doctors are becoming employees of hospital systems. While their contracts of employment may not specifically require them to send their patients to the hospital that employs them or to refer their patients to other doctors who work for the same hospital system, everyone understands that is what is expected of them. Sometimes the doctor’s compensation is based upon how much revenue the doctor generates for the hospital system. Sometimes the doctor is given a review of his or her economic value to the hospital system and it is clear to the doctor that continued employment and raises are dependent upon generating more revenue for the hospital.
Whether or not it is in the best interest of the patient to be admitted to the hospital that employs the doctor or to be referred to other hospital system doctors, there is a strong incentive for the doctor to do these things. This is the very definition of a conflict of interest.
The medical profession talks a good game. It reverently states that the interests of the patient come first while turning a blind eye to all of the ways in which doctors violate that rule on a daily basis. Don’t expect that your doctor is going to put your interests first. She may but she may not. You can’t count on the medical profession living up to its self-proclaimed ethical standards. Often, these are just window dressing. No one is going to protect you out there. It is up to you to be informed about your condition and the alternatives available to you. It is up to you to ask questions. It is up to you, if you want the best care.