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Trust is key in physicians’ relationships
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 Richard L. Lindstrom |
Physician-industry collaboration in the development of drugs and devices and the education of professionals in their use are currently the topics of much discussion. Some believe the physician-patient relationship, the very cornerstone of the centuries-old covenant to do only what one believes is in the patients’ best interests, is being subverted by an avalanche of financial industry incentives that prioritize profit over ethics. The most vocal critics believe that the typical American physician or surgeon has abandoned the Hippocratic oath and is for sale to the highest bidder.
My firm opinion after 35 years as a clinician, scientist, teacher and advocate of constructive collaboration between doctors and industry focused on the patients’ best interests is: They are dead wrong. Still, the fact that so many are expressing concern regarding this issue compels us all to take this concern seriously.
Clearly, an extraordinary amount of money is spent developing, marketing and educating stakeholders about drugs and devices. Just including CME in medicine alone, an estimated $2.4 billion is expended annually, and 60% is supported by industry.
To me, the bottom line is defined by one word: trust. Either an individual patient trusts his physician or surgeon to put his best interests first, or he does not. And on a broader scale, either the public and the men and women they elect to represent them trust physicians as a profession, or they do not. Sadly, it appears that for many reasons, many of which are not under physicians’ control, the individual patient and public trust is eroding. This is a fact. So, unfair or not, we physicians, our professional societies and the industry, must collaborate to advance the art and science of medicine. In addition, our actions need to be constructive and in our patients’ best interests.
Conflicts of interest
Conflicts of interest are unavoidable and occur daily in every physician’s practice. These conflicts include personal interest conflicts, financial conflicts and loyalty conflicts. But conflicts of interest do not necessarily lead to a breach of obligation. The presence of a conflict of interest is not in and of itself evidence of misconduct.
Because they are unavoidable, conflicts of interest must be mitigated and/or managed in order to retain trust. To resolve the moral and ethical dilemma of the inevitable daily conflicts of interest, the physician must prioritize the multitude of stakeholders in their professional lives. These stakeholders are numerous and include the patient, patients as a group, partners, colleagues in our specialty, professional societies, physicians as a group, health care providers as a group, facilities such as hospitals and ambulatory surgery centers, the educational system, insurance companies and third-party payers, regulatory bodies, industry, our families, friends and even physicians ourselves.
For me, the prioritization exercise is simple: Put patients first. This includes the individual patient in front of me at any moment, my patients as a group, every patient in my community, my state, my country and even every patient in the world. It is as easy as putting patients first … as long as all the stakeholders trust us individually and as a group to always do so. This trust is earned one patient at a time, day after day, year after year, generation after generation. But trust is a fragile thing, much more quickly and easily destroyed than created.
Disclosure from all involved
For me, part of the answer to physician-industry collaboration is honest, transparent, complete disclosure of any and all potential conflicts of interest: financial, personal and loyalty. We physicians and the industry that supports us can and should lead in this area. And clearly we are leading, as even a superficial observation of the disclosure in any medical meeting today will confirm.
I recommend we move ahead boldly and establish our own standards of disclosure and conflict management and mitigation, and that our standards be higher than any that could be passed as legislation. Ophthalmology can lead and is leading here.
However, it is also important to note that physicians are not the only stakeholders in health care with significant conflicts of interest to disclose. We physicians must also demand that our health insurance companies, third-party payers, ancillary health personnel, university medical education system, the legal profession, government employees, regulators and legislators join us in putting patients first and making full disclosure of their conflicts of interest.