From conflict of interest to conflict between doctors and patients

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Dr Laifungbam Debabrata Roy

In Manipur, the for profit healthcare industry and public academic medicine have become closely intertwined. The financial relationship between industry and academia and the risks of conflict of interest are coming under increasing scrutiny. This kind of dual practice, where the professional is in a financial arrangement with both public healthcare services and private healthcare industry has colloquially become known as `private practice`. Physicians and the media, as well as civil society bodies, have expressed concerns that secondary financial interests of individuals and private healthcare companies are creating an undue influence on primary patient care, research and educational goals. Government bodies as well as professional societies have focussed attention on illuminating financial ties between industry and physicians in an effort to differentiate collaborative partnerships that create benefits for patients and society from those that bias judgement in clinical and administrative decision making.

`Private practice` is quite a strange term because medical practitioners, including those in the non-clinical disciplines and other new quasi-clinical disciplines such as biochemistry and bio-engineering, are entitled and licensed to practice their professions. The question arises where the public sees an obvious irregularity in this practice.

Earlier this month, I wrote an article, `Proposed law to shield doctors from patients is against medical ethics and a frontal attack upon access to justice` that raise what I think are issues of very deep concern for the future of healthcare and physicians in Manipur. There is a crisis in the healthcare sector in Manipur. But this is not, as I had mentioned earlier, confined to Manipur.

The prestigious British Medical Journal (BMJ) recently this year published a study on this issue of increasing concern. The study (BMJ 2015; 351:h4826 | doi: 10:1136/bmj.h4826) was done in response to a rising concern about dual obligations of physicians in the USA, especially those engaged full time in non-profit academic institutions, to for profit companies and non-profit academic institutions which create diverse individual and institutional conflicts that vary in gravity and reconcilability depending on the academic and clinical roles. The study concludes that such conflicts have not been fully addressed by previous guidelines and warrant additional review, regulation, and, in some cases, outright prohibition when conflicts can be reconciled.
A substantial number and diversity of academic leaders, professors and other healthcare professionals hold consultant and management level position such as directorships at profit-motive healthcare centres, often masquerading as research centres, with compensation often approaching or surpassing common academic clinical salaries. Dual obligations to for profit private clinical and educational institutions pose considerable personal, financial, and institutional conflicts of interest beyond that of simple consulting relationships.

Such conflicts of interest are often translated in practice into a fuzzy world of professional and ethical conduct. The common users of the services rendered in both private and public healthcare institutions, as well as the media, are increasingly becoming aware of the impacts of such dual obligations on quality of care and costs of services. Similar to individuals engaging in consulting relationships, individuals on a managerial position or board enter a formal contract with the private company and receive financial payment for services. However, they are subject to important differences.

Firstly, unlike consultants who are compensated to provide services on a specific issue, management level position holders are subject to a fiduciary responsibility to the private company or institution shareholders to advance the general interests of the company and increase profits. Secondly, such individuals serving as directors or high-level managers are reimbursed both through larger cash fees than typical consulting contracts and through stock options, the value of which is directly tied to the success of the company. Such competing or diverging interests often lead to a conduct conflict for the individual.

It is clear that physicians, medical researchers, or medical leaders develop a conflict of interest between their primary professional obligations and their fiduciary responsibility to private institutions. Though the missions of academia and for profit institutions can overlap, they may also diverge especially when the profit mission competes with non-profit tax-payer funded clinical and research missions of academic medical and research institutions. The problem needs a careful examination of the various relationships and their effects on conflict of interest. The institutional conflicts of interest arise when secondary interests influence or risk influencing institutional processes such as quality of care maintenance, staff selection for hiring or promotion, decisions on purchasing and formulary, setting institutional research agendas, and setting educational goals.

Academic medical and/or research institutions affiliations are a formal position in a government medical institution, affiliating to a teaching hospital, or health system; overseeing research university or medical research institute with medical school partnership. Individuals with academic affiliations as leaders and professors (including assistant and associate professors) as a group hold a different set of responsibilities to their academic institutions that poses unique conflicts with their obligations as for profit services. Leaders are individuals holding positions that involve oversight of the clinical activities of their institution (hospital and health system executive officers and clinical departmental heads) or educational and research activities (university related roles, deans and departmental heads of health sciences including medicine, pharmacy, nursing and public health including heads of interdisciplinary translational research institutions and departments).

These responsibilities have often led to a serious problem of compromises. Clinical professionals, by far the majority, face individual conflicts of interest when their primary duties as clinicians, educators or researchers risk undue influence from the profit oriented goals of private health and research centres. New models of healthcare and new technologies are often diverted away from public academic and research institutes to private companies, thereby depleting their technical competence. Time allotted to primary government or public obligations and duties get whittled down, as clinicians allot increasingly more professional time to profit making. Users are consistently being encouraged or coerced to turn to private hospitals at increasingly higher costs for services. This has led to a denial of cost-effective high quality services subsidised by the tax-payer to the poor and rural masses.

The loss of confidence in the government healthcare services and increasing availability of out-of-reach private services at inflated costs have naturally led to a growing hostility and suspicion towards physicians and their commitment to their primary duties and obligations. The medical fraternity has gradually acquired the distasteful character of a commercial, profit seeking group offering their best services to only those who can pay higher prices for more expensive facilities and technologies. Due to this mounting distance between the doctors and their patients, this stereotyping has also entered the domains of private hospitals too. The conflict of interest has often become transformed in the wards and waiting areas of hospitals into open and violent conflicts between healthcare providers and the users of their services. A legislative `shield` for physicians from patients and `patient parties` is clearly not the answer. Drastic measures to review, regulate, and, effectively prohibit conflicts of interests is the only way forward to replace this loss of trust in humanity`™s most noble profession.

The author is a public health physician engaged in humanitarian health services. He may be contacted at [email protected]

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