Check Out Your Doctor's Conflicts of Interest on the Web

After several weeks of not all that much happening at the Pharma-Medicine-Ethics interface, things have gotten busy again, to the extent that our fellow bloggers have even scooped us in some cases. Herewith I attempt to catch up.

Reed Abelson wrote in the New York Times last week--

http://www.nytimes.com/2008/12/03/business/03clinic.html?_r=1&scp=1&sq=cleveland%20clinic%20conflict%20of%20interest&st=cse

--about the Cleveland Clinic's plans to create a new portion of their website in which all conflicts of interest of their staff physicians will be publicly reported. The University of Pennsylvania Medical Center reports a similar program. On the industry side, both Merck and Eli Lilly plan to start posting information on all their payments to physicians in 2009.

Abelson suggests that the media embarrassment suffered by large medical centers when previously undisclosed conflicts of interest are outed has led to this nascent movement, along with the investigative interest that Sen. Charles Grassley has shown in exposing high-rolling academic physicians who somehow have neglected to report their conflicts of interest. (See most recent post, http://brodyhooked.blogspot.com/2008/10/could-new-revelations-bring-down.html).

The Cleveland Clinic mentioned in passing that it expects that only a quarter of its physicians will have anything to report on the new website. HOOKED takes the position that disclosure of conflicts of interest is a relatively unsatisfactory substitute for getting rid of the conflicts in the first place. It remains to be seen whether physicians will be less likely to enter into conflicted relationships with industry when they know that the results will be publicly posted.

The Ideal COI Policy: Why You'll Never See It

In the previous post I suggested some problems with the recent AAMC-AAU report on institutional conflicts of interest (COI). As I was reading the model policy, and reflecting on the various documents that I have had to sign recently when I agree to give a talk for a continuing-medical-education function to assure that I personally had no relevant conflicts of interest, it occurred to me what an ideal university or medical center individual COI policy would look like. (I report in the previous post a little bit of what I think the institutional COI policy should look like, which is quite a different matter.) First I'll give you the policy, and then discuss a little of why it says what it says (and why, hence, you'll never see such a policy actually adopted).

Medical Center of the University of Southern North Dakota at Hoople
Individual COI Policy

1. If you're a member of our faculty and staff, and we find that you are involved in a COI that compromises your position of trust in research, teaching, or patient care, we'll beat the holy crap out of you. (If you wonder what a COI is, read that excellent volume, HOOKED.)
2. If you find us about to beat the crap out of you, and you think that this is not fair, you may request an appeal to our COI Committee, made up of a group of your peers.
3. The COI Committee will review your case in detail and reach one of the following three conclusions:
4. First, that there is no significant COI, and we blew it, in which case we'll apologize and stop beating you up.
5. Second, that there is a significant COI, and that anyone who claims to be as smart as you are ought to have known it, in which case we'll resume beating you up.
6. Third, that there may or may not be a significant COI, but that the circumstances aren't clear, in which case we'll talk about it some more.
7. Presumably you don't like to have the holy crap beaten out of you, and we don't like the bad rep that we get when we have to do such things to our own faculty. Therefore we strongly recommend that before you get into a situation that later could look like a significant COI, you talk with your dean or department chair or somebody who doesn't have their hand in the same till, who can advise you and warn you off before any damage happens.

This policy seems to have the following advantages:

• It puts faculty on warning that the institution takes COI seriously and that violations will result in bad stuff happening.
• It recognizes that the criteria for COI cannot always be completely specified in detail in advance of a concrete situation.
• Rather than make faculty fill out endless reports and make committees read over all those reports, it relies on an appeal to professional judgment, responsibility, and discretion.
• It focuses on the faculty who are engaged in questionable behavior and leaves alone faculty who engage in no such behavior.

You can see from the way that it is written that however sensible it is, or perhaps because of how sensible it is, no university or medical center will adopt such a policy in a gazillion years.