Conflicts of interest in medicine

I’m at the ASLME “Conflicts of Interest in the Practice of Medicine: A National Symposium.” (agenda here) This one-and-a-half day conference has featured an array of recognized national experts who will discuss, debate, and propose best practices and approaches to the problem of conflicts of interest, including Robert Steinbrook (former deputy editor, NEJM) and Bernard Lo (who chaired the IOM panel).

Many terrific presentations, but I want to focus on Sunita Sah, a post-doc at Duke and a research fellow at the Harvard Safra Center. Conventional wisdom assumes that disclosure of financial conflicts of interest in medicine is generally a good thing. Her experimental work questions these assumptions.

One hypothesis is that medical residents may accept gifts because they feel entitled in light of the sacrifice and hardship of medical school. Three questions were used in different order to create a “sacrifice reminder” survey, a “suggested rationalization” survey and a control group survey which asked the question about the acceptability of gifts from industry before asking questions about sacrifices or suggesting a rationalization. The results were interesting, but might be a tool for drug companies to increase their influence through rationalization about sacrifice:

Results Reminding physicians of sacrifices made in obtaining their education resulted in gifts being evaluated as more acceptable: 21.7% (13/60) in the control group vs 47.5% (57/120) in the sacrifice reminders group (odds ratio, 1.81; 95% confidence interval, 1.27-2.58; P=.001). Although most residents disagreed with the suggested rationalization, exposure to it further increased the perceived acceptability of gifts to 60.3% (73/121) in that group (odds ratio relative to sacrifice reminders group, 1.45; 95% confidence interval, 1.22-1.72; P[1].001).

Conclusions Providing resident physicians with reminders of sacrifices increased the perceived acceptability of industry-sponsored gifts. Including a rationalization statement further increased gift acceptability.”

Sah S, Loewenstein G. Effect of Reminders of Personal Sacrifice and Suggested Rationalizations on Residents’ Self-Reported Willingness to Accept Gifts: A Randomized Trial. JAMA 2010;304:1204-1211.

Sunita presented on a second study on unintended effects of disclosure.  Her study suggested that when physicians disclose conflicts to their patients directly, the patients are made uncomfortable and may compensate by being more likely to accept the advice.  (I’m looking for the citation)

A third study looked at how physicians address bias depending on the audience.  From the abstract:

Professionals often give advice to many anonymous people. For example, financial analysts give public recommendations to trade stock, and medical experts formulate clinical guidelines that affect many patients. Normatively, awareness of the advice-recipient’s identity should not influence the quality of advice, and when advice affects a larger number of people, if anything, greater care should be taken to ensure its accuracy. Yet, contrary to this logic and consistent with research on the identifiable victim effect, results from two experimental studies demonstrate that advisors confronting a financial conflict of interest give more biased advice to multiple than single recipients and to unidentified than identified single recipients. Increased intensity of feelings toward single identified recipients appears to drive this process; advisors experience more empathy and appear to have greater awareness and motivation to reduce bias in their advice when the recipient is single and identified.

Sah S, Loewenstein G.  More Affected = More Neglected:  Amplification of Bias in Advice to the Unidentified and Many.  Soc. Psychological and Personality Sci 2011;xxx:xx.

Aaron has written on conflict of interest at TIE

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