Conflicts of Interest and Trust in Physicians
Does trust in physicians change with disclosure of conflicts of interest?
In the fall of 2018, a top medical researcher and physician at Memorial Sloan Kettering resigned after failing to disclose financial ties to industry. The physician, Dr. José Baselga, was Chief Medical Officer at this renowned cancer center. Reports alleged that he had failed to disclose millions of dollars in payments from health care companies in dozens of research articles.
In the midst of this scandal, one of us was at a meeting where physician conflicts of interest were discussed. At the meeting, a colleague stated that she didn’t believe that any patients were harmed by Dr. Baselga’s failure to disclose his industry ties, even though for ethical reasons he obviously should have disclosed them. But this then brought up an important question: does failure to disclose conflicts of interest do harm to patients? Presumably if the physician is making decisions based on monetary incentives that may not in fact be the best medical decisions, then conflicts of interest have a deleterious effect on patient care. But what about the actual act of disclosure itself? Do patients make different decisions about which doctors to see and how much they trust them based on these disclosures?
It turns out that this question has not been answered to a completely satisfactory degree. There is not quite enough research on how patients respond to disclosure of conflicts of interest to know exactly what most people do with this information. Nonetheless, there are a few preliminary findings. In one study of 1900 patients attending an outpatient clinic, subjects received appointment reminders with disclosures of their physicians’ conflicts of interest. The disclosure resulted in no change in cancellations or missed appointments and did not affect patients’ trust of their doctors or the hospital.
In another study of 253 patients in cancer-research trials, researchers conducted in-depth interviews at five U.S. medical centers to gain a better understanding of patient attitudes about potential financial conflicts of interest among researchers and institutions. The study found that more than 90% of patients expressed little or no worry about the financial ties researchers and institutions might have with drug companies and did not demonstrate concern about how this might affect the care they were receiving. Over 70% of patients said they would still enroll in the trial, even if researchers and institutions owned stock in the company or were receiving royalty payments from the drug company. Despite these conflicts having little effect on patients’ decisions about whether to participate in the trial, a substantial minority (40%) still expressed a desire to have these relationships disclosed, which perhaps demonstrates an interest in transparency for transparency’s sake.
In a systematic review of the general public’s view of the relationship between pharmaceutical companies and physicians, there were mixed results about the perceived impact of physician-industry interactions on prescribing behavior, quality, and cost of care. In other words, it wasn’t the case that most members of the general public believed that these relationships affect patient care.
Despite general patient interest in transparency, it is still the case that most patients do not ask their physicians about any potential conflicts of interest. It’s not entirely clear why this is the case, though we suspect a lot of it might simply be that these questions may not occur to most patients to ask. Also, people either trust, or want to trust that their physicians are acting in patients’ best interest. Asking about conflicts of interest might threaten that feeling, making patients reluctant to inquire about their physicians’ potential conflicts of interest. At the same time, many members of the general public may not perceive that these conflicts have a major effect on patient care, even though there’s certainly evidence to suggest that there is an impact. Physicians who receive industry payments themselves often deny that this influences the medical care decisions they make. Yet numerous studies show, for example, that taking money from drug company is in fact associated with which drugs doctors prescribe.
Is disclosure of conflicts of interest to patients enough to reduce their influence on patient care? From the evidence we have so far, it seems that these disclosures don’t have much of an effect on patient decision-making. Nevertheless, the research basis for this conclusion is still very limited. At the same time, although disclosure to patients about conflicts of interest may not affect their actions, knowing that patients are informed about financial connections to drug and other companies might alter physicians’ behavior. Perhaps a physician who is receiving money for speaking engagements from a drug company, for example, will think twice about prescribing that company’s medication if they know that the patient is aware of the connection. Or maybe these disclosures will make physicians think twice about engaging in commercial arrangements with drug companies in the first place.
We need more research to understand patient psychology in the face of potential conflicts of interest. We also need to know if disclosure directly to patients of potential conflicts of interest at the point of service has any effect on physician behavior. If it is the case that patients underestimate the significance of these conflicts, then perhaps we need more general education on the ways in which physicians’ decisions can change in light of industry sponsorship.