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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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9. Conflict of Interest
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But tell me, is this medical practitioner a moneymaker, an earner of fees, or a healer of the sick?
~ Plato
Murky Motives
The Importance of Transparency in Managing Conflicts of Interest in Healthcare
Dr. Samantha Lee had just finished a busy day at the hospital and was looking forward to a relaxing evening at home. As she was packing up her things, she received a call from the hospital’s administrator, Ms. Ramirez.
“Dr. Lee, we have a problem,” Ms. Ramirez said in a worried tone. “One of our patients has filed a complaint against you for conflict of interest.”
Dr. Lee was taken aback. She prided herself on her ethical conduct and couldn’t think of any situation where she may have compromised her patient’s care.
“What kind of conflict of interest?” she asked.
“It seems that the patient is alleging that you referred him to a specialist who is a close friend of yours,” Ms. Ramirez explained. “The patient is claiming that you did not disclose your relationship with the specialist and that the referral was not in his best interest.”
Dr. Lee was stunned. She had referred the patient to her friend, Dr. Patel, who was a renowned specialist in the field. However, she had always disclosed her relationship with Dr. Patel to her patients and never recommended him unless she believed it was in their best interest.
“I always disclose my relationship with Dr. Patel to my patients,” Dr. Lee said firmly. “I would never compromise a patient’s care for my personal gain.”
“I know, Dr. Lee,” Ms. Ramirez said. “But we need to investigate the matter thoroughly to ensure that there was no conflict of interest.”
Dr. Lee agreed to cooperate with the investigation but couldn’t shake the feeling that someone was trying to tarnish her reputation.
The investigation took several weeks, during which Dr. Lee was required to provide evidence of her relationship with Dr. Patel and her disclosure practices. She was also asked to provide a detailed account of her interactions with the patient in question.
Finally, the investigation concluded that there was no conflict of interest on Dr. Lee’s part. The patient had misunderstood the nature of Dr. Lee’s relationship with Dr. Patel and had misinterpreted her intentions.
However, the incident had caused Dr. Lee considerable stress and had made her realize the importance of being extra vigilant when it comes to conflicts of interest. She resolved to always be transparent with her patients and to prioritize their care above all else.
Abstract
A medical practitioner’s conflict of interest is a situation where their personal interests may negatively impact the quality of patient care. Patients have the right to be informed of any conflicts of interest so they can make informed decisions about their medical treatment. Practitioners must prioritize the welfare of the patient above their own interests and avoid engaging in activities that may create conflicts of interest such as fee-splitting, self-referral, or providing care to themselves or their friends and family. Conflict of interest can arise from various sources such as fee-for-service structures, gifts from companies, and personal relationships. The practitioner must recuse themselves from any activity where a conflict of interest exists and disclose the conflict to those affected.
**
Think
[9:1] A medical practitioner’s conflict of interest is any actual or perceived influence that diminishes the practitioner’s judgment and patient-centered focus away from maximizing the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
Assess
Patient: 1) Autonomy
[9:2] Patients have the right to make autonomous informed consent decisions about their medical treatment options. Practitioners must reveal any real or apparent conflict of interest to the patient regarding treatment options so that the patient can provide legitimate informed consent in accordance with the principle of autonomy. Without a conflict of interest disclosure to the patient, the practitioner would be less prone to mitigate and eliminate the conflict, and it would be difficult if not impossible for the patient to determine if the practitioner is consciously or unconsciously being biased in the treatment options being offered and biased in the assessment of benefits and risks of the various treatment options being made available to the patient.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[9:3] The professional principle of beneficence (do good) requires that the practitioner always put the patient’s welfare before all other personal interests. This does not mean that the practitioner cannot have personal interests, rather it only means that the practitioner needs to be self-reflecting enough to recognize if and when those personal interests start to negatively affect the practitioner’s judgment, which may negatively affect patient care, violating the professional principle of nonmaleficence (do no harm).
Public Policy: 4) Justice
[9:4] The social principle of justice (be fair) argues that conflict of interest unfairly burdens the patient and unfairly benefits the practitioner. Undisclosed practitioner conflict of interest will augment the already unequal distribution of benefits and burdens.
[9:5] Conflict of interest may arise for numerous reasons. Institutional structures such as fee-for-service, where the practitioner gets x amount of dollars per service delivered, tend to cause practitioners to over-utilize services. Institutional structures such as a capitation, where the practitioner or practice gets x amount of dollars per year per patient regardless of how many services are provided, tend to cause the practitioner to underutilize services.
[9:6] Other examples of conflict of interest arise when companies:
- 1. provide gifts,
- 2. hospitality trips, and
- 3. subsidies for services.
[9:7] Fee-splitting is another temptation for the practitioner in which a professional colleague or institution shares the patient’s compensation for medical services in exchange for the referral.
[9:8] Personal conflict of interest may also occur when the practitioner is engaged in:
- 1. the sale of nonessential products to patients,
- 2. self-referring a patient to another site in which the practitioner has a financial relationship, or even more personally,
- 3. the providing of medical care to oneself, family, or friends.
Conclude
[9:9] The practitioner who has a conflict of interest must recuse themself from the activity and disclose the conflict of interest to those affected.
[9:10] In summary, in order to uphold ethical principles in medicine, practitioners must recognize and address conflicts of interest. They should recuse themselves from activities where a conflict exists and disclose the conflict to those affected. By doing so, medical professionals maintain the trust of their patients and ensure that the quality of care provided remains the highest priority.
(See also: Financial Disclosures, 21. Gifts, 46. Self-Treatment & Family-Treatment, and 47. Sexual Boundaries)
**
9. Review Questions
1. A practitioner’s conflict of interest is any actual or perceived influence that diminishes the practitioner’s judgment and patient-centered focus away from maximizing the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
2. The professional principle of beneficence (do good) requires that the practitioner always put the patient’s welfare before all other personal interests.
3. Institutional structures such as fee-for-service, where the practitioner gets x amount of dollars per service delivered, tend to cause practitioners to over-utilize services. Institutional structures such as a capitation, where the practitioner or practice gets x dollars per year per patient regardless of how many services are provided, tend to cause the practitioner to underutilize services.
4. If a practitioner exercises due diligence and stays patient-focused, then gifts, hospitality trips, and subsidies for services will not be considered conflict of interest.
**
CORRECT! 🙂
[9:1] A practitioner’s conflict of interest is any actual or perceived influence that diminishes the practitioner’s judgment and patient-centered focus away from maximizing the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
Wrong 😕
[9:1] A practitioner’s conflict of interest is any actual or perceived influence that diminishes the practitioner’s judgment and patient-centered focus away from maximizing the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
CORRECT! 🙂
[9:3] The professional principle of beneficence (do good) requires that the practitioner always put the patient’s welfare before all other personal interests. This does not mean that the practitioner cannot have personal interests, rather it only means that the practitioner needs to be self-reflecting enough to recognize if and when those personal interests start to negatively affect the practitioner’s judgment, which may negatively affect patient care, violating the professional principle of nonmaleficence (do no harm).
Wrong 😕
[9:3] The professional principle of beneficence (do good) requires that the practitioner always put the patient’s welfare before all other personal interests. This does not mean that the practitioner cannot have personal interests, rather it only means that the practitioner needs to be self-reflecting enough to recognize if and when those personal interests start to negatively affect the practitioner’s judgment, which may negatively affect patient care, violating the professional principle of nonmaleficence (do no harm).
Wrong 😕
[9:5] Conflict of interest may arise for numerous reasons. Institutional structures such as fee-for-service, where the practitioner gets x amount of dollars per service delivered, tend to cause practitioners to over-utilize services. Institutional structures such as a capitation, where the practitioner or practice gets x amount of dollars per year per patient regardless of how many services are provided, tend to cause the practitioner to underutilize services.
CORRECT! 🙂
[9:5] Conflict of interest may arise for numerous reasons. Institutional structures such as fee-for-service, where the practitioner gets x amount of dollars per service delivered, tend to cause practitioners to over-utilize services. Institutional structures such as a capitation, where the practitioner or practice gets x amount of dollars per year per patient regardless of how many services are provided, tend to cause the practitioner to underutilize services.
CORRECT! 🙂
[9:6] Other examples of conflict of interest arise when companies:
1. provide gifts,
2. hospitality trips, and
3. subsidies for services.
Wrong 😕
[9:6] Other examples of conflict of interest arise when companies:
1. provide gifts,
2. hospitality trips, and
3. subsidies for services.
9. Clinical Vignettes
1. Mr. Jake Jones, a 42-year-old technical writer presents to a practitioner with complaints of persistent headaches and fatigue. After conducting a thorough examination, the practitioner recommends using a certain brand of medication for treatment. The practitioner fails to disclose that they receive monetary compensation from the manufacturer of the recommended medication for promoting their products. What is the practitioner's conflict of interest?
2. Ms. Melody Taylor, a 52-year-old data analyst presents to the clinic with persistent headaches. During the consultation, the patient confides that they have been stressed and overwhelmed with work. The practitioner recognizes that the patient is in need of stress management techniques and refers them to a therapist. However, the therapist happens to be the practitioner's spouse. The practitioner realizes that this referral may be perceived as a conflict of interest and is faced with a dilemma. What should the practitioner do in this situation?
3. A practitioner has been assigned to care for a 42-year-old female under a capitation payment model. The practitioner is aware that under this model, they will receive a set amount of money per year for the patient, regardless of the number of services provided. Which of the following is a likely result of the practitioner working under a capitation payment model?
4. Mr. Kaleb Evans, a 42-year-old hair stylist presents with a complaint of fatigue and difficulty sleeping. The practitioner performs a thorough evaluation and determines that the patient would benefit from a sleep study. The practitioner owns a sleep study facility and would receive a fee for each study performed. What potential conflict of interest may arise?
5. A practitioner is faced with a situation where a pharmaceutical company has offered them gifts, hospitality trips, and subsidies for services. What would best describe the ethical dilemma faced by the practitioner in this situation?
CORRECT! 🙂
Explanation: The practitioner's conflict of interest is that they have a financial relationship with the manufacturer of the medication they recommend. A conflict of interest occurs when a practitioner's professional judgment or actions may be influenced by their personal interests or relationships [9:1]. In this scenario, the practitioner recommends a certain brand of medication for the patient's treatment without disclosing that they receive monetary compensation from the manufacturer of the medication for promoting their products [9:5]. This failure to disclose creates a potential conflict of interest, as the practitioner's financial relationship with the manufacturer could influence their treatment recommendation [9:3]. The practitioner's duty is to act in the best interest of their patients, and their financial relationship with the medication manufacturer could compromise this duty [9:3].
Wrong 😕
Explanation: The practitioner's conflict of interest is that they have a financial relationship with the manufacturer of the medication they recommend. A conflict of interest occurs when a practitioner's professional judgment or actions may be influenced by their personal interests or relationships [9:1]. In this scenario, the practitioner recommends a certain brand of medication for the patient's treatment without disclosing that they receive monetary compensation from the manufacturer of the medication for promoting their products [9:5]. This failure to disclose creates a potential conflict of interest, as the practitioner's financial relationship with the manufacturer could influence their treatment recommendation [9:3]. The practitioner's duty is to act in the best interest of their patients, and their financial relationship with the medication manufacturer could compromise this duty [9:3].
CORRECT! 🙂
Explanation: The most appropriate action for the practitioner in this situation is to refer the patient to a different therapist to avoid any perceived conflicts of interest, as described [9:1]. Referring the patient to the practitioner's spouse as a therapist creates a potential conflict of interest, as the practitioner's personal relationship with the therapist could influence the patient's treatment [9:5]. To avoid any perceived conflicts of interest, the practitioner should refer the patient to another therapist who is not associated with them in any way [9:1]. This approach ensures that the patient receives unbiased and objective care and prevents any potential harm that could result from a conflict of interest [9:1]. Proceeding with the referral as it is in the best interest of the patient, is not the best course of action in this situation, as it creates a potential conflict of interest [9:1]. Disclosing the relationship to the patient and proceeding with the referral if the patient agrees may not be sufficient to address the potential conflict of interest, as the patient may still perceive bias or prefer not to continue with the referral [9:2]. Not referring the patient to a therapist at all, would not be appropriate either, as it would deny the patient access to the care they need [9:1].
Wrong 😕
Explanation: The most appropriate action for the practitioner in this situation is to refer the patient to a different therapist to avoid any perceived conflicts of interest, as described [9:1]. Referring the patient to the practitioner's spouse as a therapist creates a potential conflict of interest, as the practitioner's personal relationship with the therapist could influence the patient's treatment [9:5]. To avoid any perceived conflicts of interest, the practitioner should refer the patient to another therapist who is not associated with them in any way [9:1]. This approach ensures that the patient receives unbiased and objective care and prevents any potential harm that could result from a conflict of interest [9:1]. Proceeding with the referral as it is in the best interest of the patient, is not the best course of action in this situation, as it creates a potential conflict of interest [9:1]. Disclosing the relationship to the patient and proceeding with the referral if the patient agrees may not be sufficient to address the potential conflict of interest, as the patient may still perceive bias or prefer not to continue with the referral [9:2]. Not referring the patient to a therapist at all, would not be appropriate either, as it would deny the patient access to the care they need [9:1].
Wrong 😕
Explanation: A likely result of the practitioner working under a capitation payment model is under-utilization of services [9:5]. Capitation is a payment model in which the practitioner or healthcare organization receives a set amount of money per year for each patient, regardless of the number of services provided [9:5]. In this model, the practitioner assumes financial risk for the patient, as they will not receive any additional payment if the patient requires more services than anticipated [9:5]. To manage this risk, practitioners may limit the number of services provided to the patient, leading to under-utilization of services [9:5]. They may avoid necessary tests, procedures, or referrals to specialists, as these would increase their costs and reduce their profits [9:5]. This can result in patients not receiving appropriate care, leading to potential negative health outcomes [9:5].
CORRECT! 🙂
Explanation: A likely result of the practitioner working under a capitation payment model is under-utilization of services [9:5]. Capitation is a payment model in which the practitioner or healthcare organization receives a set amount of money per year for each patient, regardless of the number of services provided [9:5]. In this model, the practitioner assumes financial risk for the patient, as they will not receive any additional payment if the patient requires more services than anticipated [9:5]. To manage this risk, practitioners may limit the number of services provided to the patient, leading to under-utilization of services [9:5]. They may avoid necessary tests, procedures, or referrals to specialists, as these would increase their costs and reduce their profits [9:5]. This can result in patients not receiving appropriate care, leading to potential negative health outcomes [9:5].
Wrong 😕
Explanation: The potential conflict of interest that may arise in this situation is that the practitioner may be more likely to over-utilize services for the patient [9:5]. The practitioner owns a sleep study facility and would receive a fee for each study performed, which creates a financial incentive for them to recommend the sleep study to the patient [9:6]. This could potentially result in over-utilization of services, as the practitioner may recommend the sleep study even if it is not necessary or appropriate for the patient's condition. This could lead to additional costs and inconvenience for the patient, as well as potential risks associated with unnecessary tests or treatments [9:1]. It is essential for the practitioner to consider the patient's best interests and provide care that is appropriate and necessary for their condition, rather than being influenced by financial incentives [9:3].
CORRECT! 🙂
Explanation: The potential conflict of interest that may arise in this situation is that the practitioner may be more likely to over-utilize services for the patient [9:5]. The practitioner owns a sleep study facility and would receive a fee for each study performed, which creates a financial incentive for them to recommend the sleep study to the patient [9:6]. This could potentially result in over-utilization of services, as the practitioner may recommend the sleep study even if it is not necessary or appropriate for the patient's condition. This could lead to additional costs and inconvenience for the patient, as well as potential risks associated with unnecessary tests or treatments [9:1]. It is essential for the practitioner to consider the patient's best interests and provide care that is appropriate and necessary for their condition, rather than being influenced by financial incentives [9:3].
CORRECT! 🙂
Explanation: The best option that describes the ethical dilemma faced by the practitioner is to decline all offers as it may be perceived as a conflict of interest [9:6]. Accepting gifts, hospitality trips, and subsidies for services from pharmaceutical companies creates a potential conflict of interest, as it may influence the practitioner's judgment or actions regarding patient care [9:6]. It is essential to ensure that any decision regarding patient care is based solely on the patient's best interest and not influenced by any external incentives. Therefore, declining all offers is the best course of action to avoid any potential conflicts of interest, maintain professional integrity, and ensure the highest quality of care for patients [9:6]. Accepting all offers as a common practice in the industry, is not appropriate, as it could compromise the practitioner's professional judgment and ethics [9:6]. Accepting some offers and declining others, may not be sufficient to avoid potential conflicts of interest and may create confusion or doubts in patients' minds [9:6].
Wrong 😕
Explanation: The best option that describes the ethical dilemma faced by the practitioner is to decline all offers as it may be perceived as a conflict of interest [9:6]. Accepting gifts, hospitality trips, and subsidies for services from pharmaceutical companies creates a potential conflict of interest, as it may influence the practitioner's judgment or actions regarding patient care [9:6]. It is essential to ensure that any decision regarding patient care is based solely on the patient's best interest and not influenced by any external incentives. Therefore, declining all offers is the best course of action to avoid any potential conflicts of interest, maintain professional integrity, and ensure the highest quality of care for patients [9:6]. Accepting all offers as a common practice in the industry, is not appropriate, as it could compromise the practitioner's professional judgment and ethics [9:6]. Accepting some offers and declining others, may not be sufficient to avoid potential conflicts of interest and may create confusion or doubts in patients' minds [9:6].
**
9. Reflection Vignettes
1. Ms. Sarah Jones, a 35-year-old graphic designer, has successfully gone into remission after a particularly difficult chemotherapy regimen. The practitioner is thrilled to share the good news with Ms. Jones and her family. The family members are so grateful for the practitioner's help that they give her a $200 gift card to a local restaurant that they own.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Mr. John Smith, a 47-year-old construction worker, comes to the practitioner's local practice with symptoms that suggest he may benefit from an MRI scan. The practitioner recently purchased an MRI machine for the practice as there are no other machines in town. The differential diagnosis for Mr. Smith's symptoms includes various medical conditions, such as a herniated disc or a spinal cord injury. The practitioner believes that an MRI scan would provide valuable information for a more accurate diagnosis and prognosis.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
