Conflicting views on conflicts—throwing the baby out with the bathwater
Conflicts of interest are not good for medicine. Why? Because when a physician has a conflict a secondary considerations (such as a lab referrals, vaccine research grants, or revenues from proprietary diagnostic tests) may compete and trump concerns about the best care for the patient. The last Lyme disease guidelines by the IDSA suffered from an abundance of conflicts of interest and no oversight. In fact, the Attorney General found extensive conflicts of interests among the IDSA panel that developed those guidelines. (Click title to read full article.)
Conflicts of interest are not good for medicine. Why? Because when a physician has a conflict a secondary considerations (such as a lab referrals, vaccine research grants, or revenues from proprietary diagnostic tests) may compete and trump concerns about the best care for the patient. The last Lyme disease guidelines by the IDSA suffered from an abundance of conflicts of interest and no oversight. In fact, the Attorney General found extensive conflicts of interests among the IDSA panel that developed those guidelines. The IDSA’s new guidelines panel, which was legally mandated by a settlement with the Connecticut Attorney General, was supposed to eliminate these types of conflicts of interests and an ethicist, Dr. Howard Brody, director of the Institute for Medical Humanities at the University of Texas was chosen to oversee these conflicts. (Please do not contact him.)
So what’s the problem? Well, expert panels are first and foremost supposed to be experts. And, while you may not want pharmaceutical interests driving the cart, you definitely want physicians who treat the disease on the panel. Brody rejected any applicant who made more than $10,000 a year from treating Lyme disease. This excluded all physicians who saw more than one patient per week who had Lyme disease. Simply put, there are no experts on this panel that treat chronic Lyme disease or who could form meaningful “expert opinions”. To put this in perspective, the last IDSA guidelines panel based the majority of its recommendations on “expert opinion”. If there are no experts on treating Lyme disease on the panel, then what type of expert opinion can recommendations such as these be based on? In short, Brody threw out the baby with the bathwater. Who would expect a cardiology panel to be populated with physicians who are not cardiologists? The notion is absurd. In law, this is known as reduction ad absurdum.
Nor is it common to regard treating physicians as having a conflict of interest. Normally, a conflict of interest occurs when a competing secondary interest may interfere with the physician’s ability to place the concerns of the patient paramount. Treating a patient in accordance with your professional judgment and treatment approach is not considered a conflict. While physicians are incentivized to treat patients under common fee for service arrangements (just as your carpenter is incentivized to provide carpentry work for a fee), these interests are generally regarded as being aligned with those of the patient care. Marc Rodwin, the author of Medicine, Money, and Morals, and an expert on physician conflicts, lists 7 potential conflicts of interest physicians may have in treating a patient:kickbacks for referrals; physician investment and self-referral;dispensing drugs, selling medical products, and performing ancillarymedical services; hospital purchase of physicians’ practices;hospital payments to recruit and bond physicians; and giftsfrom medical suppliers and HMO capitation arrangements. Notably, fee for service is not among those listed. I strongly disagree with the ethicist’s interpretation of this. Fee for service arrangements provide an incentive to provide care (just as you incentivize your carpenter by paying him) but they do not provide a conflict where competing (and typically third party) interests intervene.
Moreover, if conflicts of interest are to be intrepreted this broadly, then what is good for the goose should be good for the gander. Namely, physicians who test for Lyme disease and find “no Lyme disease” and treat palliatively or for CFS or FMS or any “alternate diagnostic” categories should be excluded from the panel because their monetary incentives are no different than those who treat. A dollar from a patient is a dollar regardless of your treatment modality.