Conflicts of Interest

I find conflicts of interest (COI) among the most basic and yet confusing issues in all of medicine. After nearly 15 years as an academic interventional radiologist, the nuances of this topic remain a mystery to me. Like recreational skydiving (why would anyone intentionally jump out of a perfectly good airplane?), it defies reason. I recently completed a term as Chairman of American College of Radiology's Interventional Radiology Appropriateness Criteria Panel. We have discussed COI at length. I have seen national recommendations. I remain confused. Government bodies such as the Institute of Medicine note that clinical guidelines must be made by people without financial conflicts of interest. Sounds simple enough except that most of the people with conflicts are among the most knowledgeable and qualified experts in the field—this is why they have conflicts, they are valuable to industry. Even our committee which is largely devoid of financial COI is not impartial. How can interventional radiologists, with their inherent prejudices, create objective, unbiased recommendations on interventional radiology? It's like letting lawyers make laws…oh wait, we have that already.

When I took over as editor of this journal, I generally divested myself of anything that I thought could be construed as a conflict of interest such as consulting agreements, stock, etc. I have consistently declined requests to be on speaker's bureaus and other such things although I am an equal opportunity lecturer. I will give educational lectures to any group when asked, irrespective of sex, race, or religion. Mostly, I divested because I couldn't bear to deal with the paperwork involved in disclosing COI. And, I am super-rich already from my massive academic salary. Yeah, right. A few years back, I played golf with an industry representative. I recognized that he couldn't pay for my round. Then I wondered if we each paid for our own round, would that be a conflict? So I paid for both of our rounds, again drawn from my enormous paycheck (I think he thought he was being “punked” and kept looking around for Ashton Kutcher). I was pretty happy with myself until someone told me that being a journal editor was a conflict of interest. At that point, I came to the realization that, I can't win, no matter what. So I often play golf by myself now.

Is industry evil? Are they in business to merely prey on poor defenseless patients like in the movie The Fugitive? Is everyone better served if industry received no advice from physicians? Despite not being paid, I find that I still do consulting work all the time—pro bono. Again, my huge academic salary serves to compensate my time. There seems to be a general assumption that anyone with a tie to industry is “tainted” and should be disqualified from serving on various decision-making bodies while the rest of us are completely objective. I would argue that we all have our biases and certainly, those with financial incentives may want to recuse themselves. But, these people shouldn't instantly be regarded as “poison.” Their input is important too, and it is a bit of a stretch to think that their financial compensation completely blinds them to reason.

If you peruse the literature on this topic, you will find that essentially any interaction you or anyone in your family has with industry, in any form, could be described as a conflict of interest. If you see a donut on a table somewhere and decide to eat it, you could be found guilty by the COI police because it may have been paid for by some large medical device company. Fortunately for me I guess, I am partial to bagels and I never seem to find a free bagel lying around anywhere. My purity is intact. Initially, many institutions used monetary values to determine what was and what was not acceptable. You could have a meal paid for as long as it was less than like $75 or so. Indispensable gifts like protractors or reflex hammers less than $25 were OK and so forth. I actually thought this was pretty reasonable. In my view, life isn't binary. We make arbitrary decisions like this all the time—like the speed limit on any given street. Then a whole body of literature emerged devoted to the idea that pretty much any “gift” of any type or value from industry constituted a bribe to physicians. So, anything paid for by industry, no matter what the value, should be strictly forbidden. This is a simple solution to make everyone equally unhappy. If in charge of traffic laws, these same people would probably make the speed limit 5 MPH on freeways to decrease traffic accidents or maybe abolish cars altogether.

What amazes me is that on one hand, a complete separation of academics and industry is held as the ideal, and on the other hand, everyone recognizes that “cooperation with industry is vital to the academic mission of universities.” My university seems to be at the far end of the spectrum. For example, interventional radiology sections of nearly all the major academic institutions in Chicago advertise in the radio and these ads are paid for by grants from industry. When I tried to do the same, I was denied and told this practice was “medicare fraud.” So then I attempted to organize a community health symposium sponsored by industry (i.e., industry would pay for refreshments and all physicians would donate their time for free). I was told this was also forbidden also because industry may indirectly benefit from patient recruitment tied to the event (even thoughwe weren't planning to serve donuts). I came to the conclusion that as academicians, we're supposed to be thought leaders, but remain detached from industry, get paid less than our private practice counterparts and watch them establish cooperative arrangements with industry because they don't have the same rules. Academic medicine is similar to a Catholic school dance. Everyone gets dressed up to look good but girls can't wear anything short or tight, and you can dance (sort of) but not touch and everybody wishes they went to public school.

This past spring, I gave a lecture on inferior vena cava filters at one of the national societal meetings. I was probably chosen because I didn't have any ties to any of the filter companies. Prior to the talk, I was asked to remove all product names from my talk. I wasn't sure how to do this—can you give a lecture on different animals and not mention the names of the animals? When I posed this question to the organizer of the course, I received no reply and instead, my talk was eliminated from their CD ROM. Good solution. On the other hand, there are a few people in academics who appear (at least to me) to be no different from other industry sales people. I don't begrudge these individuals. We live in a capitalist society and they shouldn't be castigated simply because they endorse a product. But… I find it difficult to take anything they say at face value. And guess what? I'm sure everyone else is thinking the same thing. We are bombarded with this sort of advertising every single day. Is there anyone out there naïve enough to not to recognize a sales pitch? As my 8-year-old daughter would say, “Seriously, Dad?” On my way home from work the other day, I saw a large billboard touting the oncology treatment available in one of the small community hospitals in the Chicago suburbs. I know it is a good hospital, but there is no possibly way that it is one of the leading institutions in Chicago when it comes to taking care of people with malignancies. Their slogan? “INSERT NAME HERE Hospital, leading the charge in cancer treatment!” Seriously?

Overall, in my opinion, no matter what the experts say, accepting a pen isn't the same as being paid millions of dollars or taking a junket to Jamaica; most people in and outside of medicine recognize that fact. Transparency is important—if you're being paid by industry to promote a product, it should be disclosed. But no one lives in a moral vacuum and everyone has biases irrespective of financial arrangements.

And if you see a donut, eat it.