What constitutes conflict of interest (COI) for physicians?
In general, COI exists in a situation where a person is — or appears to be — at risk of acting in a biased way because of personal interest. Physicians who engage in paid consulting and speaking arrangements, who conduct research studies to help develop new pharmaceuticals or medical devices, who invest in biotechnology companies, or who own testing facilities or treatment centers that provide healthcare services may do so to improve patient care; however, these activities come under scrutiny when physicians benefit financially.
Even when they take care to avoid it, physicians’ judgments and actions may be influenced by COI. In subtle ways, monetary payments from pharmaceutical companies may affect how physicians report results of research studies, what they teach residents about particular drugs, or what treatments they recommend for patients. Those who own or invest in treatment centers may give preference to these facilities when referring patients for care, thus benefiting financially.
On the flip side, relationships between physicians and other entities are not all bad — they actually have value in terms of physician education and new drug and medical device development. The most common way of averting problems is for physicians to clearly state their relationships with all individuals, companies, or organizations. Transparency about COI allows healthcare institutions, patients, and the public to judge whether a particular relationship may be influencing a physician’s actions. To that end, there are multiple public reporting programs listing payments physicians received from pharmaceutical and medical device companies and many medical centers provide information on their websites about staff physicians’ COI.
Why has COI become an important issue? During the lazy days of summer, dozens of physicians from some of Boston’s prestigious Harvard-affiliated hospitals signed a petition aimed at prohibiting hospital CEOs from working on corporate boards — extracurricular activities that may earn them millions of dollars but also create serious COIs.
What set off the COI tempest in Boston? A Boston Globe investigative report found that Boston hospital CEOs hold exceptionally lucrative board positions in publicly traded companies at a much higher rate than other major U.S. cities. According to the Globe report, five of seven CEOs and presidents of Boston’s major teaching hospitals also receive compensation for serving on boards of publicly traded companies – often in the form of company stock potentially worth millions of dollars.
This isn’t considered “illegal,” but it doesn’t necessarily appear ethical. The Globe report shed light on these “cozy relationships” and the potential COI and ethics issues they raise. For instance:
- A former CEO of Boston Children’s Hospital who was paid $2.7 million annually also held a seat on the board of a for-profit telehealth company, and lobbied Massachusetts legislators for telehealth funding at the start of the pandemic. Upon retiring from the CEO position in 2021, the estimated worth of this individual’s company stock — compensation for work on the board — was $8.8 million.
- In July 2020, the Brigham and Women’s Hospital president resigned from the board of biotech company Moderna “to alleviate any potential concern about the conduct of the outcomes of the COVID-19 vaccine trial” when the hospital was identified by NIH as a clinical site for the phase III trial. In March 2021, this individual stepped down as hospital president and — a mere 10 days later — rejoined the Moderna board.
Readers who are familiar with my curriculum vitae will be not be surprised to learn that I have first-hand knowledge of these issues. As editor-in-chief of several journals and a member of various pharmaceutical and biotech company boards over the years, I have worked hard to assiduously avoid any COIs. In addition to completing an annual COI review, I have always believed that sunshine is the best disinfectant — disclosure of all possible conflicts is the best policy!
There are no easy answers here, but the path forward is pretty clear. Declaring a COI is only the first step; constant vigilance is essential and it is vitally important that the most senior leaders set the appropriate tone.
It shouldn’t take a petition from physicians and medical students to call attention to this issue. Healthcare organizations and physician leaders must put real effort into preserving industry relationships that advance innovation and human health while ensuring that these relationships do not put individual and institutional reputations for integrity at risk.
David Nash, MD, MBA, is founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He serves as special assistant to Bruce Meyer, MD, MBA, president of Jefferson Health. He is also editor-in-chief of the American Journal of Medical Quality and of Population Health Management.