Managing Conflicts of Interest

Balancing competing interests is a routine part of professional medical practice and often cannot be avoided.

For instance, registrants are frequently called upon to weigh personal or professional views against individual patient preferences and stewardship of healthcare system resources. When competing interests rise to the level of conflicting interests, certain professional and ethical requirements must be followed. Registrants are expected to recognize, avoid, minimize, and disclose conflicts of interest that arise in patient care.

What is a conflict of interest?

A conflict of interest occurs when a registrant's personal, financial, or other interests conflict with their ethical or professional obligations. This can happen in various situations. For example:

• When a physician has a financial interest in a business, such as a pharmacy, medical device manufacturer, or healthcare facility, and that interest influences or appears to influence their clinical decisions.
• When a physician receives gifts or benefits from a person who stands to benefit in some way from that physician's practice. 
• In the context of personal relationships with patients, colleagues, or others that might influence professional judgments or lead to preferential treatment. 
• When a physician's role as a healthcare provider and another role, such as an administrator, leader, educator, or researcher, might come into conflict. 
• When the potential for professional advancement or research funding might influence a physician's judgment.

Registrants are expected to navigate conflict of interest scenarios by:

1. Adhering to ethical guidelines
2. Being transparent about conflicts and potential conflicts, and
3. Recusing themselves from decisions where their independence or impartiality could reasonably be questioned, as appropriate. 

Standards of Practice

CPSM’s Standards of Practice for Practice Management and Conflict of Interest detail expectations for physicians in managing their practice in a way that prioritizes patient care and avoids conflicts of interest.

Code of Ethics and Professionalism

The CMA Code of Ethics and Professionalism emphasizes the importance of recognizing, avoiding, minimizing, managing, and always disclosing conflicts of interest that arise in practice, education, and research. Applicable provisions are found under the heading ‘Managing and minimizing conflicts of interest.’ 

Real-life scenario:

CPSM was recently asked to comment on situations where practicing physicians become involved with providing advice to the government on whether a medical service should be covered while also caring for a patient who wants to pursue that service.

To add complexity, the question also asked about situations where the physician involved in care is also in an academic or leadership role in their field and is called upon to communicate the government’s position on coverage to colleagues.

These scenarios engage many important concepts and principles to keep in mind, as well as potential pitfalls.

Assessing the conflicts of interest:

Relevant factors in assessing conflict of interest concerns include:

• The physician has multiple roles and responsibilities as a healthcare provider, advisor to government, and leader. 
• How those roles and responsibilities might conflict with one another regarding the Code of Ethics.
• The potential impact of the advice to the government on the physician’s practice, patients, and colleagues.

Considerations:

1. As healthcare providers, physicians have a duty to advocate for their patients' best interests, which includes access to necessary medical services.
2. As an advisor to the government, they would be expected to provide an objective and evidence-informed opinion regarding the medical necessity of the service, including its safety and efficacy. Based on that opinion, the government needs to consider the broader implications of healthcare policies, including cost-effectiveness, public health outcomes, and equitable access to healthcare.
3. As a leader, the physician would be expected to communicate effectively with their colleagues about applicable guidelines and policies that will impact their practice.

Potential conflicts of interest include:

1. If the physician supports funding, this position could be seen as influenced by their relationship with the patient or other personal interests, such as the potential to receive more referrals or enhance their professional standing. 
2. Conversely, if they advise against funding a service from which their patients could benefit, this position could be perceived as not acting in the best interests of those under the physician’s care.

The key to recognizing and managing these potential conflicts lies in transparency and adhering to ethical principles. Physicians should:

• Adhere to professional and ethical requirements, such as those outlined in the Code of Ethics, which provides a framework for navigating the situation. The Code of Ethics emphasizes prioritizing patient well-being, promoting justice in healthcare decisions, transparency about conflicts of interest, and resource stewardship.
• Disclose any potential conflicts of interest to both the government body seeking advice and, when relevant, to the patient. Full and frank communication with patients about conflicting or competing roles and responsibilities, when the subject area touches upon ongoing care, is essential to maintaining trust in the physician-patient relationship. A failure to disclose can undermine trust and confidence in the physician.  
• Ensure the advice provided is based on the best available evidence, including clinical effectiveness and safety, rather than personal or professional interests.
• Recusal from the decision-making process might be prudent in situations where a physician's personal interests significantly conflict with their advisory role. This would maintain trust in the physician-patient relationship and professional integrity.

While providing advice to the government on healthcare, funding can present potential conflicts of interest. Careful management, guided by ethical principles and transparency, can mitigate or abate risks and ensure that the physician's contributions to policy discussions are both valuable and ethically sound.

This process also ensures respect for the relationship of trust that physicians must maintain with their patients.