Key thoughts:
• There is great value in declaring Disclosures of Interest to reinforce the integrity of academic physicians.
• Many relationships are possible with industry that may be worthy of such disclosures, including research, grants, speaking arrangements, consulting, and even a meal when learning of a new product.
• While academic physicians are being held to a higher standard that should match well-deserved stature, limiting such relationships creates further silos, and does not serve to enhance academic productivity.
The emphasis on disclosures (or conflicts) of interest comes in part from a groundswell from the press on examples of physician indiscretions with such relationships. The idea is that financial payments to physicians should not influence treatment plans for patients, the choice of a particular medication or device used, influence research study design or interpretation of the results. While large consulting fees, travel or gifts are prone to introduce bias and an obligation for the physician to reciprocate, even smaller items like lunch or dinner during an informational lecture make the physician vulnerable to scrutiny. Academic institutions need to be especially careful since their employed physician’s activity with a company may suggest that the institution endorses the product.
The word “disclosures” is preferred over “conflicts” of interest, since not all relationships are likely to risk compromising patient care. However, there is now a popular sentiment that academic physicians should have no relationships. Some simple facts will shed light on this controversy and how it should be a balanced discussion:
• Academic physicians are only 17% of the physician workforce [1, 2]. These comprise the most highly vetted group with proven talents of sub-specialty training, research accomplishments, service and advancing the public good through competitive publishing and commitments to training our next generation of physicians.
• Pay in academic practices is 13%-52% less than their non-academic counterparts, depending on the specialty [3].
• For new assistant professors, the average attrition is 25% at 4 years, and 50% at 8 years [4], with overall 43% leaving academic medicine [5]. This leaves us with a dangerous paucity of senior mentors nurtured over time, and begging why we lost them.
• The success rate for NIH research project grants was 18.7% in FY 2017, reflecting exceptional time and effort, and usually requiring re-submission before funding. Industry and private foundation grants afford some opportunity to maintain a line of research discovery that is not supplied by federal funding.
• Academic group practices are gravitating primarily towards compensation for clinical performance only with wRVUs, leaving less incentive for our commitments to research, education and service. And this is often down-scaled to older benchmarks that do not reflect actual collections.
• In the absence of pharmaceutical, instrument and device representatives, physicians have limited ability and time to be detailed about new industry products.
• Partnerships with industry exist with the US government, so it’s not clear why academic physicians should be singled out.
• Most prescription choices are now determined by insurance, pharmacy plan preferences and lower patient copays. There are plenty of generic options, and fewer new drugs on the market leaving far less influence by pharmaceutical representatives.
We all have the ability to be stakeholders in innovation, with the patient at the center. Academic medicine has been at the pinnacle of expert care and translational discovery. Rather than focus on “conflicts of interest,” we should have appropriate disclosures, follow an ethical code, and aim to advance our “common interest.” [6]
[1] https://www.statista.com/topics/1244/physicians/ -1,045,910 physicians practicing in the US in 2013
[2] The Association of American Medical Colleges represents 173,000 full-time faculty members
[3] Career Navigator, www.doximty.com
[4] Liu CQ, Morrison E. “US medical school full-time faculty attrition,” AAMC, 14:1–2, 2014.
[5] Alexander H, Lang J. “The long-term retention and attrition of U.S. medical school faculty,” AAMC, 8:1–2, 2008.
[6] Ron Kuppersmith MD, John Conley lecture, Annual Meeting of the AAO-HNSF, Atlanta GA, October 8, 2018.
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This column is part of a series devoted to clarifying and enhancing the physician-health system relationship. Dr. Ken Altman is Chief of Otolaryngology at Baylor St. Luke’s Medical Center in Houston, TX. He is also Secretary/Treasurer of the American Academy of Otolaryngology – HNS, and past-President of the American Laryngological Association.