"Trust me, I'm a doctor"

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​Doctors’ Duty & Trust
Trust between patients and their doctors has always been essential to medical care. Of what use are the best communication skills, physician empathy, or clinical knowledge if patients don’t trust the advice and information that their doctors give them?

The most important duty of doctors is to provide care that is in the best interests of patients, or in other words, to do what the patients need.

In addition, many doctors are involved in non-patient-care activities. For example, some doctors often: 

• Teach medical students or supervise doctors in training
• Conduct research studies, and through their research, help develop or invent new drugs or medical devices
• Invest in drug or biotechnology companies
• Own testing facilities or treatment centers that provide health care services. 

Doctors must also participate in educational activities in order to stay up to date with advances in their field.

Through these activities, doctors often develop relationships with various people, businesses, and organizations. Although their underlying goals may be to improve medicine and patient care, doctors may also benefit financially from some of these relationships. For example, a doctor who is involved in developing a new medical device may receive payment from the medical device company, or a doctor who has invested in owning a CT scanner at a treatment center, may profit in some fashion when people go there and get a CT scan (whether it’s needed or not).

Although money is involved in the interaction between patients and physicians, the practice of medicine differs from that of other businesses. Sick people are not consumers in the mercantile sense. They cannot (freely) shop around. They are not looking for bargains. Serious illness entails much less control, higher stakes, and intense vulnerability. Trusting a finance account manager, even with one’s life savings, poses much less distress than trusting a cardiac surgeon.

The relationship between a patient and physician is not a commodity transaction or contract, but a covenant—a formal, solemn, special kind of promise, like a will or testament. Whereas a contract is a binding agreement which benefit and protect strangers, a covenant is between parties who have a close relationship with each other. Whereas a contract is based on mistrust, a covenant is based on trust. Whereas a contract is between two equal or near-equal parties (each concerned only with its own welfare), a covenant is between two unequal parties—where one is concerned about the welfare of the other. The covenant that patients expect from physicians is “to put a patient’s interests first.”
The physician is the final common pathway for every act done to a patient. No order can be carried out without the physician’s assent. The physician cannot, or should not, be a double agent: the physician serves primarily the patient or serves primarily himself (herself) or some third party.
 
Conflict of interest describes a situation in which a person is or appears to be at risk of acting in a biased way because of personal interests. Conflicts of interest can even occur in Medicine, involving ostensibly well-meaning doctors and thereby impacting their trusting patients.
 
How Do Conflicts of Interest Arise?
When a doctor’s ability to act in the best interests of a person or group could be affected by such relationships with other people, groups, or businesses, then a conflict of interest exists. It simply means that there is a risk of bias, which can occur through subconscious forces. 

Even when doctors think they are acting without bias, their judgments and actions may still be influenced by conflict of interest. 

For example, doctors’ relationships with drug companies (including any payments or gifts received from the companies) might affect how they report results of research studies, what they teach medical students about particular drugs, or what treatments they recommend for patients. 

Furthermore, doctors who own testing facilities or treatment centers may preferentially refer patients to these facilities for care and may benefit financially from doing so, or they may order unnecessary but lucrative tests such as CT scans on unsuspecting patients who put all their trust in that professional-looking physician with that winning smile, stethoscope and crisp white coat. 

The lines are sometimes blurred between doctors’ clinical decision making and their business decisions. We grant our physicians access to our bodies and allow them to place us in situations of great peril. Without trust, we could not emotionally undergo many medical treatments.

But more and more, a visit to the doctor can seem like a business meeting, and more specifically, a sales meeting where very expensive goods and services are sold to customers. While facing this fact can be emotionally difficult for patients making potentially life changing medical decisions, it allows us to navigate more effectively in this brave new world of American medicine. If our physicians are thinking and acting more like business people, so must patients.

Managing Conflict of Interest
The various relationships that exist between doctors and other entities are not always bad however. These relationships can be important for physician education and new drug and medical device development, but they can lead to potential conflicts of interest. If researchers receive money from industry, they have a conflict of interest. There is nothing potential about it. 

If conflicts of interest arise, doctors should clearly state their relationships with all people, companies, and organizations involved. 

Depending on the situation, this disclosure may occur in person or through statements published online or in print. Being open about conflict of interest allows everyone (including patients and the public) to judge for themselves whether a particular relationship may be influencing a doctor’s actions. It also makes that doctor appear frank and insincere, like someone you can trust. What a concept!

To assist with such openness, public reporting programs list payments and other gifts that doctors have received from drug and medical device companies. 

Some medical centers provide information on their websites about doctors’ conflicts of interest. Patients can also ask doctors directly about their relationships with various entities. Ultimately, doctors’ primary responsibilities are to patients, and clear discussions about conflict of interest can help ensure that patients receive objective and unbiased care.

One recent study of almost 280,000 physicians who received over 63,000 payments, (most of which were in the form of free meals worth under $20), showed that these doctors were more likely to prescribe the blood pressure, cholesterol, or antidepressant medication promoted as part of that meal than other medications in the same class of drugs. Are these incentives really enough to encroach on our sworn obligation to do what’s best for our patients, irrespective of outside influences? Perhaps, and that’s the reason many hospitals ban them.

Because of the necessary and comforting trust we bestow on our doctors, we typically do not view healthcare decisions as business transactions in any way and leave our natural skepticism and instincts as smart consumers at the doctor’s office door. When a patient contemplates surgery, other unpleasant or dangerous treatments, or something as seemingly benign as a CT scan, even the most jaded and cynical among us wants to believe that his or her physician is thinking only of their best interest with absolutely no other motivations in play.

Many American doctors are small business owners who, like other business people, run their medical practices to maximize and grow their profits. This is part of the reality of practicing medicine in America, and it comes with an agenda that patients don’t really want to acknowledge and doctors don’t want to discuss; it’s uncomfortable for all of us.

Indeed, this inconvenient truth, that healthcare is a business in America, is quite unnecessary and a big reason why many feel that universal healthcare is needed to replace the current dysfunctional system. 

Action Steps For Patients
When faced with data such as this, it is important that Americans realize the truth about medical care and throw away our comfort and complete trust. There are many actions that can be promoted to help patients avoid inappropriate care secondary to physician financial conflicts.

Patients should be engaged to unapologetically quiz their physicians for potential conflicts of interest. These financial conflicts include ownership of surgery or imaging centers.

Ask your doctor if a test or treatment is really necessary and why, and if you’re not still not satisfied, ask if you can get your own primary care physician involved in the decision to proceed. 

Many people never even consider that their doctor might engage in these financial arrangements; for others, it may be too painful to believe that their doctors might have financial conflicts that could impact their care. All these patients could benefit from education on this issue.

Organizations that otherwise attempt to educate patients and encourage shared decision making, such as the ABIM’s Choosing Wisely campaign or the Informed Medical Decision Foundation, shy away from this topic, likely for fear of losing physician support.

Patients should always ask whether their physicians own the facility where tests or procedures will be scheduled, and whether they own the company that will sell the hardware needed for their surgery.
If a doctor will not discuss these matters, a patient should be encouraged to look elsewhere for care. While this can be difficult in urgent situations or in our era of narrow networks, patients should attempt the discussion; they can also involve their insurance carrier. 

If a doctor reveals that they have a financial interest in the procedure or diagnostic test that they are recommending, this should raise a red flag; the doctor has just admitted that they have motivations in their patients’ care other than their health and well being.

Finally, and perhaps most importantly, patients should vote with their feet; if consumers seek doctors who refuse financial conflicts, this will quickly change physician attitudes toward these financial arrangements. 
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This can only happen if we work to change our medical culture together sufficiently so that patients feel free to speak with their physicians about this issue. Then both patients and doctors can enjoy relationships built on mutual trust that makes the practice of medicine so rewarding to professionals and comforting and safe for our patients.