Patients can’t trust doctors’ advice if we hide our financial connections with drug companiesBMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g167 (Published 15 January 2014) Cite this as: BMJ 2014;348:g167
- Leana Wen, attending emergency physician, George Washington University, Washington, DC, USA
Just four months into becoming an attending physician, I’ve become an object of hatred. “This is absurd. I am way too busy to spend my time defending myself against some media manufactured crap,” one doctor wrote. “I find your work to be an invasion of my privacy,” another said. “You need to move to Russia or Cuba to practise your type of medicine,” And, more succinctly, “You suck.”
What had I done to incite so much contempt? The short answer was that I started a campaign. The longer answer was that I’d become increasingly troubled by conflicts of interest that are apparent to doctors but hidden from patients. According to a New England Journal of Medicine study, 94% of American doctors have some relationship with a drug or medical device company, including payments but also drug samples and industry lunches, for example.1 Dozens of studies have shown that these associations skew research findings and doctors’ prescribing practices.2 3 Although professional codes mean that doctors are expected to disclose such potential conflicts to each other at scientific conferences, they are not mandated to disclose them to their patients—and therefore they do not. Yet it is patients who are most affected.
Potential conflicts extend beyond the clutches of the drug industry. In the United States, where many physicians are paid through a fee for service model and monetary incentives abound, doctors’ salaries often depend on the number of tests they order and procedures they perform. Studies show up to fivefold variation in treatment provision for the same disease—a result that’s not driven by increased need or improved access but by higher reimbursement.4 The Institute of Medicine estimates that 30% of all tests and treatments done are unnecessary, to the tune of $750bn (£460bn; €550bn) every year.5 This huge waste of money represents huge avoidable harm to patients.
Doctors are well aware of the prevalence of these conflicts. Patients, though, are not. In a survey of 906 patients, four fifths said they were unaware of their doctors’ financial incentives.6 Patients feel powerless to ask their doctors about them and don’t know whether to trust their doctors’ recommendations. Are tests being prescribed because it’s in their best interest or because they benefit the doctor?
Recently I founded a campaign called Who’s My Doctor? and recruited other concerned doctors to publish our financial disclosures on a website, www.whosmydoctor.com. We pledge to be transparent with our patients: specifically, we hand patients our business card, display a sign on our wall, or wear a badge that announces our transparency. We explain that we are doctors who believe in being completely open with our patients, and we tell them about potential conflicts and how we are paid. We do this to hold ourselves publicly accountable and personally responsible. Being ill is a time of extreme vulnerability, and we are letting our patients know that we’re not hiding anything from them and that they can trust us. This is what being a doctor means to us.
I hadn’t expected so many doctors to oppose this call for a renewed professionalism. Much of the criticism is based on fear—for example, that if doctors were to tell patients the truth it would undermine trust in the therapeutic relationship. Yet research has shown that openness leads to more trust and better relationships. One study found that a single mailed letter explaining physician compensation increased patients’ loyalty7; several studies have shown that openness improved patient-physician communication and patient adherence to treatment recommendations.8 9 In addition, the expectation of openness instigates the cautionary effect: if doctors know that what they do might lead to loss of trust, they tend to stay away from that conflict.10
Other arguments are protectionist: patients won’t know what to do with this information—basically, that “they can’t handle the truth.” This paternalistic view needs to become a relic of the past. It should be up to patients to decide what is relevant to them when choosing a doctor and whether to follow that doctor’s recommendation.
There have been some efforts towards transparency. The US Open Payments Act (Physician Payments Sunshine Act) will from October 2014 require drug companies to disclose payments to doctors, but it’s unclear how useful this information is for patients, and the act does not cover other monetary incentives.11 The Association of American Medical Colleges encourages academic physicians to disclose conflicts to patients but estimates that less than 1% of 141 medical schools have policies to this effect.12
Much more needs to be done. Establishing trust is a critical part of care, and being honest with our patients is at the core of what it means to be a doctor. The Who’s My Doctor? campaign is one small step. Doctors should be mandated to disclose how their personal incentives could affect treatment recommendations as part of obtaining informed consent.
Being a transparent doctor and facing the ire of the medical profession hasn’t been easy. My patients’ responses have been gratifying. “I had no idea this is what happens,” I’ve heard many times, “Thank you for telling me.” Another patient said to me, “If you’re willing to be so vulnerable with me, I know I can trust you.”
Cite this as: BMJ 2014;348:g167
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I founded the transparency campaign Who’s My Doctor and serve on the advisory board of the Lown Institute’s Right Care Alliance. I do not receive financial compensation for either of these voluntary activities.
Provenance and peer review: Not commissioned; not externally peer reviewed.
bmj.com Observations: Why the UK General Medical Council should set up a central registry of doctors’ competing interests (BMJ 2014;348:g236, doi:10.1136/bmj.g236)