What to Do When You Suspect a Colleague Is Performing Inappropriate Procedures

Conflict of Interest: From JAMA Professionalism print series and Podcasts

It is not a rare event that doctors perform inappropriate procedures and also hospitals have an arrangement to pay a commission. This is NOT discussed and most key organisations and institutes in Sri Lanka turn a blind eye to this. However there is at least one recorded instance where a eminent. Prof of Surgery returned the payment sent to him by a big private hospital for a procedure / investigation he ordered and carried out.

When I was a Council member of the SLMA in 2020, I proposed that the new Council signs a conflict of interest when taking office in 2021. At least one other eminent Professor supported this. However I am not sure that this was done. Maybe for 2022? 


A young clinician notices that every patient he refers to one cardiologist gets cardiac catheterisations – whether they need them or not.

How should he deal with this? (In Sri Lanka the young clinician may be even happy!)

Listen to the full Audio interview (Podcast)

Is There a Conflict of Interest?

Dr Patel is an internist who recently joined a large multidisciplinary clinic. She often refers her patients to 1 of the 6 cardiologists who work there. She has noticed that when her patients are seen by Dr Wells, they almost always undergo stenting procedures, whereas when her patients are seen by the other cardiologists, a larger variety of treatment approaches are used. At first she thought it was a coincidence or that perhaps she was somehow sending patients with more severe heart disease to Dr Wells. But then a colleague made an offhand comment that “If you want your patient to get stented, send them to Dr Wells.” She is concerned that her patients may have been overtreated and subjected to needless risk and that Dr Wells may not be acting in the best interests of his patients.

What Should Dr Patel Do Next?

  1. Stop referring patients to Dr Wells without any discussion or explanation.

  2. Speak with Dr Wells and try to determine why his practice pattern seems different from the other cardiologists’.

  3. Discuss her concerns with her internist colleagues and gather their referral outcome data to better understand the practice patterns before proceeding.

  4. Bring the matter to the attention of the clinic’s medical director and leave it to him/her to address the issue.

Discussion

The Institute of Medicine has defined a conflict of interest as “a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.”2 The primary interest is usually the patient but can also include research integrity or unbiased medical education (Audio at time 13:00).3 Secondary interests can include financial gain, professional prestige, or advancement or other goals (Audio at time 13:50). Although it is not possible to avoid all potential conflicts of interest, trust between physicians and patients—and the public—is based on the premise that physicians will put the needs of patients first. It is a professional responsibility of every physician to manage any potential conflicts that would compromise the primacy of patients.1

It seems possible that there is a financial conflict of interest for Dr Wells. His pattern of performing more procedures than his colleagues suggests that he may be influenced by the secondary interest of financial gain and not acting primarily in the best interests of his patients. When physicians have ownership of health care facilities or of certain ancillary services, it can be associated with overuse of these services.4 Although Dr Wells’ financial dealings are unknown, there is potential reason for concern. In addition to financial concerns, overuse may entail increased patient risk. For this reason, the Choosing Wisely campaign has included percutaneous coronary interventions in asymptomatic patients on its list of tests and treatments that clinicians and patients should question (Audio at time 14:17).5

Resolution

Although it seems that Dr Wells’ practice pattern was well known, no one had yet addressed it directly. Dr Patel decided as a first step to stop referring patients to Dr Wells, at least for the time being, as she was concerned about their welfare. As a next step, although she had reservations about creating possible problems because if she is wrong she could damage relationships and reputations, she decided to act. If she is right about her concerns, then patients—and the health care system—would ultimately be better off if the problem of inappropriate procedures being performed was addressed. She knows that if these issues came to light and the public knew that clinicians failed to address a known problem, it would undermine the public trust in the health care system.6,7 Dr Patel discussed this problem with some of her close and trusted colleagues. For the most part, her colleagues were relieved that someone was willing to discuss the concerns openly. They decided to gather data about their own patients and approach the clinic’s medical director together. This prompted the director to collect data comparing the stent use of all the interventional cardiologists and use the comparison of the data to have a conversation with Dr Wells and the group. Comparisons between practices ended up becoming a key component of new quality improvement strategies for the group.

Bottom Line

  1. Patients’ trust in the medical profession is based on a fundamental understanding that physicians will put their patients’ interests ahead of their own.

  2. Conflicts of interest may be impossible to avoid in practice—the presence of a potential conflict does not itself constitute unprofessional behavior. However, when conflicts of interest are identified, they must be acknowledged and managed in a way that always puts patients first.

  3. Sometimes it is difficult to know if a conflict of interest exists, so physicians should continually reflect on how their (and others’) actions may appear to patients.

 

From JAMA Professionalism print series and Podcasts

A young clinician notices that every patient he refers to one cardiologist gets cardiac catheterisations – whether they need them or not.

How should he deal with this? (In Sri Lanka the young clinician may be even happy!)

 

 

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