The Unintended Consequences of Conflict of Interest Disclosure

By George Loewenstein, PhD, Sunita Sah, MD, PhD, & Daylian M. Cain, PhD.

The Journal of the American Medical Association

Conflicts of interest, both financial and nonfinancial, are ubiquitous in medicine, and the most commonly prescribed remedy is disclosure. The Medicare Payment Advisory Commission and the Accountable Care Act impose a range of disclosure requirements for physicians, and almost all medical journals now require authors to disclose conflicts of interest (although these requirements may be imperfectly heeded). Given that some relationships between physicians and industry are fruitful and some conflicts are unavoidable, can disclosure correct the problems that arise when economic interests prevent physicians from putting patients' interests first?

Given that some relationships between physicians and industry are fruitful and some conflicts are unavoidable, can disclosure correct the problems that arise when economic interests prevent physicians from putting patients' interests first?

Disclosure has appeal across the political spectrum because it acknowledges the problem of conflicts but involves minimal regulation and is less expensive to implement than more comprehensive remedies.

More importantly, even if disclosure is rarely seen as providing a complete solution to the problem, it is broadly perceived to have beneficial effects.

There are, however, reasons that disclosure can have adverse effects, exacerbating bias and hurting those it is ostensibly intended to help.

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ENHANCING THE EFFECTIVENESS OF DISCLOSURE

Despite its potential pitfalls, disclosure is almost certainly a good thing.

It should be a patient's right to know whether his or her physician is receiving financial benefits from prescribing a particular drug or will personally benefit if the patient accepts recommended tests or procedures.

The question for policy should not be whether to disclose but how to ensure that disclosure has its intended effects.

Research has revealed ways of making disclosure more effective.

<snip>

Even if disclosure is crafted in a fashion that increases effectiveness and minimizes potentially adverse consequences, it is no panacea.

Disclosure is simply not applicable to many serious conflicts of interest affecting medicine in the United States.

Although payments from pharmaceutical and device companies have received most of the attention in the literature on disclosure, other conflicts, such as financial arrangements that give physicians (and their institutions) incentives for providing high-cost services of dubious value, may be more consequential.

It is difficult to imagine how disclosure could even be applied to, let alone undo, those problems.

However, perhaps the most significant likely pitfall of disclosure is not its effects on the quality of advice received by individual patients or its inapplicability to many serious conflicts of interest, but the likelihood of a kind of moral licensing on the part of the profession as a whole--the rationalization that, with disclosure, the profession has dispensed with its obligation to deal with conflicts of interest.

Conflicts of interest, including fee-for-service arrangements, are at the heart of the astronomical increases in health care costs in the United States, and transparency is no substitute for more substantive reform.

The entire article is here.

Special thanks to Ken Pope for this information.

Q&A about Patient Abandonment or Wrongful Termination

The following exchange is taken from a national ethics listserv discussion.  We acquired permission from both parties to post this dialogue.

Jeff Younggren asks:

As many of you may know, I have been quite absorbed in the past year or so in the topic of abandonment/wrongful termination.  While I believe that we do owe our clients/patients pre-termination counseling when appropriate and possible, I also believe there conditions that make this unnecessary.

For example, I would argue that when a patient stops paying you, or threatens you or some other situation that compromises therapy or the therapeutic relationship; your obligations to provide pre-termination guidance or counseling are reduced and/or eliminated.  I contend that, emergencies aside, we have no obligation to see people for free if we do not want to (but you can if you want to).  I am puzzled as to how the profession can require someone to work for free when the patient/client violates the professional relationship by acting out, not paying a bill or threatening the professional in some way. 

What would you say about the rights of a licensing board, for example, to punish a psychologist for not providing free, non-emergent services to clients?

Gary Schoener replies:

These issues come up all the time because some clients threaten clinicians with a charge of abandoning them.  I have been involved in a number of cases where this has been litigated.

First of all, I agree that our field has no tradition of treating people without fee as an expectation. Medicine actually did have such a belief.  In fact, I began my career at a neuropsychology clinic and doctors and their families were treated for free by the psychiatrists and neurologists.

They expected us psychologists to do the same as a "courtesy" but we pointed out that:

(a) We did not get free care from any of our physicians; so this was not, with us, a collegial exchange of courtesies;

(b) While we might choose to treat someone for free, when we do it is usually for someone who does not have financial resources (not typical of doctors and their families); and,

(c) People often do not value free services; so this was questionable on that basis too.

BENEFICENCE:  In terms of professional issues, it is our duty to determine who we are capable of treating, to monitor progress and be willing to re-examine our presumption if they are not responding, and to cease treatment that is not working. 

NONMALEFICENCE:  Since all of our treatment techniques can be harmful, and because it is likely harmful in a general sense to provide 'treatment" which is not working, we are again obligated to discontinue treatment that is not working.

AUTONOMY:  The client can choose to leave therapy at any time, but autonomy does not include any "right to treatment." There is no such right.  If a client comes in and asks for  a lobotomy, a psychiatrist would not be expected to do it.  Autonomy in the current world means the right to have information and make informed choices, but it does not bind the practitioner to those choices.

FIDELITY:  The main issue here is that the client knows, going into treatment, that you will be both monitoring progress and that sometimes therapy does not work or does not help, and in that instance a referral should be considered.  In your initial discussion, you should outline your policies on payment for service.

JUSTICE:  Although not critical much of the time, if treatment of the client is harming other clients (e.g. disruption in the waiting room, disruption in group therapy), you can terminate the client.  Resources (e.g. you) are limited and our job is to use them where they can do the most good.  The clients are not "ours" and we are not "theirs" -- nobody has ownership.

Obviously, as a practical reality, practice standard, and consistent with the last revision of our APA code of ethics, we are not bound to provide free service, to continue with people who violate their agreements with us, or to continue in the face of threats by the client or anyone connected with them.

I believe our duty is to provide referrals and be willing to provide information to the new service provider.  It is not our job to find then another service provider -- just to make reasonable suggestions.  If they go into crisis, normally a referral to the local hospital or crisis service discharges ones duty.

In case law, there is that one exceptional case where a psychiatrist about to retire gave all his patients referrals.  However, one patient was very introverted and the psychiatrist himself admitted that a referral alone was probably not enough.  The man was on medications and the psychiatrist never got a records request.  The jury felt, based on the facts including the psychiatrist's own admissions, that he failed in his duty by not working to help this very vulnerable man (who had seen him for many years) make an adequate transition to another practitioner. This was not, of course, an abandonment case -- it was a duty to do more at the end.  I know of no other case, but this has been in the journals so often that it causes people to think that abandonment was the issue.

Jeff Younggren:

What is of great concern to me is that we have clinicians staying in nonproductive and adversarial treatment alliances out of their fear that they will be charged with abandonment if they stop seeing the client.  They fail to see that you can stop seeing anyone, it is how you do it that is key.  In some cases, you have no obligation to do anything other than stop seeing the client, like when your safety is threatened or a patient sues you and in others, like long-term treatment cases, you have a much more extensive obligation that likely includes termination sessions and referral.  We need to make sure that psychologists in practice understand this dynamic.

Gary Schoener:

I agree Jeff.  In addition, as is true for so many things like this, litigiphobia and anxiety are enemies of good decision-making.

Jeff Younggren:

Great point!  

Litigiphobia?  That is a new one for me.

Data Breaches Put Patients at Risk for Identity Theft

By Robin Erb

Detroit Free Press

Originally published 2/12/12

Walk into a doctor's office and chances are that some of your most private information -- from your Social Security number to the details of your last cervical exam and your family's cancer history -- is stored electronically.

Your doctor might access the information on a cell phone that could slip into the wrong hands. The staff might take it home on a laptop or a flash drive.

As Detroit-area health care providers take multimillion-dollar steps toward electronic records, they're talking about more than efficiency and better care. They're talking security, too.

"It's a great concern," said Dr. Matthew Zimmie, who is heading an $80-million conversion to electronic records at Oakwood Healthcare System.

Oakwood's security measures include passwords and security profiles — allowing a radiology tech, for example, to look only at information for radiology patients.

"We definitely take this seriously," Zimmie said.

They have to. According to a recent report by the Ponemon Institute, a Traverse City, Mich.-based firm that conducts research about privacy and security:

• Data breaches nationally grew 32% last year, mostly because of employee negligence and lack of oversight.
• Nearly all of the 72 organizations surveyed reported at least one incident of lost or stolen information in the previous year.•And although four out of five doctors use smartphones, more than half say they are not taking precautions to encrypt information.
• The top three causes for a data breach were lost or stolen computing devices, unintentional release of information by contractors and unintentional employee action, according to the report.
• More than half of the respondents reported they had little or no confidence that their organization would be able to detect all breaches.

"It's almost a matter of time before anyone can be a victim. The key is catching it early," said Dennis Doherty, an assistant prosecutor who handles fraud cases for Wayne County, Mich.

The entire story is here.

Jury awards $16.5 million in State College suit

By Matt Carroll
Centredaily.com

A jury awarded $16.5 million Thursday to a woman who said she was drugged with carbon dioxide and manipulated to believe she was raped by family members at the hands of a former State College psychologist.

Her attorney, Bernard Cantorna, asked the jury to hold Julian Metter, 59, accountable for planting a “horror story” in the woman’s mind while she was drugged with carbon dioxide.

The jurors responded after five hours of deliberation, unanimously ordering Metter to pay what Cantorna said is the largest jury verdict in Centre County history.

“They clearly wanted to send a message that Dr. Metter is a danger to the public and anyone he might attempt to treat,” Cantorna said. “They wanted to make sure anybody and everybody could find this case and make sure he can never do this to anyone again.”

Metter, who had been in practice for 20 years, lost his license to practice psychology in June 2009 when he pleaded guilty to fraudulently billing Medicare, according to the National Council Against Health Fraud.

He was sentenced in February 2011 to serve five months in prison followed by two years probation. Cantorna said Metter is free to continue treating people, just not as a psychologist, after his probation.

When contacted Thursday night, Metter said he was saddened and disappointed by the jury’s decision. He said he will appeal the verdict.

“It was very surprising,” Metter said. “Everyone with me who knows (the woman) and the situation really felt we brought forward a very accurate picture.”

Cantorna said his client was made to believe she was raped at the hands of her family and abused in cultlike rituals by prominent members of the community.

Metter was accused in the civil lawsuit of creating those images and suggesting them as reality while the woman was drugged and in her most vulnerable state.

“He took a woman who never had any history of this and made her relive the most horrific things one could imagine,” Cantorna said Thursday during closing arguments in the six-day civil trial. “He made her live it.”

The lawsuit alleged the woman suffered lasting emotional anguish as a result. It also stated she suffered a brain injury due to repeated exposures to a mixture of carbon dioxide and oxygen.

The entire story is here.

Here is the civil complaint.

Here is a copy of the Consent Agreement and Order from the PA State Board of Psychology.

Here is Metter on Autism, with his center's "treatments" that fall outside the scope of a psychologist's practice.

Russians alarmed by rash of teenage suicides

By Mansur Mirovalev

Associated Press

Originally published 2/10/12

MOSCOW (AP) — A rash of teenage suicides in Russia has set off alarm bells and experts are urging the government to take immediate action.

Russia has the world's third-highest rate of suicide among teenagers aged 15-to-19, with about 1,500 taking their own lives every year, according to a recent UNICEF report. The rate is higher only in the neighboring former Soviet republics of Belarus and Kazakhstan.

In recent years, there have been 19-to-20 annual suicides per 100,000 teenagers in Russia — three times the world average, Boris Polozhy of the respected Serbsky psychiatric center in Moscow said Friday.

"Until the highest authorities see suicide as a problem, our joint efforts will be unlikely to yield any results," he said.

In the southwestern Siberian region of Tuva, the rate reaches a staggering 120 suicides per 100,000 teenagers, while the nearby region of Buryatiya has an average rage of 77 per 100,000. Both regions are impoverished and have high crime and alcoholism rates.

Two 14-year-old girls in the Moscow suburb of Lobnya killed themselves this week by jumping off the roof of a 14-story building while holding hands. They had skipped classes for two weeks and were terrified of what their parents would do to them once they found out, Russian media quoted their friends as saying.

The entire story is here.

Most Teens Who Self-Harm Are Not Evaluated for Mental Health in ER

By Mary Elizabeth Dallas
MedicineNet.com

Most children and teens who deliberately injure themselves are discharged from emergency rooms without an evaluation of their mental health, a new study shows.

The findings are worrisome since risk for suicide is greatest right after an episode of deliberate self-harm, according to researchers at Nationwide Children's Hospital in Columbus, Ohio.

The researchers also found the majority of these kids do not receive any follow-up care with a mental health professional up to one month after their ER visit.

"Emergency department personnel can play a unique role in suicide prevention by assessing the mental health of patients after deliberate self-harm and providing potentially lifesaving referrals for outpatient mental health care," said lead study author Jeff Bridge, principal investigator at the hospital's Center for Innovation in Pediatric Practice, in a news release. "However, the coordination between emergency services for patients who deliberately harm themselves and linkage with outpatient mental health treatment is often inadequate."

The story can be found here.

The study is from Child & Adolescent Psychiatry, Volume 51, Issue 2, pages 213-222.  Here is the conclusion of the study from the abstract.

"A substantial proportion of young Medicaid beneficiaries who present to EDs with deliberate self-harm are discharged to the community and do not receive emergency mental health assessments or follow-up outpatient mental health care."

Diagnosis of a DSM 5 News Cycle

By John Grohol

World of Psychology

As I was sitting around catching up on some mental health news on Saturday, I inadvertently stumbled upon another manufactured news cycle about the DSM 5. Considering no new significant research findings were released in the past week on the DSM-5 revision efforts, I was a little surprised.

This latest fake news cycle started on Thursday, apparently with the release of a Reuters news story from Kate Kelland. Kelland notes the newest concern comes from “Liverpool University’s Institute of Psychology at a briefing in London about widespread concerns over the manual.” There’s no link to the briefing. And I’m not sure what a “briefing” is — a press conference? (And since when is a press conference a news item? It’s not really equivalent to a new research study, is it?)

Kelland fails to note that Europe and the U.K. don’t actually use the DSM to diagnose mental disorders — it’s a U.S. reference manual for mental disorders diagnosis. So while it’s nice that some Europeans are expressing concern about this reference text, their concern isn’t exactly much relevant. Context is everything, and Reuters failed to provide any useful context in that article.

Sadly, Reuters is a brand name. And once you write an article under that brand name, it cascades down an entire news cycle. Let’s follow it for fun!

Grohol's critique is here.

New Mental Health Manual is "dangerous" say Experts

By Kate Kelland

Health and Science Correspondence

Reuters

Millions of healthy people - including shy or defiant children, grieving relatives and people with fetishes - may be wrongly labeled mentally ill by a new international diagnostic manual, specialists said on Thursday.

In a damning analysis of an upcoming revision of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists, psychiatrists and other experts said new categories of mental illness identified in the book were at best "silly" and at worst "worrying and dangerous."

"Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labeled as mentally ill," said Peter Kinderman, head of Liverpool University's Institute of Psychology at a briefing in London about widespread concerns over the manual.

"It's not humane, it's not scientific, and it won't help decide what help a person needs."

The DSM is published by the American Psychiatric Association (APA) and has symptoms and other criteria for diagnosing mental disorders. It is used internationally and seen as the diagnostic "bible" for mental health medicine.

No one from the APA was immediately available for comment.

More than 11,000 health professionals have already signed a petition (at dsm5-reform.com) calling for the development of the fifth edition of the manual to be halted and re-thought.

Some diagnoses - for conditions like "oppositional defiant disorder" and "apathy syndrome" - risk devaluing the seriousness of mental illness and medical zing behaviors most people would consider normal or just mildly eccentric, the experts said.

At the other end of the spectrum, the new DSM, due out next year, could give medical diagnoses for serial rapists and sex abusers - under labels like "paraphilic coercive disorder" - and may allow offenders to escape prison by providing what could be seen as an excuse for their behavior, they added.

The entire story is here.

Critics attack DSM-5 for overmedicalising normal human behaviour

By Geoff Watts
British Journal of Medicine
Originally published on February 10, 2012

Although not due to be published until May 2013, the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is already provoking dissent among psychiatrists and psychologists in Britain.

Critics claim it will make an already problematic diagnostic system worse and result in more people being labelled mentally ill.

<snip>

"The new categories are based on lists of symptoms that don't necessarily map well on to the underlying biological and psychological processes involved in emotion, behaviour, and cognition," said Nick Craddock, professor of psychiatry at Cardiff University.

Speaking at a critical briefing on the current plans for the DSM-5 he claimed that more aspects of emotion, behaviour, and cognition are going to be labelled as diagnoses.

This will medicalise more of what most people view as normal human behaviour.

He offered the example of someone having an episode of severe low mood that met the accepted diagnostic criteria of depression.

"Currently, if this follows bereavement, it would be excluded. It would be regarded as normal. But in DSM-5 the plan is to remove the bereavement exclusion. What most would view as a normal reaction to the death of a loved one would be labelled as a depressive illness," said Professor Craddock.

Peter Kinderman, professor of clinical psychology at the University of Liverpool and also speaking at the briefing said, "DSM-5 is making the process of describing and explaining situations worse."

 He gave as an example the diagnosis of gambling disorder.

"For individuals and for society gambling is a problem.  I think it's unhelpful to regard it as an illness," he said.

"The proposed revision will include a vast number of social, psychological, and behaviour problems in the category of mental disorder, so pathologising mild eccentricity, loneliness, shyness, sadness, and much else.  One worries about what this will mean for the person who receives the label."

To be categorised as mentally ill has all sorts of consequences, he added.

Professor Kinderman suggested that "the American Psychiatric Association call a halt and convene a representative international expert panel to discuss the proposals."

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The article can be found here.
Thanks to Ken Pope for this information.