Issue 11 / 26 March 2012

LATE last year, an interesting article in the MJA and the subsequent letters regarding conflicts of interest caught my interest.

The authors summarise conflicts of interest as: “Is there anything … that would embarrass you if it were to emerge after publication and you had not declared it?”

They are referring to clinical guidelines and quite correctly state that disclosure and transparency needs to be improved.

To me, the whole conflict of interest debate is too narrow. The focus is almost exclusively on money when in fact conflicts of interest affect so many other facets of our profession and life in general.

Let’s be frank about what leads to bad behaviour in us humans — power, money and sex. Everything can be placed into these three categories.

My writing skills have not expanded into the areas of intrigue and erotica, so I will leave any medical conflicts of interest about sex to the likes of Grey’s Anatomy, All Saints or ER.

And there has been so much media and breast-beating about “big pharma” manipulating doctors with trinkets that I cannot even get a party pie out of a drug rep for lunch these days. Officeworks should have an aisle dedicated to medical centres, for all of a sudden we need to again buy pens, erasers and note pads.

I have to chuckle when attending conferences with trade booths nowadays. Have you noticed all the government agencies at these conferences? They give out pens, etc. Given big pharma is supposedly brainwashing us with gifts, where does that leave the government?

The third, mostly unspoken, category of conflict is power, and the most obvious example is committees.

Committees are the fastest growing things in health care — teamwork, collaboration, consultation, liaison, planning, strategy, development, review are just some of the buzzwords used to justify downing tools and having a yak.

We can’t just blame government for this — have a look at how many committees the AMA has created.

Many committees are very influential. A number have remuneration and benefits attached, not to mention the time off work. They can also offer the natural companion of power — prestige.

The appointments to these committees are often driven by politics, connections and geography rather than by merit.

Some are even implementing gag clauses on doctors and even medical students. If someone is subject to a gag clause it should be declared as a conflict of interest.

As a profession we need to be asking about who decides appointments, how they are decided and whether members of committees are nominees or representatives. The latter have to tow a line, the former can be independent.

Power can manifest as workforce manipulation, even without monetary gain. Examples of this are the colleges, universities, regional training providers (RTPs) and hospital networks.

How many times have we seen the students or the registrars of the professor given the best jobs? How often do the supervisors on the boards of colleges and RTPs get the best registrars while others have to make do with the lower achieving ones or none at all?

Can doing a PhD under a certain boss somehow lead to a prime hospital appointment regardless of the academic merits of the thesis? Splashing the name of the boss on a few publications — with his/her minimal input — is a way to seal the deal.

There is certainly a culture of “doing one’s time” or “being seen” that prevails within our profession. When such candidates are given jobs over those with more merit, you cannot but help conclude that major conflicts of interest are at play.

It is only because there is no paper or money trail that the conflicts of interest based on power go unmentioned and uncorrected.

It is high time we raised the bar and started examining these silent conflicts, for they are the ones that erode morale and hope — more so than money.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 26 March 2012

3 thoughts on “Aniello Iannuzzi: Conflict of power

  1. Beryl Shaw says:

    I do love your sense of humour. Yet, like the very best humour, it hovers behind such truth. Didn’t someone say ‘Power is the greatest aphrodisiac’?
    In my own work, which comes to health professionals from outside the universities and hospitals, I run into the cabals you mention all the time. Since my expertise is in demonstrating how words affect doctor’s ability to diagnose – in time to save a life; or aid nurses in helping a patient’s recovery; while increasing feelings of comfort and ability in the professionals involved, that’s not always valued.
    Not having been to university or stood by the hospital bedside as a health professional it’s obvious that I’m considered ‘just a patient’.
    Once they’ve seen how I work to improve their expertise in a much ignored discipline I am loved – they use my techniques, but I’m often not heard because the ‘power of position’ keeps me out of the loop.
    And I do understand your frustration at seeing the elevation of the less skilled who ‘sell themselves’ well, or have the powerful connection.
    Thank you so much for bringing this well known but seldom acknowledged issue out into the open, regardless of how it may be brought to bear against you.

  2. Bernie Tuch says:

    Well said…but there is also the motto, if you can’t beat them, join them. Not more paperwork, please.

  3. JohnB. Myers says:

    Let your imagination overtake your fear and include medical boards, tribunals and all government agencies including courts that are above account – the appeals process is a decoy, a pretence, at least if the Catholics are involved. This is not a racial prejudice or religiously driven one, but the result of experience in the Supreme Court in Victoria and including the High Court and the deception that has ongoing papal support.
    Thus, in regard to the bureaucratic scene in Victoria, I stood in the 2010 Victorian state election to raise the awareness of the need for a solution, namely “a System of Evaluated Decisions”, to ensure accountablity and move the tribal medieval and premedieval practices of VCAT, the Medical Board and the courts into the 21st century where accountability is transparent and real.
    It is time we looked at the legislation that frames us.
    Ask or you will not find.
    i) What does mandatory reporting do? Mandatory reporting supports and empowers those in power not those it proposes to protect – for accountablity is driven further from our reach only to be buried in their hands.
    ii) Similarly, the professional legislation that is meant to protect patients does nothing to ensure this as nowhere in the legislation is the wish of the patient taken into account. Practice being defined by peers and the public without reference to the patient’s wishes, denies context and is open to interpretive abuse, as are all third party complaints which are against the patient’s wishes – or best interest defined as emotional and psychological wellbeing [see 2010 review of the Guardianship and Administration Act 1986, a review I sought in my stand in the November 2007 Victorian State election, see also Myers J, Int Med J 2006, 2009, 2010 and Myers, Med J Aus 2009].
    iii) Failure to define vexatious leaves no room for objection on grounds of “vexatiousness”.
    iv) Lack of definition and lack of redress and of accountablity favours Medical Board, VCAT and biased court decisions.
    v) Failure to have “rules of evidence” that meet the Brigginshaw standard characterise the Medical Board and Tribunals – there to protect us – the public.
    vi) Mission statements like “this a protective jurisdiction” beg the question, protective of what? Of their own self-serving interest rid of objectivity and validity of evidence,
    vii) By deceiving us that they care and/or protect the public needs to be questioned, as in fact they protect and care only about themselves.
    As you said, power, staying in power and you forgot, harming those who do care and are honest while pretending to care and to act in the public interest but care only about themselves, the AMA included as no-one is willing to take on these agencies of bureaucrats in government in support of integrity and context, i.e. prejudice that these bureaucrats in government positions thrive on.
    viii) In the interest of justice the introduction of a system of objective review of all decisions on a random basis is required. And compensation to victims of systems abuse – new category is required as well as ability to sue those in government agencies including members on the Medical Board who abuse their positions of power for self-serving purposes and prejudice, rather than responsible and accountable practices.
    viii) FInally, we have only ourselves to blame if we allow ourselves and the patients we are here to advocate for to be bullied by those who seek to deceive by acting with authority “in their best interest” or ‘safety” rather than serve justice “to ensure” best interest, as defined above, inclusive of all [see Myers J. Int Med Journal 2006, 2007, 2010 and Myers J. Med J Aus 2009].

Leave a Reply

Your email address will not be published.