Sunita Sah

The unintended consequences of conflict of interest disclosure.

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? 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.

Nothing to Declare Mandatory and Voluntary Disclosure Leads Advisors to Avoid Conflicts of Interest

Professionals face conflicts of interest when they have a personal interest in giving biased advice. Mandatory disclosure—informing consumers of the conflict—is a widely adopted strategy in numerous professions, such as medicine, finance, and accounting. Prior research has shown, however, that such disclosures have little impact on consumer behavior, and can backfire by leading advisors to give even more biased advice. We present results from three experiments with real monetary stakes. These results show that, although disclosure has generally been found to be ineffective for dealing with unavoidable conflicts of interest, it can be beneficial when providers have the ability to avoid conflicts. Mandatory and voluntary disclosure can deter advisors from accepting conflicts of interest so that they have nothing to disclose except the absence of conflicts. We propose that people are averse to being viewed as biased, and that policies designed to activate reputational and ethical concerns will motivate advisors to avoid conflicts of interest.

The Morality of Larks and Owls: Unethical Behavior Depends on Chronotype as Well as Time of Day

The recently-documented “morning morality effect” indicates that people act most ethically in the morning because their energy wanes with the day. An estimated 40% of the population, however, experience increased energy levels later in the day. These “evening people,” we propose, should not show the morning morality effect. Instead, they should show the same or an increasing propensity toward ethicality in the evening. Two experiments supported this hypothesis, showing that people with a morning chronotype tend to behave more ethically in the morning than the evening, while people with an evening chronotype tend to behave more ethically in the evening than the morning. Thus, understanding when people will behave unethically may require an appreciation of both the person (chronotype) and the situation (time-of-day): a chronotype morality effect.

Effect of Reminders of Personal Sacrifice and Suggested Rationalizations on Residents' Self-Reported Willingness to Accept Gifts: A Randomized Trial

CONTEXT Despite expanding research on the prevalence and consequences of conflicts of interest in medicine, little attention has been given to the psychological processes that enable physicians to rationalize the acceptance of gifts. OBJECTIVE To determine whether reminding resident physicians of the sacrifices made to obtain training, as well as suggesting this as a potential rationalization, increases self-stated willingness to accept gifts from industry. DESIGN, SETTING, AND PARTICIPANTS Three hundred one US resident physicians from 2 sample populations (pediatrics and family medicine) who were recruited during March-July 2009 participated in a survey presented as evaluating quality of life and values. INTERVENTION Physicians were randomly assigned to receive 1 of 3 different online surveys. The sacrifice reminders survey (n = 120) asked questions about sacrifices made in medical training, followed by questions regarding the acceptability of receiving gifts from industry. The suggested rationalization survey (n = 121) presented the same sacrifice questions, followed by a suggested possible rationalization (based on sacrifices made in medical training) for acceptance of gifts, before the questions regarding the acceptability of gifts. The control survey (n = 60) asked about the acceptability of gifts before asking questions about sacrifices or suggesting a rationalization. MAIN OUTCOME MEASURES Physician self-stated acceptability of receiving gifts from industry. RESULTS Reminding physicians of sacrifices made in obtaining their education resulted in gifts being evaluated as more acceptable: 21.7% (13/60) in the control group vs 47.5% (57/120) in the sacrifice reminders group (odds ratio, 1.81; 95% confidence interval, 1.27-2.58; P = .001). Although most residents disagreed with the suggested rationalization, exposure to it further increased the perceived acceptability of gifts to 60.3% (73/121) in that group (odds ratio relative to sacrifice reminders group, 1.45; 95% confidence interval, 1.22-1.72; P < .001). CONCLUSIONS Providing resident physicians with reminders of sacrifices increased the perceived acceptability of industry-sponsored gifts. Including a rationalization statement further increased gift acceptability.

More Affected = More Neglected: Amplification of Bias in Advice to the Unidentified and Many

Professionals often give advice to many anonymous people. For example, financial analysts give public recommendations to trade stock, and medical experts formulate clinical guidelines that affect many patients. Normatively, awareness of the advice-recipient’s identity should not influence the quality of advice, and when advice affects a larger number of people, if anything, greater care should be taken to ensure its accuracy. Yet, contrary to this logic and consistent with research on the identifiable victim effect, results from two experimental studies demonstrate that advisors confronting a financial conflict of interest give more biased advice to multiple than single recipients and to unidentified than identified single recipients. Increased intensity of feelings toward single identified recipients appears to drive this process; advisors experience more empathy and appear to have greater awareness and motivation to reduce bias in their advice when the recipient is single and identified.

Association Between Academic Medical Center Pharmaceutical Detailing Policies and Physician Prescribing

Importance In an effort to regulate physician conflicts of interest, some US academic medical centers (AMCs) enacted policies restricting pharmaceutical representative sales visits to physicians (known as detailing) between 2006 and 2012. Little is known about the effect of these policies on physician prescribing. Objective To analyze the association between detailing policies enacted at AMCs and physician prescribing of actively detailed and not detailed drugs. Design, Setting, and Participants The study used a difference-in-differences multivariable regression analysis to compare changes in prescribing by physicians before and after implementation of detailing policies at AMCs in 5 states (California, Illinois, Massachusetts, Pennsylvania, and New York) that made up the intervention group with changes in prescribing by a matched control group of similar physicians not subject to a detailing policy. Exposures Academic medical center implementation of policies regulating pharmaceutical salesperson visits to attending physicians. Main Outcomes and Measures The monthly within-drug class market share of prescriptions written by an individual physician for detailed and nondetailed drugs in 8 drug classes (lipid-lowering drugs, gastroesophageal reflux disease drugs, diabetes drugs, antihypertensive drugs, hypnotic drugs approved for the treatment of insomnia [sleep aids], attention-deficit/hyperactivity disorder drugs, antidepressant drugs, and antipsychotic drugs) comparing the 10- to 36-month period before implementation of the detailing policies with the 12- to 36-month period after implementation, depending on data availability. Results The analysis included 16 121 483 prescriptions written between January 2006 and June 2012 by 2126 attending physicians at the 19 intervention group AMCs and by 24 593 matched control group physicians. The sample mean market share at the physician-drug-month level for detailed and nondetailed drugs prior to enactment of policies was 19.3% and 14.2%, respectively. Exposure to an AMC detailing policy was associated with a decrease in the market share of detailed drugs of 1.67 percentage points (95% CI, −2.18 to −1.18 percentage points; P < .001) and an increase in the market share of nondetailed drugs of 0.84 percentage points (95% CI, 0.54 to 1.14 percentage points; P < .001). Associations were statistically significant for 6 of 8 study drug classes for detailed drugs (lipid-lowering drugs, gastroesophageal reflux disease drugs, antihypertensive drugs, sleep aids, attention-deficit/hyperactivity disorder drugs, and antidepressant drugs) and for 9 of the 19 AMCs that implemented policies. Eleven of the 19 AMCs regulated salesperson gifts to physicians, restricted salesperson access to facilities, and incorporated explicit enforcement mechanisms. For 8 of these 11 AMCs, there was a significant change in prescribing. In contrast, there was a significant change at only 1 of 8 AMCs that did not enact policies in all 3 areas. Conclusions and Relevance Implementation of policies at AMCs that restricted pharmaceutical detailing between 2006 and 2012 was associated with modest but significant reductions in prescribing of detailed drugs across 6 of 8 major drug classes; however, changes were not seen in all of the AMCs that enacted policies.

Effect of physician disclosure of specialty bias on patient trust and treatment choice

Significance Disclosure policies, intended to protect consumers, are a popular solution across a range of industries such as health care, financial investments, mortgages, and other services in which professional advisors may suffer from potential bias from misaligned incentives. Using field data (recorded transcripts of surgeon–patient consultations) and a randomized controlled laboratory experiment, we examine and find that disclosures of specialty bias increase patients’ trust and their likelihood of choosing a treatment in accordance with the physicians’ specialty. Professionals and policy makers should be aware of the implications on advisee trust and choice when advocating for the disclosure of advisor bias. This paper explores the impact of disclosures of bias on advisees. Disclosure—informing advisees of a potential bias—is a popular solution for managing conflicts of interest. Prior research has focused almost exclusively on disclosures of financial conflicts of interest but little is known about how disclosures of other types of biases could impact advisees. In medicine, for example, physicians often recommend the treatment they specialize in; e.g., surgeons are more likely to recommend surgery than nonsurgeons. In recognition of this bias, some physicians inform patients about their specialty bias when other similarly effective treatment options exist. Using field data (recorded transcripts of surgeon–patient consultations) from Veteran Affairs hospitals and a randomized controlled laboratory experiment, we examine and find that disclosures of specialty bias increase patients’ trust and their likelihood of choosing a treatment in accordance with the physicians’ specialty. Physicians in the field also increased the strength of their recommendation to have the specialty treatment when they disclosed their bias or discussed the opportunity for the patient to seek a consultation with a physician from another specialty. These findings have important implications for handling advisor bias, shared advisor–advisee decision-making, and disclosure policies.

Investigations Before Examinations: “This Is How We Practice Medicine Here”

“All new patients have an x-ray before seeing the doctor.” As a physician, I found this sentence baffling—I had been taught that the physician’s role is to first see a patient, take a detailed history, perform an examination, and consider the differential diagnoses. Only then could I consider the investigations required to get closer to a diagnosis and determine a treatment plan. As a patient, however, my experience was different. Previously healthy with no medical problems, I began to feel a growing discomfort in my shoulder after a mandated vaccination. As the weeks progressed, the pain worsened, ultimately inhibiting me from performing routine tasks such as getting dressed. My primary care physician suggested steroid injections or a course of oral anti-inflammatories together with corticosteroids. Reluctant to have more injections, I opted for my physician’s suggestion of 1000 mg naproxen sodium daily while cautiously avoiding the oral steroids. As a small 160-cm woman, I am more sensitive than most to medications. In just 2 days, the naproxen gave me excruciating stomach pains—the treatment was worse than the shoulder pain. I berated myself for not questioning the physician about the high dosage. I stopped taking the medication and decided to try physical therapy. Within minutes of entering an outpatient orthopedic clinic for the physical therapy referral, I felt as if I was on a conveyor belt. I gave my name to the receptionist and received numerous forms covering my insurance details, medical waivers, and a single page to note my symptoms and medical history. After completing the forms, I was summoned to someone sitting at a desk with a cash register. I handed over my credit card, driver’s license, and insurance card for photocopying before returning to the waiting room. When my name was called again, I stood up and followed my escort. It did not dawn on me until I saw the large “X-Ray Department” sign that the assistant was not taking me to the physician. I asked her where we were going and was informed, “to get your x-ray.” Thinking that there was a mistake, I stopped walking and informed her that I had not seen the doctor yet. The assistant replied with equal surprise, “All new patients have an x-ray before seeing the doctor.” Still puzzled, I asked her how the doctor knew I needed an x-ray. She did not know how to respond. I said that I would like to see the doctor first. Flustered, she led me back to the waiting room. Finally, I see the physician. Opening my file, his first question was, “No x-ray?” “No,” I informed him, “I want you to examine me first since we don’t know if I need an x-ray.” I explained my injury and how I thought I had chronic inflammation. The surgeon reluctantly obliged and awkwardly examined my shoulder before hurrying back to his stooltoinsistthatIhavethex-ray. Iaskedwhy,sinceinflammation would not show on an x-ray. He replied, “To make sureyoudon’thaveanything‘bony’goingon.”“Bony?”Ienquired. “Such as what? What’s your differential diagnosis?” Hepausedandanswered,“Bonecancer.”Myeyeswidened. “Bone cancer? You think my symptoms are likely to be due to bone cancer?” He replied, “Oh no, no...” muttered incoherently under his breath and trailed off stuttering, “this...this is...this is just how we practice medicine here.” An uncomfortable silence ensued. We both knew that this was an unsuitable answer. The surgeon then gathered himself and raised his voice assertively stating that I needed the x-ray. Chastising me for disrupting the clinic’s operational efficiency, he scolded that I would have to wait longer. His frustrated tone suggested that I had done something terrible. Irecallsittingawkwardly,stillontheexaminationtable. I wanted to comply, to apologize even. But I also knew that thissurgeonordersx-raysonallnewpatientsbeforeknowinganythingabouttheirsymptoms.Howmanyx-rayswere performed on patients like me on the off chance of diagnosing bone cancer? What about radiation exposure and false-positiveresults?Anx-raywasnotmypreference,and, despite the pressure, I was not going to let him scare me into thinking that I had a high probability of something more sinister than inflammation. Against the strong innate urge to cooperate, I stated, “I’d prefer a physical therapy referral. If my pain does not improve in 6 weeks, I’ll return for that x-ray.” It was difficult to state this. However, I had been in a similar situation at another hospital a year before, when regretfully as a compliant patient, I gave in to an unnecessary contrast computed tomographic scan. I promPERSPECTIVE

Blinding Prosecutors to Defendants’ Race: A Policy Proposal to Reduce Unconscious Bias in the Criminal Justice System

Summary: Racial minorities are disproportionately imprisoned in the United States. This disparity is unlikely to be due solely to differences in criminal behavior. Behavioral science research has documented that prosecutors harbor unconscious racial biases. These unconscious biases play a role whenever prosecutors exercise their broad discretion, such as in choosing what crimes to charge and when negotiating plea bargains. To reduce this risk of unconscious racial bias, we propose a policy change: Prosecutors should be blinded to the race of criminal defendants wherever feasible. This could be accomplished by removing information identifying or suggesting the defendant’s race from police dossiers shared with prosecutors and by avoiding mentions of race in conversations between prosecutors and defense attorneys. Race is almost always irrelevant to the merits of a criminal prosecution; it should be omitted from the proceedings whenever possible for the sake of justice.

Behavioural Public Policy: Confessing one’s sins but still committing them: transparency and the failure of disclosure

If financial advisers disclose the fact that they get a bonus if their clients invest in a particular product, how will clients use that information, and to what extent will the disclosure help them make a better decision? If at all, how might the disclosure alter the advice given by advisers, or how might it affect the relationship between advisers and their clients? In this chapter, we address these questions. Reviewing extensive evidence that casts doubt on the efficacy of disclosure, we conclude that disclosure is not a panacea; it often fails to serve its intended functions and may sometimes backfire, hurting the interests of those it was intended to protect. Conflicts of interest, in which professionals have personal interests that conflict with their professional responsibilities, have been at the heart of many recent business fiascos. For example, the bubble in the American real estate market that burst in 2008 was partly supported by inflated ratings of collateralized mortgage bonds that were created by rating agencies that had financial ties to the issuers of those bonds. Many recent accounting scandals can be traced to conflicts of interest on the part of auditors, who received large consulting fees from the same firms they audited. Likewise, many health care professionals worry that similar problems have been created in medicine because of industry payments to physicians and fee-for-service compensation arrangements.