Aniello Iannuzzi: Conflict of power

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