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PRSonally Speaking
Monday, June 23, 2014
Thoughts on "the Impact of Conflicts of Interest in Plastic Surgery: An analysis of Acellular Dermal Matrix, Implant-Based Breast Reconstruction"
By Anu Bajaj, MD
 
After seeing the proposed TOC for the June issue of PRS, I was intrigued by the title of Lopez, et al.’s   “the Impact of Conflicts of Interest in Plastic Surgery:  An analysis of Acellular Dermal Matrix, Implant-Based Breast Reconstruction”.  I have always wondered whether certain biases influence our decision-making in medicine.  Most of us will deny that we are influenced by external factors and the potential for financial gain when we treat our patients.  But I’m not sure that this is always true.  And it can be far more complicated than we realize because there may be many more subtle conflicts of interest in our everyday lives.
 
"While it is tempting to say that the financial rewards we obtain from either patients or industry are our “treats”, I don’t believe that it is so simple."
 
Last year, I adopted a second lab, Scout.  Scout and I have been taking additional obedience training classes – mainly because he is my problem child.  For those of you who don’t have dogs, most of the training involves rewards (treats) for good behavior.  If he looks at me when I ask, he gets a treat; if he doesn’t growl at my neighbor, he gets a treat; if he sits and stays, he gets a treat.  While it is tempting to say that the financial rewards we obtain from either patients or industry are our “treats”, I don’t believe that it is so simple. 
 
Lopez’s article defines a medical conflict of interest as, “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).”  In the article, conflicts of interest can take many forms -- recipient of grants, royalties, stock options, member of speaker’s bureau or advisory board, and employee or consultant status; according to the article, most reported conflicts of interest were being a consultant or members of a speaker’s bureau.
 
Over the past few years, I have incorporated the use of ADMs into my breast reconstruction practice.  However, I have always had concerns about the complication rates in my patients and in the literature.  I do believe that in the right patient and under the right circumstances, their use provides a huge benefit.  Nevertheless, I have always been suspect of the studies that many of the different sales representatives have shown me about the use of ADMs; invariably, these studies report low or comparable complication rates when an ADM is used and when no ADM is used. 
 
"While this article discusses one type of conflict of interest, I started to consider the other types of conflicts of interest that each of us grapples with on a daily basis."
 
My concerns were validated after reading this article.  In Lopez et al.’s analysis, they found that there was a lower complication rate with the use of an ADM if a conflict of interest was reported; however, when no ADM was used, studies with and without conflicts of interests reported similar complication rates.  This finding correlates with the author’s initial hypothesis that industry funding of research is more likely to be associated with pro-industry findings.
 
While this article discusses one type of conflict of interest, I started to consider the other types of conflicts of interest that each of us grapples with on a daily basis.  One example would be the young surgeon who chooses to operate on a borderline surgical candidate – a woman, who is a poor surgical candidate, is referred for breast reconstruction from a general surgeon whose last patient you saw was also not a surgical candidate.  You may choose to offer this patient surgery where as two weeks ago you may not have offered her surgery because you don’t want to lose this general surgeon as a referral source or because it is a “slow” week.
 
"The reality is that we have potential conflicts of interest every day in our lives – both personal and professional."
 
Another type of conflict of interest is at the heart of our specialty.  We routinely perform elective surgical procedures for money, and on the most basic level, every cosmetic patient is a potential conflict of interest.  Once again, not all patients will be ideal surgical candidates.  For example, several weeks ago, I was supposed to perform an abdominoplasty on a woman whose past medical history was only significant for gestational diabetes.  On her pre-operative bloodwork, I discovered that her blood sugar was over 350.  She argued with me to go ahead and proceed with surgery; I chose to cancel her surgery, refunded her money, and referred her to a primary physician to work-up and treat this new diagnosis.  I had counseled her that we could perform her elective surgery once her medical issues were well-controlled and that I was trying to do what was in her best interest; however, I have to admit that as she cried and begged, it was tempting to say “ok, let’s do surgery.”
 
The reality is that we have potential conflicts of interest every day in our lives – both personal and professional.  As surgeons who strive to care for our patients and use evidence-based medicine to help our clinical decision-making, we have to be aware of these conflicts so that we can appropriately interpret the data.  We will never be able to completely eliminate these conflicts of interest.  Rather, we have to be aware of them and do our best to analyze our motives if there is ever any doubt.
 
 

 
About the Blog

Plastic and Reconstructive Surgery

PRSonally Speaking is the official blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit our blog for exclusive previews of and discussions on hot topics in plastic surgery as well as insider-tips on open access content. PRSonally Speaking is now powered by frequent contributions from the American Society of Plastic Surgeons’ Young Plastic Surgeons Forum (YPS); these practicing plastic surgeons provide the personal side of the plastic surgery story, from daily challenges to unique insights. PRSonally Speaking is home to lively, civil debate on hot topics and great discussions pertaining to our field. So, bookmark us, subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your Journal; have fun, be respectful, get engaged and interact with the PRS community.

The views and recommendations of guest contributors do not necessarily indicate official endorsements or opinions of the Journal, PRS, or the ASPS. All views are those of the authors and the authors alone.

Contributors

Anureet K. Bajaj, MD is a practicing plastic surgeon in Oklahoma City. She completed residency and fellowship in 2004, had a brief stint in academia at the University of Cincinnati, and then chose to join her father (Paramjit Bajaj MD, also a practicing plastic surgeon) in private practice in OKC, where she focuses on breast reconstruction and general cosmetic surgeries.

Devra B. Becker, MD, FACS, is an Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at University Hospitals/Case Western Reserve University School of Medicine in Cleveland, Ohio. She completed Plastic Surgery residency at Washington University School of Medicine in St. Louis, and completed fellowships with Daniel Marchac and with Bahman Guyuron. She currently has a primarily reconstructive practice.

Henry C. Hsia, MD, FACS is at Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey and also holds an appointment at Princeton University.  When he’s not working hard trying to be a good father and husband, he runs a practice focused on reconstructive surgery and wound care as well as a research lab focused on wound biology and regenerative medicine.

Stephanie K. Rowen, MD is a senior physician at The Permanente Medical Group in San Jose, California.  She joined TPMG upon finishing residency and a hand surgery fellowship in 2005.  She has a primarily reconstructive practice, about 50% hand surgery.  Outside of work she enjoys participating in triathlons and spending time with her family.

Jon Ver Halen, MD is currently an Assistant Professor in the Department of Plastic Surgeryat the University of Tennessee Health Science Center, in Memphis. He also acts as Program Director for the plastic surgery residency. His practice focuses on oncologic reconstruction.

Tech Talk Bloggers

Adrian Murphy is a plastic surgery trainee in London, England. He studied medicine in Dublin, Ireland and has trained in Ireland, Boston, MA and the United Kingdom. He is a self-confessed geek and gadget aficionado.

Ash Patel, MD is Assistant Professor of Plastic Surgery and Associate Program Director at Albany Medical College, in Albany NY. His practice is primarily reconstructive.