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.