Duties and responsibilities

Expectations of physicians in practice

Commercial interests and how physicians can avoid the pitfalls

Originally published January 2015
W15-001-E

Canadian physicians and industry have a long-standing tradition of working together to improve patient outcomes. Working collaboratively, they conduct clinical research, develop and test medical devices, and participate in pharmaceutical trials to deliver new medications. While these arrangements yield many benefits, there are potential pitfalls. Physicians can, however, take steps to minimize ethical quandaries and avoid conflicts that can arise when dealing with commercial interests.

What is a commercial interest?

In the healthcare context, a commercial interest (i.e. industry) generally develops, sells, or distributes healthcare products or services for patients, such as pharmaceuticals, medical devices, and biotechnology. Doctors may become involved with commercial interests when they provide clinical services, undertake research, or participate in professional development. Physicians may also encounter commercial interests in non-medical activities, such as advertising or leasing office space from a pharmacy or other business.

Physicians must ensure their collaborations with commercial interests align with their fundamental responsibilities to the patient and society. Conflict of interest occurs when doctors' personal relationship or business arrangement with industry is, or is perceived to be, incompatible with their professional responsibility or Code of Ethics. "Physicians should resolve any conflict of interest between themselves and their patients resulting from interactions with industry in favour of their patients"1 and in accordance with their professional responsibilities.

Ethics and professionalism

The Canadian Medical Association's (CMA) Code of Ethics2 provides an ethical framework for physicians to deal with commercial interests. Physicians must consider first the well-being of their patients and resist any influence or interference that could undermine this relationship or the physician's professional integrity. In Québec, the Code of Ethics of Physicians3 states, "A physician must safeguard his professional independence at all times and avoid any situation in which he would be in conflict of interest, in particular when the interests in question are such that he might tend to favour certain of them over those of his patient or where his integrity and loyalty toward the latter might be affected."

Canadian medical regulatory authorities (Colleges) also provide guidance to help doctors understand and appropriately manage their relationships with industry. Many of these expectations are grounded in the fundamental principles and values of medical professionalism. The College of Physicians and Surgeons of Alberta (CPSA), for example, states "A physician must not enter into a relationship with industry if it weakens the fiduciary relationship with any patient of that physician."4 The CPSA also notes that "A physician must disclose to a patient any relationship between the physician and industry that reasonably could be perceived as having the potential to influence the physician's clinical judgment.5

Tips for clinical practice

Clinical judgment should not be influenced by relationships with industry. Colleges describe potential conflicts concerning gifts and compensation from commercial interests, including when industry representatives visit a physician's office. Compensation and personal gifts cannot be accepted in exchange for meeting with industry agents. However, gifts that might advance patient education such as teaching aids may be acceptable if these primarily benefit the patient and have no value to physicians outside their practice.6 Drug samples may also be accepted, but must comply with applicable College guidelines such as not using the samples for personal or family use. If a physician agrees to allow an industry representative to provide information about products or services, meals may be accepted if they are of modest value. Physicians are generally discouraged by Colleges from selling or promoting products that are not medically necessary, such as supplements and herbal remedies.7

Information about a product or service provided by industry must be evaluated by the physician before making decisions on use with patients (including education materials such as pamphlets). Physicians participating in industry-sponsored surveillance studies should ensure the study extends medical knowledge and is approved by the appropriate research ethics body. Physicians may also be required to report patient safety incidents (adverse events) to the appropriate body or authority while participating in such a study.8

Tips for educational events

The CMA Guidelines for Physicians in Interactions with Industry provides information about organizing industry-supported continuing medical education or professional development events (CME/CPD). In Québec, guidance can be obtained from the Code of Ethics for parties involved in Continuing Medical Education9. Generally, continuing medical education content, materials, processes, physical space, and presenters are not to be influenced by industry sponsors.10 Organizers, meanwhile, must disclose industry sponsorship of the event. Any funds received from industry should be through an educational grant to the organization sponsoring the event. Fair market-value payment should be received only for presenting on behalf of industry, and can include reasonable travel, accommodation, and meals. These payments should normally come through the meeting organizer and not directly from industry (although there are exceptions if there is no organizing body). In Québec, the Code of Ethics of Physicians states, "A physician may not be party to any agreement or accept any benefit that could jeopardize his professional independence, particularly in the context of continuing medical medication activities."11

When physicians are presenting, educational materials and presentations should refer to generic names (if they exist), in addition to trade names.12 Physicians attending an educational event must not accept payment for travel, accommodations, or meals from industry, although meals of modest value provided at an event are usually acceptable.

Tips for non-clinical activities

When physicians are asked by industry to become members of advisory or consultation boards, CMA policy states physicians should have a written agreement outlining the details of this relationship.13 The agreement must indicate the physician possesses specialized medical knowledge that could not otherwise be acquired. Physicians should not participate in promotional events or educational activities on behalf of industry. Any compensation for consultation or advisory activities should be at fair market value for the services provided.

It is becoming more common for physicians to lease office space in buildings owned by other health professionals or retail pharmacies. It is a conflict of interest if the lease or rental agreement is markedly different from fair market value or dependent on the volume of business generated by a physician or third party.14 Professional guidelines state that a physician must not refer to a facility or healthcare business in which the physician has a direct or indirect interest such as a treatment or diagnostic facility, although there are a few exceptions such as in a community with an unmet need.

Resources

Given the sometimes close relationships between physicians and industry, it is not always easy to recognize the potential pitfalls of commercial interests. By being aware and taking steps to avoid real or perceived conflicts of interest, physicians can effectively maintain their professional integrity and mitigate the risk of complaints.

Most Colleges and medical associations have policies, standards, and guidelines for physicians and their relationships with commercial interests. The CMPA encourages member physicians to review these in their jurisdiction. Members concerned about potential conflicts of interest may also contact the CMPA for individual advice.

   
 

References

  1. Canadian Medical Association. Guidelines for Physicians in Interactions with Industry. CMA Policy, 2007. Retrieved October 17, 2014 from: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf
  2. Canadian Medical Association, Code of Ethics, 2004. Retrieved on October 17, 2014 from: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf
  3. Collège des médecins du Québec, Code of Ethics of Physicians of Québec, c.M-9, r.17, O.C. 1213-2002, s. 63. Retrieved on November 3, 2014 from: http://www.cmq.org/~/media/132E0C657730482DBEE837D7473D439D.ashx
  4. College of Physicians and Surgeons of Alberta. "Relationships with Industry," Reissued April 3, 2014. Retrieved October 22, 2014 from: http://www.cpsa.ab.ca/Libraries/Res_Standards_of_Practice/CPSA_Standards_of_Practice_Consolidated_Version.pdf
  5. Ibid
  6. College of Physicians and Surgeons of Ontario, "Physicians Relationship with Industry: Practice, Education and Research," Policy Statement #2-14. Retrieved October 24, 2014 from http://www.cpso.on.ca/CPSO/media/images/Policies%20and%20Publications/Rel_Industry.pdf?ext=.pdf
  7. Ibid
  8. Canadian Medical Association. Guidelines for Physicians in Interactions with Industry. CMA Policy, 2007. Retrieved October 17, 2014 from: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf
  9. Conseil de l'éducation médicale continue du Québec. Code of Ethics for parties involved in Continuing Medical Education, 2003. Retrieved on November 3, 2014 from: http://www.cemcq.qc.ca/en/documents/guide_ethique.pdf
  10. Canadian Medical Association. Guidelines for Physicians in Interactions with Industry. CMA Policy, 2007. Retrieved October 17, 2014 from: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf
  11. Collège des médecins du Quebec, Code of Ethics of Physicians of Québec, c.M-9, r.17, O.C. 1213-2002, s. 80. Retrieved on December 22, 2014 from: http://www.cmq.org/~/media/132E0C657730482DBEE837D7473D439D.ashx
  12. Canadian Medical Association. Guidelines for Physicians in Interactions with Industry. CMA Policy, 2007. Retrieved October 17, 2014 from: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf
  13. Ibid
  14. College of Physicians and Surgeons of British Columbia. Conflict of Interest: Professional Standards and Guidelines. Vancouver, 2010. Retrieved on October 23, 2014 from: https://www.cpsbc.ca/files/pdf/PSG-Conflict-of-Interest.pdf

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.