Maintaining Core Values
Specialists in hypertension pursue a number of related disciplines including epidemiology, research, medical education, and clinical practice. All are required to advance the knowledge base, disseminate the expertise, and implement the treatments designed to reduce the toll of human suffering that occurs as a consequence of chronic hypertension. Regardless of our particular area(s) of expertise, however, developments in health care seem to be conspiring to compromise our heritage as members of the medical profession and constrain our ability to provide the best available care to our patients. The advantages of a medical career traditionally included intellectual stimulation, personal autonomy, and the satisfaction of earning a livelihood by contributing to the welfare of others. How uninspiring it is to function in an environment that increasingly questions the motives of our research and defines “productivity” on the basis of relative value units, quality on the basis of adherence to arbitrary guidelines, and much of medical education as an opportunistic exercise designed to serve the economic interests of third parties.
We are frequently charged with “conflict of interest,” as if its very presence removes the legitimacy from any endeavor. In most cases, the discussion centers around the relationship between a funding source and an investigator, consultant, or speaker who allegedly promotes opinions and behavior that are more beneficial to the sponsor than to the public good. We hear much less about other types of financial incentives that are regularly directed at medical practitioners. In many health plans, physicians are financially rewarded based on the degree to which they utilize generic drugs to reduce pharmacy costs. While it is not unreasonable to utilize cost as one measure of performance, it should be recognized that this type of payment system gives the practitioner an economic incentive to favor certain treatments over others regardless of whether they are in the patient’s best interest. As Michael Weber, MD, correctly points out in a recent The Journal of Clinical Hypertension editorial, conflict of interest in the medical profession “occurs when practitioners accept personal rewards in return for actions that could violate their professional obligations” [italics added]. While the behavior of practitioners who accept insurance company incentives may be exemplary, it should be recognized that this situation involves a direct conflict of interest and must be included in any discussion regarding outside influences on medical decision making.
In these confusing times, it is useful to reaffirm our commitment to the core values of our profession and use them to resolve potential conflicts. Ultimately, we are accountable only to the patients we serve. The field of hypertension is concerned primarily with interventions designed to maintain health and well‐being. Any new drug or treatment paradigm that contributes to health maintenance should therefore be welcomed into our therapeutic armamentarium. Investigators, educators, and commercial enterprises who develop, promote, and educate others about the new treatment deserve praise if they make a genuine contribution to the health of the hypertensive population and censure if they advance their own self‐interest at the expense of the patient community by disseminating false or biased information. Similarly, practitioners who optimize resource utilization through selection of cost‐effective generic equivalents deserve our support, whereas behavior that maximizes personal income at the expense of optimal patient treatment should be condemned.
We need to recognize that conflict of interest is, in many cases, an inevitable part of rational decision making. It need not be feared or criticized but rather intelligently managed in accordance with the time‐honored principles of medical professionalism. The American Society of Hypertension endorses these principles, which mandate that—when conflicts arise—physician decision making should always be governed by concern for patient welfare.