Truth, Trust, and Transparency—The Highly Complex Nature of Patients’ Perceptions of Conflicts of Interest in Medicine

Half of all US physicians receive payments from the biomedical industry, totaling $2.4 billion in 2015.¹ While this phenomenon reflects critical physician-industry collaboration, we cannot ignore the conflicts of interest (COIs) that these financial relationships introduce into medical practice. Motivated by the notion that patients should have access to this payment information to make more informed medical decisions, the Physician Payments Sunshine Act was implemented in 2013. Under the 2010 Patient Protection and Affordable Care Act, pharmaceutical and medical device manufacturers are required to report all gifts and payments they make to physicians. Run by the Centers for Medicare & Medicaid Services, this information is publicly available, with the aim of increased transparency to engender patient trust and (ideally) improve care.² To this end, Kanter et al³ attempted to ask: did it work? Do patients trust their physicians (and the medical field) more now that they can access information on industry payments?

In their national study of 1388 US adults, Kanter et al³ performed a difference-in-difference analysis comparing the longitudinal change in trust among respondents in states where industry payments were newly disclosed via Open Payments with states where industry payment information was already available due to state disclosure laws. After controlling for demographic variables, they concluded that there was an “unintended consequence” of Open Payments: the authors found a greater decline in trust among states with newly available Open Payments information compared with states with preexisting publicly available financial disclosure data. Is it possible that increased payment transparency actually undermined patient trust in physicians?

Several major assumptions must be made to attribute this nationwide decline in patient trust to Open Payments. First, we would have to assume that respondents even know that Open Payments exists; however, prior research shows that only 12% of US adults are aware of the data.⁴ Second, we would have to assume that patients care about these payments. A study⁵ interviewing patients in cancer research trials specifically about their attitudes toward financial COIs revealed that they did not care much about whether their physicians were involved with industry, and most actually classified speaker and consulting fees as “ethical.” Another study⁶ found that some patients viewed physicians without payments as inexperienced or professionally isolated, and they alternatively viewed physicians with consulting payments as experts and better informed. Third, the biggest assumption is that we can attribute the nation’s trust in health care from 2014 to 2016 specifically to Open Payments as opposed to the myriad of other variables surfacing during this time. Health care is dynamic, and important factors like rising health care costs, frustrations with insurance coverage, availability of physicians, access to care, media coverage of health care, and publicized physician scandals (to name a few) can all potentially influence patients’ perceptions of trust. While Kanter et al³ attempted to account for confounding variables by comparing states, this approach cannot control for possible state-specific factors (ie, managed health care groups and state-run insurance programs).⁷

Nevertheless, if we make these assumptions and thus conclude that increased transparency of payments is associated with decreased trust, should we be that surprised? Is it so clear-cut that increased transparency should automatically engender trust? Research in nonmedical fields tells us otherwise. In government, transparency was historically thought to improve decision making, impede corruption, enhance accountability, and lead to a more informed citizenry; yet, evidence reveals that increased transparency can overwhelm citizens, leading to confusion and undermining government legitimacy and trustworthiness.⁸ In business, corporate transparency has increased in response to prominent corporate scandals, although this may have led to a paradoxical effect of causing “information overload,” second-guessing of senior executives’ decisions, and reducing creativity.⁹ Do these parallel phenomena mirror how Open Payments possibly contributed to information overload for patients or undermined the trustworthiness of physicians?

Only 3% of respondents in the study by Kanter et al³ reported knowing whether their physician had received industry payments. Therefore, the authors conclude that the decline in trust was not associated with by respondents’ firsthand interactions with Open Payments but rather with the newfound awareness that physician-industry financial relationships exist. As the authors discuss, without personally viewing Open Payments data, it is possible that these individuals discovered physician-industry ties through media reporting, which tends to focus on the newsworthy minority of physicians with the most egregious, highest-valued payments.¹ As we veer away from a culture of having a long-term primary care physician, it is possible that when asked about trust in “their physician” respondents thought about the last physician they encountered. Perhaps this was a specialist, such as a cardiologist, resulting in a biased sample of physicians receiving significantly higher-valued payments,¹ thus negatively painting all physicians “with a broad brush.”³ Yet, COIs are more complicated than direct correlations between higher-valued payments and greater influence on medical decision making. In fact, even physicians receiving a single industry-sponsored meal were associated with a significantly increased rate of prescribing brand-name medications.¹⁰ If small but powerful payments to primary care physicians undermine patient trust, this could arguably have a greater effect on patient care given the critical role of trust in one’s adherence to treatment, self-management, and use of preventive care services.³

The small (but vital) subanalysis by Kanter et al³ of respondents who confirmed they had looked their physician up on Open Payments revealed an interesting plot twist: trust in their physician actually increased if they knew that he or she did not receive payments, and trust in the medical field increased whether or not their own physician received payments. This small subset of respondents (only 3%) may represent a selection bias; perhaps they have a regular physician in mind whom they looked up, and they are inherently more likely to be trusting given their ongoing relationship. In addition, if they consider the physician of interest to be their physician, this may represent primary care physicians, who have lower payment values. As opposed to the “proceduralist effect” of losing trust after discovering high-valued payments, these respondents may be pleasantly surprised by the relatively small-valued payments (which is ironic given our previous discussion of the powerful potential influence of even 1 low-cost, pharmaceutical-sponsored meal). Or, perhaps this distinct subset of more trusting respondents reflects the important role of interacting with the data and developing one’s own opinion to achieve the true “transparency” that promotes trust.

Trust is complex, dynamic, and highly variable. Recent events, both big and small, can greatly influence trust in a physician. Still, the findings in the study by Kanter et al³ suggest that there could be powerful but subtle influences of physician-industry financial ties on patients’ perceptions of the medical field. It forces us to question the notion that public disclosure equates to transparency and that this transparency is enough to guarantee patient trust. Releasing the data is the first step; whether patients access it, and how they process and accept this information, is a complicated process fundamental to either engendering or undermining trust. Ultimately, the onus is on health care professionals to discuss implications of their industry relationships and develop trusting relationships with their patients to improve care. We can thank the implementation of Open Payments for starting the conversation, but it is up to us now to continue an honest, face-to-face discussion with our patients if we want to earn and maintain their trust.

Published: April 12, 2019. doi:10.1001/jamanetworkopen.2019.1929

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Tringale KR et al. JAMA Network Open.

Corresponding Author: Jona A. Hattangadi-Gluth, MD, Department of Radiation Medicine and Applied Sciences, University of California, San Diego, 3855 Health Sciences Dr, La Jolla, CA 92037 (jhattangadi@ucsd.edu).

Conflict of Interest Disclosures: Dr Tringale reported receiving grants from the National Institutes of Health (contract 1TL1TR001443) outside the present work. Dr Hattangadi-Gluth reported receiving grants from Varian Medical Systems unrelated to the present work and reported receiving other support from Vision RT outside the present work.