AMD Newsletter 21 September 2018
The concept of ‘conflict of interest’ (COI) arises in many contexts in the work of physicians, including in clinical practice, research, administrative tasks, educational activities, the conduct of meetings, the receipt of gifts and hospitality. Despite its importance and visibility, however, the concept is often loosely applied and poorly understood.
The publication of the RACP’s Guidelines for ethical relationships between health professionals and industry is an attempt to address this deficiency by clarifying the concept of COI and providing guidance to physicians about how to assess and manage relationships within which problems can arise. The comprehensive document – which took five years to develop and involved multiple internal and public consultations – is currently being adapted by the College Ethics Committee into multiple accessible, focused statements dealing with clinical issues, travel, gifts and hospitality, organisation of meetings, international work, and education. In line with the College’s approach to such documents in general, the ‘guidance’ is provided in the form of resources and access to ideas, information and arguments, rather than injunctions or paternalistic statements about how physicians are supposed to act.
This post will explain the concept of conflict of interest as developed in the Guidelines. A later one will describe some of the substantive conclusions relating to different settings. To illustrate the common confusion about what constitutes a COI one does not have to go far. The National Statement on Ethical Conduct in Human Research – the premiere Australian statement on the conduct of research – defines a COI as occurring where “a person’s individual interests or responsibilities have the potential to influence the carrying out of his or her institutional role or professional obligations…”. This definition is confused because individual “interests” and “responsibilities” often actually influence behaviour in authentic and favourable ways and serve as positive drivers for our professional activities, rather than standing in implacable opposition to them.
The RACP Guidelines take a simple, logical approach: a conflict of interest exists if and only if a person is simultaneously serving two interests that are in conflict. To be able to apply such a natural idea we clearly need to define precisely what is meant by an “interest”. While this concept has a long philosophical history, here too, there is a simple underlying idea: an interest refers to the placing of some kind of value on different aspects or components of our interactions with others. It is this value that helps us make up our minds when we find ourselves trying to distinguish between different possible courses of action.
To put this more precisely, an interest is “a commitment, goal, obligation or value associated with a social relationship or practice”. Commitments, goals, obligations and values can be financial or non-financial. Financial interests may include direct payments, gifts, shareholdings or employment responsibilities. Non-financial ones may include family loyalties, personal goals or ambitions, and political, religious or social commitments.
Clarification of the nature of an interest makes the concept of a conflict of interest straightforward. A COI occurs when two interests coexist that pull a decision-maker in two different directions at once. For example, if I am a physician looking after a particular patient, I have a defined obligation to actively protect her welfare. If I am also a researcher seeking to recruit that patient to my study, I have a coexisting obligation to science, knowledge and public welfare. If I try to play both roles at once I find myself serving two distinct interests which – in some circumstances at least – may not be completely compatible. This is because, at the moment of my decision, which of the two interests should take precedence may not be clear.
This example shows why conflicts of interest can be problematic: I cannot serve two opposing masters simultaneously. If one interest demands a particular course of action and another – coexisting – one requires a different action, how I should decide is uncertain.
Put like this, however, we have not only a procedure but also a test and a solution. The procedure is to declare all relevant interests (not ‘conflicts’ of interests) in an appropriately public and transparent manner. The test involves an independent body (e.g. a committee or a group of colleagues) assessing whether any two of those interests are in conflict in relation to a particular decision that needs to be made. If the outcome of the test is affirmative, the solution also becomes obvious: one of the conflicting interests has to be divested for the purposes of the decision – that is, I must vacate one of the conflicting roles (that of doctor treating this patient or of researcher seeking to recruit her) to another person for the appropriate time to allow us all to move on in an unconflicted manner.
A few points should be immediately apparent from this approach to COIs:
- A COI is not a mental attitude or a state of mind but an objective fact.
- There is nothing wrong or shameful about having COIs because they are just facts of life that result from the multiple roles we take on in our daily lives.
- It is the interests we declare, not the conflicts, and it is not for us to decide whether our own interests constitute a conflict, but for an outside, independent observer.
- Non-financial interests are often as potent drivers of behaviour as financial ones, even though financial interests dominate the great majority of discussions about COI.
Building on this concept of COI the Guidelines cover a wide range of issues relating to clinical practice, research, education and interactions with employers and for-profit providers of goods and services. It is hoped that the modern, rigorous approach described here will assist us as physicians in clarifying our purposes so that we can act transparently and effectively in relation to each other, our patients and the wider community.
Please feel free to share this article with colleagues and to contact me directly with any thoughts, ideas and suggestions you might have.
Professor Paul Komesaroff FRACP AM
President Adult Medicine Division
Telephone: +61 (0)417 55 26 59
AChAM President’s Report
The next APSAD webinar in the RACP Specialty Society Webinar Series will be on Performance and Image Enhancing Drugs on 30 October presented by Dr Matthew Dunn. All AChAM Fellows and trainees will receive an email indicating how to register for the webinar, but in the meantime please make sure you put this date in your calendar, so you can be sure to make it.
Registrations have now opened for the International Medicine in Addiction Conference 2019, which will be held from 1 to 3 March. Substantial savings can be made by registering early, so head to the website and register. The Program Committee are calling for poster abstracts that relate to the conference themes: behavioural aspects of addiction; stress and addiction; and controversies in prescribing and practice. Poster abstract submissions are now open until Friday, 26 October 2018 and details on how to submit an abstract can be found on the conference website.
Dr Martyn Lloyd-Jones
Australasian Chapter of Addiction Medicine
AChPM President’s Report
The Chapter Committee had a productive meeting via teleconference on 24 August. The Committee resolved to review its Evolve Top 5 List of low value practices in palliative medicine at this meeting. The current list is excellent but does not articulate low value practices for palliative medicine. It describes low value actions of all medical practitioners in regard to palliative and end of life care. We will be asking for your feedback on the revised list in the coming months.
The Chapter held a Fellows’ Update at the Australian and New Zealand Society for Palliative Medicine (ANZSPM) Conference in Manly, Sydney earlier this month, covering topics such as how the new RACP Board and committee structures are working and questions about current numbers of Fellows and trainees. The Clinical Diploma of Palliative Medicine remains a very useful and successful training opportunity for non-specialists to gain palliative medicine skills. The Clinical Diploma certificate and letter of completion has had some wording changed to articulate that the Clinical Diploma does not convey specialist status in palliative medicine. The ANZSPM conference was well supported and provided plenary talks about topics as diverse as the interface between haematology and palliative care, the economics of end-of-life care and new models and practices including how to use teleconferencing effectively. Thank you to those who attended – it was great to get together with palliative medicine Fellows and trainees from across Australia and New Zealand and further afield.
The Chapter Committee will meet on Friday, 19 October at the RACP Sydney office. Once again, if there are any issues you would like to raise with the Committee or if you have any feedback for us we would love to hear from you, so please do not hesitate to contact us through our secretariat at PallMed@racp.edu.au.
With kind regards,
Professor Greg Crawford
Australasian Chapter of Palliative Medicine
AChSHM President Report
Preparations are well underway for next year’s AChSHM Annual Scientific Meeting (ASM), which will be led by the Committee’s very own Dr Julian Langton-Lockton. The ASM will take place at the Novotel in Brisbane on Saturday, 16 March 2019 and will be followed by a Trainees’ Day at the RACP Office in Brisbane on Sunday, 17 March 2019.
The ASM Organising Committee is still seeking a Trainee Representative to join. The Organising Committee will meet for 30 to 60 minutes fortnightly via teleconference in the months leading up to the event, and some work will be completed between meetings via email. If you are interested in joining the Organising Committee as the Trainee Representative, please email the committee through the secretariat at email@example.com as soon as possible outlining why you are interested in being involved.
The AChSHM Committee will hold its next face to face meeting on Friday, 30 November at the Sydney RACP office. If there are any issues you would like to raise with the Committee, or if you have any feedback for us, please don’t hesitate to contact us through our secretariat at firstname.lastname@example.org.
Associate Professor Catherine O’Connor
Australasian Chapter of Sexual Health Medicine
Parliamentary Inquiry into Sleep Health Awareness in Australia
The Australasian Sleep Association has been talking to the politicians in Canberra in a joint campaign with the Sleep Health Foundation for over 12 months now and are pleased to announce that the Australian Parliament’s House Standing Committee on Health, Aged Care and Sport has now commenced an Inquiry into Sleep Health Awareness in Australia.
The terms of reference for this inquiry, given below, cover many areas that will be of concern to all physicians, and we would encourage individuals and/or specialty societies to make submissions to this important inquiry.
Terms of reference are to inquire into and report on sleep health awareness in Australia, in particular:
- the potential and known causes, impacts and costs (economic and social) of inadequate sleep and sleep disorders on the community
- access to, support and treatment available for individuals experiencing inadequate sleep and sleep disorders, including those who are: children and adolescents, from culturally and linguistically diverse backgrounds, living in rural, regional and remote areas, Aboriginal and Torres Strait Islander
- education, training and professional development available to healthcare workers in the diagnosis, treatment and management of individuals experiencing inadequate sleep and sleep disorders
- workplace awareness, practices and assistance available to those who may be impacted by inadequate sleep or sleep disorders, with a focus on: rostering practices for shift workers, heavy-work requirements, and the transport industry as compared to international best practice
- current national research and investment into sleep health and sleeping disorders.
It is important now that submissions are made into the inquiry.
The timeline is short (deadline for submissions is 18 October 2018), but the process is relatively easy.
For further information please visit the Parliament of Australia website.
Refugee and Asylum Seeker Health
The College has recently been active in advocating for child detainees at the Nauru immigration detention facility who are seriously unwell to be immediately transferred to Australia.
A media statement was released on 28 August and was picked up by radio. Associate Professor Karen Zwi, a paediatrician and Senior Fellow of the RACP, provided a statement saying that “The conditions, circumstances, and duration of offshore processing have damaged peoples’ health, particularly the health of children and their families,”.
For those who wish to read more about refugee health, a recent report from the World Health Organization (WHO) is available: A rapid review of evidence-based information, best practices and lessons learned in addressing the health needs of refugees and migrants: report to the World Health Organization (2018).
Convenient online learning opportunities
Diagnostic Error and Cultural Responsiveness are the focus of two Qstream courses RACP Members can register to undertake throughout November and December.
Participants are emailed case studies, based on real-life clinical scenarios, at spaced intervals. The case studies are designed with the aim of challenging physician thinking and enhancing professional practice.
The courses will run throughout November and December and take as little as five minutes a day, two to three times a week to complete via email.
Have your say on the new Basic Training programs
Have your say on learning, teaching, and assessment in Basic Training
Details about the new Basic Training programs are now available for review on the RACP website until 2 October 2018. This includes information about how the curriculum standards will be taught, learned, and assessed.
Fellows and trainees have been working in partnership with College staff to develop these proposed programs. Your feedback can help ensure that the new Basic Training programs are feasible and fit-for-purpose for implementation across Australia and New Zealand. As this is a public consultation, individuals outside the College who are interested in Basic Training are welcome to give feedback. You are invited to share the consultation with your wider network, if appropriate.
Have your say on the future of Basic Training.
Use the new Basic Training curricula standards to support your workplace learning
Earlier this year we launched new curricula standards for Basic Physician Training. These standards will start to be assessed in 2020, when the Knowledge Guides will be used as the basis for the 2020 Divisional Written Examinations.
You can now filter the curricula to see specific content relevant to you and export your filtered results to support workplace learning. Click here to try the Workplace Learning Planner.
Please contact email@example.com with any questions.
IMiA registrations are now open
The 5th International Medicine in Addiction conference will be held from 1 to 3 March 2019 at the Melbourne Convention and Exhibition Centre.
We look forward to welcoming you for two and a half days of thought-provoking presentations from internationally renowned clinical and research experts, as well as a range of practical workshops. Behavioural aspects of addiction, stress and addiction and the controversies in prescribing and practice are the focus of IMiA 2019.
To register your attendance, visit www.imia19.com.au. Don’t miss out on a discounted Early Bird rate by securing your ticket before the deadline, 30 November 2018.
Poster abstract submissions are open until Friday, 26 October 2018. This year we are seeking abstracts relevant to the conference themes:
- behavioural aspects of addiction
- stress and addiction
- controversies in prescribing and practice.
Details about how to submit an abstract are on the conference website.
RACP Indigenous Health Scholarships
Applications for the RACP Indigenous Health Scholarship Program open from Monday, 1 October to Friday, 30 November 2018. The scholarships are valued up to $40,000 and provide a funded pathway through Basic, Advanced, Faculty or Chapter training. They are offered to medical graduates, junior medical officers or trainees who identify as being of Aboriginal, Torres Strait Islander, Pacific Islander heritage, or Māori. The following are available for 2019:
Basic, Advanced or Chapter Training
- College Indigenous Health Scholarship
- Aboriginal & Torres Strait Islander Health Scholarship
- New Zealand Indigenous Health Scholarship
- Indigenous Health Scholarship in Rehabilitation Medicine
- Indigenous Health Scholarship for Occupational & Environmental Medicine
- The John McLeod Indigenous Health Scholarship in Public Health Medicine
Visit the RACP Foundation webpage for full details of all awards and prizes offered by your Division and Chapters. For more information about the eligibility criteria or the application process, please contact RACP Foundation at Foundation@racp.edu.au or call +61 2 9256 9639.
Medicinal Cannabis regulation changes in Queensland
Amendments to the Public Health (Medicinal Cannabis) Regulation 2017 enable all specialist medical practitioners in Queensland to prescribe medicinal cannabis without Department of Health approval when treating the following classes of patients: persons with chronic non-cancer pain, persons experiencing chemotherapy-induced nausea or vomiting, terminally ill persons with symptoms associated with terminal illness, children with intractable (drug resistant) epilepsy and persons with multiple sclerosis experiencing spasticity. TGA approval is still required for all unapproved medicinal cannabis products through the Special Access Schemes, Category A or B and the Authorised Prescriber pathway.
New partnership with the Pacific Community
On Monday, 10 September, the RACP and the Pacific Community (SPC) signed a Memorandum of Understanding (MoU) to support health frameworks and projects in the region and enhance capacity building in the health sector.
RACP President, Associate Professor Mark Lane, said the MoU will see the RACP and SPC work together on programs and initiatives, including some rolled out in partnership with other key health organisations such as the World Health Organization.
New Ethical Guidelines
The 4th edition of the Guidelines for ethical relationships between physicians and industry are now available. These voluntary guidelines, developed by the RACP Ethics Committee, revise previous editions of the guidelines and seek to support health professionals in identifying, assessing and managing conflicts of interest. Access here.
Blood product modifications – who needs what? Presented by Dr Zoe McQuilten
Australian & New Zealand Society of Blood Transfusion webinar
When: Tuesday, 25 September 2018 at 5:00 PM (Canberra, Melbourne, Sydney)
Register in advance for this webinar: https://racp.zoom.us/webinar/register/WN_loFymI9lSmyfc86hKgpXLg
After registering, you will receive a confirmation email containing information about joining the webinar.
This webinar is part of the Specialty Society Webinar Service pilot that is being undertaken by the Royal Australasian College of Physicians in partnership with its affiliated specialty societies.
Trainee Interest in Global Health Training survey.
Trainees are invited to participate in the Trainee Interest in Global Health Training (TIGHT) survey. Ethics approval has been granted by James Cook University Human Research Ethics Committee.
The objective of this study is to explore interest in global health careers and training amongst trainees in specialty training programs. It aims to quantify the number of trainees interested in undertaking accredited rotations in low- and middle-income countries. The findings will guide the development of future training opportunities in global health.
The survey will take you 5 to 10 minutes to complete and can be accessed via: https://www.surveymonkey.com/r/GlobalHealthTraining
Please contact firstname.lastname@example.org if you have any questions.
Are you currently planning to undertake research as part of your Advanced Training? The Evolve recommendations offer an opportunity to undertake research in low-value care in specific health priority topics, such as bronchiolitis, polypharmacy and antimicrobial stewardship. Find out more about Evolve and low-value care research opportunities in your specialty by contacting email@example.com or visit www.evolve.edu.au for more information.
Evolve Clinical Champions
Are you interested in being involved in Policy & Advocacy within RACP? The Evolve initiative offers an opportunity to advocate for high-value, high-quality care in your specialty. Find out how you can become an Evolve Clinical Champion by contacting firstname.lastname@example.org or visit www.evolve.edu.au for more information.
Evolve at Conferences
This year, RACP has presented on Evolve at RACP Congress, Choosing Wisely National Meeting, National Medicines Symposium, ANZSGM, SOMANZ and GESA AGW and are looking forward to attending ASCEPT’s ASM in Adelaide during November. We are inviting specialty societies to express interest in RACP attending an ASM to present on Evolve implementation and/or host an exhibition booth. For more information and to express interest in RACP and Evolve attending your ASM, contact email@example.com.
Bushfire Season is approaching, be prepared.
Australia is facing the possibility of having a much longer fire season of about six or seven months, with bushfire season officially starting in October 2018 and running through to April 2019.
Now is the time to prepare for the bushfire season. Click here to see Vero bushfire tips on how to prepare.
Visit your RACP Member Advantage website to find out more or give Vero a call on 1800 250 962 for a quote on home and contents insurance.
Evaluation Sub-Committee (ESC) items for the 5 October 2018 Meeting
The following items are expected to be considered at the next ESC meeting on 5 October 2018.
Submission Based Assessments
Contracted Assessment - Resubmissions
For more information on these applications please visit the MSAC website.
Conferences and Events
The Royal Australasian College of Physicians publishes notices of events and courses as a service to members. Such publication does not constitute endorsement or mandating of any such events or courses.
Australian Diabetes Society Insulin Pump & CGM Workshop
Perioperative Medicine SIG meeting 2018
International Medicine in Addiction Conference 2019
New South Wales
VMO in General Medicine and Cardiology
Contact: Dr Simon O'Connor via email at firstname.lastname@example.org