Conflict of Conscience

Mikkael Sekeres, MD, MS
Director of the Leukemia Program at the Cleveland Clinic in Cleveland, Ohio

On the first Wednesday of every month, the Innovation Management and Conflict of Interest Committee at Cleveland Clinic meets to discuss some of the thornier issues that have arisen with our staff members and their relationships with external entities. I am a standing member of this committee, and the majority of our discussions center on the types of conflicts one would expect: Dr. Kildare serves on an advisory board for the Cureall Pharmaceutical Company, for which he receives $15,000 annually and is also the primary investigator on a trial of their lead drug, tumorkillamab; or Dr. Zhivago gives unbranded talks, making $30,000 annually, as a member of the speaker’s bureau for Stablelesion Drug Corp., makers of fairlyactivemib, a drug he also prescribes in clinic. The first example represents a research conflict, the second a conflict of commitment. Both require a formal management plan, which may include public disclosure on our institution’s website, verbal disclosure to patients, written disclosure in the medical record or as part of the informed consent process, separation of the investigator from the interpretation of study results or from doing research with the external entity at all, or a combination of these.

We make similar disclosures when we submit abstracts to meetings or manuscripts to journals, or when we participate in continuing medical education (CME) programs. And while we frequently have to daven by the Western Wall of conflict of interest (COI) disclosures – bemoaning what truly awful people we are for eating that sandwich at a satellite symposium – we often don’t discuss the subtler, yet ubiquitous, conflicts that affect us daily in practice and research but can’t be quantified on an International Committee of Medical Journal Editors form.

Here, for all to see, are my conflicts, in no particular order of importance. I hope my transparency will encourage others to be equally forthright at their next public presentation or journal submission.

Conflict of having to put my kids through college. Yes, in two, six, and 10 years, my offspring will be finishing high school. If you’re doing the math, that translates to an unremitting 12-year period of sending love notes in the form of regular checks to their college of choice. College tuitions and expenses have been increasing at a rate that far outpaces the salary bumps received annually by doctors and pharmacists (my wife’s profession). Thus, I participate in pharma-sponsored activities, in part, to help ensure that my children are not living in our basement long-term. Not that I don’t love them and wouldn’t welcome having them … but they do have to leave.

Conflict of wanting to get promoted. For anyone who has gone through this process, attaining the rank of assistant professor requires having at least a regional reputation, associate professor a national reputation, and full professor an international reputation. Academic rank is based partly on publications and presentations as well as on the recommendations of external referees: people who know your work and have not collaborated with you (at least not recently), but who can attest to your being as much of a superstar as you think you are. Often, the ability to travel around the country or world to give presentations to preach your own particular gospel occurs via CME programs, including grand rounds at major institutions. Those CME programs are mainly pharma-funded. While you might argue that important research published in high-impact journals should be enough, academic medicine is a social science and facetime matters. At some institutions, if being promoted isn’t reward enough, it also translates into a salary bump. See “Conflict of having to put my kids through college” for more information on this point.

Conflict of getting new drugs for my patients. Many people come to see me because they have terrible hematologic malignancies and have run out of viable options. Given this, I consider it a personal embarrassment not to have a clinical trial available that I can offer them. The road to securing an important clinical trial at your institution is a murky one, indeed. Few new drugs are “home grown” – developed by a colleague in a lab down the hallway from your office and brought to your clinic to be tested in patients. Most come from industry, and being able to participate in an investigator- or pharma-initiated trial with one of their drugs means getting on their radar. With established investigators who have previously demonstrated good citizenship in trial participation, this isn’t such a challenge. Companies will approach previous participants or “friends” who have worked with you in the past who will recommend you. For those just getting started or who are trying to build programs, though, the usual route to company recognition is through participation in advisory boards or speakers’ bureaus.

Now, I’m not saying that it is impossible to avoid these conflicts. Certainly, my highly successful colleagues at the National Heart, Lung, and Blood Institute and the National Cancer Institute are prohibited from doing many of the activities I have mentioned above (though, they do have an intramural stream of funding that helps). And we can always refuse the honoraria that are proffered to us, choosing instead to donate the money to research funds or a charity (though this still needs to be disclosed, as the conflict has not necessarily been eliminated).

I also don’t have any easy solution to these problems, as resolving them would require a national commitment to revamping education and clinical research funding streams.

But, given the sheer number of potential conflicts – and the intangibility of the ones that probably influence our behavior most – perhaps we shouldn’t get in as much of a twist about the ones we are forced to disclose. Alternatively, we could all just recognize that, though we are all conflicted in a number of ways in our work and personal lives, we are moral human beings compelled to treat our patients with drugs that are always in their best interests. We could teach our colleagues about COIs with the sole goal of making them better health-care providers – and promise them that eating that sandwich from an educational symposium won’t influence either of these behaviors.

Even if it gives us a little indigestion.

The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.

Have a comment about this editorial? Let us know what you think; we welcome your feedback. Email the editor at