A few months ago, a commenter mentioned that they work as a conflict of interest professional, and many of us wanted to hear more. She graciously agreed to do an interview about her work, and here’s our conversation.
Can you start by describing what conflict of interest professionals do, overall?
So, broadly, conflict of interest professionals are usually housed somewhere in a company or university’s compliance department, working closely with the rest of the teams who make sure various laws or policies are being followed. In the most general sense, what we do is to ask questions about the non-work relationships and activities of our employees that could affect the person’s ability to do their work responsibilities, and if the responses indicate a potential issue, we work out how to mitigate the chances of the personal affecting the professional.
So for example, in my prior job where I was focused on conflicts of interest related to research, you look at questions like whether a person’s outside activities affect their research. If I’m part-owner of a company and I decide to subcontract part of my university research work out to my company, or if I decide to hire my sibling to work on my research, is that an appropriate scientific decision because my company is best positioned to do the work or my sibling is the best candidate? Or is that me using the university to siphon taxpayer money for my personal use and delivering subpar work or no work at all to return something of value to the taxpayer? How can we put some oversight in place to make sure it’s the former and not the latter?
In my current role I’m in a healthcare system, where the specific regulations and questions are different but the types of issues are related. So these days the questions I’m looking at look more like, if Dr. Smith has invented a new kind of knee replacement implant, and she gets royalties every time the hospital orders one, what does that mean for her clinical decisions? Are the patients aware of that, and what their alternatives are, and can they get a second opinion about whether the implant is the right one for them? Did the hospital make a decision to use this kind of implant based on her recommendation and if so did the decision maker know about her financial interest? If we look at all the doctors in the system who do this kind of surgery, does everyone use her implant at about the same rate, or is she using it four times as often as anyone else, and if so, what concerns does that raise about whether she’s making the right decisions for her patients?
What are some of the challenges you run into doing this work?
Perhaps obviously, this is a hard time to sell anyone on the idea that conflicts of interest, or ethical behavior in general, matter. Particularly when you are claiming that they have to do something because a federal regulation requires it. No one is looking at our current government or judicial system and saying, “Oh, yeah, that’s a federal system that cares about preventing personal interest and bias, that inspires me to be my best self and live up to both spirit and letter of the law.”
Some of the other big challenges in the space are things like:
• No one likes someone at work questioning them about what they do off the clock, or telling them that their off the clock activities are related to their work when they may disagree, or asking them questions about, e.g., their spouse’s salary or their sibling’s qualifications to get hired. The conversations can be really touchy, and soft skills including discretion are really important.
• It’s a specialized field without much of a professional network/organization, with often only one or two people at an institution who know anything much about it, so you’re often working on your own without much of a peer group to bounce things off of or learn from.
• It’s a field no one trains in; you tend to get hired because you have some transferable experience, and then learn fast on the job, but it’s not like you come in with some sort of certification ready to hit the ground running after doing a practicum and a bunch of advanced classwork.
• The stakes can feel really high! On the research side, I felt that to an extent, feeling responsible for making sure that responsible, ethically conducted science was being done. But on the clinical side, I feel even more keenly that any routine decision I make on a random Tuesday can directly affect how patients’ medical care is delivered even though I’ll never be in the room with a patient.
You mentioned people typically get hired for this because they have transferable experience. What kind of experience transfers well?
For transferable experience, the most common path is to find someone who has some sort of compliance or regulatory experience. In my own case, I started my career as a research lab manager, doing all sorts of tasks related to running a research project, including writing and updating the compliance documents related to human subjects research ethical review. I’ve also seen people come into the field based on experience with HR work or healthcare compliance work in other areas like patient privacy or medical coding. Export compliance (dealing with shipping both physical goods and information out of country) is another common path; export and conflict-of-interest teams tend to work closely together and sometimes have some cross-training.
Are there certain types of conflicts of interest that you see coming up a lot that people don’t seem to anticipate? In other words — probably most people know it’s going to get flagged if they try to hire their spouse or their kid (or maybe they don’t! tell me if they don’t because that would be fascinating too!) but are there things that seem less obvious to laypeople that they’re surprised to learn might be an issue?
In the research world, the big messy thing that no one ever seemed to think enough about in advance is what happens when graduate students and their advisors start companies together based on the research they’ve done together. In the ideal world that can be really great for both of them, but when it goes bad, it can be so bad because they’re in this position where they’re co-equals at the company but then still in this very difficult power dynamic at the university, and those things can bleed over into each other and make life very difficult for them and everyone else around them. And the student may not feel at all empowered to let anyone know things have gone bad, so you really want to get ahead of that from the very beginning with someone in a position to act as an advocate for that student and check in with them regularly.
How often are you having to say “no, you can’t do this” versus “you can do this but we have to do XYZ to mitigate the chances of it affecting things inappropriately”?
In my old research world, a “no” was extraordinarily rare; the university was extremely motivated to support research and entrepreneurship and to find ways to mitigate when the two got entangled in messy ways. I would find myself saying a flat no maybe once a year or so, and only to the most clear-cut things. (For example: The guy who thought he could use about six figures of university discretionary funds to just buy really expensive equipment for his company because his company didn’t have the cash flow handy.)
In my current clinical role, there are more things that are just a clear-cut policy no. Mostly things that edge up toward the appearance of being paid by, e.g., pharmaceutical companies to promote products. Both morally and legally, we just can’t have our patients left wondering whether they’re getting prescribed a medication because it’s the best one for them or because their doctor is getting wined and dined by the pharma company.
Do people ever throw tantrums about this or do people generally get it?
95% of people genuinely want to do the right thing but just don’t know what problems could arise or what the policies are, and when you tell them, they will do the right thing even if they grumble a little about the red tape. And then the other small handful do in fact throw temper tantrums, try to get their department chair to exempt them, complain that the questions are none of their workplace’s business, etc. I assume that handful of people exists in every field and job!
I published a letter once from someone whose husband didn’t want to comply with her company’s stock trading policies and didn’t think he should have to since he himself wasn’t their employee. Do you run into issues with spouses balking like that?
Yes! This doesn’t happen often. But it does happen, and I had one just recently. I worked with my leadership to talk over the person’s spouse’s concerns and we decided that for the time being, it was sufficient for the employee to confirm to us that he had reviewed his spouse’s interests and that none of them were in companies closely related to the clinical care this person provides. We did make it clear that at some point in the future we may need to revisit that decision.
Another option I could use in a case like this is, sometimes the person doesn’t want that information in a database but is willing to tell one person. So they might tell me, or their department chair, and that person then does some due diligence outside the standard process so the final record only shows that a review was done and no issues discovered. (And that’s part of the soft skills stuff — I have to have built up enough trust and credibility that if I make that offer, they believe me!)
Realistically, do internal politics ever affect the outcome when you flag a conflict? Do you see people getting away with conflicts because they have a lot of capital within the organization or are there effective safeguards against that?
You never want that to happen but it can. A university might be willing to make an exception with a $5 million grant on the line that they wouldn’t make with a $50,000 grant on the line, especially in the current scientific funding climate. Or a clinician who was a big-deal hire for a hospital might have negotiated as part of their hire some favorable terms related to outside work beyond what the policies typically permit. I do what I can to mitigate and document and make sure everyone who could be affected is aware that this is being handled differently than typical and that it’s not meant to serve as precedent. And then I brace to have to explain to five other people who have heard a rumor that X policy has changed, that it has not actually changed.
I’m super interested in the detective work you mentioned (figuring out what people didn’t tell you). When you uncover things that way, does it generally turn out to be an innocent mistake (they genuinely didn’t think about X or didn’t realize they needed to disclose X) or are you also finding some people are deliberately not forthcoming?
It’s almost always innocent — people just forget about some one-off consulting they did 11 months ago when it’s time for annual disclosure, or forgot to add something, or didn’t realize that something needed to be disclosed. I have run into situations where someone was not being forthcoming but in those cases it’s never really been about the conflict of interest itself. There’s typically some other larger issue of bad-faith conduct going on and at some point someone says “hey, we should also check the conflict of interest records.” It becomes one piece in a bigger pattern of problem behavior and I rarely get to know the whole story.
I’m also interested in the soft skills involved in having potentially touchy conversations with people about this stuff. What are some of the secrets to doing that well?
The soft skills piece is tricky for me because my natural tendency can be to lean too far in the direction of smoothing ruffled feathers and being a people pleaser. So, soft skills — but with a firm boundary somewhere underneath them. It’s a hard balance!
One thing I learned from watching a mentor years ago is that since I’m almost always talking with professors and/or clinicians who are rightfully really proud of their work and expertise, it can help set the right tone if I start off by asking them to tell me about their research or their company generally before we get into the specifics of whatever we’re meeting about. Once in a while it leads me to some useful tidbit, more often it just gives them a chance to tell me about the thing they’re proud of, and I get to tell them how cool and interesting it is, maybe ask a couple of questions — because it often really is interesting and cool! It’s usually five minutes of a meeting that doesn’t actually affect the outcome but sets a positive tone and lets me display that I’m interested in their work and not just in being a policy robot.
Beyond that, it helps to keep in mind, and sometimes to actually tell them out loud, that I’m not looking to say no — I’m always hoping to find a way to get to a version of “yes” that lets them do the work they want to do while protecting them, the institution, their discoveries, and their patients. I also make an extra effort to get to know, and be in the good graces of, department chairs and administrative coordinators — they know everything and are vital allies.
And if a professor has been an unusual pleasure to work with I make sure to mention that to the chair/administrator as well. They so often only hear complaints from people in my type of role that I try to be the voice of good news when I can, not only problems.
Can you share a particularly ridiculous/outrageous conflict you uncovered and how it was handled?
I think I can say broadly that the most ridiculous ones almost always ended up being the ones involving family. With the financial ones and even the student/teacher ones, there’s a reasonably clear way to point out to people that objectively, doing X appears to create financial benefit Y for their company, or that if they and their student have a disagreement at their joint company, it can create problems at the university. But the family relationships seem to touch a whole different nerve, maybe because it sounds like you’re telling someone you know more about how their relationships work than they do. So if I tell someone that I cannot approve them being the person who signs off on their mother-in-law’s work and approves the size and timing of their mother-in-law’s paycheck, that somehow gets a lot more upsetting to them. Because if they tell me that they and their mother-in-law are absolutely 100% capable of keeping things professional, and I try to explain that I’m sure that’s true for them but it’s not true for everyone and I can’t take on the role of evaluating each person’s personal relationships with their in-laws so we have to build the policies around something else, that starts to feel really personal.
(It was only a mother-in-law once. Usually spouses or partners, occasionally siblings or parents, rarely grown children. The mother-in-law was absolutely the worst. That person offered to have their spouse call and tell me how good the family relationships were and that it would not be a problem. In the end, their department chair had to help lay the law down that we needed a second set of eyes on the payment process. I lived in fear for the five years of that grant that the professor was going to get a divorce and blow up the family and the grant.)
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