Serving Patients

Illustration: Eoin Coveney I have some things to disclose. On a cold wet November morning, when my rain gear was not sufficient to prevent me from getting saturated on my cycle to work, I arrived to the ophthalmology department shortly before morning teaching was due to start. After peeling off my dripping outerwear, I trudged to the orthoptist's room, where the consultant-delivered lecture would soon begin. Entering the room, the smell of freshly roasted coffee beans banished my disgruntlement at the wintry morning. Coffee, tea, orange juice, and a tray of fresh pastries, granola, fruit and yogurt were arranged on display. Less immediately drawing my gaze, next to the lavish breakfast there were product information booklets for glaucoma drops and a bouquet of pharmaceutical company pens on offer. I was greeted by a smiling industry representative, who invited me to help myself to whatever took my fancy. Filling a cardboard plate, I settled down for teaching with coffee in hand. Colleagues arriving each helped themselves to the generous spread. Following this hearty breakfast, we were happily awake and alert for teaching, and afterwards in clinic we were likely friendlier and more attentive to our patients than our unfed selves would have been. APPROACHED My second disclosure: I recently arrived to theatre for my usual afternoon session. I had picked out the cataract patient from the list who would be suitable for me, the most junior team member. As I was waiting expectantly for them to be portered in, a friendly surgical devices company representative approached me. She asked me my name, where I had worked previously, and spoke about a recently developed innovative intraocular lens they were newly offering, explaining some advantages of the lens. Would I like to try a sample? I was flattered by the attention and I duly chose one of her lenses. I found it injected nicely, just as she had set it would. Disclosures aside, it is an intriguing question – how does commercial interest affect my career? ‘Career’ is a particular term, which does not bring to mind patient care specifically, but rather calls up ideas of personal goals of success, financial and otherwise. One’s career is an individual journey, which is planned for, with particular trajectories aimed at. For our career dreams we pour endless hours of toil into research, writing papers and preparing presentations. We travel to conferences, we pay for surgical courses, we limit our annual leave, we sacrifice time that could be spent with loved ones, family, friends. Commercial interests I imagine to have a positive impact on any given career in ophthalmology. A commercial interest may lead to sponsorship to travel for an important meeting, or to attend an otherwise prohibitively expensive training course. Industry may sponsor a study, allowing for a greater sample size, a superior standard of research, and a higher impact factor target journal, than what would be possible under a teaching hospital's standard budget. SHIFTING EMPHASIS But what if the question was slightly altered? What if a more vocational term was used? ‘How does commercial interest affect my patient care?’ Shifting emphasis away from career and towards patient beneficence has a significant effect. As medical professionals, we have ready access to best practice guidelines, derived from systematic reviews of high-grade evidence. We can map out our patients’ care, the best drop, the most appropriate implant to choose, based on this knowledge at our fingertips, and also on our patients’ individual characteristics and preferences. However, if we have been generously looked after by a particular company, be that wined and dined, given a research grant, or sponsorship for an education course to run in our hospital, or perhaps funding to attend a particularly interesting meeting, then accompanying our gratitude and good feeling towards this company, bias surely creeps in. Pharmaceutical companies and surgical device manufacturers contribute positively to outcomes for patients, as they support research which ultimately improves eye care. We must, however, recall that the primary objective for these businesses is not the best interest of patients, but rather to generate profits for their shareholders. Consider then, as ophthalmologists, our bottom line – we have a duty to do what is in our patients’ best interests. This duty should not be affected by our relationship with industry, and any commercial interests we develop. We must also be cautious of zealous rejection of any association with industry. Separation of clinicians from the cutting edge industry developments, where advances in the field of ophthalmology are driven forward, would be to the detriment of patient care overall. Commercial interest will affect my career, I will be exposed to different industry forces, products will be marketed for prescription or implantation. As an ophthalmologist, I have a solid grounding point to return to for guidance – my duties as a professional. Epstein and Hundert define professional behaviour as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”. I will therefore undertake to declare all my disclosures, and remember that my first priority must always be the best interests of my patients. Dr Clare Quiqley is a Second-year Resident at Mater Misericordiae University Hospital in Dublin, Ireland