From time to time, the College is contacted by members who are concerned that they may be involved in a relationship that constitutes a conflict of interest. On other occasions, members call expressing concerns about business arrangements that they think may constitute a conflict of interest and wanting advice on what they should do. The first step in the conversation is to determine if there is a real conflict, or if a reasonable person would perceive that a conflict exists (even if it doesn’t).
What constitutes a conflict of interest?
“A conflict of interest in the health-care setting exists where the health-care provider’s clinical decision making is (or is perceived to be) actually or potentially affected by the influence of factors external to the provider-patient relationship.”1
The most common conflicts occur when the physiotherapist’s personal interests conflict with the patient’s, or when the physiotherapist’s loyalty is divided between two parties (for example the patient and the third party payer).2 What immediately comes to mind when many of us consider conflicts of interest are situations where the financial interests of the physiotherapist are at odds with the interests of their patient, however conflicts of interest can arise from a variety of situations. In addition, physiotherapists need to be aware of the biases they have, in other words, the situations where they would be unable to remain objective, regardless of the reason.
Two potentially problematic scenarios occur in physiotherapy practice when physiotherapists are presented with contracts that include incentives for increased patient volumes (number of patients per day, or number of treatments per patient episode),3 or when they rent space in a multidisciplinary practice on a per patient basis and the clinic owner is also a referral source (essentially creating a “kick-back” for the referral).4 Other challenging situations arise when a physiotherapist is providing treatment for a relative of their employer or a friend. While these situations may not constitute a conflict of interest in the strictest sense, the physiotherapist must consider whether and how they will maintain their objectivity.
Why do we need to avoid potential conflicts of interest? Isn’t that a bit of a stretch?
Physiotherapists are counselled to avoid situations that “may result in a real, potential or perceived conflict of interest.”3 When it comes to potential conflict of interest, it is important to remember that when such a potential exists, (for example due to the terms of a contract) individuals may unconsciously be incentivized to engage in practices that are in their own financial interest, but not of benefit or of questionable benefit for their patient. For example, when one is involved in a contract with incentives to increase the volume of services sold (number of treatment visits), their clinical decision making and judgment could be influenced by the mere existence of such an arrangement. This is especially true when the clinical decisions fall within the “grey areas” of what is best practice. These arrangements can compromise or appear to compromise the physiotherapist’s ability to treat their patient’s impartially.2
Why does the perception of conflict of interest matter?
As health-care providers, physiotherapists have a duty to act primarily for the benefit of their patient, placing the patient’s interests ahead of his or her own, or those of third parties.1 This does not mean that physiotherapists cannot conduct a health-care business, only that they must act in a manner that maintains the public’s trust and confidence and that demonstrates “the utmost good faith on the part of the provider.”1
Trust is a key founding principle for a therapeutic relationship.5 When patients chooses to entrust their health to a physiotherapist, they have a number of expectations, including that the provider will act with beneficence and good will towards them.6 When a health-care provider accepts their role in the therapeutic relationship they also accept the moral obligations of acting with goodwill toward their patient.6 If providers engage in a business practice that undermines the trust of the relationship or their ability to act with beneficence and goodwill towards their patient, a lack of trust will result and the therapeutic relationship will be damaged. This behavior also undermines the public’s trust of the profession and the health care system in a broader sense.
Although revealing a conflict does not remove it, failing to disclose a real or potential conflict of interest to a patient has been viewed by some as a breach of fiduciary duty,1 undermines the therapeutic relationship and is a breach of the Standards of Practice.3 Physiotherapists are counselled to avoid situations where the risk of a conflict of interest exists, but when that is not possible, the Standards of Practice require that physiotherapists both disclose the conflict to the client and document that disclosure in the client’s record.3
Some employers also require their employees to disclose real, perceived or potential conflicts of interest to their manager.7 Physiotherapy Alberta recommends that all members become aware of any employer requirements regarding the disclosure of conflicts of interest that they may be subject to.
There are many situations where conflicts of interest might arise and even more where a physiotherapist may be at risk of having their objectivity compromised by their personal biases. The key point is to be able to recognize these situations, acknowledge them and act to mitigate the situation to the best extent possible.
Maintaining the public’s confidence in the profession through ethical business practices and by avoiding conflicts of interest is all of our business-and it’s good practice.
Nelson E, Flood C, Caulfield T. Financial incentives, conflicts of interest and physical therapists: A discussion paper on legal and ethical issues in managed care. 2004
Rodwin MA. Consumer protection and managed care: Issues, reform, proposals and trade offs. 1996. Houston Law Review; 32:1319.
Physiotherapy Alberta – College + Association. Standards of Practice: Conflict of Interest. 2012. Available at: https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/standards_of_practice/conflict_of_interest. Accessed on January 5, 2016.
Waldman M. Conflict of interest, physicians and physiotherapy. CMAJ 1996; 154(11):1737-1739.
Physiotherapy Alberta – College + Association. Therapeutic relationships: Establishing and maintaining professional boundaries. 2007. Available at: https://www.physiotherapyalberta.ca/files/guide_therapeutic_relations.pdf. Accessed on January 6, 2016.
Goold SD. Money and trust: Relationships between patients, physicians, and health plans. Journal of Health Politics, Policy and Law 1998; 23(4):687-695.
Alberta Health Services. Conflict of interest bylaw. 2013. Available at: http://www.albertahealthservices.ca/Bylaws/ahs-byl-conflict-of-interest.pdf. Accessed on January 6, 2016.