Studies Reveal Financial Conflicts Often Are Undisclosed, Raising Ethical Concerns

By Stacey Kusterbeck

Many, if not most, physicians fail to disclose financial conflicts of interest (COI), according to multiple recent studies. “With all the attention on transparency in medicine, especially through resources like the Open Payments database, we wanted to see whether the disclosures spine surgeons made at a major national conference lined up with what was publicly reported,” says Christopher Lucasti, MD, a fellow in spine surgery at Emory University.

Lucasti, then a resident in orthopedics at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, and colleagues evaluated inconsistencies between 432 surgeons’ self-reported disclosures and the Open Payments database.¹ Most (84.2%) presenters had discrepancies between their conference disclosures and the Open Payments data. “While some differences are understandable due to reporting timeframes or definitions, the number and size of the discrepancies suggest that this is more than just clerical error. It pointed to a real gap in either awareness or diligence when it comes to disclosure,” says Lucasti.

For clinicians, especially those speaking or presenting at national meetings, even unintentional inconsistencies create a negative impression of a lack of transparency. “With the Open Payments database being public, patients, colleagues, and institutions can easily look these things up. That can affect how your research and professional integrity are perceived,” says Lucasti.

Ethicists can help to develop clearer guidance at their institutions about what needs to be disclosed, and the reason why. Ethicists also can help institutions build systems to check for discrepancies and to offer support or education to clinicians, rather than punishment. “If we want to improve the culture around disclosure, it helps to have ethicists involved in a way that’s proactive and collaborative, rather than just regulatory. In the long run, that kind of support can help shift the mindset from ‘What do I have to disclose?’ to ‘What should I be transparent about?’” says Lucasti.

It is not just individual physicians who are failing to disclose financial ties. There also are ethical concerns about the influence of industry relationships on the integrity and objectivity of surgical and medical societies. “These societies play a central role in education, advocacy, and setting clinical standards. Conflicts of interest stemming from financial ties to industry can undermine public trust and the credibility of medical recommendations,” says Hassan Aziz, MD, FACS, clinical assistant professor of surgery at University of Iowa Hospitals and Clinics.

When applying to present at meetings of various surgical and medical societies, Aziz and colleagues noticed there were inconsistent requirements for disclosures. They also observed that societies had varied methods to address the financial conflicts that were disclosed. “We, therefore, wanted to assess the public accessibility of COI disclosure policies, analyze the content and consistency of these policies, and identify differences between surgical and medical societies in how they define, manage, and resolve COIs,” says Aziz.

The researchers analyzed publicly available websites from 78 surgical and 116 medical societies and found considerable variation in disclosure policies.² Half of surgical societies and 52.6% of medical societies had clear disclosure requirements. A significantly lower proportion of surgical societies (38.5%) defined what constitutes a “significant” COI, compared to medical societies (72.1%). Only one-third of surgical societies provided a disclosure form, compared to nearly two-thirds of medical societies. “The main issue was that there is no standardization in how COIs are identified, managed, or resolved. Many policies lacked depth,” says Aziz. Clinicians should be familiar with their professional society’s COI policies and advocate for necessary improvements, assert the authors. “Ethicists are crucial to this conversation,” says Aziz. Ethicists can address this issue with these practices, offers Aziz:

• encouraging institutions and societies to adopt and publish comprehensive COI policies;
• training clinicians and society members in recognizing and managing both financial and non-financial COIs;
• helping to design clear, accessible, and standardized disclosure forms and procedures; and
• periodically reviewing COI policies to ensure they are effective and up-to-date.

Inconsistent policies for journal authors to disclose COI are another longstanding ethical concern. Even if journals do require study authors to report COI, not all authors actually do so. Almost one-third of study authors in general surgery journals inaccurately reported conflicts of interest, a recent study found.³ “The results were not that surprising. In our own experience, we’ve found that a good proportion of surgeons don’t accurately disclose their industry relationships,” says Divyansh Agarwal, MD, PhD, the study’s senior author and chief resident in general surgery at the Massachusetts General Hospital.

Surgeons may feel that industry relationships are not relevant to their work, so they are reluctant to disclose those. Surgeons may be unclear on what needs to be disclosed. “Reporting industry relationships or any conflicts should not be seen as a penalty or a drawback. It’s an important principle in disseminating new knowledge to the public,” adds Agarwal.

Agarwal and colleagues analyzed public databases to assess the accuracy of disclosures in 918 published studies. Senior or corresponding authors disclosed inaccurately more often than first authors. “For many articles, the middle authors tend to be trainees, research assistants, or junior faculty, who may be less likely to have industry relationships compared to the more senior, established authors,” suggests Agarwal. Most payments of more than $50,000 made to authors from industry sponsors were not disclosed appropriately. “This speaks to how problematic lack of disclosures can be and how it can contribute to public mistrust, particularly when the sums are so high,” says Agarwal.

Ethicists can encourage institution-specific policies for disclosure. For instance, ethicists can help to develop a short, standardized section at the end of each manuscript that summarizes payments made by industry to each author as listed in the Centers for Medicare and Medicaid datasets. “The editorial and production teams can then verify each author’s industry payments, once a manuscript is accepted and in the production phase,” explains Agarwal.

Some aspects of COI already are well-studied. There is not much debate over the fact that many physicians and study authors fail to report financial conflicts, or that there are strong associations between industry funding and favorable results in research reporting. “So much research effort has gone into re-demonstrating some of the same things over and over again. We don’t really need any more studies documenting how many medical journals have COI policies. This has been done to death, both for individual subspecialties and multidisciplinary areas,” argues S. Scott Graham, an associate professor in the Department of Rhetoric & Writing at University of Texas at Austin.

However, little is known about which policy interventions are most effective. “We need better evidence-based COI policies. There is a need for novel research that can demonstrate what kinds of policy interventions are most likely to mitigate the risks associated with COI,” says Graham. Graham and colleagues analyzed 81 studies from 2009-2023 on policy mechanisms designed to address author COI, author industry affiliation, and industry sponsorship of research studies.⁴ Two key findings included:

• Disclosure policies are not consistently designed, implemented, or enforced.
• Disclosure policies are not particularly effective in mitigating the risk of funding bias.

“Clinicians should be aware that there’s ample evidence for the dangers of financial COI, but that current policy does little to mitigate these risks. Disclosure is an important tool, but the data show that disclosure doesn’t really address risks of bias,” says Graham. Physicians generally know that they need to be transparent if they have certain financial relationships, since most COI training focuses on disclosure policies. Physicians need more guidance on how to adjust their risk-benefit evaluations for different types of COI, however.

“There’s a widespread misperception that everyone knows all they need to know about COI. The available evidence shows pretty clearly that practicing clinicians, peer reviewers, and IRB board members often don’t fully understand how to evaluate COI when making decisions about risk. Clinicians need to raise their level of skepticism before adopting new products if they were developed in a high-COI environment. Ethicists are in a good position to help fill this educational gap,” says Graham.

Another group of researchers compared industry payments that were made to thoracic surgery program directors, compared to payments made to other thoracic surgeons.⁵ “A lot of the innovation and progress in our cardiothoracic surgery field really comes from industry. We rely on industry to develop those products and then train us how to use them, so there is a symbiotic relationship between us and industry. Anecdotally, we noticed that some people have more interaction with industry than others. We wanted to really delve further into it,” says Errol L. Bush, MD, FACS, one of the study authors and a thoracic surgeon and surgical director of the Advanced Lung Disease and Lung Transplant Program for the Johns Hopkins Comprehensive Transplant Center. Bush is associate professor of surgery at Johns Hopkins University School of Medicine.

Bush and colleagues analyzed industry payments from 2015-2021. All 77 program directors received industry payments, ranging from $58 to $2.6 million. There is a need to make sure there is equitable access to industry support, assert the study authors. Male program directors and program directors in cardiac specialties received significantly higher payments. “There seems to be some targeting by industry by different demographics in the field, and that’s what we really want to highlight,” says Bush. Physicians might not realize that they are being targeted by industry — not just because of their position or expertise, but because they have influence over others. “Cardiothoracic surgery has been becoming more competitive. This year, only about half of the trainees that applied actually got a spot. And the people who really interact with these applicants most and decide who is going to come into their training program — which really means that they are deciding who is going to have a future in cardiothoracic surgery — are the program directors. They have a lot of influence over one’s career path and who the future of the specialty is,” says Bush.

If the program directors are unfairly influenced by industry, then they potentially are going to be biased in what techniques future surgeons are exposed to. “Trainees should experience everything, and then they decide how they want to practice,” says Bush. Trainees might see three or four different ways to do a procedure and can ascertain which ones work best in their hands and which ones get the best outcomes for the patient. “The concern is that if program directors are influenced by industry to favor one technique, trainees may end up using that technique because that’s what they’re exposed to — and not necessarily because the data supports using that technique over another technique,” explains Bush.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

References

1. Vallee EK, Alben MG, Chipman DE, et al. Spine surgeon conflict of interest disclosure discrepancies between a national conference and the open payments database. N Am Spine Soc J. 2025;22:100602.

2. Wittrock K, Kane S, Chang J, et al. Conflict of interest statements and disclosure policies for surgical and medical societies. Am Surg. 2025; Jun 10. doi: 10.1177/00031348251351005. [Online ahead of print].

3. Bharani T, Yuan C, Mahida K, et al. Accuracy of conflicts in interest in general surgical journals. Ann Surg. 2025;282(2):249-253.

4. Graham SS, Grundy Q, Sharma N, et al. Research on policy mechanisms to address funding bias and conflicts of interest in biomedical research: A scoping review. Res Integr Peer Rev. 2025;10(1):6.

5. Nudotor R, Ha JS, Ruck JM, et al. Securing the future: Financial ties of thoracic surgery program directors to industry. J Thorac Cardiovasc Surg. 2025;170(1):107-113.