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To the Editor: The Special Communication by Dr Brennan and colleagues¹ effectively reviews how physicians' conflicts of interest provide challenges to their professionalism. However, we believe that the focus was too narrow and the proposed solutions were incomplete and possibly misguided.

Brennan et al implied that the only important conflicts of interest are those involving individual physicians and pharmaceutical or device manufacturers. However, conflicts posed by physicians' relationships with managed care may be just as important. Dr Kassirer, one the coauthors, has elsewhere written that "market driven health care creates conflicts that threaten medical professionalism."²

Conflicts of interest permeate health care, affecting not only physicians but also other health care decision makers, particularly the leaders of large organizations.³ A survey of the American College of Physician Executives (21% response rate) found that 66% of respondents were concerned about conflicts of interest affecting nonphysician leaders of health care organizations, while 11% . . . [Full Text of this Article]

Roy M. Poses, MD
rposes@firmfound.org
Foundation for Integrity and Responsibility in Medicine
Warren, RI

Scot Silverstein, MD
Institute for Healthcare Informatics
Drexel University
Philadelphia, Pa

Wally R. Smith, MD
Department of Internal Medicine
Virginia Commonwealth University
Richmond

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