CCPP Module 20, Section 3: Managing Conflicts of Interest and Dual Relationships
MODULE 20: ETHICS, PROFESSIONALISM, AND COMPLIANCE

Section 20.3: Managing Conflicts of Interest and Dual Relationships

Practical strategies for identifying and managing potential conflicts of interest—whether financial, personal, or professional—to ensure that clinical judgment remains unbiased and patient-centered.

SECTION 20.3

Managing Conflicts of Interest and Dual Relationships

Maintaining Objectivity When Professional Duties and Personal Realities Collide.

20.3.1 The “Why”: The Erosion of Unbiased Judgment

As a pharmacist, you have been conditioned to see yourself as an objective, evidence-based clinician. Your professional identity is built on a foundation of scientific rigor and an unwavering commitment to the patient’s best interest. You trust your judgment. You believe in your ability to make unbiased decisions based solely on clinical data and patient needs. This self-perception is both a strength and a potential vulnerability.

A conflict of interest is not a moral failing; it is a mathematical certainty in a complex professional life. It is any situation where a secondary interest—be it financial gain, a personal relationship, a professional ambition, or even a strongly held belief—has the potential to unduly influence your primary professional judgment. The key word is potential. The mere existence of a conflict of interest does not imply wrongdoing. However, its existence creates a powerful gravitational pull, subtly and often unconsciously warping decisions away from what is purely best for the patient and toward the secondary interest. Similarly, a dual relationship—where you are simultaneously a patient’s healthcare provider and their friend, neighbor, employee, or family member—creates a similar distortion, blurring the professional boundaries necessary for objective care.

The “Why” of this section is to dismantle the dangerous myth that good intentions are enough to overcome these powerful influences. They are not. Resisting the pull of a conflict of interest requires more than just being a “good person.” It requires a systematic, disciplined approach to identification, disclosure, and management. You will learn to recognize the subtle and insidious ways these conflicts manifest in a collaborative practice setting, from the allure of a pharmaceutical company’s speaker’s bureau to the challenge of managing the care of a fellow colleague. You will gain the practical tools and communication scripts needed to navigate these situations with transparency and integrity. Mastering this skill is essential for protecting your most valuable professional asset: the patient’s absolute and unshakeable trust in your unbiased judgment.

Pharmacist Analogy: The Biased Compass

In your pharmacy career, you navigate the complex world of patient care using a finely calibrated professional compass. The needle of this compass is your clinical judgment. Its “True North” is always the patient’s best interest. You rely on it instinctively to guide every decision you make.

Now, imagine you are given a new, high-tech compass. It’s beautiful and works wonderfully. But, unbeknownst to you, a powerful industrial magnet—a conflict of interest—has been placed nearby. For example, you have joined the speaker’s bureau for a company that makes a new, expensive diabetes drug.

When a patient with simple, diet-controlled diabetes comes to your clinic, your compass should point directly to “True North”—recommending continued lifestyle modification. But the powerful magnet is now pulling the needle of your judgment. The needle might only deflect a few degrees at first. You find yourself thinking, “Well, metformin is the standard of care, but this new drug is a very good drug. Maybe it’s not too early to start it.” The more you speak for the company and the more you are compensated, the stronger the magnetic pull becomes. Over time, your compass needle may begin to point directly at the magnet, and you may not even realize that what you now perceive as “True North” is, in fact, a completely different direction.

A dual relationship is like trying to navigate while standing on a tilting ship. If your new patient is your clinic’s nurse manager, the deck is no longer level. Every recommendation you make is subject to the pitching and rolling of your professional relationship. You might hesitate to challenge her non-adherence for fear of creating workplace tension. You might be tempted to approve a questionable prior authorization to stay on her good side. The platform on which your compass rests is unstable, making an accurate reading nearly impossible.

The goal of this section is not to eliminate all magnets or to find a perfectly stable ship. It is to make you an expert navigator. You will learn to detect the presence of magnetic fields through identification, to announce their presence to your fellow crew members through disclosure, and to use sophisticated navigational techniques to correct for the deviation through management, ensuring you always find your way back to the patient’s True North.

20.3.2 The Spectrum of Conflict: Identifying Financial, Personal, and Professional Pressures

Conflicts of interest are not monolithic. They come in many forms, some obvious, many subtle. To manage them, you must first become an expert at identifying them in the wild. We will break them down into three major categories: financial conflicts, personal conflicts (dual relationships), and professional conflicts.

Category 1: Financial Conflicts of Interest

This is the most widely recognized type of conflict. It arises when a pharmacist has a financial relationship with an external entity—typically a pharmaceutical manufacturer, device company, or pharmacy—that could reasonably be perceived as influencing their clinical decision-making. The core concern is that the desire for financial gain could consciously or unconsciously prioritize the interests of the company over the interests of the patient.

Masterclass Table: Navigating Financial Conflicts in Collaborative Practice
Type of Financial Conflict The Scenario The Ethical Risk The Management Strategy (Disclosure & Mitigation)
Promotional Speaking & Consulting You are paid by “PharmaCorp” to be on their speaker’s bureau, giving talks to other providers about their new anticoagulant, “Clot-No-More.” Bias Creep. You begin to favor Clot-No-More over older, cheaper, and equally effective alternatives. You may downplay its risks or overstate its benefits, even unconsciously, because you are now a paid advocate for the product. Full Disclosure is Non-Negotiable. You must disclose this relationship to your employer, the P&T committee, and your care team. When making recommendations, you must be hyper-vigilant. Script: “Team, for this patient, we could use Xarelto, Eliquis, or the new drug, Clot-No-More. Full disclosure, I do promotional speaking for the company that makes Clot-No-More. Setting that aside, based on this patient’s renal function and co-pays, I believe Eliquis is the most appropriate choice here.”
Industry-Sponsored Research You are the principal investigator for a clinical trial funded by PharmaCorp for their new heart failure drug. Your clinic receives significant payment for each patient enrolled. Recruitment Bias. There is a powerful incentive to enroll patients in the trial, even if they are borderline candidates or if a standard-of-care therapy might be a better option for them as an individual. Firewall Creation. The pharmacist involved in the research should ideally not be the same pharmacist making the initial clinical recommendations for the patient. If that’s not possible, an independent clinician must confirm that the patient is an appropriate candidate for the trial and that all other standard-of-care options have been discussed. All research activities must be approved by an Institutional Review Board (IRB).
Industry-Provided “Educational” Materials & Meals A drug rep brings in lunch for the whole clinic staff and provides glossy brochures and branded pens for their new inhaler. The Power of Reciprocity. Even small gifts create a subconscious social obligation to reciprocate. Studies have consistently shown that even a free lunch can significantly influence prescribing habits in favor of the promoted drug, regardless of its merits. Institutional Policy & Personal Discipline. Most reputable institutions have strict policies limiting or banning industry-provided meals and gifts (e.g., the PhRMA Code). You must know and follow these rules. Personally, adopt a policy of politely declining such offers. Script: “Thanks so much for the offer of lunch, but our clinic policy is to not accept meals from industry. I am happy to review any peer-reviewed, non-promotional data you have on your product.”
Ownership or Investment Interests You are a part-owner of a local specialty pharmacy or home infusion company to which your clinic frequently refers patients. Self-Referral. This is a major conflict. You have a direct financial incentive to refer patients to your own business, even if a competitor offers better service, lower prices, or is more convenient for the patient. Requires Formal Management Plan. This must be disclosed to your employer and, in many cases, to the patients themselves. Federal (Stark Law) and state laws often regulate such relationships. The management plan may require you to be completely removed from the referral process, with all referrals being handled by another provider who has no financial stake in the company.

Category 2: Personal Conflicts & Dual Relationships

This category of conflict arises when your professional role as a pharmacist becomes entangled with a personal relationship. The risk is that the emotions, obligations, and social dynamics of the personal relationship will compromise the objectivity, professional boundaries, and confidentiality required for a therapeutic relationship.

The Core Danger: Transference and Countertransference

These are psychological terms that are critically important here. Transference is when a patient unconsciously redirects feelings and attitudes from a person in their past onto the clinician. Countertransference is when the clinician does the same to the patient. In a normal therapeutic relationship, these are managed with professional boundaries. In a dual relationship, the wires get crossed. You may see your friend not as a “patient with diabetes,” but as “Bob, the guy I watch football with,” which may cause you to downplay the seriousness of his high A1c (countertransference). Bob may see you not as his clinician, but as his “buddy,” making him less likely to disclose embarrassing but clinically important information (transference).

Masterclass Table: Navigating Dual Relationships
Dual Relationship The Scenario The Ethical Risks The Management Strategy (“The 3 D’s”: Detect, Disclose, Decide)
Treating Friends or Family Your brother asks you to manage his complex hypertension regimen through your collaborative practice agreement. Loss of objectivity; difficulty asking sensitive questions (e.g., about sexual dysfunction from his beta-blocker); pressure to provide “special” treatment; emotional distress if there is a poor outcome. Detect: This is a clear dual relationship. Disclose: To your collaborating physician. Decide: The widely accepted best practice is to avoid treating close friends and family whenever possible. Script: “I love you, and because I love you, I can’t be your pharmacist in this capacity. My judgment would be clouded. It’s essential that you have a provider who can be completely objective. Let me help you find another excellent pharmacist in a different clinic to manage your care.”
Treating Colleagues or Employees Your direct report, a pharmacy technician, becomes a patient in your anticoagulation clinic. Power Dynamics & Confidentiality. You now have access to their sensitive health information, which could (even unconsciously) influence your professional relationship (e.g., performance reviews). The technician may feel unable to be fully honest for fear of professional reprisal. Detect: This is a high-risk dual relationship. Disclose: To your department head and HR. Decide: A formal management plan is required. The best practice is to transfer the employee’s care to another pharmacist who does not have a supervisory relationship with them. If that is impossible in a small system, strict boundaries must be established and documented.
Social Relationships with Patients A patient you’ve grown close to in your clinic invites you to their daughter’s wedding. Boundary Blurring. Accepting social invitations can transform the professional relationship into a personal one, making it difficult to maintain objectivity and the necessary therapeutic distance. Detect: This is a boundary-crossing event. Disclose: It may be wise to discuss this with a trusted colleague or mentor. Decide: The safest course is usually to politely decline while affirming the therapeutic relationship. Script: “Thank you so much for that incredibly kind invitation. It means a lot to me that you see me that way. However, to maintain the professional nature of our therapeutic relationship, which is so important for your care, I have to decline. But I would love to see pictures when you come back for your next appointment!”

Category 3: Professional Conflicts of Interest

This is the most subtle category of conflict. It arises when a pharmacist’s professional duties or ambitions conflict with their primary duty to a patient. These are not about money or personal relationships, but about competing professional roles, institutional pressures, and the desire for academic or professional advancement.

The Conflict of “Competing Duties”

As a collaborative practice pharmacist, you wear many hats. You are a clinician for individual patients, a steward of resources for the hospital (justice), a preceptor for students, and a researcher for your academic institution. Sometimes, the duties of these roles conflict.

The Classic Example: The Teaching Dilemma. You are precepting a pharmacy student. For the student’s education (your duty as a preceptor), it would be best for them to conduct a full MTM session with a complex new patient. However, the patient is anxious and overwhelmed, and you know that you could conduct the interview more efficiently and with less stress for the patient (your duty as a clinician). Management: Your primary duty is always to the patient. In this case, you must prioritize the patient’s well-being. The best approach would be to have the student observe you, and then debrief with them afterward, perhaps allowing them to handle a less complex patient later in the day. You must balance your competing duties, but the patient’s interest always comes first.

20.3.3 The Management Playbook: A Framework for Transparency and Mitigation

Simply recognizing a conflict of interest is not enough. You must have a robust, proactive strategy for managing it. The goal of management is not always to eliminate the conflict, but to neutralize its potential to influence your judgment. The universal framework for this process is: Disclose, Review, and Manage (or Recuse).

1. Disclose

Bring the conflict out of the shadows and into the light. Transparency is the foundation of trust.

2. Review

Engage an independent party to review the situation and help determine the level of risk.

3. Manage or Recuse

Implement a specific plan to mitigate the risk, or if the conflict is unmanageable, remove yourself from the situation entirely.

Deep Dive: Implementing the Management Framework

Step Key Action Practical Application & Pharmacist Script
1. Disclosure To Your Employer/Institution: Most organizations have a formal process for disclosing external relationships, usually through an annual COI form. Be exhaustive and transparent. It is far better to over-disclose than to under-disclose. This is a formal, written process. You will list all financial relationships with industry, leadership roles in professional organizations, and any other relationships that could be perceived as a conflict.
To Your Team/Patients: This is an ongoing, verbal process that occurs at the point of care when the conflict is relevant. Script (to the team): “Just as a reminder to everyone as we discuss this new formulary addition, I have a consulting relationship with the company that makes the competing product, so I will present the data but will abstain from the final vote.”
Script (to a patient): “The clinical trial I mentioned is one that I am involved with as a researcher. I want you to know that, so you can be sure my primary focus is on what is best for you, not on the research.”
2. Review Independent, Unbiased Review: The disclosed conflict should be reviewed by a party who is not involved and has no stake in the outcome. This could be your direct supervisor, a departmental committee, or the institution’s formal Conflict of Interest Committee. This review assesses the magnitude of the conflict. A $100 honorarium for a single talk is very different from a $50,000/year consulting contract. The committee will determine if the conflict is manageable or if it requires recusal.
3. Management or Recusal Developing a Management Plan: If the conflict is deemed manageable, a specific, documented plan is created to mitigate the risk. This is not an informal agreement; it is a formal plan. The plan could include: independent review of all your clinical decisions related to the conflict by another pharmacist; being prohibited from participating in formulary decisions related to the company’s products; having a chaperone in the room during industry-related discussions.
Recusal: If the conflict is too significant to be managed (e.g., treating a spouse, having a major ownership stake in a referred-to company), the only ethical option is recusal. Recusal means complete removal from the conflicting situation. You will transfer the patient’s care to another provider. You will resign from the P&T committee. You will step down as the primary investigator. It is a decisive action to preserve the integrity of the medical decision-making process.