Appendix 2
Disclosure of Financial Conflicts of Interest Survey
PLEASE READ THE FOLLOWING:
Introduction
In academic institutions such as the University of Connecticut Health Center (UCHC), surgeons sometimes receive financial compensation for their time and research from companies that make products that are used in surgery. Compensation can come in a number of forms depending on the situation. We are interested in assessing your understanding of financial conflicts of interest and your opinions on this.
Disclaimer
The questions that you answer today will remain anonymous. Your surgeon will not be able to link this survey to you. The results will be compiled and will be used to improve upon the process of disclosing conflicts of interest to patients. Your participation is completely voluntary. You may choose to not answer any question that makes you uncomfortable. Completion of this survey implies that you consent to be in the study. If you have any questions, please contact Dr. Jay Lieberman at (860) 679-2640.
Disclosure of Financial Conflicts of Interest Survey
Section I
Please answer the following questions.
1) How old are you? ______
2) Are you male or female? ______
3) Please circle the highest degree that you have obtained.
Some High School High School College Master’s Degree Doctorate Degree
4) How would you describe yourself (please circle one choice below)?
Asian or Pacific Islander African American Hispanic Native American Caucasian
Other (please specify) ______
5) What type of surgery did you recently have?
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Section II
Please circle the number that best applies to how you currently feel. 1 represents strongly disagree and 5 represents strongly agree.
1) You feel satisfied with your surgery. 1 2 3 4 5
2) You feel satisfied with your surgeon. 1 2 3 4 5
3) You trust your surgeon to do what is best for your medical care. 1 2 3 4 5
4) Your surgeon is careful and thorough. 1 2 3 4 5
Please provide any comments on the above questions.
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Section III
Please circle your response to the following question.
1) Have you ever received information from a surgeon related to potential financial conflicts of interest?
Yes No
Section IV
Please circle the number that best applies to how you currently feel. 1 represents strongly disagree and 5 represents strongly agree.
1) You have heard about financial ties related to clinical research in the news. 1 2 3 4 5
2) You are worried that your surgeon has financial conflicts of interest. 1 2 3 4 5
3) You are worried that UCHC has financial conflicts of interest. 1 2 3 4 5
4) The medical school has guidelines in place to safeguard against financial conflicts of interest.
1 2 3 4 5
5) I want my surgeon to disclose financial conflicts of interest. 1 2 3 4 5
6) I want to know the extent of these financial conflicts of interest. 1 2 3 4 5
7) I would trust my surgeon less if he had a financial conflict of interest. 1 2 3 4 5
8) I have a problem with my surgeon having a financial conflict of interest. 1 2 3 4 5
9) I trust my surgeon to use products that are best for me no matter what. 1 2 3 4 5
Please provide any comments on the above questions.
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Section V
For the following questions, please rate if the following circumstances would influence your decision to have a particular surgeon operate on you. 1 means that it would be less likely that you would have a particular surgeon operate on you, 3 means that the given situation would have no effect on your decision, and 5 means that you would be more likely to have the surgeon operate on you.
1) My surgeon developed a prosthesis being used in my surgery. 1 2 3 4 5
2) My surgeon receives revenue from a company for studying a product used in my surgery.
1 2 3 4 5 3) My surgeon has stock in a company that makes a product used in my surgery. 1 2 3 4 5
4) My surgeon may receive future revenue from a product being used in my surgery. 1 2 3 4 5
5) My surgeon is paid by the company that makes a product used in my surgery. 1 2 3 4 5
6) My surgeon is paid by the company that makes a product not used in my surgery. 1 2 3 4 5
Please provide any comments on the above questions.
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Section VI
Please circle your response to the following question.
1) Do you remember signing a form entitled “Written Patient Disclosure: Orthopaedic Inventions and Know-How”?
Yes No
Section VII
If yes, please complete the following questions. Circle the number that best applies to how you currently feel. 1 represents strongly disagree and 5 represent strongly agree.
1) I understand the purpose of signing this form. 1 2 3 4 5
2) The form was easy to read. 1 2 3 4 5
3) The form was easily understandable. 1 2 3 4 5
4) I understood the form after reading it. 1 2 3 4 5
5) My questions were fully answered regarding the form. 1 2 3 4 5
Please provide any comments on the above questions.
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Section VIII
The following set of statements addresses your understanding of the form. For each statement, please circle whether it is true or false.
1) Some orthopaedic surgeons at UCHC work directly with manufacturing companies researching new products and devices.
True False
2) These products and devices are not used in surgeries on actual patients.
True False
3) These surgeons may get paid by the manufacturer to research products. True False
4) The purpose of paying these surgeons is for their time and intellectual property. True False
5) UCHC will not get paid as a result of the research by these surgeons. True False
6) Patients are told if their surgeon has a financial relationship with a manufacturing company that makes a product in their surgery.
True False
Please provide any comments on the above questions.
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