Conflicts Grow Over Conflicts-of-Interest Policies and Practices

Debates over conflicts of interest (COIs) in medical research and practice are intensifying with recent proposals to ban industry funding of medical education, to better “manage” industry-physician relationships, and to mandate public disclosure of industry payments to physicians and medical institutions. Caught in the cross fire are prominent psychiatrists accused of underreporting payments received from pharmaceutical companies.

At its June annual meeting, the AMA’s Council on Ethical and Judicial Affairs (CEJA) contended that existing mechanisms to manage potential COIs were “insufficient” and recommended that physicians and institutions of medicine, including medical specialty societies, not accept industry funding to support professional education activities, such as live or Web-based CME programs. It also asked medical schools to limit industry marketing on their campuses and urged health professionals to seek noncommercial funding of professional education activities.¹

CEJA’s report warned that commercial support of providers accredited by the Accreditation Council for Continuing Medical Education (ACCME) keeps rising, reaching $1.2 billion in 2006, and that academic medicine–industry relationships are entangled. To support its point, CEJA cited a 2006 national sur-vey of department chairs at US medical schools and teaching hospitals.² The survey showed that nearly two-thirds (60%) of the responding department chairs had some form of personal relationship with industry—including serving as a paid consultant (27%), a member of a scientific advisory board (27%), a paid speaker (14%), an officer or executive of a company (7%), a founder of a company (9%), or a member of the board of directors (11%). Two-thirds (67%) of departments as administrative units had relationships with industry (eg, 65% of clinical departments received industry funds for CME and 37% for residency training).

“The full CEJA report was presented to the House of Delegates, and some people were shocked by it,” said Mark Levine, MD, former CEJA chair and associate clinical professor at the University of Colorado’s School of Medicine. Other AMA members, he said, worried that the report called for immediate implementation (it does not) and some protested that it did not distinguish between certified CME and promotional activities.

On the recommendation of the reference committee, the AMA’s House of Delegates decided to refer it back to CEJA for possible changes and presentation at a subsequent AMA meeting, Levine added.

Alan A. Stone, MD, Touroff-Glueck Professor of Law and Psychiatry at Harvard University, warned that the economic entanglements between medicine and the pharmaceutical and medical device industry as well as other parts of corporate America “go much deeper than the general public and many doctors appreciate.”

These entanglements have occurred, in part, he said, because doctors have had to find other ways to make money, now that their income is limited by managed care.

“It is . . . going to be a very difficult task at this point to extract everyone in academia and in research from these economic connections,” Stone told Psychiatric Times. “For example, there are all sorts of distinguished professors who not only take money from drug companies but sit on their boards, and there are medical schools and drug companies in joint ventures. So the idea that we are going to find some simple way to extract ourselves from this set of problems I don’t think is going to happen.”

Policy Restrictions

Still, attempts are being made. As part of a 2-year project, the Institute of Medicine’s Committee on Conflict of Interest in Medical Research, Education, and Practice is sponsoring 6 hearings before creating a consensus report.³ The task of managing COIs, the committee said, has become more challenging since industry is now the leading funder of medical research and is involved in funding the development of evidence reviews and practice guidelines. At the committee’s March 13 meeting, Carolyn Robinowitz, MD, then American Psychiatric Association (APA) president, described APA’s COI procedures for meetings, publications, and DSM-V committees.

The consensus report, due before July 31, 2009, will examine COIs in research, practice guideline development, and other areas and will propose principles and policies to identify and manage COI “without damaging constructive collaboration with industry.”

In June, the Association of American Medical Colleges (AAMC) urged all medical schools and teaching hospitals to adopt policies that prohibit drug industry gifts and services to physicians, faculty, residents, and students and to limit industry support of CME activities. The recommendations were part of a new AAMC taskforce report, “Industry Funding of Medical Education,” that was unanimously approved by the association’s Executive Council. In adopting the report, the AAMC’s leadership urged all association members to implement policies and procedures, consistent with the report’s guidelines, by July 1, 2009.⁴

Among its recommendations, AAMC proposed that academic medical centers establish a central CME office to receive and coordinate the distribution of industry support for CME activities and strongly discourage participation by faculty in industry-sponsored speakers’ bureaus.

Other attempts to help prevent COI have involved determining which medical schools have already adopted both institutional and individual COI policies and practices and how comprehensive they are. Ehringhaus and others,⁵ for example, published a survey of deans in 125 medical schools to collect data on the existence and nature of policies for addressing potential institutional COI.

The American Medical Students Association (AMSA) also surveyed 150 academic medical centers to obtain their COI policies regarding industry interaction with medical school faculty and trainees to create a comparative scorecard and promote stronger policies. Each responding school’s policies were rated according to 11 potential areas of conflict, such as restrictions on gifts. Schools received A to F grades. Only 7 of the 150 medical schools included in the rankings received a grade of A on the AMSA PharmFree Scorecard 2008 (http://amsascorecard.org) posted in June. Sixty schools got a failing grade because of weak policies or failure to respond. Some 28 schools, or nearly 1 in 5, were in the midst of revising their COI policies.