The Conflict of Interest Movement in Medicine. Part 2: Influence and Education
A Conversation between Harriet Rosenberg and Adrienne Shnier
May 18, 2016
HR: Your research also looks at financial conflicts of interest in Continuing Medical Education (CME) for practicing physicians.
AS: There are about 60 Canadian Professional Medical Association (PMAs) that host continuing professional education for doctors. We found their policies to be generally weak and they leave plenty of room for industry involvement. For example, a pharmaceutical company might co-sponsor an event with a professional association, or a speaker at an event might have financial conflicts of interest that are not declared—so industry presence is not always apparent to the audience. It is also the case that the presence of industry is viewed as so normal that it may be rare for doctors to ask questions about industry influence at these events billed as “education.”
We know that prescriptions for brand-name drugs increase after educational events at “hot destinations” —at vacation locations that are paid for by drug companies.
So doctors tend not to learn much about how to detect conflicts of interest in medical schools or what this might mean for their practice of medicine—yet when they are practicing physicians—they seem to assume that they are aware of industry presence and are not influenced by it. There is research that shows that they think that their colleagues may be influenced by financial conflicts, but they are not (see here, here and here).
HR: There have been attempts to make these industry payments to physicians more transparent. In Canada, at present the situation is moving towards voluntary disclosures by drug companies of what they pay to physicians.
But in the US things are different.
AS: The United States Physician Payment Sunshine Act (PPSA) was the first government-pursued and country-wide initiative to systematically identify and document for public access the financial relationships between medical professionals and the pharmaceutical and medical device industries. Alongside the PPSA, a group of US-based investigative journalists at ProPublica also created a database of financial interest disclosures that are publicly accessible.
HR: The influence of industry also extends to clinical practice guidelines from Canadian professional medical associations. These guide doctors in their prescribing habits and probably the public assumes that there are stringent standards to avoid conflicts of interest among the panels and the associations that write these guidelines.
In the US, there have been controversies over guideline writing panel members failing to make clear their financial connections to industry.
AS: The Institute of Medicine in the US (IOM) has recognized this and has provided recommendations in response to the nondisclosure of fCOIs in clinical practice guidelines in the US, and this problem is mirrored in Canada.
HR: This is very disconcerting—the omnipresence of industry in all these areas—from medical school, to clinical trials and journals, to continuing medical education, to clinical practice guidelines.
AS: It is not surprising considering the trend toward privatization, deregulation and belief in market authority for the regulation of information. This has contributed to an environment that is pro-commercial where medical information—medical knowledge—is now proprietary—it is viewed as a product in a deregulated regime.
HR: This is very different from our assumptions about science, especially medical science, which we think of as a public service. The neo-liberal win-win philosophy of public-private partnerships in medicine can, it seems, in practice, mean the domination of private, vested interests at the expense of the public interest and patient safety.
AS: Yes, this is about the commodification of science and the argument that science should be conducted for profit. There has been a structural shift in the way that medical research is being both considered and conducted and that is why looking at conflict of interest policies is so important.
HR: The prevalence of financial conflicts of interest in medicine would not be possible without a culture within the medical profession accepting this as normal—that is the belief that it is fine for scientific inquiry to originate with industry—okay that industry poses the research questions, does the research, analyzes the data, writes about the benefits and harms of its own products and partners in the education of doctors about these products.
AS: There are some that do not see this situation as conflict of interest at all—who do not feel that relationships with industry should be regulated at all. The study of fCOI relationships is a very contested area. There are attacks on the conflict of interest movement, but the movement has gained ground in Canada and around the world.
There is a push for disclosure of relationships with industry but at the same time many regard financial ties to industry as a sign of prestige. Disclosure in and of itself is a first step to achieving transparency, but as a solution, it doesn’t do much.
There needs to be a change in culture so that it is seen as exemplary for administrators in medical schools, faculty and students to avoid financial conflicts of interest. These views are, in part, dictated by the general funding model for medical research.
HR: Some have proposed expansion of public funding for health research and clinical trials.
AS: Industry has said that it should rightfully be a partner in medical research and education—that they are among those who want to promote better patient outcomes and better quality of life for patients. This can be done through anonymous funding to a pot of money administered independently of pharma. If serving patient interests and not only shareholders is their goal, then this can be achieved by donating anonymously.
There have been many scandals and in the US, between 2006 and 2015 over $30 billion in fines where industry has overstated the benefits of their products and concealed information about harm.
HR: It has also been pointed out that these fines do not really act as a deterrent but are thought of as a cost of doing business (see here). An interesting point was made by Ralph Nader’s watchdog group Public Citizen in the US. They pointed out in 2012 that Big Pharma was the leading defrauder of the US government having surpassed the defense industry.
Another interesting aspect of these legal approaches—prosecutions and fines—seem to be confined to the United States.
As far as I know, the Canadian government has never prosecuted any of the companies who paid huge fines for committing fraud in off-label promotion, and failure to disclose safety data like GlaxoSmithKline (GSK) or Pfizer. In the US, GSK paid a total of $3billion –$1billion in criminal charges and $2billion in civil charges in 2012. The drugs involved included anti-depressants like Paxil and Wellbutrin and the diabetes drug Avandia which are sold in Canada.
It is not clear to me why no actions were taken in Canada by the government.
AS: However, Health Canada itself has been sued for not protecting Canadians from a product that it “knew or ought to have known” had significant risks.
HR: All of the issues you have described in relation to financial conflicts of interest intersect with other reform movements in medicine—the data transparency movement and the regulatory reform movement. Knowledge activists in these arenas are pushing for a variety of reforms to make patient-level research data available and make regulatory activities more transparent and more patient-centered.
AS: Financial conflict of interest relationships are common within the medical profession, in medical research, and in medical education. These financial relationships have served as one method by which drug companies have been able to exert their influence and increase their involvement in the daily research and practice of medicine. While we can all agree that drug companies have produced life-saving and quality-of-life enhancing medications, there is also a substantial literature on dubious and outright illegal promotional activities, suppression of data, and behind-the-scenes management of medical science by for-profit companies. This has not gone unnoticed—it has been met with resistance.
There are mobilizations against the negative aspects of pharma influence that are engaging medical students, practicing physicians, journal editors, journalists, citizen scientists, watchdog groups, and members of the public questioning these relationships to industry. Their goal is simply to promote medical science in the interest of the public good.
HR: Can you name some examples?
AS: Interested readers can go to the website for AllTrials, and also COMPare which looks at discrepancies between registered trial outcomes and what is actually reported, articles in the BMJ about the work of RIAT (Restoring Invisible and Abandoned Trials). In 2009, newspapers like the New York Times carried articles on ghostwriting in medical journals as did PLOS Medicine. There have been medical student and practicing physicians who under the banner of “No Free Lunch” oppose freebies from industry. And also there are independent watchdog drug and device evaluators like the Therapeutics Initiative in British Columbia, Public Citizen’s Health Reform Group and Prescrire in France, for example.
In addition, an important source of information about drug safety can be obtained from going to Health Canada and the US FDA websites for publicly available information which does not get as much publicity as direct-to-consumer ads that we see on US TV or online.
Medical institutions should of course strive to disseminate information to healthcare professionals, patients and members of the public that are not influenced by industry marketing goals. And there are a variety of ways that this can be done including more stringent and enforceable conflict of interest policies.
But in addition, the public should seek out independent information, and use critical skills when assessing articles and guidelines. Much that reads like objective medical science may in fact have its origins in marketing.
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Ford AR and Saibil, D. The push to prescribe. Women’s Press. 2009
Goldacre, B. Bad Pharma: How medicine is broken, and how we can fix it. 2013
Gotzsche, P. Deadly medicines and organized crime. CRC Press. 2013
Healy, D. Pharmageddon. University of California Press. 2013