A true conflicts-of-interest policy

Dean Powell’s proposed COI reform for the Medical School is significantly diluted.

A conflict of interest is the distraction from one’s primary goal (patient care) by a secondary interest or influence (like gifts from a pharmaceutical representative). The University of MinnesotaâÄôs Medical School needs to maintain working relationships with the pharmaceutical and device industries, but it also needs to remain focused on the humanitarian principles of medicine. Dean Deborah PowellâÄôs office recently released its second-draft conflict-of-interest policy recommendations for the Medical School. This document is based on recommendations made by her COI committee âÄî of which I was a member âÄî but PowellâÄôs draft is substantially diluted. Whereas the American Medical Students Association applauded the COI committeeâÄôs recommendations, the association âÄî which grades COI policies across the nation âÄîregards the new recommendations as âÄúborderline.âÄù Though PowellâÄôs draft still contains some good and needed policy, it ignores key committee recommendations that would have put us on par with the best medical school conflict-of-interest policies. Continuing medical education PowellâÄôs draft, unlike her committee recommendations, permits industry-funded CME. We know that pharmaceutical companies have successfully manipulated CME to promote off-label drug prescribing and delimit the focus of CME to topics that result in increased prescribing of their drug product. The University’s Department of Family Medicine and Community Health has already removed industry funding from CME. Our commitment to scientific objectivity in patient care behooves us to independently fund CME. Big pharma, small gifts Small gifts are marketing items of nominal value, such as mugs and pens given by pharmaceutical salespeople. Though cheap, they serve as durable advertisements for a drug product or company. They are inexplicably allowed in Powell’s second draft. We know from experimental social psychology that nominal gifts affect behavior and we have numerous accounts of former pharmaceutical representatives on the effectiveness of small gifts. The Saint Mary’s Duluth Clinic system and others in Minnesota have already banned small gifts. The best-rated medical school COI policies do as well. Similarly, PowellâÄôs draft permits pharmaceutical industry on campus, without stipulation, as long as there is departmental approval. From a seminal review article in 2000 out of McGill University, we know that industry representatives include misinformation in their pitches and we know that such misinformation is retained. Drug marketing does not belong on campus. Marketing talks PowellâÄôs draft allows a professor to deliver drug talks as long as he or she is also hired as a consultant. We know these presentations skew prescribing. From an internal Merck document obtained by the Wall Street Journal in 2005, we know that, in the case of the drug Vioxx, âÄúdoctors who attended a lecture by another doctor wrote an additional $623.55 worth of prescriptions for the painkiller Vioxx over a 12-month period compared with doctors who didn’t attend.âÄù Marketing talks are commercials in the guise of education. Professors in the medical school should not deliver them. Research and the public interest Though the COI committee did not address the availability of research products, the UniversityâÄôs mission statement makes explicit our commitment to the public good. The HIV drug Abacavir was developed at the University during the 1990s and licensed to GlaxoSmithKline. Though a public relations battle ensued in which many implored the University to make the drug available to the poorest countries, this never happened. Today, many schools have policies that allow limited generic licensure, permitting availability of the drug to the poor while protecting the profits of the academic institution and of the industry partner. Our stated priorities would make such a policy highly appropriate. Research bias Industry funding impinges on several characteristics of research. A sweeping review performed by researchers at Yale in 2003 found that industry-funded research is more likely to use inactive controls or sub-optimal dosing of a competitor drug in head to head trials. The review found that researchers funded by industry were more than twice as likely to take commercial considerations into account when selecting research topics. We must somehow mediate these effects. Consultancies From a 1994 Journal of the American Medical Association article examining physician formulary requests (the formulary is the list of drugs carried by the hospital), we learn that physicians who made specific requests had nearly 20 times the odds of having a financial relationship with the maker of the drug than other physicians. PowellâÄôs draft requires that these financial relationships be subject to an âÄúapproved written agreement defining such aspects as specific deliverables, goals, services and fair market compensation.âÄù This is the standard, according to the American Medical Students Association, but we also need to limit and monitor these positions, as they very likely affect behavior. If we, as an academic community, are sincere in our mission statement, and are to adhere to the principles of a publicly funded institution, we need to take this opportunity to create a sound conflict-of-interest policy. Why should we settle for mediocre when we could have a top-notch COI policy that insures the integrity of medical education, patient care and research? One that truly prioritizes public health? Josh Lackner is a student at the Medical School and a member of the erstwhile COI committee. Please send comments to [email protected]