On July 29, the Sydney Medical School at the University of Sydney held a workshop aiming to raise awareness among faculty members about conflict of interest issues.
It is becoming ever clearer, however, that these are not only important issues for medical academics and clinicians more broadly, but are also relevant for public health professionals.
And they are also timely for journalists and the media, especially given the controversy around the sponsorship of this week’s Walkley Foundation media conference by the oil giant, Exxon Mobil, a company which has been in the headlines for promoting disinformation about climate change.
I will return to this particular issue towards the end of this blog, so that it can be examined within the broader framework of recent related developments in health and medicine.
The University of Sydney seminar was trying to gee-up some interest in a topic that many academics seem to regard as irrelevant, tedious or confronting (judging by the numbers in attendance, anyway).
The broader context to the seminar is that Australian universities are dragging the chain in dealing with their staff’s conflicts of interest, at least compared with institutions in the US, where there is a growing push to reduce the commercial ties of health and medical professionals, researchers and educators, and to ensure greater transparency around such arrangements.
• The US Department of Health and Human Services plans to toughen up reporting and disclosure around significant financial COIs for NIH funded researchers. The regulations aim to shift the burden of responsibility for disclosing significant financial interests from individual investigators to their institutions. Proposed regulations would require institutions to develop a management plan for every identified financial COI, which may include reduction or elimination of the FCOI. They would also require every NIH-funded institution to post, on a publicly accessible Web site, information on certain significant financial interests that the institution has determined are related to NIH-funded research.
• The national health reform agenda in the US has taken up the recommendations from a landmark 2009 report from the Institute of Medicine that called for laws to require pharmaceutical, biotechnology and device companies to report, through a public website, the payments they make to doctors, researchers, academic health centres, professional societies, patient advocacy groups and others involved in medicine. A number of pharmacy and device companies have already begun to release details of their payments to practitioners and patient groups on their corporate websites.
• The Association of American Medical Colleges recently released this report, In the Interest of Patients: Recommendations for Physician Financial Relationships and Clinical Decision Making, which follows two earlier reports dealing with COIs in research and medical education settings. This latest report recommends that institutions should inform patients of providers’ significant financial relationships and should make additional information about those relationships readily available to patients. It also says that physicians should normally be required personally to make the disclosure to the patient and document the disclosure in the medical record.
• In other recent developments, Harvard Medical School released a revised COI policy in March that included a swathe of recommendations. Some of these focused on increasing the scope of COI education and integrating COI curricula throughout the continuum of education and training. They also recommended increased transparency about the COI of those faculty providing education. In other words, this is not only an issue for patients or research owners but for students. The guiding principle, the policy said, was to prevent not punish conflicts.
Meanwhile in Australia, there is very little news of this sort to report, although the NHMRC plans to issue a discussion document on COI-related issues after the election.
Why do COIs matter?
At the seminar Associate Professor Ian Kerridge, director of the Centre for Values, Ethics and the Law in Medicine at the University of Sydney, gave a thorough overview of what is known about the extent and impact of pharmaceutical industry ties with medicine.
Here is a short summary (a copy of his full presentation with references is available from Croakey on request)
• An increasing amount of clinical research is industry funded. 60-85% of clinical research in US is sponsored by the pharmaceutical industry. In Australia it is estimated that 60% of clinical research is sponsored by the pharmaceutical industry (and increasing). 75% of all clinical trials published in NEJM, JAMA, Annals and Lancet sponsored by industry (35-45% of all clinical trials in BMJ).
• US data based on 3,167 physicians found 94% accepted gifts; 83% accepted lunch/dinners; 78% accepted and used drug samples; 38% personal sponsorship to attend meetings; 28% personal payments for giving lectures or consultations; 20% shareholders.
• Less is known about the extent of interactions in Australia, but 85% of professional organisations are sponsored by, or receive advertising revenue from, the pharmaceutical industry, and 80% of patient/consumer groups receive support from the pharmaceutical industry. As well, many medical students have accepted gifts from industry and had extensive contact with industry-sponsored education and promotional materials before graduation.
• Negative consequences of these interactions can include distortion of care, evidence and the research agenda and methods, and erosion of rational prescribing and quality use of medicines. Plus the loss of researchers’ independence and integrity, an increase in secrecy in medicine and research, and the delay or non-publication of key findings for commercial reasons.
Another major negative (my emphasis) is the “erosion of public trust in research, medicine and health professionals”.
• The impact of the interactions with pharma is difficult to assess but there is evidence in most spheres of interaction that contact with industry does alter data, research, decision-making, prescribing, policy and attitudes. There is evidence that all types of practitioners are subject to influence, and industry-sponsored trials rarely produce results unfavourable to sponsor.
• While most (60-90%) of physicians deny that contact with industry influences them in any way, all evidence is to the contrary. Prescription and demand for specific products are increased by gifts, entertainment, travel, assistance at meetings, sponsorship of meetings, membership on advisory boards. One study found, for example, that physicians who accept travel sponsorship to attend a meeting are 10 times more likely to prescribe that company’s product and 7 times more likely to request that the product be listed on the hospital formulary than someone who attends the same conference but is self-funded.
• Kerridge also presented the results of a study of Australian medical specialists showing that within the previous year, 96% had accepted gifts (and the value of gifts was higher if the physician was in an active research relationship with that company or were on the advisory panel of that company); 84% had attended a sponsored symposia or product launch (as distinct from a conference); 52% had accepted travel sponsorship and 30% had accepted travel support for their partner; 23% had been a member of an industry advisory panel; 6% had acted as a paid consultant; 7% owned shares in pharmaceutical companies that produced drugs that they prescribed. Those with active research relationships were more likely to earn more than $5,000 from industry contacts, be on advisory panels and be guest speakers, receive travel expenses, and hold more favourable views about industry-funded research and about industry in general.
What are the issues for public health?
My presentation to the seminar argued, in summary, that these are not only issues for doctors but also for nurses and all others involved in providing or researching health care, as well as for public health professionals, and those involved in contributing to health policy.
I also said that it would be useful to have a central online registry where journalists and others could easily search to see the commercial ties and COI policies of health and medical experts. This might also be useful for patients, especially when making major health care decisions. I was heartened to hear one psychiatrist in the audience is considering how best to declare such information to patients.
Meanwhile, I also showed this image of a flier distributed at the Dietitians Association of Australia conference in Darwin last year.
This is nothing peculiar to Australia: we just recently learnt that American Dietetic Association had done a sponsorship deal with the confectionary giant Hershey. And there is ongoing debate about Coca Cola’s deal with the American Academy of Family Physicians. The soft drinks company is sponsoring patient education material on obesity prevention.
The fact that the company has no input into the education material is immaterial. In fact it would reduce the value of the company’s association if this was the case. All Coca Cola needs to get out of the arrangement is the reflected glow of being associated with an august medical body at a time when the world’s obesity epidemic is putting the company and its products under scrutiny. And a time when policy makers are under pressure to introduce tough measures – such as a tax on soft drinks – in order to reduce soft drink consumption.
The value of this association for Coca Cola is pretty close to priceless. But it’s a very costly arrangement for the reputation and credibility of the American Academy of Family Physicians.
Writing recently about the deal, Dr Howard Brody of the Institute for the Medical Humanities and Department of Family Medicine, University of Texas Medical Branch, said debate about conflicts of interest give rise to a “multitude of rationalizations that tend to obscure rather than to illuminate the core ethical concerns.”
He also said conflict of interest is not a particularly useful term because it actually understates the moral seriousness of the situation. The usual language makes it sound as if one has two interests and they are in conﬂict. Actually, the physician’s or the medical organization’s commitment to patient and public health is a moral duty and not a mere interest.
He added: We live in a capitalist society, and it is both legal and ethical for companies to market their wares. The problem is not good vs. evil but differing interests (or duties).
Implications for the media
So what does this all mean for journalism in general and the Walkley Foundation (which is an initiative of the journalist’s union, the Media Entertainment and Arts Alliance)?
The evidence showing that doctors and researchers’ behaviour can be influenced by gifts and commercial ties with companies does not signify that doctors or researchers have a particular moral or character deficit. It is simply a reflection of human nature and psychology. It would be unwise to assume that journalists or media organisations are any different (hopefully we are human too, after all..) If we accept gifts or sponsorship funding, then this is not without consequence.
Recently, I wrote in Crikey about a fraccas over PepsiCo sponsoring a blog about food and nutrition at the respected ScienceBlogs. The result was damage to the credibility and brand of ScienceBlogs. After an international outcry and the resignations of many of its own bloggers, the publisher announced the PepsiCo blog had been canned and said: “We apologise for what some of you viewed as a violation of your immense trust in ScienceBlogs.”
Likewise, if I look at the arrangement between Coca Cola and the American Academy of Family Physicians, it’s clear who is the loser out of the association.
Similarly, it seems pretty clear that the Walkley Foundation and the MEAA – and by association their members – are the ones with the most to lose from the association with Exxon. At a time when we are fighting for a future for journalism (I don’t think that’s an overstatement), as a profession we cannot afford to jeopardise public trust or our integrity. As Brody wrote: “Trust is a delicate matter that often depends as much on appearance as on reality.”
Ray Moynihan, a health journalist with long experience in investigating COIs in medicine and a colleague of mine (in our book, Ten Questions You Must Ask Your Doctor, we encourage patients to ask their health care providers if they have ties to the products they are recommending) is strongly critical of the Exxon/Walkley arrangement.
“As a very long term member of this union, I was appalled to learn of that deal,” he told me tonight. “It’s naïve to think that these arrangements don’t come without consequences. At the very least, the union is selling its credibility to a corporation that wants to clean its image. As a member, I’m appalled that my union is assisting Exxon’s marketing strategies. Yes, of course we need funds to run events, but perhaps we can rethink the way those events are run if we need to start selling our credibility in order to maintain the material quality of these events. The MEAA needs a fundamental revision of its policies on sponsorship if this can happen.”
Crikey readers will know that Wendy Bacon, director of the Australian Centre for Independent Journalism at the UTS, has sent an open letter of protest to the MEAA, asking for the organisation to withdraw from the sponsorship deal. You can read the MEAA’s response here.
It seems to me that the media, like some other of society’s powerful institutions, have quite a way to travel in understanding and addressing these issues.
• As mentioned, Ian Kerridge has agreed for his presentation to be made available to Croakey readers, on the understanding that material from it is not to be used without attribution. Just post a request below.
I am a longstanding member of the MEAA, have an honorary appointment at the University of Sydney and am involved with Ian Kerridge, Wendy Bacon and others on an NHMRC-funded study of journalists’ interactions with corporate interests in the health sector. I signed the UTS letter, and will be presenting at the Walkley conference on Thursday about the Public Interest Journalism Foundation’s YouCommNews initiative.