The comments of David Bollier, Adriane Fugh-Berman, Howard Brody, Dan Brock, and Suzanne Gordon all add important insights to the discussion, while generally supporting the view that financial conflicts of interest are a serious impediment to good medical research, education, and clinical practice.
Fugh-Berman’s observation that drug companies rely on physicians not so much to sell drugs as to sell diseases is right on target. Her description of the launch of a drug to prevent the newly dreaded CLASS would be hilarious if it were an exaggeration, but it’s not. Drug companies frequently engage in such campaigns to prepare the way for a new drug or a new use for an old one. One example was the creation of an epidemic of “social anxiety disorder,” formerly known as shyness, and the marketing of Paxil to treat it.
And, of course, the problem is not merely the promotion of spurious disease, but of unhelpful drugs for legitimate ones, as Brody reminds us. The Tamiflu story shows clearly one of the harmful effects of the growing control of drug companies over the research they sponsor, even when the investigators are members of academic faculties. This is not just a matter of appearance; the consequences can be devastating, as in the case of the continued marketing of Vioxx for years beyond the initial indications that the drug increased cardiovascular risks.
Brock, like Fugh-Berman, agrees that drug companies should have no role in teaching providers about the use of prescription drugs because of their obvious conflicts of interest. The education that drug companies support comes from their marketing budgets because that is exactly what it is—marketing.
Brock also raises the question of whether medical journals should contain pharmaceutical advertising. As a former editor of the New England Journal of Medicine, I lived with pharmaceutical advertising for years. I would have been delighted if the Journal had not carried prescription-drug ads, but since the publisher (the Massachusetts Medical Society) would not have permitted that, my two predecessors and I made sure that the ads were not interleaved with the editorial content and could not have been mistaken for it.
Of course, if medical journals didn’t carry pharmaceutical ads, very few of them could survive. Since many journals are little more than vehicles to deliver ads, that wouldn’t be so bad, but some very good journals would not be able to survive either. Still, I would rather see them carry ads for other consumer products, such as cars and computers, since there would be no risk that those ads would distort physicians’ practice. I would make only one addition to Brock’s insightful commentary: sometimes the detail persons are attractive young men.
Suzanne Gordon reminds us that American nursing is now “being contaminated by the pill pushers.” That is probably partly because the recent legislation requiring drug companies to disclose gifts to providers doesn’t apply to them, as Fugh-Berman points out. But Gordon also suggests that because nurses are “tired of being overshadowed and under-valued by their physician colleagues,” they are especially vulnerable to drug company blandishments. Perhaps physicians in the community, who are increasingly beset by the demands of insurers and administrators, are also feeling some of the same lack of respect, and for that reason, like nurses, “react by taking whatever attention they can get.”
Problems presented by the relationship between industry and the medical profession will continue to plague us until we clarify where our commitments lie.
Whereas I have no important disagreements with Bollier, Gordon, Fugh-Berman, and Brock, that is not true of David Korn and even less true of Emma D’Arcy.
I believe Korn is entirely too sanguine about the current efforts to “manage” conflicts of interest. He makes much of the protective policies of academic medical centers, but those policies have shown themselves inadequate. They place too much emphasis on disclosure of conflicts of interest and not enough on prohibition. Disclosure does not eliminate conflicts; it simply requires those who depend on the work to decide whether the conflicts lead to bias. Where the policies do prohibit conflicts, they seldom do so absolutely. Usually they simply limit them, but allow them to exist.
Consider Harvard Medical School’s Policy on Conflicts of Interest and Commitment. It consists of nine densely worded pages filled with almost Jesuitical exceptions and qualifications. For example, faculty members doing clinical research on a company’s drug are not supposed to have stock in the company unless (a) the company is publicly traded, (b) the value of the stock does not exceed $30,000, and (c) there is no relationship between the acquisition of the stock and the research (e.g., if the stock was inherited). The notion of stock as a family heirloom that simply cannot be sold before undertaking a research study is new to me.
Another example: in the wake of media revelations that the chief of medicine at the Massachusetts General Hospital was earning more than $200,000/year as a member of Pfizer’s board of directors, the decision was made to restrict income from serving on corporate boards to a very generous $5,000/day. But limiting the income misses the point, which is that serving as a director of a drug company, whatever the remuneration, constitutes a dual loyalty.
As weak as the policies are, they’re still only loosely enforced. The requirement that researchers “annually report to their institutions their outside financial interests that are in any way related to their academic responsibilities” has been flouted, and in some cases, such as at Emory University School of Medicine, the violations could hardly have escaped the notice of the institutions.
All of this raises the question of why it is apparently so difficult to prohibit conflicts of interest. Korn implies that we need a “nuanced” approach because these financial relationships somehow facilitate the development of new treatments. But I see no evidence for that. As I pointed out in my article, before conflicts of interest became virtually ubiquitous in academic medicine, research was at least as innovative. Furthermore, collaboration with industry on research does not require the personal enrichment of the researchers, nor does it require that faculty have myriad irrelevant financial associations with industry. I’m afraid that the gingerly treatment of the problem has more to do with preserving income than with facilitating development of new treatments. I am also unsympathetic to the notion that the public is somehow responsible for making academic medical centers behave badly.
Emma D’Arcy is simply wrong in nearly all of her assertions. First of all, there is plenty of proof that conflicts of interest distort medical research, education, and clinical practice. Second, medical and pharmaceutical professionals do not “aspire to the same goals,” as Brody’s story about Roche and Tamiflu makes clear. The primary goal of investor-owned companies is to maximize their shareholders’ stock. As I mentioned in my article, nearly every major drug company has had to pay enormous fines because they engaged in illegal activities to do so, and there are well-documented instances of companies suppressing evidence that their drugs were dangerous. Third, neither consumers nor physicians are “adept at distinguishing between overt brand promotion and useful information.” In fact, it’s the drug companies that are adept at disguising one as the other. Finally, I believe D’Arcy should have disclosed the fact that she works for the Chandler Chicco Agency, a large public relations firm that counts among its clients nearly every major pharmaceutical company.
Health care in the United States faces many problems. Recently passed legislation might mitigate some of them, but those presented by the relationship between industry and the medical profession will continue to plague us until we clarify where our commitments lie. For all our sakes, the medical profession needs to be true to its purpose.