Pharma support of medical societies raises conflict-of-interest concerns

New guidelines say no more than 25% of physician organizations' budgets should come from the drug industry. Two groups announce plans to take less industry money.

By Kevin B. O’Reilly — Posted April 13, 2009

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The American Psychiatric Assn. in March said that to erase the risk of bias, it will phase out the $1.5 million in drugmaker money it uses to fund continuing medical education. The same month, the American College of Cardiology declined to distribute nearly half a million dollars in industry-funded, logo-branded tote bags, lanyards and badges at its annual scientific session.

The moves reflect physician organizations' growing sensitivity about potential conflicts of interest. And if an expert panel has its way, the actions will mark the start of a shift toward reducing medical societies' reliance on financial support from pharmaceutical companies, drugmakers and industry firms.

In an April 1 report in the Journal of the American Medical Association, a group of 11 researchers and doctors -- many with experience as medical society leaders -- said physician organizations should strive for zero dollars in industry funding of their activities. In the short term, the group said, any medical society that counts on industry for more than 25% of its budget -- except income from exhibit halls and medical journal advertising -- "should immediately reassess its policies to reduce its dependency and protect the integrity of its agenda." The panel said exhibit halls and journal ads are OK because they clearly are understood as marketing and so do not pose a conflict.

Medical societies play a critical role in educating physicians and drafting the guidelines that shape clinical care, the panel said. They should take every step possible to assure patients that their activities are not improperly influenced -- or appear to be -- by industry's prerogatives, according to the panel. The experts urged medical societies to toughen their conflict-of-interest policies and strive to appoint doctors without financial conflicts to key decision-making positions.

"It doesn't matter whether there is, in fact, a quid pro quo," said Steven Nissen, MD, a panel member, former ACC president and chair of the cardiovascular medicine department at the Cleveland Clinic's main campus. "When professional medical societies accept money from industry, it creates an appearance of influence. And that appearance undermines the most important thing we own in medicine, and that's the trust of patients."

The recommendations come amid political and news media scrutiny of physicians' ties to industry. Under a bipartisan Senate bill, the Physician Payments Sunshine Act, doctors who receive $100 or more from an industry firm over the course of a year would have those payments posted to a government-operated Web site.

Sen. Charles Grassley (R, Iowa), one co-sponsor of the bill, also has led a wide-ranging inquiry into some doctors' financial relationships with drug- and device-makers.

"These recommendations carry a lot of weight and represent a desire to build confidence and take away questions raised by financial ties," Grassley said in a statement. "I'll continue my effort to bring about full disclosure of money from industry to physicians."

Ken Johnson, a senior vice president of the Pharmaceutical Research and Manufacturers of America, said the recommendations would deprive medical societies of some of the most knowledgeable doctors because drugmakers often pay them for their expertise.

The JAMA authors "seek to sharply restrict industry funding of the very activities that improve public health and protect patient safety," Johnson said in a statement.

Track record of change

There is reason to believe the panel's recommendations will lead to change.

The group was convened two years ago by the Institute on Medicine as a Profession, a nonprofit housed at the Columbia University College of Physicians and Surgeons. In 2006, an IMAP panel proposed conflict-of-interest policies for academic medical centers. Many medical schools adopted the policies, and most of those recommendations later were included in a 2008 Assn. of American Medical Colleges report.

"We're asking medicine to clean its house," said David J. Rothman, PhD, lead author of the JAMA paper and IMAP president. "We don't want to wait for the Grassleys of the world."

Leaders of the APA, the American College of Physicians, the American Academy of Family Physicians and the American Academy of Orthopaedic Surgeons said they already were working to strengthen their conflict-of-interest policies and would review the panel's recommendations. All said their reliance on industry funding falls below the 25% threshold.

The AMA Council on Medical Education and the Council on Ethical and Judicial Affairs will issue companion reports on industry funding for consideration at the AMA Annual Meeting in June.

"It is essential that a broad array of stakeholders take an active role in developing guidelines to govern the relationships between the medical profession and industry," AMA Board of Trustees Chair Joseph M. Heyman, MD, said in a statement. "The issue remains an important topic of discussion at AMA policy-making meetings, and the AMA continues to advocate for high ethical standards to be a cornerstone of the medical profession."

Dr. Heyman added: "While the AMA has no direct policy regarding this issue, we do hold ourselves to the highest ethical standards in all aspects of our organization. As a result, the AMA's budget contains far less than 25% industry funding."

In addition to refusing industry sponsorship of meeting materials, the ACC is considering whether to ask companies to contribute to a general pool of funds to minimize further industry influence, a spokeswoman said. The APA's decision to phase out industry-funded symposia over the next several years is tougher than the panel's recommendations.

Daniel J. Carlat, MD, served on an APA committee that recommended the change in the association's policy and said it made the right call.

"Any organization has to make a trade-off between ethical purity and their financial bottom line, and the APA has decided to draw a line somewhere, and I think that's the right decision," said Dr. Carlat, assistant clinical professor of psychiatry at the Tufts University School of Medicine in Massachusetts.

James H. Scully Jr., MD, APA medical director and CEO, also served on the IMAP panel. He said he disagreed with the group's zero-dollar goal for all industry support of physician organizations.

"There are ways of being transparent and firewalling relationships that are in everyone's interest," Dr. Scully said. "And as we have [relationships], they will be quite open and reviewable."

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Reducing industry's role

Medical societies' reliance on industry funds "inevitably creates the perception of and reality of conflicts of interest and jeopardizes public trust," an influential panel of prominent physicians and researchers said in April. To address the problem, the group said professional medical associations should:

  • Aim for zero-dollar support from industry over the long term; reduce industry funds to 25% or less of the operating budget as soon as possible.
  • Refuse any industry funding for guideline-writing activities and appoint to guideline committees doctors who have no financial conflicts.
  • Require physicians who will serve in leadership positions to end any industry relationships before taking office.
  • Only accept industry funding of continuing medical education, research, fellowships and training if the grants are absolutely unrestricted.
  • Ensure that the doctors charged with deciding how to spend industry funds disclose any financial conflicts or, preferably, have no conflicts.
  • Refuse to endorse or accept funding for any industry-sponsored satellite symposia during a society meeting, and refuse to make lists of attendees available to drug- and device-makers.
  • Ban company sponsorship and branding of tote bags, lanyards, pens, notepads and publications distributed at conferences.
  • Make it possible for doctors attending meetings to avoid the exhibit hall.

Source: "Professional Medical Associations and Their Relationships With Industry: A Proposal for Controlling Conflict of Interest," Journal of the American Medical Association, April 1 (link)

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JAMA actions reviewed following conflict

Controversy over how editors at the Journal of the American Medical Association handled a letter about undisclosed conflicts of interest in a study of antidepressants and stroke has landed the matter before the American Medical Association Journal Oversight Committee.

Jonathan Leo, PhD, associate professor of neuroanatomy at Lincoln Memorial University-DeBusk College of Osteopathic Medicine in Tennessee, coauthored a March 5 letter in the British Medical Journal, regarding a March 28, 2008, JAMA study.

The study's lead author failed to disclose a financial conflict, the letter said. Leo had written to JAMA to voice his concerns but was frustrated at what he perceived as the journal's slow pace in addressing the issue. The journal published a March 11 letter from the author of the antidepressant study reporting "an incomplete financial disclosure."

Leo and his dean said top editors threatened to ban Leo from publishing in JAMA and ruin the medical school's reputation if the BMJ letter was not retracted. JAMA editors Catherine D. DeAngelis, MD, MPH, and Phil B. Fontanarosa, MD, said in a March 20 editorial that their tone in the conversations was "strong and emphatic" but their intentions were misunderstood. A JAMA spokeswoman declined further comment.

In the same editorial, the editors outlined a new policy: Individuals who alert JAMA to potentially undisclosed conflicts of interest should not address the matter in any other journal or news outlet until JAMA has completed its investigation and published its findings.

"The issue is no longer my letter, but is now JAMA's new policy, which seems like a form of censorship," Leo told American Medical News via e-mail.

The AMA did not give a timeline for the Journal Oversight Committee's review. The findings will be presented to the AMA Board of Trustees. The committee's next meeting is in early May.

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External links

"Professional Medical Associations and Their Relationships With Industry: A Proposal for Controlling Conflict of Interest," Journal of the American Medical Association, April 1, abstract (link)

"Health Industry Practices That Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers," JAMA, Jan. 25, 2006, abstract (link)

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