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Some Thoughts on Conflict of Interest

I noticed that Dr. Alan Rubin’s recent Guest Post here at The Mine stirred up some heated discussion over conflict of interest (COI) — an issue that seems to lurk behind every corner in the business of health and medicine.

When is it OK to be sponsored by pharma company? And when is it OK to trash them, even as they produce the medicines and devices that keep us alive?

I’m no authority on this complex issue, but the way I see it, there’s a tricky dichotomy going on here: We patients (and doctors and CDEs, too?) have a love/hate relationship with the pharma industry. On the one hand, we depend on them and deeply appreciate their work. On the other hand, we sometimes view them as big, greedy conglomerates out to exploit us all. Unfortunately, a number of recent scandals back the latter view.

Nevertheless, I think we, the Diabetes Community, just have to accept that we are symbiotic with pharma. We need them as much as they need us, and vice versa.

So where do we draw the line when it comes to sponsorships, promotions, and such?

Personally, I think it’s OK to promote a book (like Dr. Rubin’s) that has something valuable to say — even if that something is about the overhype of other goods and services. With the flood of information and entertainment vying for everybody’s attention these days, how would we know about any good books without proper promotion?

The way I see it, there are basically three pretty obvious cardinal sins of COI:

1) Non-disclosure — it’s not OK to hide connections or agreements an individual or company may have with another. This is the big imperative we now call “transparency.”

2) Hypocrisy — also definitely not OK to falsely present yourself as righteous on certain topics, while playing the other side of the field as well. So if you’re going to be someone who shouts from the rooftops about the evils of Big Pharma, for example, then you should not be accepting sponsorships from same.

3) Exploitation — no inappropriate hype of something (or some group) where it doesn’t belong. No misleading people (patients) into buying things they don’t need or paying exorbitant prices for no good reason.

I haven’t told you anything new here. These rules apply to any industry, and in fact to credibility in general. It’s just that since diabetes is both a deadly disease and a billion-dollar industry, it’s inevitable that interests conflict. So it’s important for us all to keep a (constructively) critical eye peeled, I believe.

Your thoughts?

Explore posts in the same categories: D-News Examined, Health 2.0

Wednesday, August 27th, 2008 | Permalink | Comments (7)

Comments

Since you brought up conflict of interest, I thought I would share a video that highlights the culture of “improper dependence” that underlies our discussion of “conflict of interest”.

In the video I link to below, Lawerence Lessig, a professor of law at Stanford University argues that dramatic change is urgently needed in the U.S. Congress. This is not a partisan plea—not a Republican nor Democratic party promotion. Rather it is a call for the people to demand our politicians sever the improper relationship they cultivate with money and those who lobby them with it.

What does this have to do with doctors and pharma?

Well, one of the broader cultural examples used in the video is that of Genentech and the AHA—a sample of one study that has the feel of being corrupted by improper financial dependence (i.e. a conflict of interest). Other examples include the Sugar Industry connection to federal dietary recommendations, etc. etc.

So I invite you fellow diabetics, to consider that our concerns over physicians and their pharma reps is in fact a broader issue in our culture. That in fact we need to reform and reconstitute the trust-relationship we have with many in authority in our culture. And among those most central is Congress.

You can watch the video presentation at Change Congress in 20 Minutes.
Posted by: Snowflak Seven | August 27th, 2008 at 9:39 am
We are influenced. We are never truly independent. It is important, however, to simply disclose our ties and let the readers determine if we are speaking independently. This is exactly what studies in journals do - the authors of a study have to disclose their ties. It does not rule their opinion out, it simply gives a possibly valuable piece of information. I personally think that clear disclosure is accountability in itself - if you disclose, you will be more careful to be independent.

Regarding physicians? We gain much from our association with pharma - I have been educated much about new treatments (even got taught about insulin pumps via a pharmaceutical company - they paid for the Minimed course). Was I influenced? I am sure I was, but I do what I can to do what is best for the patient over what is best for the drug rep.

This is becoming a non-issue, as most doctors will stop seeing drug reps within the next few years. The ties to pharma carry too bad of a connotation. They are even stopping giving us pens and paper as of January 1. Why? I am not sure. I don’t think I have ever been unduly influenced by a drug rep’s pen. But the reality is that the sun is setting on this practice.
Posted by: Rob | August 27th, 2008 at 2:40 pm
The medical profession likes to have its cake and eat it too. On the one hand, they routinely claim to follow practices of “evidence-based medicine” yet many seem to routinely fail to disclose any ties to the drug industry. The practice is deeply entrenched; while seemingly innocuous practices like accepting free samples is harmless enough, taking all expense-paid golf trips to Pebble Beach for the weekend raises questions as to just how free from influence they really are, so its a very fine line. Radio personality Dr. Laura Schlessinger has said something which is quite relevant here:

“When you’re the victim of the behavior, it’s black and white; when you’re the perpetrator, there are a million shades of gray.”

The medical associations and journals have not done a sufficient job of policing even minor violations (to mention nothing of major violations), a practice which needs to change if they wish to maintain any shred of integrity.
Posted by: Scott | August 27th, 2008 at 6:10 pm
This is a very important blog. I’m so glad I found it. I’m linking over right now.
Posted by: therapydoc | August 27th, 2008 at 8:07 pm
Excellent paper, Merrill. I especially like your statement that for medical professionals:

“It is curious that constructive collaboration with industry is the value highlighted in the scope of work. Why not protecting patients; or improving health; or fostering objectivity and independence? ”

Who’s job is it to protect patients, anyway? (When even the big non-profit associations are so closely tied to industry interests?)
Posted by: AmyT | August 28th, 2008 at 8:56 am
This is an important topic.During my Medical School days I and many of my friends held strong views against accepting sponsorships and gifts.As we entered the profession our principles got diluted and diluted and now it is non existent.
An individual doctor will not be able to with stand the Pharma onslaught of offerings. Strict guidelines from Medical Associations and Government will help in a long way.
Posted by: Charakan | August 30th, 2008 at 12:37 pm
The issue is solely trust. Who do you trust and who can you trust?

The trust issue is not limited to patients deciding which doctor or treatment to put their trust into, no sir, not by a long shot.

As the revelations that keep coming vividly warn us, the trust issue is more importantly whether the doctors who treat us can trust the information they got in MedSchool, from their specialty Medical text books that line their office bookshelves, current Medical Journals, Drug reps, Equipment sales companies, other doctors, their own hospitals, etc.

‘If’ in the end each and everyone of them is only looking out for their own pecuniary interests patients are at substantial risk of loss of life and or quality of life.

Our physicians face the following kinds of mind expanding clinical course correcting treatment information altering how they perform/behave almost daily and if they don’t change their ways their patients won’t, don’t and can’t get better.

For example in the past week alone we have learned that taking Fish Oil is best for patients with CHF in terms of longevity; that taking Statins for CHF provided no benefit to longevity; that the elderly taking the flu shot do not prolong life or prevent death from the flu; and more than four years of intensive lipid-lowering therapy with ezetimibe/simvastatin (Vytorin) did not slow the progress of aortic stenosis and has shown little or no benefit vs. risk.

Please do check all of the above claims out at Medpage.com, a part of the U. of Pennsylvania Medical School.

These shocking results are the result of Evidence Based Medicine research by researchers and physicians getting serious about what it is that is being done to patients.

My recommendation, find an evidence based physician, not a physician salesman.

Happily, there are many thousands of M.D.’s that you can trust with your life. I put the odds at roughly 1 in 10 or 75,000 ‘trustworthy’ M.D.’s.

That doesn’t mean that the other 9 are bad, just misinformed and blindly going along with the current paradigm and not rocking the boat. Indeed, most of them are fine people and fine physicians.

But you will have to go out and find that 1 in 10 physician yourself. Rest assured they do exist.

Isn’t the very reason for the success of this Blog b/c the average Diabetic (and those of us who love them) can get honest unadulterated feedback and information on all thing diabetic FROM SOMEONE WE CAN TRUST?

May this site have continued great success.
Posted by: im1dc | September 2nd, 2008 at 12:58 pm