New England Journal of Medicine Editorial on COI In Academic Medicine – Misses the Mark

Using the recent change in policy at Partners Health Care in Boston, Massachusetts, as an example, Bernard Lo, M.D., recently wrote an article in the New England Journal of Medicine (NEJM) examining “Serving Two Masters: Conflicts of Interest in Academic Medicine.”

While he acknowledges that “relationships between academia and industry have both benefits and risks,” his article seems to focus more on the risks. Specifically, he tries to analyze the differences between academic health centers (AHCs) and for-profit medical companies to highlight the potential problems that may arise from industry-academic relationships. One problem with such a contrast is that it underscores the “close collaboration between academia and industry that has facilitated the development of many new drugs” that Dr. Lo himself professes.

In addition, using this “apples and oranges” comparison ignores the fact that academic-industry relationships allow “key interests to be aligned.” For example, as “the public seeks effective new therapies, academia wishes to translate basic discoveries into treatments, and industry wishes to develop new products.”

Dr. Lo also recognizes that the new Partners policy notes that “both academia and industry may benefit when academic leaders serve on company boards.” He even asserts that such work with “companies may benefit from the wisdom of senior academic physicians who learn about emerging trends in basic research and health care.” As a result of this collaboration, Dr. Lo admits that “academic leaders may learn innovative approaches to organizing scientific research teams or running large, complex organizations, and their networking with other board members may enhance fund-raising.” Essentially, this work creates an environment that encourages further success in all stages of creating new drugs and treatments for patients.

Although he discusses the obvious benefits from these relationships, Dr. Lo still maintains that because the goals of AHCs may “diverge from that of for-profit medical companies,” organizations must “take the initiative to promote a culture of accountability and a commitment to professionalism.” It seems apparent that AHCs who facilitate the development of new drugs, and who translate basic discoveries into treatments are promoting the highest level of accountability and professionalism, since their work is helping patients directly.

Dr. Lo believes however, that only AHCs “are driven largely by the goals of deepening our understanding of health and disease and providing high-quality care.” In reality, AHCs and for-profit companies work together to accomplish these goals. In fact, without industry support, many of the goals from AHCs would never be realized and as a result, their understanding of health and disease and ability to provide high quality care would be significantly diminished.

Just because companies “develop profitable new products” does not mean they share a different goal from AHCs. In fact, companies who develop profitable new products almost always invest their profits immediately into developing new drugs and treatments. Dr. Lo’s belief that for-profit companies only undertake public health work if it enhances their or conforms to their plan for charitable giving is problematic for two reasons.

First, for-profit companies, like GlaxoSmithKline support public health regardless of profits, as we previously wrote. Second, medical companies by their nature of risk and investment must undertake projects that return profits otherwise, the expenses associated with testing, research and development would shrink significantly, causing less drugs and treatments to be made. Despite these contradictions, Dr. Lo recommends that several questions regarding the relationships of AHCs and for-profit companies should be asked.

First, can situations be identified in which academic leaders who are board members face a sharp divergence between the interests of the AHC and those of the company? Second, in such situations what strategies might be adopted to reduce the risks to the AHC to an acceptable level (e.g. recusal)?

Third, could the interactions between academic leaders and industry be restructured in such a way as to preserve the mutual benefits of the relationship while greatly reducing the risks? Dr. Lo suggests that “leaders of AHCs might serve as consultants or nonvoting board members, rather than as officers who assume fiduciary responsibility to companies.” Fourth, what amount of money in directors’ fees may the AHC leader retain? Lastly, is effective oversight in place at the AHC? Dr. Lo mentions the recent report he coauthored on conflicts of interest from the Institute of Medicine (IOM), which recommended using the board of trustees of the AHC to review COIs.

Since AHCs work with industry to facilitate the development of new drugs and translate basic discoveries into treatments, the benefits of academic-industry relationships far outweigh the risks. Additionally, it is evident that bringing new drugs and treatments to patients allows industry and academia to maintain trust with patients, although we agree with Dr. Lo that strong COI policies should be in place to maintain program integrity.  

In the end, working in collaboration with industry has helped physicians find the solutions to tackle difficult and complex problems in their roles as clinicians and researchers. Consequently, using these skills to help improve COI policies should only be undertaken if it does not impede such collaboration.