A Hard Look at Physician-Industry Relationships and Ad Hominem Attacks by Critics

Arguing against science is difficult, so what we have seen lately is rather than arguing the science and eventual benefit to society, attacks on the character of those delivering the science.  This sums up the entire conflict of interest in medicine debate.  It is taking the easy way as opposed to the principled way of debating an issue.

The core principle of universities is that, “the pursuit and free exchange of ideas is vital and uplifting, and efforts that seek to impose a particular viewpoint to the exclusion of others should be fiercely resisted.” 

Today however, many of our universities, medical schools, and academic medical centers are following short of this principle by allowing the concerns of a few overpower the agenda.  A recent article from Forbes explained how one group, the Pharmascolds, is leading a movement to “impose a particular viewpoint” on medical students, faculty and the greater public.

As the author pointed out, Pharmascolds are “critics who worry about university/industry interactions,” and “constriction of academic freedom is typically cited as a key concern.” 

To the Pharmascolds, “industry represents an inherently corruptive influence on students and trainees, and threatens to impose a restrictive and biased world view upon them.”  Although Pharmascolds may have made the headlines for some stories, the article noted that, “there’s another competing narrative to consider.”

Those who wonder how academic orthodoxy is enforced in practice need look no further than the response to a recent lecture given at Case Western University by Dr. Tom Stossel, the American Cancer Society Professor of Medicine at Harvard, and Director of the Translational Medicine Division of the Brigham and Women’s Hospital, where he is also an attending physician. 

Stossel’s lecture, entitled, “A Hard Look at Physician-Industry Relationships AKA ‘Conflicts of Interest’” examined a multitude of research and discussion about the recent focus on industry-physician collaboration. 

At the beginning of his lecture, he noted how the Harvard Medical School 2009-2010 Report on Conflicts of Interest and Commitment clearly asserted that, “Interactions between academic and industry are crucial to science and to facilitating the translation of knowledge from the research bench to the patient bedside.” Then, his lecture went on to look at 1) the history of conflict of interest regulation, 2) weak & false evidence justifying regulation and high cost policies, and 3) why regulation of physician-industry relationships originates and persists.

Part of his presentation showed a chart examining “Articles per year concerning conflicts of interest,” which showed that since 1990, there has been a tremendous spike, something Stossel referred to as a “Conflict of Interest Mania.”

Stossel also presented a slide on a study he conducted of papers published in the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine (NEJM) Concerning Physician-Industry Relationships.  His slide noted that of the articles examined between 1999 and 2009:

• 96% of articles showed physician-industry relationship risks, while only 4% showed relationship benefits
• Only 44% provided evidence or relationships risk, while 100% showed evidence of relationship benefits
• 76% drew inferences about patient outcomes based on relationship risks, however 0% drew evidence about relationship benefits
• Only 43% acknowledged an alternative viewpoint with respect to relationship risks, while 100% showed an alternative viewpoint on relationship benefits; and
• Only 3% critiqued alternative viewpoints of relationship risks, while 100% critiqued alternative viewpoint for relationship benefits.

The lecture then discussed how policies now mandate “massive confession and prophylactic rules,” which affect every aspect of medicine.  He noted:

• All corporate payments to physicians are disclosed
• Peer-to-peer speaking is prohibited (i.e. Harvard and Partners Healthcare)
• Physician-industry relationships preclude editorials, journal review articles, or service on guideline or FDA review panels
• No gifts, however trivial
• Heavily restricted payments for meals and travel
• Samples and detailing prohibited or limited
• And payments for value are eliminated or limited

Moving along, Stossel noted how the mania surrounding conflicts of interest use allegations to justify conflict of interest regulations.  These critics make arguments such as:

• Industry’s profits exceed value added
• Industry’s marketing is fundamentally deceptive
• Industry relationships degrade and bias research and cause physicians unwittingly to promote or prescribe unsafe and / or unnecessarily expensive products that harm patients; and
• Payments to physicians for time or work erode “professionalism” and public trust

Consequently, he then moved on to show how physician-industry collaboration has produced significant value, through longer life-expectancy, and better survival rates for severe and chronic disease such as cancers, HIV, and heart disease.

Nevertheless, Stossel showed a number of slides quoting famous academic researchers and leaders of medical institutions who ascribe to the belief that physician-industry collaboration is harmful for the reasons noted above.  Moreover, Stossel specifically addressed one study in particular that critics of industry point to, the Wazana study, and recognized that despite the study’s claims about harm to patients, “no study analyzed by Wazana used patient outcome measures.”

However, Stossel recognized how such viewpoints are misguided considering:

• There has been no decrease in the esteem with which physicians are held by the public in the past 20 years
• 90% of citizens surveyed believe physicians and industry should work together; and
• Most patients in cancer trials have no concern about their physicians commercial relationships

Additionally, Stossel’s lecture explained how conflict of interest rules and regulations are a “purposeless resource diversion.” He noted how the “redundant industry, health center, state and impending federal (“sunshine act”) payment disclosure registries are:

• Expensive
• Inaccurate
• Almost useless; and
• Abusive

Forbes Article

Interestingly, the author noted that Stossel’s lecture “was well-attended.”  However, the real news he noted, “was the three sentence email received by members of the Case Western faculty prior to Stossel’s lecture — a nastygram sent by a colleague at the neighboring Cleveland Clinic.

Subject line: “Re: Medicine Grand Rounds — Tuesday September 13th” (i.e. Stossel’s talk).  Body of the email (in full): 

”This guy is an embarrassment to the medical profession.  Can’t believe you would have him provide Grand Rounds.  Your trainees deserve better.”

The Forbes article noted how this kind of email, written by industry’s leading critic Steve Nissen, attempted to discredit Dr. Stossel. 

The author noted that Nissen used an “ad hominem attack (baseless) against Stossel merely because he is an industry critic.  The article noted how “the critique was especially striking given that Stossel’s academic credentials are far more robust than most (if not all) of the Pharmascolds, including in particular a number of medical journal editors who have little original academic record to speak of, and have achieved almost all their considerable fame and now academic prominence by climbing on board the conflict-of-interest bandwagon.”

Moreover, the article recognized that, “the relatively small fraction of Stossel’s academic publications that do speak to conflict-of-issue issues strike me as all the more remarkable given the obvious comfort level that many medical journals (and their peer reviewers) have for confirmatory papers in this space, and their natural reluctance to publish (and arguably validate) disfavored arguments such as Stossel’s.”

Accordingly, the author recognized that with regards to Nissen, “the medical profession deserves better.”  

Rather than challenging the arguments of Dr. Stossel, Dr. Nissen used a ad hominem slight of hand to discredit those he disagrees with.  In the end thanks to the email the lectures were packed and students were able to learn the value of the relationships with industry.