Recently, the American Medical Students Association (AMSA) held their annual conference. Interestingly, one of the participants of the conference provided an ongoing commentary of the events and happenings at this year’s conference.
Of particular interest, the commentator noted that AMSA sold the Association of Accredited Naturopathic Medical Colleges a booth at the 2011 convention. As the author pointed out, AMSA will not take money from pharmaceutical companies, but they have no problem with taking money from “pseudoscience.” Perhaps a conflict of interest?
Consequently, the author described how he went up to the booth to find out what
naturopathy is. He was told that they are “primary care physicians” who treat the “whole patient in a holistic way.” In addition, one of the table reps told the author that naturopathy subscribes to the use of homeopathy, herbalism, acupuncture, therapeutic touch, and “all sorts of other nonsense.” The author also pointed out that their “written materials were more straightforward about their quackishness.” Ultimately, while AMSA “professes to support evidence-based medicine,” the author was disturbed by the fact that AMSA would legitimize “quackery of this sort.”
What is problematic about AMSA’s approach of accepting alternative medicine and banning pharmaceutical support is that it creates an inherent bias among the organization. This bias is detrimental to advancing medicine, science, and medical education, particularly because AMSA is a vocal voice in the medical community. Such a revelation that AMSA is willing to accept money from “pseudoscience” instead of hard science, should cast many doubts on the positions that the organization maintains on various policies. Calling for evidence-based practices, while accepting money from alternative medicine—hardly even close to evidence based—should also cast serious concerns about the Soros and Pew funded PharmFree Campaign started by AMSA in 2002.
PharmFree Campaign
The campaign was started for medical students to advocate for evidence-based, rather than marketing-based prescribing practices, the removal of conflicts of interest and global access to essential medicines. AMSA provides toolkits, talks and training institutes to help medical students advance these goals.
To advance these goals, AMSA released its first “PharmFree Scorecard” in 2007. This initial Scorecard graded medical schools on the presence or absence of a policy regulating the interactions between their students and faculty and the pharmaceutical and device industries. In 2008, AMSA worked with The Pew Prescription Project, an initiative of the Pew Health Group, to develop an updated Scorecard, which used a rigorous and transparent methodology to assess the content of policies at medical schools throughout the country.
This framework was used again in the 2010 AMSA PharmFree Scorecard, published last month. The AMSA PharmFree Scorecard evaluated conflict-of-interest policies at 152 medical colleges and colleges of osteopathic medicine in the United States, with a focus on interaction between students or faculty and the pharmaceutical industry.
Using letter grades to assess schools’ performance in eleven potential areas of conflict, the Scorecard gives a comprehensive look at the current and changing landscape of conflict-of-interest policies across American medical education, as well as more in-depth assessment of individual policies that govern industry interaction. It also examined potential conflicts of interest created by industry marketing at the level of the individual physician and trainee.
Method
The PharmFree Scorecard methodology was developed jointly by AMSA and the Pew Prescription Project, an initiative of the Pew Health Group. Assessed domains are broadly consistent with those identified in recent literature – primarily Brennan et al. Health Industry Practices that Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers. These include policies related to acceptance of gifts and meals from industry; consulting relationships; speaking relationships; disclosure of financial conflicts; and pharmaceutical samples.
Two blinded assessors independently score each set of policies in the eleven areas included in the scorecard, and then use a formula to derive a letter grade.
2010 AMSA Scorecard
As of December 15, 2010, 140 of 152 medical institutions had participated in the Scorecard, a 92% participation rate, improved from 88% in 2009. Of 152 US medical schools:
– 19 receive As (13%)
– 60 Bs (39%)
– 24 Cs (16%)
– 18 Ds (12%), and
– 26 schools (17%) receive a grade of F.
In 2010, over 50% of medical schools, now have grades of A or B (78 schools). This was a tremendous increase from 45 A and B schools (30%) in 2009 and shows a continued progression from 29 A and B schools in 2008. Additionally, 21 schools improved their scores to a C or above after submitting updated policies for review.
AMSA noted in response to this data that “Conflict of interest has clearly become a central issue in medical administration and education and more schools are recognizing the importance of thorough policies.” Specifically, AMSA recognized the University of South Dakota Sanford School of Medicine, Tufts University, and Des Moines College of Osteopathic Medicine for “submitting dramatically improved policies which increased their scores from Ds to As.”
The 2010 Scorecards also recognized 9 other schools that improved at least 2 letter grades: Wake Forest University, New York Medical College, Virginia Commonwealth University, University of Minnesota-Twin Cities, Temple University, Case Western Reserve University, University of Illinois, and University of New England College of Osteopathic Medicine.
The report also noted that medical schools in California, Pennsylvania, New York, Texas, Florida and Massachusetts continued to excel, with a majority of medical schools in each state earning strong grades on the Scorecard. In addition, between 2008 and 2010, the number of perfect scores increased in every domain graded by the Scorecard.
For example, in 2010, three times as many schools received perfect scores for addressing industry support of scholarships, off-campus continuing medical education, purchasing, and gifts compared to 2008. Notably, the number of institutions with model curriculum on conflict of interest quadrupled between 2008 and 2010.
Nearly one-third of schools now teach medical students to understand institutional conflict of interest policies, to recognize how industry promotion and marketing can influence clinical judgment, and to consider the ethics around conflict of interest. The areas with fewest perfect scores were on-campus continuing medical education (CME) and the access of sales representatives.
Discussion
AMSA’s national president, Dr. Brian Hurley, noted that “AMSA’s Scorecard is meant to be not only a yardstick for measuring U.S. medical school conflict-of-interest policies, but also a guide for medical schools working toward adopting stronger and more practical policies.”
Robert Restuccia, executive director of The Prescription Project asserted that “The schools that earned ‘A’ and ‘B’ scores are to be commended for setting a high bar and aggressively moving forward to ensure medical education, training and patient care is free of commercial bias.”
Heather Pierce, JD, senior director of science policy and regulatory counsel at the Association of American Medical Colleges (AAMC) asserted that “The positive changes reflected in this assessment highlight the active engagement of the academic medical community in addressing industry interactions, both through policies and the education of its faculty and students.”
However, the Association of Clinical Researchers and Educators (ACRE), which supports relationships with drug companies, called AMSA misguided for its lack of understanding about how such partnerships can benefit students and patients. ACRE noted in its statement that “AMSA has devoted their time and resources rating medical schools on biased, meaningless subjects which reflect little on their actual education.”
Additionally, one physician stated that he was proud that the academic medical center he worked at, Western University, received an F from AMSA Scorecard. Specifically, Jeff Unger, MD, associate director of metabolic studies at Catalina Research Institute in Chino, asserted that the AMSA Scorecard and Pew Prescription Project are an “obscure group of liberals who have nothing better to do than criticize those of us in the private sector trying to improve the lives of our patients.”
Dr. Unger’s editorial offered AMSA and Pew a historical lesson about the pharmaceutical industry in hopes that they might spend their time on something better than “releasing results of such useless surveys.” He pointed out how the discovery of insulin in 1922, which was mass-produced by pharmaceutical companies such as Eli Lilly, changed the landscape of medical science and proved that chronic disease could be treated effectively with a specific medication. Since 1945, the pharmaceutical companies have spent billions of dollars developing new classes of drugs to treat diabetes.
As a result, he asserted that “None of these accomplishments would be possible without pharmaceutical company innovation, education and support.” Morever, Dr. Unger recognized that “pharmaceutical companies are not the enemy, and that all increasing government interference with companies has done is drive up research and development costs.
Dr. Unger further acknowledged that the role of industry is important because pharmaceutical companies “provide educational opportunities to physicians, physician assistants, nurses, nurse practitioners and certified diabetic educators about disease state awareness and treatment guidelines.” As he noted, “these programs are tightly regulated by the FDA and providers who attend these programs overwhelmingly approve of the educational format and the professionalism of the presentations.”
With respect to other policies graded by the scorecard, Dr. Unger explained that “Patients should thank physicians who see pharma reps because they enable physicians to provide patients free samples for medications they are unable to afford because their insurance will not cover them. These samples are extremely important for diabetes patients because the medications used to manage diabetes “are often safer and more effective than those available on standard third-payer formularies.”
He also pointed out that with the assistance of pharmaceutical representatives, physicians can help patients in applying for company programs that help patients pay for drugs they cannot afford.
One important observation about the important role of industry that Dr. Unger offered was a recent experience he had while lecturing. He explained that the speakers “before him, who were from Ivy League schools that did not allow visits from pharmaceutical reps, gave the audience incorrect information regarding a particular diabetes drug.” As a result, he had to “correct the audience by explaining the latest FDA approvals regarding the particular drug, which a pharmaceutical representative had explained to him three days prior to this national meeting.”
Conclusion
Ultimately, the impact of the AMSA Scorecard remains questionable, especially given the new revelation that AMSA accepts money from alternative medicine, but not industry. Where does the actual quality of teaching or patient care get ranked in their system? Does ‘improved’ score equate to anything other than less media attention of non-issue? While it is important that academic medical centers continue to implement policies for interacting with industry, until evidence shows that less industry-academia collaboration improves patient care and outcomes, these Scorecards will continue to hinder collaboration and innovation, and AMSA and the Pews will continue to be “thorns in the side of medical progress.”
As Dr. Unger recognized, academic medical centers “should continue to welcome pharmaceutical reps and pharma companies onto the campus and their medical students should learn the value that these liaisons share in changing the lives of individuals afflicted with acute and chronic diseases.” Moving forward, Dr. Unger noted that instead of listening to AMSA and Pew, “the voices of patients who suffer from chronic diseases are the only ones that should count in the finally tally.”