Fifty years ago you would arrive at the physician’s office to receive the ultimate source of knowledge on what could be wrong with you and how to treat it. Today, you have looked up your symptoms on the internet and come ready with several potential diagnoses. As the physician gives you your prognosis, you pull out your smart phone and you start looking up treatments, if the physician prescribes something you have never heard of you look it up. In effect you and technology have moved ahead of the practice of medicine. No longer is the physician the “high priest of medicine” and that is hard for many doctors to accept.
Over the past half century, we have seen tremendous achievements in medicine and science. There has been a 50 percent reduction in cardiovascular mortality despite an epidemic of obesity; a dramatically decreased cancer mortality rate; and the conversion of AIDS from a death sentence to survival with good life quality.
As a recent article explained, this progress has not been easy. Instead, the key to these successes has “been the growing number and complexity of collaborations between academics, physicians, regulatory agencies, and—not least—industry.”
“Unfortunately, over the past 20 years, a mania has taken hold that discounts the social value of collaboration and has mounted an inquisition against it,” wrote Thomas P. Stossel, MD, Director of Translational Medicine at Brigham & Women’s Hospital and an American Cancer Society Professor of Medicine at Harvard Medical School. This mania has been encapsulated by the epithet “financial conflict of interest (fCOI).” Critics’ unwarranted allegations that such conflicts cause bias have limited the sources of intellect that can contribute to a given project.
Stossel recognized how “medical journals have taken a leading role in promoting this mania.” In fact, a recent study, which Stossel authored and was published in the April issue of Nature Biotechnology documents the pervasiveness of this mania: a content analysis of 108 articles in four highly cited medical journals (The New England Journal of Medicine, JAMA, Lancet, and Lancet Neurology) found that 89 percent of the publications emphasized what they considered risky or problematic with industry collaborations.
But what is the basis for this assertion? Approximately half of these articles presented no evidence whatsoever for their conclusions. They merely postulated them as self-evident. When provided, the evidence was weak, and the interpretations one-sided: “fewer than 15 percent even mentioned any alternative interpretations, and only 3 percent bothered to discuss them. In contrast, the comparatively few papers emphasizing benefits of collaboration all cited evidence, and recognized and attempted to rebut opposing viewpoints.”
Discussion
The unfair portrayal of physician-industry relationships is most pervasive in the “academic community,” according to Stossel. “Many universities reflexively ban industry-sponsored peer-to-peer speaking events, pejoratively dubbed “speakers’ bureaus,” that physicians attend often and voluntarily. Sheer prejudice, not fact, prompts the censorship.” What’s more problematic about such bans is that overwhelming evidence has shown that industry support causes no bias.
Emphasizing his displeasure with the role academia has played in creating and feeding this mania, Stossel pointed to a recent commentary entitled “Does conflict of interest disclosure worsen bias?” authored by the editors of PLoS Medicine and discussed recently in The Scientist. The editors referenced an article published in their journal documenting that a large and increasing fraction of psychiatrists who contributed to updating the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Psychiatric Disorders (DSM) have fCOIs.
According to the PLoS editors, the use of psychiatrists with industry ties was evidence of a commercial conspiracy: an “explosion of diagnostic categories and new diagnoses (and thus markets) is…a virtual bonanza for the pharmaceutical industry.” The editors bashed the APA for not banning physicians from receiving unrestricted industry grants or from participating in industry-sponsored peer-to-peer speaking. The PLoS editorial blames this laxity on the APA’s financial dependency on industry to which the society therefore panders by allowing “conflicted” consultants to make recommendations based on industry interests.
Stossel addressed the concerns of these editors exquisitely. “The DSM is an evolving effort to codify diverse mental behaviors to better inform research and treatment of psychiatric disorders. Why would the APA predominantly select DSM consultants with industry relationships? In searching for bias, Stossel acknowledged how the PLoS Medicine editors should first look in the mirror themselves.
That DSM contributors have relationships with industry partners might actually be praiseworthy. Why wouldn’t industry seek out the best, brightest, and most productive experts for collaboration? It’s in their financial interest to do so. And how could unrestricted grants, ideal for research that follows up serendipitous findings, possibly be problematic? The money leads to better research that can benefit patients.
Furthermore, the DSM does not recommend specific treatments, meaning DSM consultants are not able to actively push their products in this medium. On the contrary, it could be that the increasing number of diagnoses to which the PLoS editors refer may actually lead to more patients partaking in talk or cognitive behavioral therapies, which do not involve drugs, and thus cannot benefit the drug industry.
The PLoS editors’ confidently assert: “It is widely established that conflicts of interest impair objectivity and integrity in medicine.” But “widely reported” should not count for “widely established.” Even a voluminous Institute of Medicine report on COI, itself riddled with speculation as to its dangers, admitted that there is no empirical evidence that fCOIs have any impact on what should count most—patient outcomes. Moreover, the widely cited Wazana study (social science) also did not use patient outcomes when testing for the influence of industry.
Conclusion
Ultimately, “the one-sided messaging by medical journals, led by editors arguably motivated to market their publication, has inflamed the fCOI mania that in turn has reduced physician-industry collaboration and industry-subsidized medical education.”
Stossel maintained that this mania has also driven “a prosecutorial racket that forces companies to pour money into settling dubious allegations under threat of debarment penalties that would prevent them from selling any of their products to Medicare or Medicaid.”
Instead of causing all this mania and wasting millions of dollars fighting through smoke and mirrors, Stossel asserted that “money could be better applied to finding more effective treatments and cures for the suite of ailments that continues to plague the human species.” Accordingly, he recommended that “patients and industry resist this blatant intellectual dishonesty.”