Med Schools Failing on Conflict of Interest Policies

While medical schools have had clear guidelines for conflict of interest policies since 2006, many fall short of meeting the policies set forth by the Association of American Medical Colleges, the Institute of Medicine, and others, research shows.

The nation's medical schools have made progress over the last five years developing clinical conflict of interest policies but they all still have a long, long way to go, a study shows.

Institute for Medicine as a Profession researchers compared changes in medical schools' policies from 2008 to 2011, and found that while many institutions made progress implementing some COI policies, nearly two-thirds still lacked policies to limit ties to industry, including gifts, meals, drug samples, and payments for travel, consulting, and speaking. Only 16% met national standards in at least half of the areas, and no school met all the standards.

"It is a good news-bad news situation," says Susan Chimonas, lead author of the study, associate director of research at the Center on Medicine as a Profession at Columbia University. The study appears in the October issue of Academic Medicine.

Chimonas says medical schools have a clear blueprint for conflict of interest policies that have been put forward since 2006 by groups that include the Association of American Medical Colleges, the Institute of Medicine, the American Board of Internal Medicine Foundation, and IMAP.

"That is the thing that is interesting to me," she says. "We actually have these standards. We've had three independent bodies of experts coming to basically the same conclusion about what these policies should look like or involve. Several years have gone by now and many schools are not coming even close to meeting those policies."

The study notes that in 2008, "no policy" was the most prevalent finding in all but one CCOI area. By 2011, almost all schools had made strides, and the number of schools with no policies dropped sharply from more than a quarter in 2008 to less than 2% in 2011.

Policies in the "moderate" range more than doubled, from 14% to 30%. However, the proportion of schools with strong policies in eight or more areas barely increased, from 1% in 2008 to 4% in 2011. Less-than-stringent policies remained typical for all areas except ghostwriting. Eighty-four percent of schools had substandard policies in seven or more areas.

Chimonas says her study doesn't ask why the schools aren't moving more quickly on conflict of interest policies, but she speculated on the reasons.

"Maybe there is faculty resistance," she says. "Physicians might like getting the gifts and the payments. So it could be a difficult thing for schools to move forward and implement these things. It could also be institutional resistance. Medical schools have a lot of other things on their plate that are maybe more urgent on a day-to-day basis. So maybe this isn't a priority for them yet."

"There are many reasons we could think of for why progress isn't being made more quickly. The point we can agree on is that more progress needs to be made and we have to figure out how to help or encourage schools to move forward from this point on."

The top five medical schools that came closest to meeting the national CCOI standards were:

• Emory University School of Medicine
• University of Massachusetts Medical School
• University of Iowa Carver College of Medicine
• Boston University School of Medicine
• University of Arkansas for Medical Sciences College of Medicine

Among schools with the weakest policies:

• Saint Louis University School of Medicine
• George Washington University School of Medicine and Health Sciences
• Weill Cornell Medical College
• University of Nebraska College of Medicine
• Case Western Reserve University School of Medicine

Heather Pierce, senior director, science policy for the Association of American Medical Colleges, says AAMC is "pleased" with the progress that medical schools have made in the last few years to strengthen COI policies.

"As the study notes, the progress that institutions have made since the AAMC task force reports outlining recommendations for COI policies that strike a balance between appropriate, principled partnerships with industry and protecting the integrity of clinical care decisions is encouraging," Pierce said via email.

"We are encouraged by the robust and continued dialogue surrounding these issues. These discussions have also been spurred by national transparency initiatives such as the newly implemented rule on financial conflicts of interest in federally funded research as well as the information that will be available to the public through the Open Payments database of payments made to physicians and teaching hospitals under the provisions of the Affordable Care Act known as the Physician Payments Sunshine Act."

Chimonas says effective conflict of interest policies are needed to maintain public trust in the medical profession.

"It is important for patients to know and feel confident that the care they are getting isn't influenced by pharmaceutical marketing interests," she says. "When you go to your doctor you want to know that he is giving me this prescription or recommending this treatment because it's the best thing for me and not because he gets $50,000 a year to read a speech that was written for him by a pharmaceutical company, or because last night he got a $100 dinner paid for by another company."

"It is also important at a broader level that the public, all of us together, that we have trust in the medical profession. This is a profession that we all look up to. It's not just individual doctor that you look up to. It's the whole profession. We want to have confidence that the profession is regulating itself properly. We rely on the medical profession."

The study also analyzed whether a school's status, hospital affiliation, or source of funding influenced CCOI policy strength. Although hospital ownership and public or private status had no impact, medical schools with greater funding from the National Institutes of Health were more likely to have stricter policies than those with less funding.

To track progress and encourage stronger policies, IMAP has launched a new Conflict of Interest Policy Database that houses policies from medical schools across the country. The publicly accessible database allows anyone to search a school's CCOI policies, compare them with other institutions, identify where progress needs to be made, and learn best practices, Chimonas says.

As a reward for that longstanding public trust, Chimonas says physicians are given leeway to self-regulate. "It is unfortunate that we've got this set of standards, there is a consensus by these three expert bodies," she says. "And yet the schools that are in a position to actually implement some things that would show that the medical profession is serious about getting this right, that it is too slow, it's not going quickly enough, and this really jeopardizes the public trust."

If medical schools don't act more assertively to install conflict of interest policies, Chimonas says they could risk an unwanted intervention by an outside entity such as the federal government.

"It is something that would be much better if the medical profession did it instead of the federal government. Government is a blunt instrument and it is important that this be done right because some of the relationships between doctors and companies are positive," she said.

"We want to make sure we have the right balance and medicine is in the best possible position to know what that balance is. I am wary that if this doesn't get done well within a reasonable time frame that something could come down from an outside body. That concerns me but on the other hand maybe the threat of that will help the schools move more quickly."