It’s time to blow the whistle on the individuals who are promulgating overly restrictive policies regarding relationships between physicians and industry. The insistence by academic journals that all such relationships be rigorously restricted is impractical and will compromise patient care. In reality, we need to take a time out and examine in a scientific, balanced, and evidence-based manner the nature of physician relationships with industry and with government so that we can all work together to deliver drugs and devices that our patients need.
The Institute of Medicine defines a professional conflict of interest as "a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest. Drivers of bias may be financial, academic, professional status, or personal" (N. Engl. J. Med. 2009;360:2160-3).
Many of us find ourselves conflicted professionally when we participate in a promotion process, a search committee, or a program committee in which we are privy to a competitor’s work. In such situations, we are asked to use our judgment and place the interest of what we are trying to do above our own personal interests. We are never asked to disclose these other kinds of conflicts, and it’s extremely rare that we are asked to excuse ourselves from the process.
In fact, one of the greatest conflicts of interest we have as physicians is the way in which we are reimbursed – whether by capitation or fee for service. What is in our personal best interest may not line up with what is best for our patients, but this is not something we disclose. So why is it that the commercial relationship between physicians and industry or physicians and professional organizations has received such scrutiny? And why have so many authors ignored the benefits that have accrued from physician/industry partnerships, choosing instead to demonize money and commercial interests exclusively? In the spirit of evidence-based medicine, it’s time to bring balance to this heated debate.
I have been a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) for more than 20 years, and I am certain that this society wouldn’t be what it is today if the conflict-of-interest rules currently being forced on us had existed in the 1990s or the early part of the past decade.
When I joined SAGES, the organization was a fringe group with about 300 members with no representation on the American Board of Surgery. Our leaders had a passion for minimally invasive surgery and made it their mission, often through strategic partnerships with industry, to advocate for new technologies and educate surgeons about how to use them. Without these partnerships, initiatives such as the Fundamentals of Laparoscopic Surgery (FLS) skills enhancement and assessment module would never have come to pass. To the best of my knowledge, no SAGES leader has received a dime from FLS, and the society itself has struggled to recoup the investment made with its own funds. Meanwhile, the FLS has been adopted by the American Board of Surgery, which means that our patients will benefit.
Similarly, most minimally invasive surgery fellowships wouldn’t happen without industry support. Obviously, the companies do derive benefits, but the primary beneficiaries are the patients whose procedures are performed by fellowship-trained surgeons rather than by surgeons who are struggling to surmount the learning curve or using outmoded techniques. If future generations of surgeons lack training opportunities because of restrictions, patients will be the big losers.
With respect to research, the implication that industry-funded science is inferior to government- or university-sponsored science is ludicrous. Certainly companies want to be successful, but doing so at the expense of patient health and safety would simply be bad business. The financial impact of a scandal involving the safety of a drug or device so far outweighs the potential profits that no rational CEO would make a decision to risk it. Additionally, drug and device companies anticipate the rigors of the Food and Drug Administration review that is required before their products are brought to market. If fraud is discovered or a patient harmed, the consequences can put the company out of business.
Investment in biomedical research over the past 30 years has led to increased life expectancy in this country, and decreased overall mortality and disability among the elderly. The research that has helped to deliver these outcomes was conducted not only in universities, but also in the labs of pharmaceutical and device companies, and much occurred through partnerships between physician investigators and corporate sponsors. Before the fruits of this research could save lives, products had to be manufactured, marketed, and distributed, and this was done by industry, not by universities. I’m sure that conflicts were ubiquitous, but the bottom line is that cooperation among physicians, scientists, and commercial interests has led to dramatic improvements in health care, and no one faction could have done it alone.