Med schools are ignoring conflict-of-interest problems

Julia Belluz on a study with disturbing implications for patients

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Dale Dewar, a family doctor based near Wynard, Sask., has seen it all. She practiced in rural Iqaluit, and taught in the villages of Pakistan and Northern Iraq. In her decades on the job, the 69-year-old says there was one thing starkly missing from her medical education: adequate warnings about the side-effects of drugs.

One, in particular, stands out: Diazepam, commonly known as Valium. “We were told it was good,” she said over the phone. “It was being used for people who were anxious, and depressed people who presented.” She was even prescribed the medication for a bout of postpartum depression and not warned of the side-effects, which can include addiction. “I don’t remember once being told that we should be concerned about this new drug because the studies are not quite complete, or that only one study has been done.” Dewar wonders if the oversight stemmed from any conflicts of interest at her medical school. “I had no idea the extent of drug companies’ role in medication development and sales,” she said.

But now we do. Research over several decades has shown us that many things can cloud a doctor’s judgment, from industry-sponsored education to encounters with pharmaceutical-company sales reps, and even drug samples provided by those companies. The impact of these practices—over-treatment, mistreatment, death—is well documented and probably familiar to you. And yet, despite the Big Bad Pharma cliché and all the calls for change, we now have evidence that medical schools in Canada may have shrugged at the problem.

A first-of-its kind study, published yesterday in the open-access journal PLoS One, analyzed the conflict-of-interest policies at all 17 medical schools across Canada. Overall, the researchers found policies were “permissive”—meaning most medical schools allowed interactions with sales reps, turned a blind eye to faculty’s relationships with speakers’ bureaus (so instructors who teach students may also have speaking contracts with drug companies), and failed to educate newbie doctors about conflicts of interest despite the minefield they’d be entering. Protocols surrounding drug samples—which we know can influence physicians’ prescribing practices, sometimes for the worse—were practically non-existent.

One medical school (the Northern Ontario School of Medicine) didn’t have a conflict-of-interest statement, telling the Toronto Star that their policy is in development. Others (McMaster University) had policies that dated back to the 1970s, and still others (University of Toronto, University of British Columbia) had either no policy or lax policies when it came to things like academic ghostwriting (when researchers take studies or parts of studies that were written by pharma and pass them off as their own independent work without disclosing the industry ties).

To put things into perspective, the researchers ranked the strength of medical schools’ guidelines out of a possible 24 points. Top scores went to schools with tough conflict-of-interest policies, barring activities like ghostwriting and taking gifts from pharma. Western University—which scored the best in Canada—got 19 points or 79 per cent of the maximum score. Northern Ontario School of Medicine got zero points. Of the 17 schools, 12 got a failing grade of less than 50 per cent.

Medical school Per cent of maximum score
Western University 79
University of Manitoba 67
University of Ottawa 63
Dalhousie University 58
Université de Sherbrooke 54
Laval Université 46
University of Toronto 33
McMaster University 21
University of British Columbia 21
McGill University 17
Memorial University of Newfoundland 13
University of Calgary 13
University of Saskatchewan 13
Université de Montréal 8
Queens University 4
University of Alberta 4
Northern Ontario School of Medicine 0

Queen’s University scored near the bottom for weak or non-existent policies around conflict of interest. Leslie Flynn, the interim vice-dean of education for health sciences, said she was surprised by that conclusion. “The methodology the authors deployed didn’t capture the depth of our policies,” she told Science-ish. “They make an association that the policies don’t exist, and that’s not accurate.”

Adrienne Shnier, the lead author on the study and a PhD candidate at York University in Toronto, told Science-ish that she and her co-investigators made repeated attempts to verify their findings with all medical schools, and most complied. Still, she was disturbed to find out about the lack of education in medical school around how doctors should deal with conflicts. “Curriculum is really important. That’s where students gain the toolbox they will take into the world in dealing with patients. When they are not taught about conflicts of interest, it doesn’t give them the tools to deal with this stuff in practice.”

Of course, there are powerful interests protecting weak policies. “The fact that some of the big hitters—samples, sales reps, speaking engagements—aren’t regulated,” Shnier added, “it’s fair to attribute that to some conflicts the institution may have.”

Such complex, systemic problems are not easily solved. And the medical community is working to change the status quo so that better, cleaner evidence underpins the health decisions we make every day. But while things may have improved in recent years, Navindra Persaud of St. Michael’s Hospital in Toronto told Science-ish change is happening a little too slowly. In 1981, one of his colleagues published a paper on the issue of industry influence in medical education. Thirty-two years later, in 2013, Dr. Persaud published a similar paper. His case study, in the Journal of Medical Ethics, meticulously outlines how industry ties corrupted the pain-management education of medical students and other student health professionals at the University of Toronto.

Unbeknownst to learners, the lectures were partly funded by Purdue Pharma, which makes the painkiller OxyContin. Their teacher had ties to the company. Even their free textbook was produced by the drug-maker. Most concerning, he found that the side-effects of opioids like OxyContin were downplayed and their benefits overstated. This all took place less than 10 years ago and he said current guidelines wouldn’t prohibit similar events now.

Persaud’s case exemplifies why lax policies at medical schools are problematic. If the findings of this PLoS article are accurate, Canadian medical schools have some explaining to do, and Science-ish welcomes their comments.

Science-ish is a joint project of Maclean’s, the Medical Post and the McMaster Health Forum. Julia Belluz is the senior editor at the Medical Post. She will be on a Knight Science Journalism Fellowship at the Massachusetts Institute of Technology. Check back for periodic updates here or reach her at julia.belluz@medicalpost.rogers.com or on Twitter @juliaoftoronto




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Med schools are ignoring conflict-of-interest problems

  1. The total possible score is 24, not 25 (2 points each for 12 categories), which is why the percentages quoted are correct. But what is the basis for saying 50% is a passing score? Surely we should expect better than that from a medical school.

    • Amen…ties well with the joke about what do you call a 50% med school graduate? Dr. The Dr profession with the right fortitude should have addressed this ages ago…they still could…a blight on the awesome Drs out there

  2. Doctors are in fact well aware of the side effects that drugs have on the patients who take them, but you are incorrect in laying all of the blame with health professionals. The patients are the ones who determine whether or not the benefit of the drug outweighs the side effects they experience from taking it. If being able to go outside of your home without having a panic attack outweighs dizziness and nausea, or even dependence, than the patient will make that decision. If it doesn’t outweigh the original problem, then they will stop taking it and find other ways to deal with it.

    Another perspective you haven’t considered, is how pharmaceutical companies have influenced the public. Many people come into the office with a pre-set agenda, and demand a pill that will “fix their problems”. There is a whole social movement towards pharmaceutical medicine, and this is the result of many other societal factors of which pharmaceutical-physician relationships are a very small piece.

    I am currently in medical school, and we are definitely educated on good prescribing habits, and the side effects of the many drugs we will no doubt give to our patients. All I am saying is we are all in this together, and the blame does NOT fall squarely on physicians shoulders.

    • If doctors are so aware of side effects why is there a web site done by doctors to demonstrate that not all side effects are known by doctors?

      I certainly agree with some of what you say but by all means not it all.

      Why have some doctors been involved with fraud connected with pharmaceutical companies?

      • You do realise that some side effects are such a rare occurrence that even the most intense trials would not uncover them don’t you?

        Also you do realise that medicine isn’t an all or nothing practice don’t you?
        Sometimes it’s a least worse or most best outcome that is available. That is the way it is with most things in life.
        A lot of people in many occupations have been involved in fraud, it’s called human nature. I’d have been more worried if no doctors had been convicted of such fraudulent behaviour, it would mean that they were getting away with it. “Scientists” are currently disputing climate change on behalf of oil companies and rich oligarchs, this activity has the potential to ruin the lives of many more people than the doctors you highlight but for some reason when medicine is involved we become quite irrational.

        • “A lot of people in many occupations have been involved in fraud, it’s
          called human nature. I’d have been more worried if no doctors had been
          convicted of such fraudulent behaviour, it would mean that they were
          getting away with it.”

          I still don’t see a justification for this sort of behavior in this retort. It’s a fair point that it’s impossible to know each and every single variable and possible mishap that could go wrong with medical practice but I can’t help but feel replies like these are attempts to dodge a very real and concerning trend with the influence of money in medical practice.

          In my experience a lot of people don’t like talking about this stuff because it gives people like the anti-vaxer cranks ammo for saying medicine is a racket to line the pockets of big pharma and shouldn’t be trusted. However, in spite of such people and the fear of giving them rhetorical ammunition I don’t see a justification for not discussing the influence big pharama does have on medical education and practice.

          • In another comment I did say the same as you,
            “While one should always be wary of links between vendor and customer and the possibility of some corrupt practices sneaking into the process one should also look at this rationally.”

            A crime is a crime and should be investigated, but medicine and Pharma have created a much better world and have progressed from a really closed and private system to what we see today. I’ve no doubt more safeguards will evolve as the system becomes more open as well.
            But this is not just an issue for medicine it is an issue for all areas of commerce where industry and governance intersect. Lobbyists for mining and their regulators are a great example. Most knowledge about mining is resident within the mining industry, so who is going to know the most about mine safety, run-off treatment etc.It’s going to be the engineer who works day to day in that trade, not the regulator. Doctors who conducted trials for industry and saw the product through from beginning to the end are an obvious choice to explain it to other doctors who didn’t, because they know more about it. Yes there is a reliance on the honesty of the doctor, but lawyers, judges and almost any other public servant are faced with the same requirement too. So why a special attention to doctors who have overseen the greatest advance in living conditions in the past 100 years?
            It just seems irrational.

          • Obviously I agree with you that medical science, and yes even many pharmaceutical companies have done tremendous good over the past 100 years. But to be clear, many of those forces have also done tremendous evil in the forms of bad science and callous indifference to human suffering and potential risk for the sake of profit , e.g. the release of elixir sulanilamide to the public and the formerly common practice of lobotomies. But clumsy and frequently effective steps have been taken to ensure such mistakes aren’t repeated.

            Where we probably have the strongest disagreement is here:

            “So why a special attention to doctors who have overseen the greatest advance in living conditions in the past 100 years?”

            I disagree that this special attention isn’t warranted. Medical practice carries a much higher ethical standard than resource harvesting if only because the former must adhere to a tenant of ‘do no harm’. I’m not saying that in terms of a quantifiable ‘good’ done for the population at large focusing more so on issues such as climate denial and global poverty won’t do more good. But considering that the current model of medical ethos where ensuring that a patients harm must not come from the sake of profitability nor expediency I feel this attention is warranted.

          • And reasonable people can discuss the degrees of evil to goodness and also lament some of the bad decisions made in the past for many different reasons.

            Also how many of the various acts that were enacted following major catastrophe’s in the past have been repealed or watered down recently and history has repeated itself. Glass-Stegal in the states is a very obvious non-medical example. Politicians taking money from companies are just as culpable if not more so than the doctors and the companies involved; after all they create the legal framework within which doctors and the companies exist and operate. Look at the proposed recent reduction in safety planning and environmental assessments for pipelines and oil extraction sites. These are the wishes of companies, but they are facilitated by politicians in the name of reducing red tape and raising donations.

            My take is that any worker in any industry should work to make their work site and product as safe and as fit for purpose as possible. To do otherwise is negligence, but as long as the law insists on maximising profits as being paramount there will always be a tendency to find the cheaper route. The problem is partially with the worker but is really an issue of law and politics.

        • side effects are not a rare occurrence!! They are most often not reported, either by the patient or passed through the correct information channels through the doctors!

          • I love the way the intellectually challenged try and engage with those who might have a clue about that on which they speak. I also note that they have to lie in order to make their point.

            That would be you TJ. If you are not going to honestly engage then go away you hack, I have no time for those who ignore what is said and instead take a statement out of context or deliberately misrespresent what was said.

            “You do realise that some side effects are such a rare occurrence that even the most intense trials would not uncover them don’t you?”
            verses your take
            “side effects are not a rare occurrence!”

            You are an idiot and as such I will not engage with you.

    • “All I am saying is we are all in this together, and the blame does NOT fall squarely on physicians shoulders.”

      The article seems to be taking more exception with where these physicians are educated as opposed to the physicians themselves.

      I admit that I don’t know much about the interplay of pharmaceuticals and medical education but if there is any truth in this article about the existence and practice of some of this shady behavior, such as academic ghostwriting, I can scarcely think of a better reason to be concerned.

      • We read medical articles specializing in a condition
        that obviously concerns the reader who is searching for information /knowledge for immediate or later use trusting that the author respected in his/her field is
        sharing learned knowledge with the reader although
        the information may actually be written by a medical ghost writer on some big pharma payroll and with only one end in mind…market the drugs to millions.
        Our medical institutions are a farce if they allow this to continue while they preach that the public should
        take control of their own health. Medical professionals
        should take control of themselves by putting a stop to their accepting freebies, trips, scholarships money etc from drug companies whose only agenda is often all about how many drugs can be unloaded on the public
        before they are proven unsafe.

    • And drug usage is affected by essentially political processes as well. Thalidomide, for example, is still a useful drug… just don’t take it while pregnant.

      But those who did suffer from the famous side effects actively lobby not to let it be used for anything.

    • The patient should be educated along with the Physician
      of all side effects and future dangers associated with the drug.
      If neither are properly informed by Pharma no informed
      decision can be made.

  3. While one should always be wary of links between vendor and customer and the possibility of some corrupt practices sneaking into the process one should also look at this rationally.

    Over the past 69 years (the time period your critic collected her anecdotes over) how has modern medicine fared in terms of improving the quality of life as well as the length of life? Longevity has increased across both sexes and all races by around 20 years since 1935 according to the CDC. The length of ones expected healthy/productive life span has increased and the use of vaccinations has rendered many traditional fatal diseases moot. Smallpox is no more and it is only the actions of the superstitious and criminally self entitled that are preventing more diseases from going down that route. This was all under the present or even more secretive system that you are criticising.

    As for side effects; anything you put in your body from food to drugs could have unintended consequences. Viagra and grapefruit, peanuts and anaphylactic shock etc, Drugs trials will highlight the most obvious of these, but the less frequent side effects and the effects of combining drugs will always be tough to identify until they arise in the population. Deliberately covering up these events is wrong, but then so is panicking and withdrawing a drug that is effective for many and has a detrimental effect on a very few.

    The anecdotal evidence of one doctor is not good science, it’s not even science-ish and I realise scary stories sell, but what you are doing is similar to the anti-vaxers and you should think ling and hard about the unintended consequences of your actions.

    • This is a totally vacant apology for medical practice.

      First of all, you can’t attribute the increase in lifespan solely to medicine (though some things, like inoculations, certainly helped, though that’s an old technology that doesn’t originate in the West).

      Secondly, the anecdote in the article is treated as exactly that, an anecdote. The mass majority of the article is based on a study, not the anecdote. Did you even read the article?

      Third, it’s been revealed that drug companies have systematically hidden or downplayed the incidence of adverse affects of their drugs while overemphasizing their positive effects for years (e.g. antidepressants). One of the ways they’ve done this is through ghost-writing, another is hiding studies that don’t flatter their drug.

      Why anyone would jump to the defence of this total lack of worry about conflict of interest is beyond me.

      • First, I was talking about medicine, you decided geography was a factor.

        Second, yes I did and I read the study too; did you?

        Third, it’s also been revealed that every single industry has been subjected to fraudulent behaviour in the past and has lied about data. The people who usually uncover this are people working in the same field within the same industry, using sound methodology.

        I have no problems with baring “conflict of interest in mind” but I won’t throw out the baby with the bathwater because of over hyping a theory about behaviour, without admitting the benefits that also accompanied the practice in the first place. Anyone who cannot see the benefits of pharmaceuticals and a legitimate relationship between the manufacturers and the prescribing authority is not worth engaging in serious conversation.

        Evidence based medicine is still one of the most scrutinised practices around today. Any other form of advocated alternative not only has the same issues to resolve as EBM, but has additional ones all of its own to overcome too.

      • Joe C, what is not mentioned in this article in the role of those who employ physicians in our country…namely provincial governments under the guise of regional health authorities. These health authorities and each provincial college of physicians and surgeons is under the ethical obligation to ensure that each and every physician licensed to operate in the province is doing so in an ethical manner. If a patient has reason to complain about a physician’s prescribing practices, they can file a formal complaint with the provincial college and the physician must explain his/her practice.

        In some of the programs I have worked in, it was not acceptable to take a free sandwich from a pharmaceutical rep., let alone something valuable. Sample medications, however, tend to be accepted because they allow physicians to provide free medication to working poor who are not on welfare. When it comes to the practice of providing free samples of an antibiotic to a working poor family so they can treat their child with a serious bacterial infection, I hardly think there is some sort of criminal conflict of interest going on. The physician is providing humane care in an expedient manner.

        In province of Alberta where I live, University boards decide on what medication studies are approved and they have strict rules around how the studies are conducted. For instance in our province, a study participant can have their expenses for parking reimbursed but they cannot be paid for their participation in the study.

        Given that I have worked in mental health for almost twenty years, I can tell you that my anecdotal experience with medications in general and antidepressants in particular is a little different than yours. The only really successful treatment for very serious mental illness such as schizophrenia is with medication. Anyone who tells you different, is not being honest or accurate. Yes, antipsychotics have side effects that can be quite troublesome but the side effects are no where as devastating as the symptoms of the disease if left untreated. The same thing applies to major depression. If a person is going to suicide, then taking antidepressants to survive is a better option. This is also the case with anti-hypertensives and other medications that allow people to remain alive and functioning v. disabled or dead. Everything becomes a matter of risk v. benefit…does the benefit of the medication outweigh the risks of the side effects.

          • I just went to the site and immediately saw a few things that struck me. First was the characterization of the physician as a less than trustworthy individual pushing a medication as “good’ and the characterization of the patients as SHEEP who need to be rescued and enlightened. The next thing that struck me was the categories of “risks”. Hair loss was in with suicide.

            Yes, some medications do cause some hair loss. Yes, some medications used to treat Bipolar Disorder which is a very serious and debilitating disorder do cause some hair loss. I have had patients complain about hair loss. I have asked them to run their hand through their hair and pull and see how many hairs come out. Inevitably it is almost none. They have noticed hair loss in the bathtub. These meds also cause some tremors in the hand while it is at rest. Yes, this side effects are a bit bothersome but are they worth being able to work and function in life? In the manic stage of Bipolar Disorder, people have been known to strip off their clothes and direct traffic in a busy city street. In the much more prevalent and long-lasting depressive state, they cannot get out of bed for months. They often take their lives. That is what I am talking about in terms of risk/benefit.

            When it comes to sexual side effects, yes many medications cause an inability to perform sexually but given that the other choice is a heart attack and death and given the availability of male performance enhancing medications, I think again you have to weigh the risk with the benefit.

            With regard to issues like suicidal ideation and psychosis as side effects, those are something completely different. The monitoring of the patient becomes vital. It doesn’t mean the medication shouldn’t be used because in the case of antidepressants in young adults who were already suffering from major depression, you must try every possible treatment given the high risk of suicide especially among males in this cohort.

    • “the use of vaccinations has rendered many traditional fatal diseases moot. Smallpox is no more.” Actually smallpox is a poor example for you to use. The vaccine proved deadly to many, and later was found to be rather ineffective. The “eradication” was made possible through the use of cards with pictures of the symptoms of smallpox. These cards were passed along to virtually every person living in areas where smallpox was still rampant. Early identification led to patients being quarantined before the virus could be spread further. May I conclude by quoting your earlier post: “I love the way the intellectually challenged try and engage with those
      who might have a clue about that on which they speak. I also note that
      they have to lie in order to make their point.”

      • Not sure I follow your use of my words. I haven’t lied, but the CDC disagrees with your view of smallpox vaccinations. The CDC says and I quote,

        “Smallpox vaccination provides high level immunity for 3 to 5 years and decreasing immunity thereafter. If a person is vaccinated again later, immunity lasts even longer. Historically, the vaccine has been effective in preventing smallpox infection in 95% of those vaccinated. In addition, the vaccine was proven to prevent or substantially lessen infection when given within a few days of exposure. It is important to note, however, that at the time when the smallpox vaccine was used to eradicate the disease, testing was not as advanced or precise as it is today, so there may still be things to learn about the vaccine and its effectiveness and length of protection.”

        The words “effective” and “eradicate” kind of knock your claims in those areas on the head, wouldn’t you agree?

        As for side effects, of course you’re right there, they happen at the rate of 1000 for every 1000000 vaccinated and in varying degrees of severity. But how many people died of smallpox prior to the use of the vaccinations?

        Now I’m not going to accuse you of lieing like you somewhat erroneously did to me because I believe that, unlike TJ. you are trying to add to the conversation. But you are stating facts counter to the views of the CDC and I’m afraid I cannot agree with you.

  4. Everything has a side effects but the thing is, good effect outweighs the bad one :) Italy puzzles

  5. There was something interesting and troubling reported a few days ago out of Vancouver. It is a story reporting the late effects of certain cancer therapies on children who were treated with large doses of chemo and radiation in their childhood and now in adulthood are suffering all kinds of medical problems.
    At the time (20 years ago) these children were very ill and were dying. The physicians were not certain of the effects of the medications and radiation and the families were desperate for them to do whatever was necessary for the children to live. Apparently late effects were not considered because no one really expected the children to live and the treatments have involved greatly since that time.
    Now a physician is trying to locate these “children” and assess their well being and provide some sort of program with easy access to follow up care for them but unfortunately that has not been easy to do because the contact information is old and people are very transient.
    This story illustrates for me the difficulties that face physicians. People come to them complaining of suffering and they want it to stop. Physicians lay out what they can offer. If the patient doesn’t like what the physician has to offer, they move onto the next one. Physicians for the most part provide the best care they can based on the information that is available to them. It isn’t like today’s medical consumer isn’t well informed or has any excuse not to be. Every medication and ALL of the side effects are listed on the internet, not to mention chat rooms devoted to same. Further you can find everything you want to know about a physician on the internet. People have no fears about giving their opinions. The anti-vaccine crowd feels free to play fast and loose about the truth on a regular basis. Like the med student said, the patients come in demanding the meds so it isn’t like the physician is selling anything.

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