Monday, January 19, 2009

On Wisconsin's "Talking Heads"

Last week, the Milwaukee Journal-Sentinel ran an investigative series on conflicts of interest affecting faculty at the University of Wisconsin medical school, one of the better known and more prestigious US state supported institutions. (The two main articles were "Doctors Face Pressure to Disclose All Side Pay," and "Drug Firms Wine, Dine and Pay Up for Doctors' Speeches.") Several of our fellow bloggers have discussed this excellent series already, including Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma blog, and Prof Margaret Soltan on the University Diaries blog.

So I will not go over the series in detail. Suffice to say that while the Journal-Sentinel's reporting is fresh, the problem may be tediously familiar to Health Care Renewal readers.

Although the University of Wisconsin (UW) is said to have an unusually stringent policy for "managing" conflicts of interest, the reporting requirements are vague, particularly about the financial magnitude of conflicts. The Journal-Sentinel report noted that some faculty who disclosed making only "more than $20,000" a year, a range prescribed by UW, made much more than that. Some faculty were paid by multiple companies. Some faculty were paid by medical education and communication companies (MECCs), which were presumably in turn paid by drug, device, or biotechnology companies whose identities were not disclosed. Some faculty were paid thousands to gave promotional talks which were not accredited as continuing medical education.

One orthopedic surgeon, Dr Thomas Zdelblick, disclosed yearly payments from device manufacturer Medtronic of over $20,000. The Journal-Sentinel reporters found he actually received as much as $400,000 a year in consulting payments, supposedly for working about eight days (that is, at a rate of $50,000 a day). A subsequent article in the Wall Street Journal found that Dr Zdelblick got even more than that. His total compensation from Medtronic was over $2 million a year, and as much as $4.6 million a year.

So again the picture is of a web of conflicts of interest affecting many faculty at one medical school. This adds to the now voluminous evidence that large numbers of medical academics have financially significant conflicts of interest. These financial arrangements are rarely fully disclosed, even as part of the university's attempts to "manage" them.

I spot-checked a few publications of two of the faculty named in the article, finding that they were no more explicit in their disclosures to readers of scholarly journals.

For example, Dr James Gern (who was, according to the Journal-Sentinel, a speaker and consultant for Merck from 2003 to 2007, who made about $35,000 - $70,000 a year for 28 days of work, and who was funded by Merck in a study of the effects of montelukast on people infected with the cold virus,) provided the following disclosures:
- In a 2008 single-author review of the linkages between viral respiratory infections and asthma(1), "the author has received honoraria from Merck Inc...."
- In a 2008 multi-author research paper on rhinovirus infections and asthma(2), he did not mention his relationship with Merck.

More strikingly, Dr Thomas Zdelblick, the orthopedic surgeon who got millions a year from consulting fees and royalties, provided the following disclosures:
- In a 2007 multi-author report of a clinical trial of the Medtronic Sofamor Danek cervical disc device(3), "the authors have received or will receive benefits for personal and/or professional use from Medtronic Sofamor Danek in relation to products named in this article."
- In a 2004 multi-author clinical research article on managing spine fractures,(4) "one or more author(s) has/have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript: e.g., honoraria, gifts, consultancies, royalties, stocks, stock options, decision making position."

Thus, while the usual approach of most universities to such conflicts of interest is to proclaim how they will "manage" them, this "management" often did not even include disclosure of the conflicts, and certainly not disclosure in detail sufficient for its audience to appreciate the degree to which the conflict might have biased seemingly authoritative academics.

Also, often financial arrangements between medical faculty and industry are proclaimed necessary to foster collaboration necessary to "innovation" and the development of miraculous new drugs and devices (for example, the Journal-Sentinel reported the Dean of the UW medical school said "consulting with the pharmaceutical industry can accelerate drug development and lead to job creation....") However, despite these ostensible benefits, many faculty seemed uncomfortable with and reluctant to talk about their relationships.
- Dr Barry Fox, who "worked for seven different drug companies in just one year," "would not discuss his drug company work...." When reached by telephone, he initially said, "I have nothing to hide," but when asked "what kind of work he did for a drug company, he said, 'I'm not comfortable with this conversation,' and hung up."
- Dr Zdelblick "did not return phone calls."
- 3 doctors who gave talks sponsored by drug companies would not discuss their work (see this side-bar article)

One doctor who gave approximately 20 drug talks did speak with the reporters, and was very frank.

It's promotional. We all know why we are there and what we are going to hear. You are going to hear about that drug.

We're just talking heads.

As the series noted, faculty and the university stand to benefit when drug and device companies pay doctors.

Medical schools have good reason not to prohibit such activities.... It [sic] allows them to pay their star faculty less because they can make substantial money working on the side for a drug or medical device company....

The school may also benefit, of course, when the companies who pay faculty on the side also give the school research or educational grants.

But while faculty and schools make money, they sacrifice the trust of community physicians, patients, and the public. As long as academics take big money from industry, often without much honesty about what they are doing, their independence will be suspect. Who knows when the talk, the article, the glitzy program is meant to disseminate the truth, or to help in marketing? Who knows whether the research study was manipulated? Who knows whether the policy pronouncement mainly would benefit vested interests?

Maybe academics and academic administrators would sleep better if they no longer had to dodge reporters' calls, twist rationalizations, or admit to being "talking heads." Those who used to depend on academic medicine to seek and disseminate the truth might sleep a lot better if it became independent once again.

1. Gern JE. Viral respiratory infection and the link to asthma. Pedi Infect Dis J 2008; 27: S97-103.
2. Jackson DJ, Gangnon RE, Evans MD et al. Wheezing rhinovirus illnesses in early life predict asthma development in high-risk children. Am J Respir Crit Care Med 2008; 178: 667-672.
3. Mummaneni PV, Burkus K, Haid RW et al. Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. J Neurosurg Spine 2007; 6: 198-209.
4. McDonough PW, Davis R, Tribus C, Zdelblick T. The management of acute thoracolumbar burst fractures with anterior coprectomy and Z-Plate fixation. Spine 2004; 29: 1901-1909.

1 comment:

Anonymous said...

I just read another article about how the North American Spinal Society is mandating its members to disclose financial ties and funding amounts. The article appeared on today at: