Monday, April 23, 2007

Kassirer on: Who Really Controls Medical Professional Organizations?

The journal Perspectives in Biology and Medicine's first issue of 2007 was about "medicine and industry." Since many of my colleagues are returning from the US American College of Physicians meeting and others are getting ready for the Society of General Internal Medicine meeting, I thought starting with the first topical article in the issue, by Jerome P Kassirer, entitled "Professional societies and industry support: what is the quid pro quo?" would be apt. [Perspectives Biol Med 2007; 50: 7-17.]

When I was researching my article based on physicians' thoughts about what was going wrong with health care [ Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003: 14: 123-130 here] I found many cases of large health care organizations acting against physicians' core values, and of ill-informed, conflicted, and even corrupt leadership of such organizations. I was struck by how rarely physicians and other health care professionals caught up in these cases could find useful allies to defend their values, and particularly how rarely their medical associations and societies provided any useful support.

Dr Kassirer explained why this may be so. From his introduction,

Professional societies see themselves in noble perspectives. Their mission statements are nearly all the same: they tout their intentions to support research, improve care, advocate for patients, educate physicians, and foster communications. They implement these goals with numerous activities, including continuing medical education (CME) programs, clinical practice guidelines, informational brochures and Web sites, and grants to investigators. Some run gigantic annual meetings attended by tens of thousands of participants from all over the world. They give travel awards to promising investigators and achievement awards to leaders in their field who have distinguished themselves in science or practice. Undoubtedly they accomplish a great deal of good. Yet the growing support that nearly all of them solicit and receive, often millions of dollars each year, from the pharmaceutical, device, and biotechnology industries can threaten the very goals they espouse.

Kassirer went on to catalog cases in which medical societies' noble goals seemed compromised by conflicts of interest. They included:

  • Society sponsorship of practice guidelines that supported the vested interests of the societies' commercial sponsors. Examples included: 1) an Endocrine Society guideline favoring aggressive testing for and treatment of androgen deficiency in older men, written by a panel with financial ties to the manufacturer of testosterone; and 2) the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition's guideline that recommended Propulsid for reflux in children after the drug's manufacturer donated almost half a million dollars to the society. (Another more recent example is the National Kidney Foundation's Amgen supported guidelines on the use of epoetin in anemia due to chronic renal failure, see post here.)
  • Society sponsored educational materials that supported the vested interests of the societies' commercial sponsors. An example was a booklet on nocturnal gastroesophageal reflux produced by the American Gastroinestinal Association, underwritten by a drug company (Wyeth) that makes a proton pump inhibitor (PPI) drug, written by a panel all of whom had financial relationships with producers of PPIs, supposedly in response to a survey suggested and underwritten again by Wyeth.
  • Society meetings "conflating informational material with commercial messages." Examples included intermixing scientific presentations and industry sponsored talks during meeting sessions, and allowing commercial logos on the society's newsletter.

Kassirer noted the various types of conflicts of interest that can affect medical societies. These included not only the sorts of conflicts implied above, but also:

  • Society officers or board members who have financial relationships (e.g., consulting arrangements) with commercial firms
  • Editors of society medical journals who have such relationships
  • Society managers who know their financial position will be enhanced by industry funding of the society.

I should note that this list may not be exhaustive. There are a larger set of conflicts that can afflict societies' medical journals. Journals may have institutional conflicts of interest due to support from commercial sources in the form of "unrestricted" educational grants. Journals also get substantial revenue from pharmaceutical/ biotechnology/ device company advertising, (see relevant post here) commercial support for special supplements, and bulk purchases of reprints. Furthermore, associate editors, members of editorial boards, and reviewers can all have significant financial ties to commercial firms.

It is also possible that the full-time staff of medical societies have individual financial relationships which may cause conflicts of interest. I am unaware of any public discussion of this issue.

The broad implication, that various health care corporations, particularly pharmaceutical, biotechnology, and device manufacturers, may exert major influence over physicians professional societies and academic health care associations is very troubling. If physicians and other health care professionals do not control their own professional organizations, we have fallen into a sorry state.

WHAT IS TO BE DONE? - Kassirer closed with some concrete recommendations:

Restore professionalism to the organizations.

  • Appoint as officers only those physicians who have no financial conflicts of interest.
  • Restore a professional environment to medical meetings by gradually reducing the circus-like atmosphere of the exhibit halls, discontinuing the support of the industry-sponsored symposia, and insuring that scientific programs are not intermixed with industry-sponsored talks that can be mistaken for unbiased science.
  • Rein in management's enthusiasm for financial support from industry.

Preserve and protect the integrity of medical information.

  • Reject restricted grants for activities (guidelines, educational ventures) that have not been previously specified as one of the society's products. Accept unrestricted funds from industry only if they are unencumbered, in other words, requiring no payback.
  • Require that all medical society journal editors who are in a decision-making mode in accepting or rejecting manuscript submissions have no financial conflicts.
  • Protect clinical practice guideline committees from the bias of financial conflicts. As with society leaders and editors, the ideal is to choose those with no financial ties.

Make financial arrangements transparent.

  • Do not provide demographic information of members and conference attendees unless these individuals grant their permission to do so.
  • Insist on review of all new industry support for any possible quid pro quo by a committee of unconflicted society members.
  • Reveal all sources of industry support on the society's Web site, including the amounts given. Identify also the specific purposes and projects for which the funds were employed.

I would urge physicians and other health care professionals who want their societies to represent their core values (and to be available to help members whose values are challenged by external threats) to push their societies' leaders to adapt Kassirer's recommendations at a minimum.

Of course, doing so may make for less lavish meetings, and somewhat higher dues. Wouldn't these costs be worth it to have professional societies that really uphold professional values?

Have we fallen so low that we cannot even control ostensibly our own professional organizations?

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