Wednesday, December 26, 2007

University of Massachusetts Tightens Conflict of Interest Policy

As reported by Liz Kowalczyk in the Boston Globe, the University of Massachusetts Medical Center has just adopted "some of the strictest conflict of interest rules in the country." In particular,

It prohibits doctors and other clinical staff from eating meals paid for by companies; bans all gifts, from candy to medical journals; stops drug companies from giving money directly to individual physicians and departments for educational programs; and places a complete ban on doctors joining company 'speakers bureaus' to give talks about products.

This policy seems more stringent than others recently adopted at other medical schools in the US.

The UMass Memorial policy goes further than those at most other hospitals in several ways. It bans company-paid meals off and on campus. It also establishes strict rules for doctors who serve on committees that decide which drugs and devices the hospital should buy in bulk to treat patients. Most hospitals require doctors simply to disclose their financial relationships with companies to other committee members.

But UMass Memorial decided that doctors with consulting agreements or grants from companies cannot serve on these committees, meaning some current members may have to resign. The danger, conflict of interest specialists say, is that doctors may select a drug for the hospital's 'formulary' because he or she does work for the manufacturer, not because it is the best, lowest-cost medication.

In addition, I don't believe many other medical schools ban faculty from receiving honoraria from pharmaceutical companies for giving talks.

Nonetheless, the policy does not address some conflicts of interest that are potentially important because of the amounts of money involved. It does not restrict faculty who serve as consultants to industry. Not even discussed in the Boston Globe article were physicians who get royalties from device companies. We recently posted about some examples of academic orthopedic surgeons getting astronomical payments of this sort (see this post and links backward). Also not discussed were physicians who serve on the boards of directors of for-profit health care companies. Directors may receive relatively large payments and stock options grants. Serving on a board presents potential conflicts beyond just those involving receipt of money. Board members have a fiduciary duty to protect the interests of company stock-holders, in fact, to have "unyielding loyalty" to them. (See recent post here.)

Nonetheless, the Boston Globe article quoted experts who were worried about restrictions on conflicts of interest going to far.

'You don't want to chase drug company money out of the system completely,' said David Rothman, a history of medicine professor at Columbia University and director of the university's Center on Medicine as a Profession. 'Drug companies are not tobacco companies. We all need them.'

But, Rothman said, hospitals need to 'sever the tie between the company and the prescribing physician.'

Rothman was a coauthor two years ago of an article in the Journal of the American Medical Association that called for teaching hospitals to sharply limit the gifts and money they accept from pharmaceutical and medical device makers, and laid out a blueprint for a policy.

Obviously, drug (and device and biotechnology companies) make very important products without which modern medicine would grind to a halt. Yet nothing in the University of Massachusetts policy threatens these companies' existence. Nor would a ban on faculty being paid consultants of, receiving royalties from or being on the the board of directors of health care corporations. It's funny how restrictions on financial relationships between medical school faculty and health care corporations seem to bring out slippery slope arguments. Faculty could talk to and work with health care corporations to advance science without directly being paid for such work. And nothing in the proposed, or even more stringent policies would prevent companies from hiring people with expertise they needed, just as long as such people did not pretend to also be full-time faculty at medical schools.

On the other hand,

Partners HealthCare, which includes Massachusetts General Hospital and Brigham and Women's Hospital and is the largest provider network in the state, 'will be tightening up' its policies, said Dr. David Torchiana, head of the Massachusetts General Physicians Organization. But, he said, he doesn't want to go overboard.

'Academic medical centers are here to advance knowledge, but discoveries have no value to patients unless they get made into products,' he said.

'We don't want to kill that by enforcing an overly strict conflict of interest policy. It's a little bit of a runaway train right now: If you've ever eaten a slice of pizza supplied by a company you are irredeemably tainted,' he said.

Again, it's interesting how different people interpret the notion of an "overly strict conflict of interest policy." There is some common sense in worrying that a policy that focuses on slices of pizza may be too strict. But contrast Dr Torchiana's approach with Dr Rothman's approach to focus on all ties to the practicing physician, while being much more lenient on the faculty member with a $100,000 a year consulting gig.

In my humble opinion, even slices of pizza may convey some small sense of obligation, and lots of pizzas, pens, and mugs spread over thousands of doctors may have some collective effect. But it would make more sense to concentrate first on the much bigger and consequential ties among the most influential doctors and health care corporations, then large consulting payments, often even larger royalty payments, and service on boards of directors. Yet that seems to be the opposite of what is going on.

But give the University of Massachusetts kudos for some small steps in the right direction.


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Anonymous said...

Today’s Canton Repository (viewed at has an interesting article outlining a legal suit filed by Mercy Medical against Aultman Hospital and its subsidiaries. The major complaint is Aultman has endeavored to monopolize the local market for medical care.

Aultman, a non-profit, has used its for-profit subsidiaries to lavish vacations, tickets, and other valuable items on decision makers to influence their insurance and medical choices.

How can we expect doctors and staff to forgo items provided by vendors when the institution itself is using the same tactics to generate additional business.

Steve Lucas

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