2007 Proceedings

The following is taken from the 2007 Massey Grand Rounds Symposium Conference Proceedings. Click here to download the document.

Proceedings of the

2007 Symposium on 

“Medical Schools:  A Nexus of Education and Industry”

 

 

Massey College, at the University of Toronto

4 Devonshire Place

Toronto, ON  M5S 2E1

Canada

 

Wednesday, April 18th, 2007

Noon – 5:00 PM

 

Organized by

Massey Grand Rounds

 

Telephone: +1 416.506.1597

Email:  masseygrandrounds@gmail.com

 


Proceedings of the

2007 Symposium on

“Medical Schools:  A Nexus of Education and Industry”

 

 

TABLE OF CONTENTS

 

 

Program

3

Keynote address

4

Issues and Perspectives

8

Models for a Constructive Relationship: Interactive Panel Discussion

12

 

Summary Remarks and Open Discussion

18


PROGRAM

 

12-12:50 pm                         Registration and Light lunch – Junior Common Room

 

12:50 pm              Call to Order: Patrick Wong, Jr. Fellow

 

Opening Remarks and Welcome– Upper Library

Master John Fraser; Dr. Aubie Angel

Fiona Menzies and Martin Betts, Jr. Fellows

 

1:15-2 pm             Keynote Address – Introduced by Jai Shah, Jr. Fellow:

 

Speaker – Dr. Lawrence K. Altman, Medical Correspondent, New York Times

“Medical Education: Tensions and Conflicts of Interest for Students, Faculty and Patients”

 

2-3:15 pm            Issues and Perspectives – 20’ talks + 5’ Q & A 

Session Chair:  Martin Betts

 

Dr. Allan Detsky, Professor of Medicine and Health Policy Management & Evaluation

“Conflicts of Interest in Academic Medicine: Some Evidence”

 

Ms. Leslee Thompson, VP Health Systems Strategies

Medtronic of Canada

“Addressing the Changing Landscape: One Company’s Experience”

 

Dr. Lorraine Ferris, Professor of Public Health Sciences, Faculty of Medicine, U of T

“Medical education programs can offset the challenges of commercial inducements”

 

3:15 pm                                   Nutrition Break – Junior Common Room

 

3:30-4:30 pm    Models for a Constructive Relationship: Interactive Panel Discussion

Intro: Fiona Menzies

Moderator: Dr. John Evans, Chair of MaRS Discovery District, Toronto

 

Dr. John Evans – “The MaRS Project: A View from the Top”

 

Dr. Irfan Dhalla, Chief Medical Resident, St. Michael’s Hosp.

A resident’s perspective”

 

Ms. Maureen Brosnahan, Senior National Correspondent, CBC National News

The media and health reporting”

 

Dr. Patrice Roy, Executive Director, Rx&D

Enhancing the capacity and performance of health research in Canada”

 

4:30-4:55 pm    Summary Remarks and Open Discussion

Dr. David Goldbloom, Professor of Psychiatry and Senior Medical Advisor, CAMH

 

4:55 pm                 Closing Remarks – Jai Shah, Dr. AubieAngel

5:00pm                  Reception –Junior Common Room

Keynote address

 

Dr Lawrence K Altman, Medical Correspondent, New York Times

“Medical Education: Tensions and Conflicts of Interest for Students, Faculty and Patients”

 

Dr Altman introduced the theme of tensions and conflicts of interest in medical education as it affects students, faculty and patients.  He said that attention to this issue is somewhat belated – the medical profession has avoided examining many of these basic issues for too long.  He added that wherever problems and abuses occur we should keep two things in mind:  1) money is at the root of most tensions and conflicts of interest, and 2) problems and abuses are not limited to the medical-industrial complex.  He spoke from an American perspective, but much of what he said applies to the Canadian medical education environment as well.

 

Altman stated that his intention was to be provocative and to expand the discussion beyond the medical-industrial complex, which is focused on drug companies and medical device manufacturers, to the medical-government complex, involving academia, doctors, research institutions, government health insurance providers and governments, and the medical-publishing complex.

 

Attention to the topic is belated because we are focusing on problems nearly as old as the medical profession itself.  Physicians today know little about the history of the profession because few medical schools require a course on the history of medicine.  He said, “Without an understanding of where we have come from it is hard to know where we are and where we might be headed.”

 

Evolving role of industry in medical research

In the past, physicians did medical research, at their own personal interest and expense, in their spare time or when the opportunity presented itself.  Dr Altman presented two examples that represent the circumstances and financing issues of early medical research.

 

In the 1820’s, William Beaumont, a surgeon in the US army, treated a man for a severe bullet wound that left an opening from the surface of the skin into the stomach.  Over the next several years, Beaumont personally supported the man while making fundamental discoveries about human digestion.

 

Frederick Banting and Charles Best discovered insulin at the University of Toronto in 1921.  This represented a transition in the funding of medical research as it took place at a publicly funded institution.  Collaboration with the drug company Eli Lilly made mass production of insulin possible.  This collaboration between the university and a drug company represents the best in the medical-industrial complex.  Since then, other universities have also developed strong ties with industry without major problems with tensions or conflicts of interest between the university and industry.

 

However, Altman described one example of tension between academia and industry in which a researcher withdrew a paper about to be published because the pharmaceutical company that had sponsored the research refused permission for publication.  This was seen as an infringement on academic freedom and was widely criticized by academic researchers.

 

The tension also affected the structure of Grand Rounds, traditionally in the format of interaction between faculty and students, but that now resemble lectures that can be seen at any medical meeting.  Faculty and students are required to attend, and are fed lunches paid for by drug companies.  Drug companies often sponsor the speakers as well.

 

Changes in medical education

A major turning point in how academia funds medical research came after World War II as the US government poured money into medical schools.  The money brought changes in medicine and created tension and potential conflicts of interest among students, faculty, and patients.  Public funding affected medical education because now the public had the right to accountability and the right to determine how those tax monies were spent.

 

Altman spoke of other changes in medical education that created tensions and conflicts of interest, such as the change in exams from essay questions to multiple-choice exams.  Multiple choice exams allow standardization and save time, but they do not accurately evaluate a student’s knowledge or their ability to explore patients’ complaints.

 

Another interesting issue is that the risks and responsibilities of becoming a physician are not explained clearly to students before they enter medical school.  Applicants to medical school rarely receive information about a physician’s obligation to treat people, the traditions of the medical profession, and the ethical obligations of physicians.  Critics maintain that failing to specify codes of behaviour to students before admission leaves them free to say “no one told me” even when they know their behaviour is wrong.  Medical students would be better off knowing what is expected of them by society and the profession to avoid conflicts between their own interests and those of their patients.

 

An ethical dilemma arose soon after AIDS appeared, when many doctors avoided caring for AIDS patients.  This became a problem for medical schools that required students to care for such patients.  Some students resisted, as did some faculty, leading to discussions about the obligation of students and faculty to care for patients with dangerous communicable diseases.  Similar situations occurred during the SARS outbreak in Toronto.  If students must play a role if another outbreak of SARS or similar dangerous communicable disease occurs, then medical schools should ask for informed consent from applicants about such risks.  Not doing so could be considered a tension if not a conflict of interest.

 

Impact of research funding

The flow of money into medical schools after World War II began to change the operations and composition of medical school faculties in the United States.  The schools received overhead funds for administering the grants, and the grants began to play an increasingly more important role in the budgets.  Medical schools replaced medical practitioners with research-oriented faculty who were more interested in being investigators than in caring for patients.  And the curriculum became more focused on research than on patient care.

 

The grant mechanism seems to have benefited clinical disciplines more than preventive medicine or public health.  It has taken SARS and other outbreaks to awaken medical schools and governments to the importance of public health and veterinary medicine.  Though the links between human and animal health are important – many of the pathogens in recent outbreaks originated in animals – they remain separated by vested interests.  Altman thought that if these disciplines had received more financial and curriculum support in recent years, we would be closer to achieving the international network that would be required to deal with global health problems.

 

The medical-publishing complex

The final portion of Altman’s lecture addressed another source of tension and conflicts of interest, the communication of medical information to the profession and the public.  Doctors have long mistrusted journalism and the need to communicate with the public, and felt it was more important to communicate with their peers in technical jargon than to the public in simpler terms.  The public in turn perceived many physicians and health workers as arrogant, thus creating tension between the public and the medical profession.

 

Health professionals mainly communicate with each other through reports in scientific journals, and these journals keep doctors and patients abreast of medical advances.  But what most academicians and doctors don’t realize is that many journals have become commercial.  They represent scholarship, but they are also an industry, raising hundreds of millions of dollars in advertising revenues and profits each year.  The public pays much of the cost of the scientific press through federal and provincial funding and not-for-profit agencies, but the journals profit from the arrangement.

 

Faculty members rarely discuss the financial agreements they make in publishing in such journals.  Many complain about not having enough money to do their research, yet many of those who have received public money to do research think little of turning it over to the journals.  Authors are not paid for their articles published in scientific journals, as was the case a century ago.  Now, authors may pay processing fees or “page charges” for the publication of their articles.  And publication helps ensure additional grants and the sustaining of an academic career.

 

Another change in journal and academic practices is that each group is increasingly using impact factors as criteria for promoting the quality of their work, in spite of criticism of the pseudo-scientific nature of impact factors.  There are complaints that journals use the impact factor to enhance their economics, and further complaints that the impact factor is distorting science, and possibly adversely affecting promotions in medical schools, and thus the composition of faculty.  There are tensions and conflicts of interest here, given that many faculty members are also journal editors.

 

Journals and medical faculty

Journals help to shape the faculty of medical schools.  Academia is well known for a “publish or perish” system, and promotions are based on the number of papers published and the journals in which they appear.  More “brownie points” are given for publishing in certain journals, even though no scientific evidence exists for the reliability of what appears in a “prestige” journal over what appears in another peer-reviewed journal.

 

Journal editors usually come from academia, and many come from the faculty of medicals schools.  These faculty journal editors often direct papers from their students and colleagues to their particular journal rather than the competition.  So there can be potential or perceived conflict of interest in the dual roles of faculty members who are also journal editors.

 

Embargoes

Embargoes imposed by journals determine not only what scientific information gets disseminated but also how soon it is publicly disclosed.  They restrict what authors may disclose before it appears in a journal, and even limit what is disclosed at scientific meetings and in interviews long before the work is submitted to a journal.  To ensure that a paper remains eligible to be submitted to certain journals, presenters have chosen not to fully disclose their findings at meetings where it may become available to reporters.  That has a chilling effect on the free flow of information paid for by taxpayers.

 

Embargoes can be an effective marketing device for increasing circulation, ad revenue, and profits of scientific journals.  This allows privately owned medical journals substantial income from publishing reports from taxpayer-supported research.

 

Many journals are owned by professional societies or by for-profit companies.  We know little about where the profits go in the non-profit journals owned by professional societies.  If the profits support lobbying, the practice is a conflict of interest.

 

Peer review

The widely used practice of “peer review,” meant to imply standardization and objectivity, is actually a subjective practice of editing.  It is an editing tool, yet journals rarely describe their policies and criteria for peer review, and there are no standards for peer review between scientific journals.  Yet it is held out as the gold standard even though studies have not shown peer review to be superior to any other method of review.

 

Journals justify embargoes on the importance of peer review, and the embargoes allow the news media to report the findings on the same day as journal publication.  Thus, medical news may be the most managed of all news.  Using peer review to justify embargoes, journals assume an enormous responsibility for ensuring the validity of the data they publish.  But editors say they cannot provide such a guarantee, and they acknowledge that peer review cannot detect fraud.  They examine only what the authors have provided for review and examine primary data only when its validity is questioned.  If journals impose embargoes and make claims for their reliability based on peer review, but reviewers are unable to detect fraud, then one has to question the quality of the literature that is the basis for scientific literacy.

 

Altman challenged the audience with several questions:  Who profits from the practice of medical publishing?  How are the journal profits spent?  How often are the profits returned to scientific work?  Why do scholarly medical and scientific journals need advertising?

 

Altman concluded with a disconcerting notion.  With the widespread acceptance of journal rules, it can be said that researchers cannot get new ideas accepted without agreement from journal peer reviewers, who are often competitors, and from journal editors who judge the papers.  And if medical researchers cannot or choose not to discuss ideas before they are published because limits exist to what can be discussed in a scientific meeting, what has become of academic freedom?

 

Issues and Perspectives

 

Dr Allan Detsky, Professor of Medicine and Health Policy Management & Evaluation

“Conflicts of Interest in Academic Medicine: Some Evidence”

 

Dr Detsky presented three pieces of evidence for conflict of interest in academic medicine:  1) in the development and publication of Clinical Practice Guidelines, 2) in the growing business of academic society meetings, and 3) in contact between medical student and pharmaceutical company representatives.

 

Clinical Practice Guidelines

Clinical Practice Guidelines, produced by government bodies, agencies, medical societies, subspecialty societies, etc, are meant to be a synthesis of the data (evidence) and actual recommendation on how to diagnose and treat specific medical conditions.  Their development involves large groups of people and elaborate processes.  Most of the advice comes from academic clinicians who give their best advice based on evidence.

 

Detsky and his co-investigators surveyed authors of Clinical Practice Guidelines (CPGs) and asked them to what extent they had financial relationships with industry.  87% reported that they did, with an average of 10.5 companies with which they had such relationships.  The relationships included travel funding, speaker honoraria, educational program support, research support, and employment/consultant status.  They then asked the authors whether they believed that those relationships influenced their opinions.  Only 7% responded yes, but 19% believed that their colleagues would be influenced by such relationships.

 

Academic Societies

Academic society meetings were once exchanges of scientific information.  Now these meetings have developed into a business that is heavily sponsored by pharmaceutical companies.  A large part of the income from these meetings comes from the sale of satellite symposia.  Some academic societies now make about half of their income from annual meetings.  This requires the hiring of more professional staff to run the larger organizations, generally an irreversible trend.  Data on income and expenses for Continuing Medical Education (CME) in the United States show a vast increase in commercial support over other income from 1998-2003.

 

University Teaching Activities

Detsky and co-investigators studied the effect of contact between medical students and pharmaceutical company representatives (PCRs).  In 1992 a policy was established at McMaster University’s department of medicine to limit interaction between medical residents and PCRs.  Drug companies were banned from sponsoring formal activities for house staff at McMaster.  The policy was based on the assumption that contact with PCRs during medical studies creates bias.  In comparison, the practice at the University of Toronto was to educate the medical staff on how to interact with PCRs, ie, to learn to recognize bias early in order to more effectively deal with it later in one’s career.

 

This difference in policy gave investigators the opportunity to observe the level of interaction and influence on clinicians five years post-residency and relate it to the level of interaction while a student.  They studied McMaster graduates from periods before and after the implementation of the restrictive policy, and University of Toronto graduates.  The results showed a large statistical difference between the Toronto and post-policy McMaster groups in the amount of current contact between clinicians and PCRs.  (The pre-policy McMaster group was essentially the same as the Toronto group in this measure.)  When asked about the perceived benefit of PCR information, the distribution of responses showed the Toronto group found PCRs to be more helpful than did the post-policy McMaster group.  (Again, the pre-policy McMaster group was similar to the Toronto group.)  The conclusion was that early contact with PCRs leads to a greater level of later influence on clinicians.

 

On how to deal with the problems of conflict of interest in academic medicine, Detsky recommended that 1) we admit to the problem and increase transparency in interactions, and 2) we look for ways to minimize it, eg, do not allow pharmaceutical companies to buy lunch at CME activities.

 

 

Ms Leslee Thompson, VP Health Systems Strategies, Medtronic of Canada

“Addressing the Changing Landscape: One Company’s Experience”

 

Ms Thompson added the perspective of Medtronic, a medical technology company that has been working closely with medical students, physicians, and scientists since its inception in 1949.  The founder of the company worked closely with physicians to first make heart pacemakers portable, then to make them implantable.  The continuous development and improvement of their products requires a great deal of contact between clinicians, engineers and researchers.  And thorough training and education of clinicians is required for the safe and effective use of their devices.  Medtronic is developing innovative methods of training clinicians, eg, with simulators, to develop the best possible skills associated with the devices.

 

While such close contact inevitably has potential for conflict of interest, Medtronic believes they deal with it effectively through a code of conduct that is embedded in all aspects of the organization.  The code provides a framework for ethical business conduct and includes guidance on dealing with physicians and health care administrators.  Employees practise through role-playing how to deal with situations that are inconsistent with the company/industry code of conduct, including resistance from physicians and institutional customers to comply with the code.

 

Thompson thought that to create an environment that promotes, encourages, and enforces ethical business behaviour at all times, key stakeholders – companies, physicians, professional societies, regulatory and enforcement agencies – must form meaningful partnerships.  All have to contribute and collaborate to achieve the goals of transparency, ethical and evidence-based decision making, and innovation.  Constant feedback is required to learn from challenges that occur, to learn to work in the best possible way with clinicians, and to discover new ways to bring innovation to the clinical environment.  Medtronic sees itself as providing leadership in the collective responsibility of safeguarding the public trust.

 

 

Dr Lorraine Ferris, Professor of Public Health Sciences, Faculty of Medicine, U of T

“Medical education programs can offset the challenges of commercial inducements”

 

Dr Ferris defined commercial inducements as incentives that unduly influence professional or institutional judgment concerning a primary interest (e.g., maintaining academic mission, academic values, professional values, patient care) because of secondary gains.  While collaboration and cooperation between academia and industry is important, we have to learn to interact in a better way, or certainly in a more transparent way.

 

She quoted Jordan J Cohen, past-president of the Association of American Medical Colleges, who said, “medical schools and teaching hospitals must model professionalism and not allow themselves to become involved in conflict of interest activities that contribute to the undermining of their professionalism.  Medical educators must ask themselves what lessons students take away from their immersion in learning environments so rife with commercial influence and industry bias.”  So, how can medical education programs offset the challenges of commercial inducements, both real and perceived?

 

Learning for medical students takes place in many different environments (medical schools and various teaching hospitals) and in many different ways (classroom, rounds, clinics, at the bedside, etc).  If we look seriously at medical education programs and how to deal with commercial inducements we have to look across all the institutions and the learning environments.  We must critically review medical curriculum and learning environments to address areas of disconnect.  For example, clear and concise guidelines for CME have been developed and are in effect, but do professors declare any conflicts of interest in their classrooms?  What do these declared conflicts mean to the students?  Ferris suggested that we also have to do curriculum mapping across medical education courses to see who is teaching the courses, and whether conflicts of interest have been declared.  She believes that if the conflicts exceed a specific benchmark, the individual should not teach the course.

 

We must also nurture a culture of critical thinking by teaching and encouraging students and faculty to critically evaluate individual and institutional commercial interactions, and examine these as they relate to academic values, professionalism, and public perception/trust.  They should learn to critically think about what is okay and what is not okay, and then establish rules with others about how to address these across all the learning environments.  We must also give students and faculty a forum for open discussion about commercial interactions and inducements where they can be heard by those who can do something about them.

 

Ferris used the phrase “dancing with porcupines” (used in the past by Elizabeth Wager, BMJ) to describe some of the relationships we must learn to have with industry, in which we maintain our own values and they maintain theirs.  The reality is that a large percentage of CME activities are funded by industry.  Should industry not be involved at all?  In a publicly funded system we may not have the resources to take over the cost of CME from industry.  If we do not have the resources then we have to learn to dance well with porcupines so that we get what we want and they get what they want while maintaining our own values and mission.

 

We have to create a culture of public responsibility.  We owe a responsibility to each other to maintain academic values, professionalism, and the public trust.  When someone does something to forfeit that or to be induced into not doing anything about it, there has to be a mechanism to let that individual know that they ought not to be doing that.  What we rely on now is a culture that allows people to “blow the whistle.”  We have to create a culture where it is okay to ask questions about whether or not something is an inducement.

 

We have to create, monitor and enforce an appropriate policy environment so that the rules are the same from one hospital to another. The issue is a national one as well. Canada has 16 academic health sciences centres all with various policies and guidelines to avoid commercial inducements and with various ways to teach students about commercial interactions and inducements.  What we haven’t had is a national forum.  If we had a national statement with national principles that all agreed to adhere to, we could better address COI and manage the interactions with industry and do so in a similar way.  As it currently stands with each academic health sciences centre addressing the issues alone, it becomes time-consuming and resource-consuming for medical schools and confusing for students now or in the future (if the different institutions apply different principles).

 

To accomplish all of this, there must be a willingness of medical schools, teaching hospitals, faculty and students to self-reflect on these issues and a willingness of industry to engage in these discussions with us.  There are already excellent examples of best practices in institutions across Canada that can be drawn from to develop a national consensus about offsetting commercial inducements in our medical education programs.  It will take institutional commitment to work nationally as this is a time and resource drain in the interim, but certainly worthy of our efforts for our future.

 

 

 


Models for a Constructive Relationship: Interactive Panel Discussion

 

Dr. John Evans –

“The MaRS Project: A View from the Top”

 

MaRS is a not-for-profit, private-public corporation created to try to do a better job of commercializing the results of research that have come from the huge public investment in science and technology in this country.  It was apparent that to be successful, one would have to work hard to establish the critical mix and critical mass to achieve a brand and recognition, because attracting scientific entrepreneurs and business capital would be critical to make it succeed.  The aim was to create a neutral “sandbox” – not part of the university, not part of the hospital – for business, venture capital, and science to play in.  The aim was to establish an entrepreneurial culture and also to provide business services that would enhance the chances of commercial success of those entrepreneurs.

 

In September 2005, the doors of MaRS were opened and a Chief Executive Officer, Dr Ilse Treurnicht, was recruited.  There is now a strategic mix of 75 tenants, 2/3 of which are private sector and 1/3 public.  There is a large offering of educational programs addressing relevant entrepreneurial issues.  There is a sophisticated group of business development services to mentor entrepreneurs and help them make their commercial entities successful.  There is an increasing wide network of communities of business, venture capital, and science that is part of the regular dynamic interactions in the building.

 

The incubator has 27 emerging tech companies, and over 160 business entrepreneurs working with the business development group.  The aim of this mentoring is to help the entrepreneurs design their businesses more effectively, and to create a culture of commercialization where they can interact with other entrepreneurs.  Great ideas in new companies in development come from serendipity, people talking casually, interacting, finding things that fit in an unexpected way that is innovative and important.

 

MaRS is an independent platform or convergence centre.  Its goal is to ensure more commercial success from new discoveries that are emerging from the substantial investment in research.  The entrepreneurs aren’t all academic people.  Of the current tenants, the majority of them do not do research directly with universities.  They look at ideas, put those ideas together, and then tie them in to venture capital.  It is a place where a lot of university research goes directly through the technology transfer function of each of the teaching hospitals and universities, but a lot of it comes from spontaneous ideas of entrepreneurs.  They are the kind of people who are relentlessly pushing to try to identify and put together ideas and create jobs, small businesses and wealth for this country.

 

He says MaRS would be successful if a lot of start-up companies get to market faster than they would otherwise, and if there are fewer failures en route. Also, if the technology transfer capability, which is at the moment vested in individual institutions, went into a collaborative, federation mode, it would be more powerful and specialized in achieving this commercialization.  Most of all, one hopes that the knowledge economy, which is such an important part of the future of Canada and other industrialized countries, would get a lift through more effective commercialization of the output of the terrific research that we have in this country.

 

There are reasons why Evans and the other founders thought MaRS should be a neutral sandbox.  It distinguishes it from an institution, like a university, where the primary objective is education and research and where commercialization is a subsidiary objective.  With MaRS, the primary objective is the commercialization of research.

 

 

Dr Irfan Dhalla, Chief Medical Resident, St Michael’s Hospital

“A resident’s perspective”

 

Dr Dhalla shared the perspective of a physician-in-training, giving his thoughts about relationships with industry and models for a constructive partnership.  He related two anecdotes relevant to the discussion about conflict of interest.  The first he experienced as a medical student on a family practice rotation, where a pharmaceutical representative used hockey and baseball tickets to persuade the physician to prescribe a particular drug more frequently, even though it was more expensive and less effective than other medications.

 

In the second anecdote he described a CD set produced by a faculty member to teach cardiology residents about diseases of the aorta.  The set would be distributed free of charge to cardiologists across the country.  The considerable amount of time spent producing the educational program and the cost to distribute it were supported by a drug company with no financial interest in this particular set of diseases.

 

Dhalla referred back to the “disconnect” mentioned by Dr Ferris, also referred to by some medical educators as the “hidden curriculum.”  He gave examples of practices on the wards by attending physicians that conflicted with what was taught in the classroom.

 

He noted two things he has observed about the relationship between academic medicine and industry:

1) That it is extraordinarily difficult to do research without industry support.  Government funding for research fluctuates;  industry support tends to be more constant. What this means is that the research agenda is skewed – research that might benefit industry is more likely to get funded, and hence completed..

 

2) That physicians-in-training are relatively insulated from industry.  Government subsidies and tuition fees support education during medical school and residency.  But once physicians are in practice, they must either pay for continuing education themselves, or they have to let industry pay. And even if a physician is willing to pay, he or she may not be able to ‘buy’ the education he or she desires, especially in the subspecialties.

 

To establish a constructive relationship, Dhalla suggested we remember that companies have a fiduciary responsibility to their shareholders to produce a return, and that physicians have an ethical and moral obligation to provide the best possible care for their patients. Some may say that those two goals cannot be reconciled, but Dhalla thinks that they can and must be reconciled.  He repeated the example of the mass production of insulin so that all diabetic patients could benefit.  He hoped that that is where we are going with concepts like MaRS.

 

 

Ms Maureen Brosnahan, Senior National Correspondent, CBC National News

“The media and health reporting”

 

Ms Brosnahan described our world as one where medical teleconferences, daily podcasts of medical news, blogs, listservs, and instant information through the Internet, allow the public access to much of the same medical information as the medical community.  But with that constant flow of information comes a large responsibility for journalists who cover medical news.  They must sift through the information, test its validity and accuracy as much as they can within their own experiences, and try to separate the wheat from the chaff.

 

Most medical reporters in this country are not specialists.  A few may have a science degree; none have a medical degree. They acquire their knowledge through dealing with people, asking questions and challenging assumptions.  But most of the mainstream medical stories originate from news releases, news conferences, and advance notices of what is being published in journals. Public relations firms provide news releases complete with visuals and sound bites, all ready to use.  Because of the deadlines of daily journalism, the material is often just accepted as it is without much scrutiny.

 

She mentioned that journalists routinely ask questions of academics at medical schools about industry associations, like being on the board of a company, and who is paying for their research.  But they do not routinely ask questions of their interviewees about interests and biases other than who funded their studies.  Usually an individual’s academic positions are included in a story in mainstream media, but not their affiliations with industry.

 

There is reluctance on the part of medical researchers to talk to journalists.  They risk an article not being published if they speak to journalists first, because of embargoes imposed by journals on the information.  An individual may also be accused of grandstanding by their colleagues if he or she is quoted too often, especially in the lay media.

 

This is unfortunate, because that is where medical researchers can build relationships, to be seen as helpful in explaining things.  If the people in the medical and academic communities think appearing in the popular media won’t help their cause of explaining things in an accurate, credible and understandable way, who will journalists rely on when panic stories arise?  An ongoing relationship enhances the quality of information that goes out and the understanding of it.

 

When stories are complicated by ethical and moral questions, it would be helpful if the medical community was available and comfortable in helping people deal with the issues.  There needs to be a thoughtful, reflective dialogue along with complicated issues.

 

So much of innovation starts with bench top research, which may not seem to mean anything right now or for a long time.  But for journalists it has to mean something right now otherwise it’s not necessarily a story.  In the world of medical research those small incremental steps are very important, but it’s hard for people to understand why they are really important.

 

We need to let people know about associations with industry.  People are generally sophisticated enough to know that industry plays a role, and they expect it to play a role, but the need for transparency is even more present there.  If it is revealed after the fact, people are suspicious about why it might have been covered up or not declared right away.  They will find out one way or another.

 

 

Dr Patrice Roy, Executive Director, Rx&D Health Research Foundation

“Enhancing the capacity and performance of health research in Canada”

 

Dr Roy gave an overview of the pharmaceutical-based industry and spoke about research partnerships.  He said the pharmaceutical industry is highly regulated, more stringently than any industry because human health is involved.  New innovative medicines are developed through research and development, with the primary objective of improved health for Canadians.  He disputed the earlier comment that pharmaceutical companies respond first to the needs of the shareholders.  He maintained that patient welfare comes first.

 

He spoke of an apparent wall between industry and academia where few scientists move back and forth.  Greater exchange between the two groups would lead to a better understanding of each other.  Dr Roy is involved in creating programs with universities to involve graduate students in knowledge translation, so they understand more about application to patients and commercialization and also how to sell oneself.  They need to learn that they are actually a small enterprise that they have to sell to funders to get grants.  Understanding that would help them work with industry.

 

Innovation is the cornerstone of better health, and industry and academia must work together to achieve it.  Dr Roy sees two kinds of partnerships:  companies can invest in research taking place in medical institutions, or through what he is doing with the Health Research Foundation, which works with federal and provincial funding agencies.  It partners with companies and medical schools to support training and provide faculty awards for younger scientists, and provide research chairs and operating grants for the more established scientists.  It’s objective is to feed the drug development pipeline.  Areas of arm’s-length partnerships include funding scientists who have found novel targets, innovative drugs, or new technologies.

 

The mission of the Rx&D Health Research Foundation (HRF) is to demonstrate the importance and value of innovative health research and its role in advancing medical knowledge and the quality of health care in Canada.  Its partnership objective is to promote meaningful community-based actions in support of advancing medical knowledge and the quality of health care.  They are interested in partnering with other disease-specific foundations, and will partner with foundations that want to promote science interest into young students.

 

In the 40 years of partnership with medical and pharmacy schools, the HRF has fostered the study and development of science of therapeutics in the support of research and training units in clinical pharmacology.  It has sponsored over 2000 trainees through scholarship and fellowship awards.

Dr Roy mentioned a tension in that many scientists do not cite their support from industry in their publication of research findings.  If the investment of the pharmaceutical industry was better acknowledged, people would realize that industry is supporting research that that benefits to the entire community.  This failure to acknowledge funding from the pharmaceutical industry does not help in building positive relationships between industry and academia.

 

Dr Roy described career opportunities for many specialties in the vertically integrated pharmaceutical industry, all the way from basic research to marketing.  He thought there should be more connectivity of employment between industry and academia, where working in parallel would encourage movement between the two communities.

 

He said that industry does not work in isolation in working on treatment for a disease.  There is a balance between the objectives of the company, what the research community thinks should be done, and what the agencies believe is important.  The Health Research Foundation is currently working with CIHR to develop operating grants that will support specific research in specific disease areas.

 

 

Q&A session

 

Q  The discussion this afternoon was pretty polarized.  Do you see that as a problem in Toronto?

 

Evans – There is a recognition that what industry does is important, and what universities do is very important.  But you have to be very cautious about substituting the goals and practices of one in the location of the other.  One of the reasons we set up the MaRS project was to provide a neutral sandbox – it isn’t a university, it isn’t a corporation.  It’s letting the entrepreneur find a way of building and developing the entrepreneur’s ideas.  And so it avoids some of the complications and ambiguities that occur between the areas of research and education, the classical goals of university, and commercialization, which is a subsidiary goal of the university.

Dhalla – I’m not sure whether we’re polarized in Toronto or not. I think today we’ve heard from people at different points on the spectrum of beliefs and relationships and attitudes. I also suspect that  Toronto may not be different from other centres.

Q (follow-up) – From a results perspective it is.  We haven’t produced the knowledge-based industries that many other centres, especially in the United States, but also the University of British Columbia have.  We may have too much of a polarized situation within academia.

Roy –We need to try to understand one another better but also why we’re having those difficulties.  So, if there is a true need for industry investment into CME activities, where is the problem?  For me the problem is that there is too much knowledge to manage, and who is going to pay to transfer that knowledge on a timely basis to physicians?  If we look now at when we discover a new drug and we look at the fitness of the product monograph, because of the knowledge base in science that we require, we’ve got many more scientific questions to be answered before any treatment gets approved.  But that’s more knowledge that everybody needs to understand.

Evans – the kinds of conversations that are going on in this room today are trying to address how do we get a greater transparency and understanding from the partners on both sides.

 

Q to Dr Dhalla.  Would you as a medical student or resident feel comfortable reporting the incident (of the physician and the hockey tickets) you related to your program director in the Faculty of Medicine?  Secondly, do you think there is a role for the College of Physicians and Surgeons of Ontario to monitor this sort of behaviour?

Dhalla – I would feel comfortable reporting such behaviour today. I didn’t report what happened then, probably because I was more shocked than anything and the thought didn’t occur to me that I should report it.

The College of Physicians and Surgeons (CPSO) has a mandate to protect patients, and in this particular instance the patient was harmed, mainly financially.  The CPSO should have a policy on what kind of relationships should be acceptable between physicians and industry.

Evans – perhaps the experience also illustrates Gordon Guyatt’s view on providing some sort of sensitization early in training.

 

Q Something that has been left out is that this discussion takes place in a distinctly Canadian context, but a vast majority of the research that fills the journals that we’ve been talking about today takes place within in a very different medical environment in the United States.  I understand from what I’ve heard that the pharmaceutical industry holds the interests of the patients before those of the shareholders.  I think the public health care system is close to the hearts of most Canadians when they think of this issue.  And I’m wondering whether or not these questions and how we educate physicians and how the medical schools operate and their relationships with industry would far prefer to exist in a more American health care system.  How those questions impact this debate today.

 

Brosnahan – I do think there is a very different culture here in Canada with a public healthcare system, but also beyond that, this issue of the relationship between academia and Industry.  It’s not just in the medical community.  It’s also in other fields such as engineering that academia feels they may get tainted by association with industry.  We draw such a line between public health care and private health care and we tend to put industry in that private sector and feel that any kind of relationship with it is going to taint it and move us into a more “outside-the-box” medical care system.  And that underlies a lot of the discomfort in the tentative nature of what’s been in this conversation today.

 

Dhalla – The government has put a lot of time and resources into producing more doctors, but I’m not sure they’ve put as much effort into producing better doctors, nor have they put resources into ensuring that doctors continue to improve once their out in practice.  Someone’s got to pay for that process of improvement, and either it’s industry or it’s physicians or it’s taxpayers or it’s private donors, and right now it’s mostly industry.  There is an option that the public can choose to pay for CME.

 

The second point that you were getting at is the tension in Canada between the pharmaceutical industry and the public.  In many cases, once a drug is developed and marketed, it’s paid for by the government.  And that’s a huge tension, and I don’t think any of us has come up with a good answer.  And it is made even more difficult to address because so many of the researchers and those who write Clinical Practice Guidelines have ties to industry.  For example, the Canadian Diabetes Association wrote guidelines on what kinds of insulin should be subscribed.  They made a recommendation that a new long-acting insulin should be prescribed.  There were lots of people with close industry ties on the guidelines committee.  The government-appointed panel that looks at these kinds of decisions said there is not a lot of evidence to support the drug and did not recommend that the government pay for it.  Huge tension, but no solution.

 

Roy – From our perspective, the environment in Canada is somewhat favourable in terms of the industry being able to work with the community.  We do have our own code of conduct for the industry.  Regarding the comment about the medical association, I think it would be great if such a code existed.  We find a lot of the time we hold ourselves responsible for educating the physicians on how to behave, and that does not make any sense to us.  To tell them that our code says “this is how you should behave” doesn’t make any sense.

 

Summary Remarks and Open Discussion

Dr David Goldbloom, Professor of Psychiatry and Senior Medical Advisor, CAMH

 

Dr Goldbloom drew on each of the speakers’ presentations to summarize the afternoon. He noted that  Dr Altman said, and it was echoed by nearly everybody, that medicine’s relationship with industry is essential.   Dr. Goldbloom said we have confluence of interests and we have conflicts of interest.  And our challenge as a university is to create a culture and a climate of discussion, of self-scrutiny, and of critical thinking in juggling these interests.

 

He said there are clearly examples where physicians act reflexively or without thinking, and that Allan Detsky touched on this briefly.  There is an intense belief that we are uniquely different from all of our colleagues.  And in fact the research that Allan alluded to points out that among residents, medical students, and practising physicians, the belief in their own personal immunity from conflict of interest does not apply to all of their colleagues.  They  believe that their colleagues are more vulnerable to such conflicts.

 

For many physicians, the media is seductive. We’re often flattered that they call, or sometimes terrified that they call.  As Maureen Brosnahan indicated, we actually have a responsibility to interact with the media.  We have a mission of knowledge transfer, of health promotion, of advocacy and of public health, that does not allow us to stay secluded in obscure journals.  That mission requires us to use the power of the media to get important messages out and correct some of the mythology.

 

This symposium coincided with the launch of Open Medicine, the free online medical journal founded by staff that left the Canadian Medical Association Journal.  This represents a significant shift in the future of medical publishing.  The nature of and influences on medical publishing are going to change dramatically, and the Internet will ultimately take us to more of a free flow of intellectual property than has been the case before.

 

Leslee Thompson told the exciting story of medical devices and their impact on human health.  But we have to remember that these are highly competitive businesses.  They provide extraordinary products without which many of us could not do our jobs, but they remain highly competitive businesses.  And physicians wittingly or unwittingly are part of that competitive process.

 

Lorraine Ferris said that we need to find a better way to interact because “we don’t have the resources.”   Goldbloom believes that there is no greater self-deception in the Faculty of Medicine than the line “we don’t have the resources” when it comes to education. He thinks that there has been a profound abdication of responsibility for continuing education on the parts of faculties of medicine in North America to industry.  Industry is very effective in providing continuing medical education – but does it with its own goals and objectives in mind.

 

Goldbloom described a 2-day clinical therapeutics course for general practitioners that has been running for about 20 years at McGill University.  It has never had any kind of sponsorship.  GPs pay the fees themselves and give up two days of their practice.  The course can accommodate about 350 GPs and it is always oversubscribed.

 

He believes that there is a culture of dependency in continuing medical education. Many physicians are in the top 1% of income earners in this country but they say that they cannot afford their own continuing education.  He says the simple reality is that they can.

 

Ferris also asked that we try to harmonize policy across the teaching hospitals of the university.  Goldbloom described an experience that illustrates the difficulty in such harmonization.  He chaired a task force and wrote a report for the Department of Psychiatry at the University of Toronto on interactions with the pharmaceutical industry.  The Dean of Medicine asked him to bring the finished report to the meeting of the Chairs of all the clinical departments.  The response to the report confirmed what Dr Altman said about money being the source of many conflicts.  The clinical Chairs said that they could not implement the policy, as it would hit the faculty too hard financially.  As a result, the policy for the University of Toronto is more diluted..

 

John Evans provided a description of one of the more innovative solutions to this problem with his idea of a “neutral sandbox.”  However, even in that neutral context there still has to be a set of rules that govern interaction, because people come to MaRS from many different hospitals and institutions.  Similarly, when students go to classes there should be only one purpose for which they are there.

 

Industry is vitally necessary for research, but research institutes must keep industry’s contributions in balance with other sources of funding in order to maintain control of their research agendas.  Similarly, it is reasonable for journalists to ask physicians questions about their own conflicts of in order to maintain balance in opinions solicited.  Within industry, the term for physicians who speak in speakers’ bureaus is “opinion leaders.”  So there is a designated role for those individuals and that is to shape opinion.  When these opinion leaders are too closely affiliated with industry, the balance of opinions quoted in the media may be tipped towards those of industry.

 

Goldbloom mentioned two noteworthy items in the slide presentation by Patrice Roy that were not discussed. One, that the highest paid entry-level position in industry was in sales, far above that of an entry-level researcher.   This illustrates the bipartite mission of industry – the development of new therapeutic products and improving the quality of life of people, and the responsibility and accountability to shareholders and the obligation to provide the best return on investment.  The other item was the inclusion of sales and marketing in the list of partnerships.  Goldbloom felt that sales and marketing should not be on the list of partnerships with hospitals and physicians, because it is against the spirit of the rules of the medical governing bodies.  It is exactly in that area where concern usually arises.

 

He believes that hospitals and universities have abdicated some of their responsibilities and that industry has played a very active role in filling the void.  Annual meetings of medical organizations have indeed been transformed; they are now dominated by satellite symposia sponsored by industry.  And he likened the opening of the exhibit hall to the running of the bulls in Pamplona as attendees rush in to pick up the promotional items distributed by exhibitors.

 

 

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