Wednesday, July 23, 2008

Challenging the dogma on conflicts of interest

Although I’ve already linked to Harvard Medical School professor Thomas Stossel’s Medscape commentary a couple of times it’s so rich I just can’t let it rest. Finally the leaders of the grand inquisition of doctors and drug companies have been taken to task, their dogma publicly held to a rigorous standard of evidence. Although Stossel’s article was in response to the AMA Council on Ethical and Judicial Affairs report calling for a ban of industry supported CME he addressed the broader issue of commercial involvement in medicine and its impact on professionalism:

My intention here, however, is to challenge the fundamental beliefs underlying The Report that transcend medical education to affect medical practice and medical research in general. These beliefs are that commerce in general is detrimental to medical professionalism and that "medicine" and "commerce" have sufficiently misaligned interests to justifying their segregation from one another.

He noted that the arguments for these severe claims were remarkably one sided:

Citing both sides of controversial issues is a requirement of serious scholarship. Violating this mandate, Brennan and colleagues not only ignored the benefits of commercial contributions to medicine, but exercised confirmation bias by referring only to publications critical of industry influences on medicine, although others rebutting these criticisms existed when the Brennan paper appeared.[19-23] All of the references that Brennan and colleagues cited were to books, medical journal articles, and newspaper reports supportive of the authors' claims. These references were compilations of anecdotes, purportedly exemplifying industrial corruption of medical research. Not only has follow-up due diligence challenged the interpretation of some of these stories (eg, Shuchman[24]), but, more importantly, considering the enormous expansion of corporate interactions with medicine, the paucity of examples is striking and their frequent repetition is not legitimate evidence.

The Brennan paper, frequently referenced in Stossel’s commentary, argues for severe restrictions in pharmaceutical industry support of education and research, and is one of the most widely cited papers by the critics of Pharma influence.

Although marketing activity does influence doctors there’s no evidence for a net effect leading to patient harm:

Unable to marshal evidence that corporate promotion adversely affects patient outcomes, The Report resorted to indirect arguments intended to convey that industry influence adversely biases physicians' judgment. In one, it mentions 2 notorious cases in which drug companies accused of promoting off-label drug use paid settlement fines to prosecutorial authorities. The obvious intention of mentioning such anecdotes is to imply that all corporations are fundamentally unethical. Considering the vast scope of corporate-sponsored medical education compiled by The Report, such extrapolation from isolated incidents -- meant to insinuate that such conduct is typical -- is grossly extravagant, bordering on slander.

I made the same point in a post from 3 years ago. The advocates for severe policy change should be required to sustain their burden of proof. They cannot.

If you’d like to watch a companion video, Stossel recently gave Grand Rounds on this topic at Dartmouth-Hitchcock Medical Center. He was heckled by the audience although no one could effectively challenge him in the Q&A. You can access the video here.

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