I’ve alluded to AMSA’s… interesting choices regarding who they will and will not take money from (or at least, who they will claim not to take money from). Here’s the long-promised photographic evidence: the swag I collected from conference exhibitors.
What you’ll find below the cut includes:
- A pamphlet, a bag, and some pens from Medical Protective, a professional liability insurance company owned by Berkshire Hathaway.
- A Merck Manual (yes, that Merck… the one that makes all these ”pharms” of which AMSA claims to be ”free”).
- Materials from various academies of quackery (as seen earlier).
- A pen, a magnet, and some other swag from the FDA.
- Application forms for various forms of insurance/consumer credit provided by or through AMSA.
- Some stuff from banks.
- Swag NOS.
[My efforts at live-blogging/tweeting have been foiled by the fact that this conference occurs two levels below ground where there is no connectivity of any sort. I guess this means the hotel has me on tape delay...]
The first talk of the morning was by a second-year medical student (Shahram Ahari, UC Davis)who spent some time as a sales rep for Eli Lilly after graduating from Rutgers. He went into sales because he thought it would be an opportunity to connect with clinicians at an intellectual level and discuss the science. Because that’s what a private-sector sales job is all about. Needless to say, he was somewhat disillusioned, especially upon finding that most of his salesforce colleagues weren’t scientists, but… salespeople. Go figure.
The presentation wasn’t irrationally hostile to pharm companies, though I might have caught the suggestion at the end that physicians have an “obligation” to vote the interests of their patients. He explained the many ways in which pharm sales people use the same techniques employed by salespeople in any industry: appeals to emotion backed up by data about the client that is never overtly mentioned.
The discussion was focused almost entirely on the prescriber-marketing interface; I was hoping for some evaluation of the appropriate nature of researcher-industry relationships, which is where (in my view) the controversy is much hotter. Nonetheless, it was an entertaining talk that explained the psychological basis behind all sorts of marketing techniques such as giving away free stuff…
Oh, right! Free stuff! AMSA might claim to be pharm-free, but a quick visit through their exhibition hall revealed a whole host of characters whose money AMSA was more than happy to accept in exchange for a booth. Some of these groups are more savoury than others.
Details to come… truly extraordinary.
I’ve blogged before about the conflict-of-interest issues raised by the various ways in which physicians interact with pharmaceutical and medical device companies. Since starting my medical training at SUMS, I’ve had the opportunity to think about these issues further, especially since SUMS has taken their approach to the issue to an extreme level of demagoguery that I had previously thought impossible outside the realm of parody. To wit, the first-years were recently subjected to a presentation on the school’s COI policy from a “researcher” who proudly described himself as an “anti-pharma zealot” [the Z-word is 100% verbatim]. The official reply letter to be sent to any vendor* with the temerity to send a holiday gift reads like a mix between a legal filing and a letter home from a high school principal outlining the sins of the schoolchild.
There is a very defensible (I would say persuasive) case that reactions such as SUMS’ go too far. Perhaps the best exposition of this side of the argument comes from Richard Epstein, an NYU law professor whose writings on the topic can be found here and here. The crux of his argument is that these regulations of COI are ostensibly designed to advance a goal, and that they should be considered in light of how well they advance that goal, not in terms of how well they stick it to the drug companies. His argument is that the most extreme reactions — those on display at SUMS, for instance — do more to retard the goal of human progress in the medical field than they do to advance it.
Many U.S. medical investigators who manage drug trials abroad say they prefer to work overseas, where regulations are lax and “conflict of interest” is a synonym for “business as usual.” Inside the United States, doctors who oversee trials are required to fill out forms showing any income they have received from drug companies so as to guard against financial biases in trials. This explains in part why the number of clinical-trial investigators registered with the F.D.A. fell 5.2 percent in the U.S. between 2004 and 2007 while increasing 16 percent in Eastern Europe, 12 percent in Asia, and 10 percent in Latin America. In a recent survey, 70 percent of the eligible U.S. and Western European clinical investigators interviewed said they were discouraged by the current regulatory environment, partly because they are compelled to disclose financial ties to the pharmaceutical industry. In trials conducted outside the United States, few people care.
I see two evils here, and have a pretty good sense of which one I feel to be the lesser. I wonder how many lives SUMS’ local “zealot” would be willing to sacrifice on the altar of anti-corporate ideological purity…
* – Given that I’m paying tuition to SUMS in exchange for an education, I can’t help but wonder if I should consider them to be my “educational services vendor,” and if this COI business holds for the vendors to my vendor. All those verboten food baskets have to go somewhere…
As the New York Times, its Prescriptions blog, and the San Francisco Chronicle have been reporting, there’s been a scandal of slightly more-than-minor size involving the UCSF Chancellor’s stock holdings. Dr. Susan Desmond-Hellmann — the oncologist at the head of UCSF’ — disclosed shareholdings in the area of $100,000 in Altria, the company formerly known as Phillip Morris that makes most of its money from tobacco-related products. Since that disclosure, followed promptly by divestment, Dr. Desmond-Hellmann’s holdings in health products/pharmaceutical companies and fast food companies — this time to the tune of millions of dollars — have come to light. The investments were apparently made by a third-party financial advisor without her knowledge, and this advisor has since been instructed to purge her shareholdings in alcohol, tobacco, and firearms manufacturers.
Reading these articles prompted me to consider one of my earliest posts here, in which I argued that there is nothing unethical, unseemly, or untoward about life/health insurance companies holding shares in fast food companies. Does the same argument apply to Dr. Desmond-Hellmann’s holdings?
Yes and no.
In my mind, the most problematic of her stocks are the pharmaceutical and health products companies. These firms are probably vendors or research sponsors at UCSF, or have the potential to be. The Chancellor’s shareholdings in these firms are substantial, and the potential for a conflict of interest is definitely present. As one of the ethicists quoted by the Chronicle points out, recusal from decisions that would trigger this conflict may be all that is required, but continuing to hold the shares certainly creates the appearance of impropriety. While some have pointed out that physician-industry relationships aren’t always eeevvvilll, as others would have us believe, there is a difference between productive collaboration of the sort Dr. Rich discusses and passive shareholding of the sort at question here.
I personally find her other shareholdings to be less objectionable. Alcohol, firearms, soft drinks, and fast food are all legal products that can be used or abused, depending on who is doing the ab/using. I see nothing intrinsically “evil” about them that should force medical leaders to steer clear. Many of these firms (McDonalds, Pepsi, etc.) are also components of major equity indices, and as such may well have been chosen for that reason. It’s highly unlikely that they will be directly involved with UCSF as vendors, donors, or sponsors, though I could be wrong about this. Tobacco, however, doesn’t pass the smell test with me, especially not when we’re discussing an oncologist. Arguably, it’s the only one of the products in question that is inescapably harmful regardless of how it’s used. Of course, I would be remiss if I didn’t point out that there are lots of anti-smoking groups out there who have let their love for tax revenue outweigh their desire to reduce smoking. This doesn’t make Dr. Desmond-Hellmann’s Altria holdings more palatable, in my view. It just places them in the context of “how worse could it be/what company is she in.”
There is a growing obsession with rooting out conflicts of interest in healthcare, often under the rubric of reducing “waste and fraud.” Much of this is a good thing, though as people like Dr. Rich point out, this obsession comes with a risk of harmful side effects. More and more attention seems to be paid to “who owns which shares.” Given that companies like McDonalds, Pepsi, and Altria are major blue-chip companies that are components of the DJIA/S&P 500 — thus likely to be held by many people and institutions — and targets for public health activists, it will be interesting to see how this plays out in the future, and where the line will be drawn for medical professionals who want to be perceived as “ethical investors.”
My first substantive post on this blog dissected an article in the American Journal of Public Health in which a group of Harvard-affiliated medical researchers strayed far from what one would imagine is their usual area of expertise. Their claim was that various health and life insurers hold outsized stakes in fast-food companies, and thus are unethically profiting from their policyholders’ unhealthy behaviour. A rudimentary look at their numbers and some basic familiarity with how insurance works are all that is needed to realize that this claim doesn’t hold water.
Now the NEJM has done something similar. The Drug and Device Law blog looks at a recent NEJM Special Report on the experiences of qui tam whistleblowers in lawsuits against drug companies, and rips the authors to shreds. The full post is well worth a read.
I’m not the most avid reader of medical journal articles (I see some of them when they’re recommended to me), but I suspect that this sort of thing has been going on for a while, and is likely to continue apace. More and more spheres of life, especially law, policy, “social issues,” etc., are being recognized for their effects on people’s health, and interest in these areas from medical academia seems to be growing. One could argue whether this is part of a larger trend of overmedicalization of society, but that’s a question for another time. What is clear from these two specific examples is that in order for observers to take seriously medicine’s contribution to scholarship and policy in these areas, medicine’s contribution has to reflect a reasonably sophisticated understanding of how the law/political process/various environmental determinants of health actually work.
When, as in these two cases, medical researchers don’t even get the basics straight, it’s just embarrassing.
(DDL post found via Overlawyered)