AAMC Reporter: May 2007

Viewpoint:
Stanford's Policy on Conflicts of Interest in Education

Philip A. Pizzo, M.D., Dean, Stanford University School of Medicine

When I graduated from medical school at the University of Rochester, I remember being offered a doctor's bag emblazoned with the logo of a major pharmaceutical company. That was in the late 1960s, when it was in vogue to rebel against the business establishment. And so I and some of my fellow graduates politely refused the gift. In the intervening years, I have witnessed the growing intrusion of commercial interests—i.e., pharmaceutical companies and medical device makers—into the day-today practice of medicine. Industry gifts—pads, pens, logo bags, and the like—have become commonplace. Industry sales representatives have become familiar faces in the halls of academic medical centers. And the free lunch, courtesy of industry sponsors, has become an accepted way of life.

All of these actions have contaminated the practice of medicine. They have also led to a growing mistrust of the medical profession on the part of the American public, as physicians are perceived as being too closely allied to the companies whose products they prescribe. That is not to say we do not value our relationships with industry. Indeed, we depend on our industry partners to carry the fruits of our research to market. The connections between academicians and our industry colleagues have led to the introduction of many new drugs and technologies that have significantly improved the lives of adults and children.

At the same time, however, I have seen a dramatic shift in the balance, with economic incentives and marketing tactics becoming all-too-pervasive in how we interact with our commercial partners. The result has been a disturbing blur of the line between academia and industry.

I had been concerned about this issue for some time and in the summer of 2005, I asked Harry Greenberg, M.D., Stanford's senior associate dean for research, to gather together a group of faculty to develop a policy on how we should work with industry to ensure our relationships are ethical and appropriate. I engaged the faculty in a discussion of the issue through our Dean's Newsletter and sought input at every stage of the process. We had many lively debates.

The result was a far-reaching policy we put into effect in October 2006 across the entire Stanford University Medical Center campus, which includes the School of Medicine, Stanford Hospital and Clinics, and the Lucile Packard Children's Hospital at Stanford. The new policy complements longstanding school of medicine guidelines that govern potential conflicts of interest in the research arena.

The new policy prohibits our faculty from accepting gifts of any kind, however small, anywhere on the medical campus or at off-site facilities where they may practice. It bars industry sales and marketing representatives from wandering the hallways of our two hospitals and our laboratories, allowing them access only by appointment. It prevents companies from directly paying for meals in connection with educational programs. And among other provisions, it requires that those involved in the decision to buy formulary drugs or clinical equipment disclose any related financial interests they may have, with the possibility that they may be excluded from the decision-making process.

The policy is all-encompassing in that it applies to all physicians who have privileges at the two hospitals, as well as the 700 community physicians who serve on our adjunct faculty. It is not our intent to police the daily activities of these individuals. Rather, we aim to set standards and create a climate that will encourage anyone with a Stanford affiliation, including our trainees, to honor these important guidelines.

I am happy to say the policy has been very well received in its first year. Faculty members tell me they are relieved to be free of the lingering presence of pharmaceutical and device vendors. Residents say they appreciate having better clarity in our industry relationships. And though they don't benefit anymore from industry-sponsored meals, they still enjoy the occasional free lunch—at the school's expense.

We are continuing to refine and clarify the policy as issues arise. For instance, some raised concerns about whether physicians could continue to accept free drug samples to supply to needy patients. The Stanford Industry Interactions Policy brochure, which is posted on our Web site, contains a clarification: while drug samples cannot be accepted by individual physicians, they can be accepted by the hospital pharmacies, which can in turn distribute them to patients who need them.

We also are developing more specific guidelines for issues addressed only in broad terms in the policy. For instance, the policy states that physicians should not make clinical care decisions based on potential economic gain. We are developing additional guidelines in this area and also in the area of physician participation in “speakers' bureaus,” in which physicians receive honoraria from companies for participating in presentations related to company products. This practice should be strongly discouraged. We are also working on a set of rules that would require clinicians who prescribe medications or order diagnostic tests to disclose any substantial, relevant financial interests. These rules would be similar to those currently in place for physician/scientists engaged in research.

Since our policy went into effect, several other academic medical centers have followed suit in what I see as a growing trend. As we train the next generation of physicians under these new standards, we will sow the seeds for what could be a wholesale cultural change in the medical profession. So it is my hope that as our students graduate and move on, they too will politely refuse proffered gifts of logo bags

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