AAMC Reporter: September 2008

A Word from the President: "Institutional Conflicts of Interest — The Continuing Challenge"

By now, I am sure many of you have read our recent report, Industry Funding of Medical Education, and its guidelines for helping medical schools and teaching hospitals better manage industry relationships. While charting new territory in its emphasis on potential conflicts of interest (COI) in medical education, the report also underscored a critical point Jordan J. Cohen, AAMC president emeritus, made several years ago.

During his 2000 annual meeting address, Jordan said: "Maintaining public confidence in the integrity of what we do requires more than assuring ourselves that external financial interests have not tainted our scientific and ethical standards. We must also reassure the public that we have done everything in our power to ensure that their interests are not subordinate to ours."

As Jordan so eloquently stated, when it comes to maintaining public trust in our profession and in our institutions, our work must be ongoing. Jordan's words sparked a series of superb AAMC reports on COI, and our medical schools and teaching hospitals have made remarkable progress in defining and maintaining a culture of institutional integrity in our mission areas these past eight years. However, at the national level, we are only beginning to address other aspects of this important issue. In fact, one might argue that the deepening and increasingly complex nature of our industry relationships (as well as their greater prevalence) have served to expand considerably the potential for COI and therefore increase both the challenges and imperatives associated with maintaining public trust.

For example, there are some key differences between the operating environment we faced in 2000 and the one before us today. First, there has been growing public recognition that the interaction between industry and the academic medicine enterprise is vital to the public's health. The tremendous strides we have made in heart disease, cancer, and other areas of biomedical research have heightened awareness that these relationships are essential to new treatments and cures. Fueled in part by the 1980 Bayh-Dole Act, these collaborations have spurred the transition of medical products and devices from lab to marketplace.

At the same time, public expectations that the integrity of our missions is not compromised by these relationships have never been higher. While such scrutiny is not unique to academic medicine, our community's intrinsic and profound commitment to the public interest and to our patients' welfare appropriately creates for us a much higher standard.

Another difference from eight years ago is the acute awareness by federal and state governments that scientific research is integral to economic growth. Consequently, the pressure for academic-industry relationships to flourish has become enormous. Some of the rhetoric surrounding the establishment of new medical schools has created the expectation that they will become "red hot research engines" and, thereby, key agents to enhancing economic development.

While these pressures have been directed at the academic scientific enterprise, our community now faces similar challenges in medical education and patient care. These challenges arise, in part, from growing public recognition that our institutions have become increasingly dependent on industry support for all their missions. They also occur because academic physicians, as other health care professionals and administrators, have become more accustomed to routine interactions with industry marketing representatives and frequent exposure to industry gratuities in various settings.

While most medical professionals believe that gifts from industry have no effect on their decision making, mounting scientific evidence from different disciplines indicates that these favors—no matter how small—can indeed prejudice independent judgment, often unconsciously. As noted at our 2006 symposium and report on the topic, The Scientific Basis of Influence and Reciprocity, "self-interest unconsciously biases well-intended people."

What all of this tells us is that institutional integrity is a precious and complex commodity with many dimensions. As I talk with more of our members, I am convinced there is now a much broader understanding of the potential for COI and fuller awareness of its impact. As our institutions work to develop policies along the guidelines suggested in our newest report, it is important to keep in mind the following.

First, industry relationships are essential, but they must be carefully managed. By developing clear and well-considered guidelines, we can optimize the benefits inherent in the academic medicine–industry relationship, while at the same time, minimize the risks. In other words, we need partnerships that are principled, productive, and transparent.

Second, although each institution must decide for itself how to develop and implement its own policies and practices, the urgency of addressing these issues cannot be overstated. Conflicts of interest have the potential to undermine the credibility, integrity, and trustworthiness on which rests the privileged status of academic medicine in our society.

Third, given that research strongly suggests we do not always recognize our own bias, we—as institutions and as professionals—must question ourselves whenever we encounter new situations. Not only must we accept that our decisions and actions may be subject to rigorous internal and external scrutiny, we also must ensure we are capable of withstanding it. COI policies may vary across institutions, but our standards must remain consistently high and credible to even the most skeptical.

The challenges of implementing new policies, maintaining vigilance, and engaging in continuous self-reflection are formidable. However, the stakes have never been higher and, as Jordan himself would say, nothing less than the integrity of medical professionalism is at stake.

Darrell G. Kirch, M.D., AAMC President and CEO

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