Conflicts of interest among department chairs in academic medical centers

Via Health Care Renewal, I've learned of a study that, certain people may be surprised to learn, troubles me. Published yesterday in JAMA, it is, as far as I know, the most comprehensive quantification of one type of tie between industry and academia, specifically how many department chairs have ties to industry and what kind. Here's the abstract:

Institutional Academic-Industry Relationships

Eric G. Campbell, PhD; Joel S. Weissman, PhD; Susan Ehringhaus, JD; Sowmya R. Rao, PhD; Beverly Moy, MD; Sandra Feibelmann, MPH; Susan Dorr Goold, MD, MHSA, MA

JAMA. 2007;298:1779-1786.

Context Institutional academic-industry relationships have the potential of creating institutional conflicts of interest. To date there are no empirical data to support the establishment and evaluation of institutional policies and practices related to managing these relationships.

Objective To conduct a national survey of department chairs about the nature, extent, and consequences of institutional-academic industry relationships for medical schools and teaching hospitals.

Design, Setting, and Participants National survey of department chairs in the 125 accredited allopathic medical schools and the 15 largest independent teaching hospitals in the United States, administered between February 2006 and October 2006.

Main Outcome Measure Types of relationships with industry.

Results A total of 459 of 688 eligible department chairs completed the survey, yielding an overall response rate of 67%. Almost two-thirds (60%) of department chairs had some form of personal relationship with industry, including serving as a consultant (27%), a member of a scientific advisory board (27%), a paid speaker (14%), an officer (7%), a founder (9%), or a member of the board of directors (11%). Two-thirds (67%) of departments as administrative units had relationships with industry. Clinical departments were more likely than nonclinical departments to receive research equipment (17% vs 10%, P = .04), unrestricted funds (19% vs 3%, P < .001), residency or fellowship training support (37% vs 2%, P < .001), and continuing medial education support (65% vs 3%, P < .001). However, nonclinical departments were more likely to receive funding from intellectual property licensing (27% vs 16%, P = .01). More than two-thirds of chairs perceived that having a relationship with industry had no effect on their professional activities, 72% viewed a chair's engaging in more than 1 industry-related activity (substantial role in a start-up company, consulting, or serving on a company's board) as having a negative impact on a department's ability to conduct independent unbiased research.

Conclusion Overall, institutional academic-industry relationships are highly prevalent and underscore the need for their active disclosure and management.

Roy Poses summarizes the findings in a nice tabular form; so I don't feel the need to go into the nitty-gritty, other than that 15 of the hospitals were those that received the most NIH funding in 2004, and the population seemed custom-designed to capture departments likely to have the most funding from industry:

At each institution, we sampled 4 clinical department chairs (medicine, psychiatry, and 2 randomly selected clinical department chairs). We focused our study at the department level because departments are key actors in academic centers, and in pretesting, we found that department chairs reported high levels of confidence in their ability to accurately answer questions about IAIRs. We purposefully sampled chairs of medicine and psychiatry because these departments are often large and are likely to have funding from industry to support their educational activities. Also, at each institution we selected the chair of the department of microbiology and a randomly selected nonclinical chair. We purposefully selected all chairs of departments of microbiology because these are often among the largest nonclinical departments in medical schools.

The design of the study leads me to tend to disagree with Dr. Poses when he concludes that the estimate in this study represent a lower bound of industry involvement. Even so, its results reveal that such connections are more pervasive than even I had thought. Maybe it's because I'm more or less a peon in the scale of things. Yes, I have private foundation and NIH grant funding, but other than a small payment for licensing the rights to a patent that I received over 12 years ago, I've never received any grants or financial support from a pharmaceutical or biotech company.

It is not surprising that there should be such extensive contacts between academia and industry, given that partnerships between universities and industry have been not only tolerated but encouraged over the last decade or two. Moreover, declining public funding from the NIH makes it increasingly difficult for investigators to resist the siren call of funding from big pharma. The problem with such funding is that it's a two-edged sword. On the one hand, partnerships between industry and academia can benefit patients when they are related to research into specific treatments for diseases and conditions, leading to the development of better drugs or medical devices. As Dr. David Korn, senior vice president, division of biomedical and health sciences research at the Association of American Medical Colleges in Washington, D.C., put it:

"Supported research is fulfilling a social mandate...After all, the public support of NIH [U.S. National Institutes of Health] funding is really driven by the desire to see practical results . . . and the only way those practical results can come to pass is by having productive relationships between the discoverers of new information and the organizations that our country has established to determine whether that information can be developed into useful products for public health."

The problem, of course, is at some point all this largesse risks producing undue influence or jeopardizes the ability of academic departments to provide unbiased education to their trainees. What this point is is arguable, but what is fairly clear is that few department chairs appreciate how much influence such gifts can potentially have. As the authors state:

Our results suggest that department chairs consider both the size of a gift and whether it is restricted when judging the possible detrimental influence on independent education and training. Almost 20% of chairs deemed a restricted grant from industry of less than $10 000 detrimental to a department's ability to offer independent unbiased medical education and training, while 42% responded this way for restricted grants between $10 000 and $100 000. When asked about unrestricted gifts, however, only 6% considered a gift of less than $10 000 detrimental and 21% considered an unrestricted gift between $10 000 and $100 000 detrimental.

These findings illustrate the common misconceptions that small gifts are less influential than larger gifts and that unrestricted gifts are less influential than restricted gifts. However, research in human behavior has shown that even small gifts and ones without restrictions can influence actions without being tied to explicit demands.19 The belief that the benefits of unrestricted and/or small gifts tend to outweigh the detriments may unintentionally make medical school leaders less vigilant about ensuring independent unbiased curricula and research. For instance, one of the most frequent forms of IAIRs involved clinical departments receiving discretionary funds to purchase food and beverages.

The problems this study raises are at least two-fold. First, how much funding and what kinds from industry are likely to result in bias or undue influence? This is not as easy a question as it sounds on the surface. Completely banning such relationships is problematic, given how dependent the system has become on collaborations between industry and academia, but such a high level of entanglement is even more problematic, particularly if there is no transparency. Certainly eliminating research funding from such companies would likely do more harm than good, although, again, transparency, all too frequently missing from such funding, is imperative. I'm not sure I would go as far as Dr. Poses in advocating a complete ban of personal financial relationships between faculty and pharmaceutical, biotech, or medical device companies. However, sharply limiting such relationships to a fraction of faculty salary and banning faculty from simultaneously being faculty and serving as an officer, executive, or member of the the board of directors of for-profit corporations, coupled with a mandate for transparency, would go a long way towards limiting the potential for interference with practicing and teaching evidence-based medicine.