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Conflict of interest in medicine: how medical students can become catalysts for change

I was a fifth year medical student when I attended an elective seminar at my university in Italy about “Conflict of interest in the medical profession.” The speaker described several examples of the strategies the pharmaceutical industry uses to influence policies, research, and professional practice. It was just a two hour event, but for me it was a turning point. During my clinical rotations in the following days, I started to notice the presence of pharmaceutical companies in the everyday life of health professionals—from the contact with sales representatives, to the sponsored education materials, to the pens, notebooks, and other gifts that find their way into the doctors’ office. Until that moment, these practices were completely normal to me. During my medical training no one had ever told me to question them, or told me about the effect of industry influence on healthcare. 

I therefore decided to work with other medical students to raise awareness of these issues within our universities. While organising advocacy activities around conflict of interest in Italy, we soon realised that we were not alone. Several medical students’ associations around the world showed us how grass-roots movements can become catalysts for policy change, and gave us hope that we could make a difference. 

In 2002 the American Medical Student Association (AMSA) launched the “PharmFree Campaign” (now called Just Medicine Campaign) to advocate for a conflict-free medical education environment. As part of the campaign, AMSA developed a “Model PharmFree Curriculum” which aims to provide students with the skills necessary to understand and properly manage physician and industry relationships. [1] Since 2007, AMSA has been producing a scorecard that rates medical schools on their conflicts of interest policies using 14 policy domains such as prohibiting gifts and meals from industry, and the presence of a formal curriculum on conflict of interest. [2] The scorecard has generated extensive media attention and has successfully prompted other universities in the United States to develop conflict of interest policies. [3] This is important because the introduction of restrictive conflict of interest policies, and educational interventions about pharmaceutical promotion have been associated with changes in prescribing behaviours and attitudes towards industry marketing practices. [4,5] The AMSA scorecard has also resulted in similar analyses of institutional conflict of interest policies in other countries such as Australia, Canada, France, and Germany. [6-9]  

As well as assessing their universities’ conflict of interest statements, some students’ associations have been at the forefront of developing policies governing corporate sponsorship for their own organisations. For example, the Italian Secretariat of Medical Students and the Australian Medical Students’ Association have committed to not accepting sponsorship from or entering into partnership arrangements with pharmaceutical companies. [10,11] When I attended workshops organised by both the associations, I had the opportunity to witness that it is possible to do things differently and to organise educational events without depending on pharmaceutical industry sponsorship. For example, holding such events inside the local hospitals or academic institutions and moving away from venues such as hotels or restaurants, limited expenses for venue hire, meals and entertainment. Could this also become a model for professional medical associations that often rely on industry funding for their conferences? [12] 

Another positive example comes from the International Federation of Medical Students’ Associations—a network of 133 students’ associations from 123 countries.  During its annual meeting in Taiwan in August 2019, the Federation adopted a policy on “Integrity and Transparency in medical education.” [13] The document contains a strong call to action for governments to ensure transparency regarding financial relationships between industry and health professionals, for medical schools to implement conflict of interest policies and ban the presence of pharmaceutical representatives on medical campuses, and finally for national students’ organisations to refuse funding from the pharmaceutical industry and to advocate for eliminating commercial biases in medical education. The Federation represents more than one million students around the world, so the fact that this policy was adopted is indicative of a broad interest in policy reforms and improved education in this field among medical students. 

The issue of conflict of interest in the medical profession has reached a tipping point. Studies show that ties with pharmaceutical manufacturers can influence scientific research, clinical practice, and the quality of patient care. [14-16] More stringent regulations, as well as a profound cultural change in the medical profession, are needed to tackle this issue. 

Physicians’ views and attitudes towards industry tend to form quite early in their career and are shaped by the environment in which they train. [17] Implementing educational interventions and strengthening institutional policies, as several student organisations are now advocating for, could allow medical schools to take the lead in dealing with the issue of conflict of interest, influencing how future doctors interact with industry and ensuring that public trust in the medical profession is preserved. [18,19] Medical students’ activism in this area is a positive sign that this is being taken seriously and could be a driver for change.

Alice Fabbri is a public health physician. She works as a postdoc at the Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, University of Southern Denmark. Her research focuses on pharmaceutical policy and on corporate influences on health. 

Conflict of interest: None

References:

  1. American Medical Student Association. Evidence and Recommendations for a Model PharmFree Curriculum. Available from: https://www.amsa.org/wp-content/uploads/2015/03/ModelPharmFreeCurriculum.pdf (Accessed October 2019)
  2. Carlat DJ, Fagrelius T, Ramachandran R, Ross JS, Bergh S. The updated AMSA scorecard of conflict-of-interest policies: a survey of U.S. medical schools. BMC Med Educ. 2016;16(1):202.
  3. Korn D, Carlat D. Conflicts of Interest in Medical Education: Recommendations From the Pew Task Force on Medical Conflicts of Interest. JAMA. 2013;310(22):2397-8.
  4. Kao AC, Braddock C, 3rd, Clay M, et al. Effect of educational interventions and medical school policies on medical students’ attitudes toward pharmaceutical marketing practices: a multi-institutional study. Acad Med. 2011;86(11):1454-62.
  5. King M, Essick C, Bearman P, Ross JS. Medical school gift restriction policies and physician prescribing of newly marketed psychotropic medications: difference-in-differences analysis. BMJ. 2013;346:f264.
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  9. Grabitz P,  Friedmann Z, Gepp S. et al. Conflict of Interest Policies at German medical schools – A long way to go.” bioRxiv 809723; doi: https://doi.org/10.1101/809723
  10. Segretariato Italiano Studenti di Medicina. Policy Statement. Conflitto d’interessi nella pratica medica. Available at: https://nazionale.sism.org/download/
  11. Australian Medical Students’ Association. Policy Document. Pharmaceutical Sponsorship and Relationship with Industry, 2018. Available from: https://www.amsa.org.au/sites/amsa.org.au/files/Pharmaceutical%20Sponsorship%20and%20Relationship%20with%20Industry%20%282018%29.pdf (Accessed October 2019)
  12. Fabbri A, Gregoraci G, Tedesco D, et al. Conflict of interest between professional medical societies and industry: a cross-sectional study of Italian medical societies’ websites. BMJ Open. 2016;6(6):e011124.
  13. International Federation of Medical Students’ Associations Policy Proposal Integrity and transparency in medical education. August 2019. Available from: https://ifmsa.org/wp-content/uploads/2019/09/AM19-Integrity-and-transparency-in-medical-education.pdf (Accessed October 2019)
  14. Institute of Medicine Committee on Conflict of Interest in Medical Research E, Practice. The National Academies Collection: Reports funded by National Institutes of Health. In: Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US) National Academy of Sciences; 2009.
  15. Lundh A, Lexchin J, Mintzes B, Schroll JB, Bero L. Industry sponsorship and research outcome. The Cochrane database of systematic reviews. 2017;2:Mr000033.
  16. DeJong C, Aguilar T, Tseng CW, Lin GA, Boscardin WJ, Dudley RA. Pharmaceutical Industry-Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries. JAMA Internal Medicine. 2016;176(8):1114-10.
  17. Austad KE, Avorn J, Kesselheim AS. Medical students’ exposure to and attitudes about the pharmaceutical industry: a systematic review. PLoS Med. 2011;8(5):e1001037.
  18. Grabitz P. A Catalyst For Change: How Medical Students Are Pushing for Industry Regulation on Campus. 2019. Webinar available from: https://www.youtube.com/watch?v=dbvXGFR8mxg (Accessed October 2019)
  19. Brennan TA, Rothman DJ, Blank L, Blumenthal D, Chimonas SC, Cohen JJ, et al. Health Industry Practices That Create Conflicts of Interest: a Policy Proposal for Academic Medical Centers. JAMA. 2006;295(4):429-33.