Today the Senate Special Committee on Aging (chaired by Herb Kohl, D-WI) held hearings on conflict of interest in medical education and research. Several speakers provided testimony, and if I have spare time in the coming days I will review their statements and maybe find some time for a separate entry on them. But one witness caught my eye, and his statement I read, and that is the subject of today's entry.
Thomas Stossel is a senior physician (Hematology) at the Brigham and Women's Hospital and a professor at Harvard Medical School. As I wrote last week, Stossel was the prime mover & shaker in arranging a conference for a group dedicated to the proposition that industry collaboration with physicians has been much more beneficial than harmful to patients over the past several decades. The goal of the group (Association of Clinical Researchers and Educators, or ACRE) is to organize a pushback against what they see as a movement comprised of anti-industry "zealots" who are out to "infect...medical school ethics instruction with guilt." (NB: this is more a paraphrase than an exact quote, although every word in quotations comes directly from his testimony.)
I noted after perusing their website that they were long on hot rhetoric but short on facts, and after reading Dr. Stossel's statement to the Senate Special Committee I remain not terribly impressed. His thinking seems to rely on a characterization of industry-funded CME critics as Luddites, who have a reflexive hatred of the profit motive: the "oft-repeated mantra that 'companies have a fiduciary responsibility to shareholders whereas physicians' fiduciary responsibility is to patients'...[is an] opaque platitude imply[ing] that business has no social responsibility and that physicians only behave in a venal manner when contaminated by business." In other words, Stossel believes his opponents think that industry (or profit, or both) is always equivalent to evil, and that physicians must remain pure from the evil profit motive.
Of course, that notion itself is so facile it can only induce a sigh. The issue, at least from my perspective, has always been one of bias. Physicians are a bit like little siblings of scientists in that scientists try to discover "truth" and in doing so are constantly vigilant against anything that could bias their view, while physicians have more practical concerns (their ultimate goal is generally to heal patients) but still are, and should be, deeply preoccupied with bias. Well, if lucrative financial deals don't constitute a profound source of bias, then pray tell what does?! It's not about the good or evil that comes of the profit motive, and indeed, the absolutely abominable behavior of some of the drug companies has given a bad name to the many good corporate citizens who do churn out useful products and deserve to profit from them. But to pretend that such bad behavior doesn't exist is to stick one's head in the sand. Moreover, regardless of the extent of bad behavior that has gone on in the past several years (of which there are an ample number of examples), ignoring the potential bias that can result in a physician's mind from financial perks doesn't merely ignore common sense, it ignores a great deal of psychology research that would suggest otherwise.
One can get a yuk or two in (should one be inclined to get yuks out of reading congressional testimony) by glancing at the beginning of Dr. Stossel's statement, in which he alleges that even the use of the phrase "conflict of interest" is a ploy (his exact word! see shortly) designed by that coterie of critics who wish to create an uneven playing field in the public relations war designed to win the hearts and minds of the public, and that nobody has any business even bringing the phrase to the discussion. I'm not kidding. Here is the paragraph (which, as a former English teacher, induces a cringe in me for being the polar opposite of lucid, with all of its subordinate clauses piled on top of one another, but you be the judge):
"'Conflict of interest' is only a meaningful term in terms of regulatory implications in the context of self-dealing by persons in positions of political or judicial power--and physicians and researchers do not even come close to having such influence. Therefore, the intent of the phrase in the context of medicine is a ploy, used since the beginning of recorded history, of adversaries to invoke allegedly evil motives of an opponent--such as greed--as a weapon in an argument they cannot win on substance."
Got that? Only someone in a position of political or judicial power can have a conflict of interest. Alas, this very, very narrow reading of the term is not what most people think when they utter the phrase "conflict of interest." Take this very simple, workman-like definition from Webster's New World College Dictionary: "a conflict between one's obligation to the public good and one's self-interest." That's how lots of people would define it, although even "public good" seems a touch narrow, since teachers or lawyers or the clergy have obligations to students, clients, and parishioners respectively rather than the public good. You can see how this contention that "conflict of interest" is a manufactured phrase doesn't hold up under even cursory scrutiny.
More damning to Stossel's contention, however, is the definition provided by the National Institutes of Health. That is, this is the principal body in the US that defines the ethical behavior of medical research: "a conflict of interest occurs when individuals involved with the conduct, reporting, oversight, or review of research also have financial or other interests, from which they can benefit, depending on the results of the research." Their definition doesn't even trouble itself with the characters that Stossel wants to reserve for exclusive use--judges and politicians.
Ignoring such obvious interpretations of the term might be viewed as, you know, maybe, um, a weapon in an argument one cannot win on substance.
(If the former English teacher can also get in a teaching point here, it is this: please read out loud your statement to a Senate committee before you go to Washington! The phrase the intent of the phrase in the context of medicine is a ploy really should have been written the phrase is a ploy--an "intent" can't be a ploy. Eliminate useless words, class! If there is evidence in this blog entry to the contrary, keep in mind that this blog is pretty much a first-version essay each time out with no time for revisions, and I'm not testifying before Congress.)
It's quite tedious to have to respond to the more fanciful accusations riddling Dr. Stossel's remarks: that nobody wants industry to fail, that physicians can have collegial relations (or even productive collaborations) with medical industry corporate employees, that...oh, you get the picture. The point that has to be made, again and again apparently, is that physicians can be biased by pharmaceutical companies, and that pharmaceutical companies have a responsibility to make money while physicians have a responsibility to treat patients. It's good that there's a profit incentive for corporations. It's bad when physicians are given financial incentives to try to influence the prescription patterns of their colleagues--precisely because those financial incentives allow bias not merely to creep in, but rather knock down the door, barge in, put up its feet on the coffee table, pop open a beer (or, since were talking about physicians, uncork a nice bottle of cabernet) and watch TV. That's bad for patients.
Dr. Stossel also implies that critics of my ilk are clamoring for governmental oversight into every nook and cranny of the industry-physician relationship. For my part I would prefer that government not have to legislate on such matters. Honestly. But here's the rub: I would likewise prefer that my professional brethren and sistren regard the baubles offered by the pharmaceutical industry with contempt, for after all, if the drugs the company makes are good, they will surely flourish under a peer-reviewed system in which no conflict of interest exists, right? I would hope that this would be the prevailing attitude among medical students, for instance. But--good God!--it's not even the majority position among the faculty! And if we can't get the house in order, and further and further evidence of abuses mounts, leading any sane person to conclude that there's a systemic problem out there, well...that's when you get Congress to take note. And as we have found in so many recent episodes in our country, it's not necessarily a good thing when Congress gets involved. But if it does, the fault will lie at the doorstep of the physicians who have abused the goodwill of their patients, as well as their apologists like Dr. Thomas Stossel.
Dr. Stossel's statement can be found here. It takes some time to get through but for those interested in the CME issue it's worth the time investment. In the coming days I hope to have more to offer on some of the other witnesses (or even some of the Senators!).
Hat-tip to the Carlat Blog for the link as well as his attendance. I wanted to make it to the conference as it's down the road from my house, but pressing research issues (including a meeting with the boss) took precedence.