Physicians and Industry - Conflicts of Interest
Conflict of interest exists in medicine when the physician's primary responsibility to the patient is influenced by secondary competing considerations such as, for example, personal gain or the obligation to control health care costs. As professionals we all ascribe to the primacy of the welfare of our patients and this is reflected in advancing the patient's interest above our own self-interest and the interest of others. The application of these fundamental professional obligations has become all the more difficult in the current context of health care restructuring and abundance of competing loyalties. Among these challenges to professionalism, are the many interactions that occur between members of the health care industry (pharmaceuticals, manufacturers of devices and equipment, etc.) and physicians whether involved in care, education, research, administration or other roles.
Royal College Policy The Royal College has adopted both the Code of Ethics of the CMA and the CMA policy statement Physicians and the Pharmaceutical Industry (Update 2001) that define a framework around which ethical sound relationships between physicians, residents, medical students, and industry can be built. These same documents provide the foundation for approving accredited group learning activities (Section 1) under the Maintenance of Certification Program of the Royal College. The College also supports the position of Le Conseil de l=éducation médicale continue du Québec as defined in its recent document Code d=éthique des intervenants en éducation médicale continue.
Historically, both industry and the profession have worked collaboratively to achieve the best health for our patients. Physicians engaged as educators, researchers, or care providers, as well as those in training, must exercise diligence when they relate to industry to ensure that any real or perceived conflicts of interest are properly managed. The best way to manage such conflicts is to either eliminate the conflict or, alternatively, acknowledge that it exists and identify strategies for minimizing the potential effects on medical decision-making. When in doubt about the significance of conflicts, one can reflect on what our patients, peers, members of the public, and the media would think about these relationships that are morally unclear.
Industry Support for Personal CME and Professional Development This is particularly relevant with reference to the financial support for physicians who attend educational events. For example, direct industry support for physicians, residents and medical students in the form of reimbursement for travel and maintenance costs to attend CME events, complimentary golf games, and other gifts are contrary to Royal College policy. The CMA policy statement speaks clearly on this issue (Section 17-24).
Section 24 of the CMA policy states: Travel and accommodation arrangements, social events and venues for industry-sponsored CME/CPD activities should be in keeping with the arrangements that would normally be made without industry sponsorship. For example, the industry sponsor should not pay for travel or lodging costs or for other personal expenses of physicians attending a CME/CPD event. Subsidies for hospitality should not be accepted outside of modest meals or social events that are held as part of a conference or meeting. However, faculty at CME/CPD events may accept reasonable honoraria and reimbursement for travel, lodging and meal expenses. Scholarships or other special funds to permit medical students, residents and fellows to attend educational events are permissible as long as the selection of recipients of these funds is made by their academic institution.
Physicians must be vigilant in discerning the difference between education and marketing. Although many of us believe that we are immune to such forms of influence, there is ample evidence that we are all influenced by the marketing initiatives of industry and such influence insinuates itself between the physician and the patient.
Professional Obligations When physicians are seen or perceived to be in conflict of interest there is an inevitable erosion of that trust which is fundamental to ensuring our professional relationship to our patients and to society. Such conflicts interfere with our obligations to consider first the patient and to act in a manner where personal gain or advantage is subsidiary.
Conflicts of interest can create bias and threaten the independence we as physicians claim to exercise when we advise patients and work with them collaboratively so that they can make the best choices for their own health.
Physicians have a professional obligation to maintain competence. There is no obligation on industry to underwrite or facilitate this responsibility. Should industry wish to support educational and research activities, the guidelines from the profession are clear about how this can be done.
Physicians, residents, and medical students are encouraged to educate and reacquaint themselves with their professional obligations by reviewing the referenced educational package attached to this document.
Suggested Reading
- Code of Ethics, Canadian Medical Association.
- Physicians and the Pharmaceutical Industry (Update 2001), CMA Policy.
- Physician-Industry Relation. Part 1: Individual Physicians. Ann Intern Med 2002; 136: 396-402.
- Physician-Industry Relations. Part 2: Organizational Issues. Ann Intern Med 2002; 136: 403-406.
- Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med 202; 136: 243-246.
- CanMEDS 2000 project, RCPSC, September 1996.
- Code d=éthique des intervenants en éducation médicale continue, CÉMCQ, 2003.
- Rx&D Code of Marketing Practice, January 2003.
