Disclosure of potential conflicts of interest (COI) from relationships with the pharmaceutical and device industries is recommended in publishing, research, and education of residents, faculty, and students. Such disclosures in continuing medical education (CME) are required and are also mandated for federally funded research through the National Institutes of Health (NIH).
Consequently, the authors of a recent study suggested that, “Disclosure in education may foster critical evaluation of information and assessment for potential bias,” however, they noted that the effect of such disclosure is “unclear.” To determine the effects of such disclosures, the authors conducted a survey of medical students at a medical school that recently adopted a new COI disclosure policy. The study, which was published in the Journal of the American Medical Association (JAMA), was supported by an institutional grant from the Josiah Macy Jr. Foundation
Among other important findings, the authors discovered that “Few [medical] students believed that educational content or quality were influenced by educator relationships with industry.” The study evaluated a 2010 policy at the Mount Sinai School of Medicine, which mandated conflict of interest (COI) disclosure by lecturers to preclinical students. In addition, the majority of students (73% to 74%) thought disclosure would lessen the likelihood of presenting biased material, showing support for the argument that transparency can be enough to fight perceived or potential bias despite calls from critics who want complete bans on such relationships.
Nevertheless, when presented with pharmaceutical disclosure information by faculty members prior to lectures, students were more likely to support limiting industry contacts with students, residents, and educators than before disclosure policies were in effect. “Our findings suggest that a conflict of interest disclosure policy to students is feasible and may influence student attitudes toward industry prescribing but not education,” the authors concluded.
Students saw financial relationships with industry as an influence, with about 70% agreeing that lecturers were more likely to recommend companies' products during class if they had such relationships, and a little over half agreeing that their educators should limit such relationships, reported medpage Today.
However, about three-quarters saw their lecture content as evidence-based and unbiased regardless of what conflicts of interest their lecturers might have. Just under 60% thought the quality of their own education wasn't influenced by any industry relationships their teachers had.
The authors suggested that this was the first study “to evaluate the association between COI disclosure and preclinical medical students' attitudes.” Interestingly, they noted that students “were more aware of the potential influence of industry relationships than students in past studies.” Such an observation is problematic, however, because it suggests that the pool of participants may have been tainted or slanted against industry relationships or collaboration prior to the survey, and thus the results may be unreliable or unrepresentative.
In September 2010, Mount Sinai School of Medicine began mandating COI disclosure by lecturers to preclinical medical students. Using the natural experiment created by this new policy, the authors studied the association between routine COI disclosure with preclinical medical students and students’ attitudes toward disclosure and industry interactions. Policy implementation included a brief presentation to students introducing the disclosure policy, routine COI disclosure by faculty during lectures, and continuous student online access to faculty disclosures.
The authors verified faculty posting of online disclosures but not disclosure during lectures. Among 188 lecturers to preclinical students, 146 (78.9%) posted disclosures; 130 (89.0%) reported no potential COI.
The authors then adapted a published survey to assess student attitudes toward COI disclosure and the appropriateness of industry gifts to physicians, industry-sponsored education, and industry-faculty relationships with responses on a 4-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree). All year 1 and year 2 students were eligible to participate. Students were surveyed during class meetings at the beginning and end of the 2010-2011 academic year, comparing attitudes (combined agree and strongly agree responses) before and after policy implementation
Nearly all students (>97.0%) favored disclosure in both surveys . Attitudes toward academic-industry relationships changed after policy implementation. After the policy went into effect, more students thought schools should limit industry meetings with:
- Students (72% versus 57%, P=0.004)
- Residents and house staff (53% versus 39%, P=0.01)
- Educators (57% versus 40%, P=0.002)
Students were less likely to think that industry should be involved in funding medical school programs (62% before versus 44% after, P=0.002). There was also a trend for more students to think that receiving gifts or food from industry has an influence on physician prescribing (70% before versus 79% after, P=0.052).
Attitudes did not change regarding the influence of COI on educators or educational content. Few students believed that educational content or quality were influenced by educator relationships with industry.
Independent of the policy, many favored disclosure by educators and limiting industry interactions, and believed that industry interactions influence prescribing. Routine COI disclosure was associated with an increase in student desire for limitations in some industry relationships, but not with perceptions of disclosure, the effect of industry relationships on educational content, or instruction by faculty with relevant COI.
“The lack of association may be related to students’ relationships to professors or the rarity of faculty conflict of interest,” the authors wrote. “The introduction of the policy, rather than disclosure itself, may have influenced the students’ attitudes.” The authors also recognized several limitations to the study, including the single-site, predisclosure and postdisclosure design, and potential social desirability bias.
Ultimately, the value and results of this survey are unremarkable and mostly counterintuitive. The study was conducted at a medical school that recently adopted a COI disclosure policy and practically indoctrinated its youngest students with the policy, so it is no surprise that many of them favored such a system—they don’t know any better. Moreover, the fact that 80% of the professors had no COI disclosures raises two important points.
First, this is clearly not a medical school that values collaboration with industry; or at the very least, does not encourage such relationships among its faculty; so again, the survey results are unsurprising.
Second, the faculty and professional staff of the medical school are the ones who adopted and crafted the COI policy and had the motivation to do so. Therefore, the culture and surroundings at the school make it highly unlikely that students would be non-conforming and support industry-relationships when their superiors and even older students would not dare break rank with persons who control their future livelihood—whether it be grades in medical school, recommendations, residencies, internships, or research positions.
Ultimately, conducting future research on this area, while interesting, is likely unnecessary. All medical students should be educated about their institution’s COI disclosure policy, and medical faculty should educate their students about relationships with industry—including their own. There has been recent discussion about the need to include in the medical school curriculum ethics courses that highlight the nature of COI’s and the history and background of physician-industry collaboration.
Before we continue to bias the next generation of medical students that industry is “evil” and relationships with industry create potential COI’s, there needs to be an appropriate dialogue with medical schools and stakeholders from all sides to ensure that students are getting objective and balanced information about relationships with industry. As we have previously written, relationships and collaboration with industry have changed the lives of hundreds of millions of patients.
With healthcare reform speeding ahead, America is asking our doctors to do more with their time, spending less money, and increasing efficiency. The advances of drugs, medical devices, and new treatment and care plans may help achieve that goal, however, cutting medical students off from the industries that create such products, or instilling in medical students the notion that such industries are problematic will make realizing those goals more difficult.