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April 10, 2014

JAMA Opinion Article Looks for Bias in Academic Health Systems and Board Membership

The Journal of the American Medical Association (JAMA) recently published an opinion piece entitled "Conflict of Interest Policies for Academic Health Systems Leaders Who Work with Outside Corporations." As we have come to expect from JAMA, the article was packed with generalizations, but low on real facts and relevant data to support their claims.

JAMA has been active in the past few months, recently taking aim at continuing medical education (CME). There, the authors so desperately rummaged for "conflicts of interests" that they failed to differentiate between promotion companies and accredited medical education companies. The article ignored the firewalls, standards, and oversight that have been in place for several years to prevent the alleged bias the authors claimed.

Apparently JAMA has moved on. The new article focuses on academic health system leaders – presidents, vice presidents, deans, CEOs – who work for outside corporate entities. The authors argue that these higher-ups who are involved in financial and business decisions have fiduciary responsibilities that "preclude a paid relationship with an outside entity…unless a case can be made that there is a compelling institutional interest in the leader's service in such a role, or if the role with the outside organization is outside the scope of the leader's role at the academic health system."

JAMA provides an interestingly specific illustration of such a carve-out from their calls for an end of all corporate relationships. The article notes, that an "example of a compelling institutional interest" would be "the leader's role as a founder of an academic health system start-up company based on his or her intellectual property."

The lead author, Etta D. Pisano, Vice President for Medical Affairs Dean, College of Medicine; Professor of Radiology, Medical College of South Carolina, ironically fits neatly into her exception:

"Recently Dr. Pisano co-founded her own company, NextRay, Inc., which will commercialize a device she and the other cofounders invented, a technology which creates medical images using x-rays through diffraction enhanced imaging which provides superior image quality at a dose that is substantially lower than is currently available" (available here).

While her efforts in the medical device arena are laudable, it begs the question: who does Dr. Pisano expect to buy her company, and how is this not a commercial interest? She speaks to the "very difficult" issue of conflict of interest in the article, but enjoys one with her own company.

This is not the first time that JAMA has been engaging in the very behavior it spends an article decrying. In the JAMA CME piece, JAMA criticized medical education companies' policy of sharing data, when JAMA's own policy includes sharing data with undisclosed third parties.

It is tough to take an article too seriously when the authors are actively doing the opposite of what they are writing. In the most innocuous case it suggests that JAMA does not have a full grasp on the material it offers. The fact that the article includes the specific carve-out, however, would tend to imply that the authors knew the deal.


The article looked at the 50 largest pharmaceutical companies and compiled data on the prevalence of AMC leaders on the companies’ boards of directors. The study found that 19 of the 47 companies with public data on governance had at least one board member who concurrently held a leadership position at an AMC, including “16 of 17 (94%) US companies.” In total, “[f]orty-one board members had AMC leadership positions in 2012, receiving a mean financial compensation for board membership of $312,564 (excluding the 6 industry executives).” 

Jama pics

Putting aside the issues of credibility, the main issue with the opinion piece is that it raises questions, but does not attempt to answer them. The article states: "Having a fiduciary responsibility to 2 separate entities is at best a very difficult situation. Will the leader direct business inappropriately to the outside company on whose board he or she sits? Will the leader inappropriately use information about the institution he or she leads to influence decisions by the outside corporation?"

Questions about someone's personal conflict of interest are easy to raise, but the article provides no real-world context. Furthermore, the authors fail to include any evidence of academic institutions ever being harmed by an executive's roles with corporate entities.

We argue that there are actually many benefits to such a relationship with outside entities:

  • The current landscape for academic medical centers is bleak. Many academic centers cannot compete in efficiency with local for-profit medical centers. An academic leader who understands the private sector could provide industry practice to an otherwise inexperienced entity.
  • Relationships could help academic centers recruit and retain faculty members by providing them with the opportunity to engage in outside interests, enabling them to identify new research scholarship topics and apply their theories.
  • Relationships can increase the potential outside financial support for the institution—either directly or indirectly—through joint ventures and the activities and networking of faculty members in the larger community, including the business community.
  • Often companies are crucial to translate academic research into actual medication that can benefit patients.


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