A counter proposal to manage financial conflicts of interest in academic psychiatry.

As stated by Giovanni Fava, the issue of financial conflicts of interest in medicine, and in psychiatry in particular, has strained the credibility of academic researchers in the eyes of the public as well as fellow physicians. Fava documents legitimate criticisms leveled against the pharmaceutical industry. He suggests that part of the solution is to establish a system to support a group of experts who are free of financial conflicts of interest and who can act as arbiters of truth and can evaluate available evidence with a dispassionate and objective eye. These groups can then produce conflict-free reviews and advise other groups (governments, hospitals, other physicians) who make financial and policy decisions about risks and benefits of psychiatric treatments. Fava's proposals have substantial merit. It would be ideal to have some system to support objective physician researchers who could provide the services outlined. And his call for training in recognizing the effects of conflicts of interest and potential bias is reasonable. But, ultimately, the solution outlined may not serve the public as well as he suggests. In some ways, the problem of conflicts of interest brings up the business of medicine and the pharmaceutical industry. Is the capitalistic system that focuses on profit good or bad for patients? Is the pharmaceutical industry focus on marketing - and the explicit or implicit cooperation of experts in marketing - the actual culprit as opposed to academicians' financial conflicts of interest? If experts are to have relationships with industry, what type of relationship between expert clinical researchers and pharmaceutical companies would serve patients best? Can drug development be improved with the input of experts or would drug development be better served by excluding those experts in order to manage financial conflicts of interest? I will make the case that a mutually beneficial relationship between experts and industry, with clear ethical rules, can help patients, and that excluding experts from this process may impede drug development. I will also argue that non-financial conflicts of interest are just as important as financial ones and these, too, need to be understood and managed. I write this commentary as one who has evolved from rejecting any industry influence on practice (I rejected the offer of a free stethoscope from Eli Lilly during medical school) to someone who has collaborated with the pharmaceutical industry whenever I felt that it would eventually benefit patients. I believe that my relationships with industry are mutually beneficial and I value my relationships with the companies that produce the medications that help my patients. I also believe that, without the capitalistic forprofit motive of the pharmaceutical industry, we would not have any innovative treatments. Few, if any, treatments have arisen from government alone or from non-industry sources. At their best, pharmaceutical companies want to make a profit by helping patients and want to help patients while making a profit so that they can afford to make new treatments and repeat the cycle. At their worst, pharmaceutical companies market medication through direct and physician advertising and continuing medical education (CME) symposia that act as hidden (or not so hidden) marketing. I worry that we have abrogated our responsibility for our ongoing post-graduate education and, instead, we have deferred to industry to fund it. This type of pseudo-education is justly criticized by Fava. I fear that there is a dearth of independently funded CME or at least CME that, if funded by industry, includes a firewall that separates it from marketing. One such CME with a firewall has been launched by the Massachusetts General Hospital Psychiatry Academy (www.mghcme.org). Within the site, interested readers can find the integrity policy and statement, view some of the content, and make a decision about the effectiveness of the firewall. Several pharmaceutical companies fund the Academy, but none have any input into content or speakers. But, relevant to this commentary, is it a conflict of interest for me to include the Academy website? While I teach for the Academy, I get no additional revenue from writing about it here. Nor will I get invited to give more talks for the Academy because it is listed here. The results of any study or any review that I publish have no bearing on my invitation to teach. Would drug development be helped by excluding some experts from participating in industry-academic relationships and, in effect, serve as industry watchdogs? I think not. Industry needs the perspective of those physicians who best know the disorders of interest. Which relationships constitute an acceptable conflict of interest and which are unacceptable? Giovanni Fava outlines a reasonable set of criteria to define sources of financial conflict of interest, but it is less clear which of these will lead academics to be unacceptably biased such that they will minimize risks and magnify benefits of drugs. A more challenging question is "What would constitute an ethically acceptable, mutually beneficial relationship between academics and industry?". I propose that such a relationship be guided by ethical behavior that ultimately helps patients and avoids any harm. I am not so sure that developing panels of independent researchers/academics that are completely free of relationships with industry will solve the problems so well outlined by Giovanni Fava. His solution may veer to the other side by assembling a group that has a negative bias against industry and innovation - without any way to disclose, manage, or check this. His proposal to have professional training programs and the recognition of conflicts of interest can, however, be practical and should be implemented. Such training in critical thinking about any evidence and the detection of any bias, no matter its source, should be an integral part of any training program. Finally, non-financial conflicts of interest can also contaminate research and produce unacceptable biases. These non-financial conflicts of interest include advancing one's career, academic promotion, achieving success, attracting non-industry funding, pride, status, power, fame, prestige, recognition, and a desire to avoid impeding the progress of research (through membership in institutional review boards) (1-3). Foster warns us that "we are expected to have a dominant commitment to serving others, rather than to personal gain" (2). Yet, he also outlines the varieties of activities that can lead physicians astray, since their most human of motivations will still respond to reward and he acknowledges that the "tension between altruism and self-interest is unavoidable". Korn further warns: "Those who propose new remedies to deal with financial conflicts of interest in academic biomedical research should take care that in their zeal to recreate an idealized state of virtue in which financial conflicts of interest no longer exist, they do not interdict a developmental pathway of immense social benefit" (3). That a group of experts free of financial conflicts of interest would be free of non-financial conflicts of interest is probably unrealistic. That academic researchers can strive to achieve the highest levels of ethical behavior in their dealings with industry and attempt to minimize bias may be equally unrealistic, but should be the goal. Perhaps the solution to the problem of conflicts of interest is somewhere in the middle between Fava's stance and the one I have outlined here: partial support of experts from impartial financial sources and peer oversight of activities which have even the appearance of bias due to conflict of interest.