Medical Societies Told To Shape Up

The latest manifesto from the Pew-funded Center on Medicine as a Profession gang (led by Dr. David J. Rothman) follows up nicely on the previous post--medical societies are being told to go forth and do like the American Psychiatric Association in eschewing industry funding, only more so.

The commentary appears in the current week's JAMA (subscription required to access), and one of the co-authors is Catherine DeAngelis, JAMA's editor-in-chief. This juxtaposition renders especially ironic JAMA's recent tantrum (http://brodyhooked.blogspot.com/2009/03/jama-editors-need-to-come-down-off.html). If I may digress for a minute, there has been to my knowledge utter and complete uniformity of opinion on JAMA's ill-advised attempt to impose gag orders on anyone who reports an undisclosed auctorial conflict of interest to them. Not a single party has yet agreed with the JAMA position. When are the editors going to admit that they have no leg to stand on and back down?

Back to present business. In keeping with their general stance on conflicts of interest in medicine, the authors argue for a policy of divesting from industry funding in most of the essential functions of professional medical associations (PMAs). The exception that they would permit is the sale of journal advertising and exhibit space at meetings. These exceptions are defended because they can be seen clearly to be advertising, and because any physician who wishes can simply avoid those pages of the journal or that part of the exhibit hall. I will list some specific proposals first (worth detailing because if previous publications from this group are any indication, this paper will be widely cited in the future) and then return to the authors' overall proposal, because I am concerned that there may be a serious discrepancy.

Specifically Rothman et al. urge:

• No direct industry sponsorship of any part of the CME program
• Strict conflict-of-interest (COI) guidelines for members of CME program committees
• No promotional gifts distributed at meetings (such items are presumably already banned by PhRMA anyway under new guidelines)
• No assistance to industry to publicize or provide for sponsored satellite symposia that accompany regular meeting (e.g., no sales of attendee list to industry)
• Strict safeguards for any acceptance of research funding by PMA from industry
• No strings of any sort attached to industry-funded fellowships, etc. awarded to physicians-in-training
• Zero tolerance for COI among members of guideline writing committees
• No product endorsements (criticism is heaped on the American Academy of Dermatology for charging high fees to endorse sunscreens)
• Same strict rules to apply to affiliated foundations attached to PMAs
• Zero tolerance for COI among officers and board

The overall objective acording to Rothman et al. should be a PMA that is completely self-supporting with zero industry funding, which they admit would require a major culture shift and at least a few years. They suggest that a suitable immediate goal is that each PMA should seek to reduce dependence on industry to less than 25% of its operating budget, "except for journal advertising revenue and exhibit hall fees".

Here I would challenge the proposal. Had the authors read HOOKED (they don't cite it) they would have been aware of the estimates I was able to provide for my own professional society, the American Academy of Family Physicians. I was fortunate to be able to provide these estimates as a result of personal aquaintanceship with an AAFP official; most societies see no reason whatever to share these figures publicly. Out of an annual budget of roughly $60M in 2002, AAFP earned $13.6M from journal ads and another $3M from all commercial support of its CME programs. Let's for now guess that half of the CME support was exhibit hall rental. That puts the total income that Rothman et al. would allow as unproblematic at about $15M or already 25% of the total operating budget. If AAFP were allowed to receive 25% of its budget from industry not counting these sums, it would have been allowed actually to increase its total level of dependence on industry funding in 2002 (to 50% from its actual level of 37.5%).

The analysis I suggested in HOOKED noted that there are two ways industry can unduly influence a PMA--through specific items of funding, and through the total level of reliance on industry funding. The latter is critical because the internal budget process of a PMA is almost completely fluid. If AAFP (to continue to pick on them) needs $60M to operate each year, it hardly matters that some of the money comes in as journal ads and some comes in as "special project" grants. If the industry were to stop buying journal ads but jack up their special project grants by the same sum, it's a wash. However, AAFP is in trouble if the total amount of its industry support falls. Then it has to ask its members for more dues--a move that hardly ever endears a PMA to its membership, and can have the consequence that membership falls off to an extent that outweighs any increase in dues revenue--or it can cut back on its operations and lay off staff (which could also cost it membership). The net result is that when an organization like AAFP depends on industry for 37.5% of its total revenue, it has a very strong incentive to keep industry very happy with its activities. And this happens to the same extent whether all, some, or none of that revenue arrives in the form of journal ads and exhibit hall rental.

If my concern is not yet clear, imagine a PMA that today gets half its operating budget from industry. Let's say that for some reason it now has no ads in its journal and no exhibit hall at its meeting. Industry currently just hands them the money as a special grant each year. The leadership reads Rothman et al. and decide they are in ethical hot water and need to reform. So they go to the industry and beg them to give them only half as much next year as an outright grant, but instead to use the remaining sum to buy ads in the new ad section of its journal, and rent exhibit space in the new exhibit hall that it just opened at its annual meeting. According to Rothman et al. that PMA is now behaving more ethically than it used to. By my analysis it has not changed its spots in any fashion.

Now this is all of no real consequence if the 25% figure is simply a way station before the real goal of $0 funding from the industry, that Rothman et al. repeat numerous times. But if what they mean by $0 is $0 except for ads and exhibit rentals, they have allowed a huge loophole that will nullify a good part of their ambitious goal.

Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA 301:1367-1372, April 1, 2009.