A drug company sales representative stands in front of a class of University of Toronto medical students and delivers her well-rehearsed sales pitch about the benefits of her company’s birth control pill.

Hold on: Isn’t this sort of interaction between the pharmaceutical industry and med students supposed to be forbidden because of concerns about conflicts of interest (COI)?

Well, yes. But on this day the presentation — usually made directly to practising physicians in their offices — is part of an education session on ethics and professionalism.

Professors have given the students “assessment sheets” to help them identify the marketing strategies that have been employed, and the sales rep even agrees to engage in dialogue about how the sales pitch was constructed.

“It’s the only time I’ve had direct contact with a drug company representative,” says third year U of T med student Jesse Kancir, who was part of the class.

Kancir, who is president elect of the Canadian Federation of Medical Students, says that in his view it’s important to prepare medical students for the reality of industry sales pitches, not to “just protect them.”

Industry sales pitches, gifts influence physician behaviour

After all, it’s well established that sales pitches and gifts from industry do influence physician prescribing and professional behaviour.

How much (if any) interaction should medical students have with the pharmaceutical and medical device industries? What kind of COI problems can arise and what policies should be in place?

A study published last month in the Journal of Medical Ethics (“Questionable content of an industry-supported medical school lecture series: A case study”) described the involvement of pharmaceutical companies, and of a physician member of Purdue Pharma’s speaker’s bureau, at a U of T pain management course, where a textbook on pain management, copyrighted by Purdue and edited by the speaker was distributed free to students.

The talk by the Purdue-sponsored physician promoted the use of that firm’s painkiller OxyContin which, along with some other prescription painkillers, has been associated with tens of thousands of overdose deaths in Canada and the United States.

U of T has since developed a policy that would disallow such pharmaceutical company involvement, “but there’s no reason to be complacent,” says Nav Persaud who, as a medical resident, raised concern about the drug company involvement and authored the study.

“Many people just don’t want to discuss this situation”

“If I thought the situation was unique to U of T, I would not have written the case study,” he says. “Universities are supposed to be places where you can discuss controversial issues, but many people just didn’t want to discuss this situation,” he says.

But publication of the case study appears to have given “legitimacy” to concerns about industry involvement in education, and is empowering others to raise controversial issues, he says.

A “culture shift” is taking place in medicine and, as COI policies are established, “there’s a perceived sense of loss” among some physician faculty members, says Dr. Genevieve Moineau, president of the Association of Faculties of Medicine of Canada (AFMC).

“But you have to carry on even if there are resisters because this is the right way to move forward.”

The AFMC endorsed the principles articulated in the 2008 document, Industry Funding of Medical Education, from the Association of American Medical Colleges.

The AFMC subsequently began bringing together medical school representatives to share information about developing COI policies, says Jocelyn Lockyer, senior associate dean of education with the University of Calgary’s faculty of medicine.

Two face-to-face meetings have been held, and medical faculty representatives have been informally sharing ideas about to craft policies for their faculties, she says.

COI policy can take years to develop

Lockyer says it has taken four to five years to get a COI policy in place at her university, and the university is now working on developing a disclosure form for faculty members to disclose any potential conflicts of interest.

This task is not without controversy as “some people feel their rights are being violated” when they are required to disclose their potential conflicts, she says.

Just last week, a study published in PLOS examined Canadian medical school conflict of interest policies as they existed as of September 2011 and concluded they are “too few and too weak.”

Of the country’s 17 medical schools, some had their own COI policies, while many operated under university-wide COI policies. Using a scorecard based in part on the American Medical Students Association “pharmfree” campaign and scorecard, but modified with other criteria, 12 of the 17 Canadian medical schools scored below 50% of the maximum possible score.

Study found most schools don’t cover COI in curricula

Persaud notes in his article that the pharmfree scorecard criteria used in the United States would not disallow industry sponsorship of medical school speakers who receive funding from the same companies.

Importantly, the Canadian study found that 70% of the medical schools failed to cover issues of conflict of interest or drug promotion in their curricula.

Yet the Canadian Federation of Medical Students, in the 2011 document from its industry funding working group, stresses the importance of education about potential conflicts of interest with industry “early on in training.”  It also recommends that medical students and their societies not accept gifts or funding for events from the pharmaceutical industry. This issue has also been taken up by practising physicians (click here) and the investigative news organization pro publica tracks industry funding to physicians (click here).

COI education “woefully lacking in Canada”

“Education about COI is woefully lacking in Canada,” says Bryn Williams-Jones, director of the University of Montreal’s bioethics programs who also writes a blog on COI at universities. He stresses the critical importance of education about conflicts of interest — how to identify them, which ones are problematic, how they might be able to be managed etc.

“What is important is a dialogue, not a declaration…people need tools to think through the issues and think about the harms.”  Williams-Jones has been working on the U of M’s website on COI, which he says will soon carry videos and training resources.

Allan Detsky, a University of Toronto professor, physician, economist and health policy expert, takes a different position.

He says he used to think that full disclosure was the answer to COI concerns, but subsequent research convinced him that disclosure is not the answer. Instead, “if you want people to be completely conflict free you have to raise a new cohort of medical educators and researchers with no relationship with people who have a financial stake in the outcomes of research.” (Further, he argues that medical societies should “divest themselves of relationships to pharma, to which they have become addicted.”)

For her part, Lockyer says that eliminating collaboration with industry is not realistic or desirable. “We need the partnerships in order to advance science. We just need to balance the (potential) conflicts.”

She also says while the university recognizes there are other potential conflicts of interest — with government and voluntary agencies — the initial effort has been to “get the language right around industry.”

Twenty years ago, Gord Guyatt took a lot of heat from the pharmaceutical industry and some colleagues when, as head of the residency program at McMaster University medical school, he acted to eliminate marketing contact between residents and the pharmaceutical industry.

“Now there is a lot more attention to the issue. Things have changed. Industry is not as extravagantly giving perks, but lots of gift giving does continue,” says Guyatt, who is now examining COI issue with respect to clinical guidelines.

Calls  for a national COI policy for Canadian medical schools

While the AFMC is encouraging medical schools to develop their own policies, Joel Lexchin, who co-authored the recent PLOS article, and Persaud argue there should also be a model national COI policy. Physicians with more than one affiliation find themselves subject to a variety of differing policies, Persaud notes.

For their part, Moineau and Lockyer say that national accreditation policies for medical faculties may, in the future, align COI policies across the different faculties.

For practising physicians, the Canadian Medical Association has established guidelines for interaction with industry.