We must address conflicts of interest to protect our integrity

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  • Linda Wilhelm says:

    The issue is not as black and white as the authors of this article believe. The physicians with declared conflicts are also the ones who are the most knowledgeable about the conditions the drug is being reviewed for. I would think that the health outcomes of their patients would come before any financial incentives from the pharmaceutical industry. I guess I have more faith in my doctors than the writers of this article!

    • Samir Grover says:

      Thanks for your comment.

      Whether payments to physicians influence clinical decision making is not black and white. Physicians have an essential role in driving innovation in pharma and devices, and part-and-parcel of these relationships will be a financial payment to physicians.

      The National Academy of Medicine provides a very reasonable framework to balance FCOIs among clinical practice guidelines, where expertise is required, but where undue influence may potentially affect content. Notable in these guidelines are that (1) the chair be free of conflict; and that (2) <50% of the membership be conflicted. This we believe is the current benchmark standard that should be used by specialty societies to mitigate potential risk, applied a priori when designing CPG committees.

      Whether clinical decisions of physicians are affected by payments is also uncertain. However, as we mention, there are many examples of associations where payments to physicians associate with certain drug choices over others when both are indicated. As an example, in the study by DeJong and colleagues that we reference in the article, even small payments such as those of meals are associated with a change in practice to use of branded over non-branded medications, indicated for the same purposes. While causation is hard to ascertain, it is hard to imagine <$20 payments being reflective of payments made because of expertise.

      Finally, you are correct that it is quite possible that patient outcomes are improved by decisions made by conflicted physicians – but this has yet to be investigated. Transparency in identifying these payments in Canada will allow this to be evaluated.

  • Joel Lexchin says:

    Thanks for the article and for advancing the discussion on this topic. In some cases I think that you downplay the significance of conflict of interest. In the study that I did on Health Canada committees and panels, six of the 11 had a majority of members who declared a direct or indirect financial interest. Whether these financial interests led to biased voting is not known since the summaries of the meetings that Health Canada publishes don’t give individual voting patterns. It’s true that we don’t know how COI affects voting patterns on clinical guideline committees but the guideline from the American Psychiatric Association on the outpatient treatment of major depression shows a very strong association between COI and flaws in the guideline. All the panel members had conflicts with an average of 22 conflicts per person. In the guideline only 44% of the cited studies supporting the recommendations met criteria for high quality, 34% of cited studies did not study outpatients with major depressive disorder, 17% of cited studies did not measure clinically relevant results
    and 20% of references were not congruent with recommendations.

  • Sandra Tychsen says:

    Excellent start on a complex issue.


Rishi Bansal


Rishi Bansal is a medical student at McMaster University, co-founder of the storytelling initiative Faces of COVID, and a deputy editor at Healthy Debate. He is interested in health systems leadership, advocacy, and innovation.

Rishad Khan is a medical student at the Schulich School of Medicine and Dentistry.

Michael Scaffidi


Michael Scaffidi is a medical student at Queen’s University and a research student at the Grover Lab at St. Michael’s Hospital.

Nikko Gimpaya


Nikko Gimpaya is a Master of Education student at the University of Toronto and a research assistant at the Grover Lab at St. Michael’s Hospital.

Samir C. Grover


Samir C. Grover is an associate professor in the Department of Medicine at the University of Toronto, and is a gastroenterologist at St. Michael’s Hospital.

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