Saturday, January 25, 2014

How a fish rots

As we wait for the Board of Trustees of the University of Illinois to indicate whether they plan to investigate the various ethical issues surrounding the recent usurpation of the University of Illinois name and reputation, it is illustrative to look at other aspects of financial dealing between high-ranking University officials and private firms.  As state employees, these folks file annual disclosure forms with the Secretary of State, and the information I summarize here is taken directly from those filings.  I don't have time to go through them all, so I will focus here only on one person.

The Dean of the College of Medicine is required by the University's research processes to sign off on financial disclosure forms and manage and mitigate any potential conflicts of interest.  The Dean indicates on his own annual state forms that he is on the board of Novartis, self-styled as "one of the highest-ranked pharmaceutical and healthcare companies by sales in the world." He also receives consultant fees from Forsight Labs and Alcon Labs, a Novartis company.

Let's reflect on the Novartis code of conduct, which includes this thoughtful advice to employees and governing bodies:


Would your family and friends think it was ethical for a Novartis board member who oversees a large portfolio of research at a university, including research related to the areas in which Novartis and its competitors conduct business, to make determinations of whether researchers in that school are infringing on conflict of interest standards?  Would the answer matter if a portion of that person's own research and educational funding or consultant fees or honoraria had come from that company before becoming Dean?  Would you be comfortable reading about that relationship in the media?

Please understand that I am not suggesting that this person has done anything illegal or that he is personally immoral.  Indeed, the facts presented above are those filed by him in the state documents. But what message is sent to other doctors by this affiliation? Does it send a clear signal of high ethical standards, of the need to protect the University's excellent clinical and research programs from possible disrepute?  The salaries paid by the University are set by the Trustees to be sufficient, in and of themselves, to attract world-class people to work in leadership positions.  When deans ultimately step down from their jobs, they are viewed as extremely attractive candidates for health science company boards.  Why not just wait a few years to cash in, when there is no likelihood of sending the wrong signal throughout your faculty?

6 comments:

Gary Levin said...

I always enjoy your posts Paul. I think however you are assuming these funds from Alcon, Novartis are used by the recipients for personal gain. In my experience this is not true. The grants often go to the redipents research programs and fellowship funding for trainees.Often times with out these 'awards' a program would be uable to fund scholars.

Paul Levy said...

Thanks, Gary,

I understand that. Such funds still raise the potential for conflicts of interest, in that advancement of a professor's research and education budgets are of substantial importance to his or her professional standing and influence within an institution (and in the field as a whole.)

I would never suggest that academic medical people are solely--or even mainly--swayed by money. Power and influence (and even space!) are equally important parts of a university's currency!

Anonymous said...

You are now reaching into the heart of the problem, which of course extends beyond UI. I am quite sure that all the people whom you have contacted are justifying this behavior by using the same excuse as the former governor of VA, who was just indicted for exchanging influence for gifts: "it's legal, and every other politician is doing the same thing." It is a common human failing to rationalize away moral doubts about our personal or professional behavior, and being in a lot of company makes it even easier.
Unfortunately, the great god of Money and its sidekick, Power/Ego, has medicine in its grip now like many other formerly respected endeavors, but it is particularly distasteful when it involves saving lives. It is so pervasive that it's difficult now to even know where to draw the ethical line, when it shouldn't be. I wish it were a few bad apples in the barrel, too, but I have seen it ensnare many an otherwise ethical physician. I even found myself keeping quiet and rationalizing making 4 times what I expected to during my career.

There are really only two solutions: either the profession itself rises up and leads the charge to completely expunge unethical behavior from our ranks (instead of actually being complicit as is our current leadership) and return to our roots, or - and I fear, the greater likelihood - the public does it for us, and money is removed from the equation as doctors and hospitals, now discredited, become paid like other worthy but poor professions like teaching and police work.
Perhaps the latter is what we deserve after all, but at least it will drive out the money-mongers and the people who persist in it then will do so because they care about patients, not money.

nonlocal MD

Barry Carol said...

nonlocal,

As a retired physician, I know that you are far more knowledgeable about this than I am so I would be interested in your assessment of the following:

60-70 years ago, there was relatively little that medicine could do for us patients. In recent times, thanks to the development of many very useful new drugs, medical devices, and less invasive surgical techniques among other things, there are vastly more tools available today. Some surgeons may have invented or helped design a device for which they now receive royalty payments. Influential doctors at academic medical centers are paid to speak to other doctors about the virtue of new drugs that really have helped patients in their own practices.

As long as the doctors disclose these payments, I don’t have a big problem with it. What I do have a problem with is the lack of price transparency with confidentiality agreements prohibiting hospitals from disclosing what they pay for medical devices not only to other hospitals but even to surgeons who practice within their own hospital. I find that outrageous. At least drug prices can be determined before they are prescribed or purchased.

In the University of Illinois case, would it have been OK to include a disclaimer in the ad that said something like “The University of Illinois was paid $500,000 by ISRG for its endorsement of ISRG’s equipment and other minimally invasive surgical techniques are also available”?

Paul Levy said...

Barry,

There might be state laws here that prohibit ANY endorsement of a private company by the University, in that it is a public body.

Anonymous said...

Barry;

You raise a very difficult question for which I do not have an answer. There is no question of course that collaboration between medical experts and industry can benefit patients; the difficulty lies in where to draw that ethical line which would allow a doctor to avoid having to resist temptation in order to do his/her best for his patient. You think transparency would do it; I do not think that is sufficient. There is abundant evidence, for instance, that physician-owned imaging centers, etc. are an irresistible temptation for docs to pad their incomes, disclosure or no. As another example, an orthopedic surgeon relative of mine told the story of an orthopedist who helped develop a new total hip prosthesis with a company, and of course used it at every opportunity. Not only did he make $$ but of course he thought it was the 'best.' Shouldn't he be held to a standard of evidence? Who is to say if it was 'best' besides him? The poor patient should not be put into the position of attempting to hold his doctor accountable; he just wants to get well.

The other problem is that medical vendors - device companies, pharma, instrument vendors, all are extremely sophisticated in how they approach relatively naive hospitals and doctors. One can be drawn halfway down the slippery ethical slope before you know what has happened to you. I was very hostile to lab instrument vendors during my career, and they were expert at defusing it, offering me little tidbits to entice me along. One had to stop and make an ethical decision at every offer - is this too far? Is that too far? It is exhausting.

My view is, draw a very bright line very far up the slope at the outset. This should be done by the AMA (a joke) or by speciality societies such as with ACOG and the robotic hysterectomies. No, I don't believe in royalties or in physician-owned imaging centers or in doctors in any way being paid to promote anything. If they think a drug is great, the collegial information-sharing for the benefit of patients should be the method by which they give speeches to other doctors to tell them; don't pay them for it. Allowing Grand Rounds to be co-opted by the drug companies was another huge mistake.

The beauty of a bright line drawn by national leadership is that it would also protect the docs from pressure by unethical hospital administrators to do some of these things.

As you see, I could go on and on, but I think you get my drift. We are so far over the line now that getting back will be nigh impossible; short of a major come-to-Jesus moment by the leadership of medicine, like ACOG.

Perhaps anon said it best in the last comment on Paul's 'follow the money' post: "There is something holy in medicine that needs to be preserved."

nonlocal