Is Academic Medicine for Sale?

N Engl J Med 2000; 343:508-510August 17, 2000DOI: 10.1056/NEJM200008173430712

Article
Citing Articles (1): To the Editor:

In her editorial, Dr. Angell (May 18 issue)1 discusses the increasing ties between academic medical institutions and industry. She notes that the benefit for the former is needed cash and that the benefit for the latter is access to talented researchers. But, in fact, the benefit for industry is access to patients much more than access to talented researchers. If corporations sought access only to talented researchers, they could use promises of better facilities, better support staff, and higher salaries to attract great researchers to their industrial complexes. Industry does not want to buy these researchers outright because it needs patients for clinical trials. No one goes to the headquarters of Merck or Bristol-Myers for clinical care, but people do go to Harvard-affiliated hospitals to obtain care from clinician-researchers.
Dr. Angell is right to acknowledge the concern that industrial funding may bias researchers and lead to bias in published data, which in turn may lead to erroneous recommendations for clinical practice. But we are or should be more concerned about the conflict of interest that is created when clinician-researchers are given incentives to sell their patients to industry, because of the effect on the doctor–patient relationship. Patients come to academic medical centers trusting that their physicians are focused on their interests; they do not come to help us promote industry's research agenda. Our fiduciary obligation to our patients is what is at stake as academic medical centers sell themselves to industry. The interjection of industry into the doctor–patient relationship is disturbing; worse, patients often are not aware of its presence.

Lainie Friedman Ross, M.D., Ph.D.
University of Chicago, Chicago, IL 60637-1470
1 Reference

To the Editor:

As an academic psychiatrist and neurologist, I have been invited by pharmaceutical companies on a number of occasions to educate my colleagues on such topics as depression and dementia. In my attempts to present balanced information, I deluded myself into thinking I was educating physicians, and not being swayed by the sponsors.
Several months ago, however, I wrote a series of case reports reflecting my experience with the side-effect profile of a certain medication. The problem was that the profile was less favorable than that of medication made by a competitor of one of the companies for which I often spoke. My invitations to speak suddenly dropped from four to six times per month to essentially none. As a father of five children, I began to feel uneasy. Had I done something wrong? By presenting my clinical experience, was I now depriving my family of a source of income?
I found myself seeking out representatives of the company to let them know I was still “on the team.” I began to worry that I was not prescribing enough of their medication. I was amazed at how I had become seduced by pressure to be kind to the sponsor's product.
This experience has opened my eyes, and I will proceed with caution — that is, if I am ever invited to be a speaker again.

John W. Norton, M.D.
University of Mississippi Medical Center, Jackson, MS 39216-4505

To the Editor:

In the past 10 years I have been involved in a number of the situations described by Dr. Angell and Dr. Bodenheimer (May 18 issue),1 including receiving funding for a research project, working with a contract-research organization, and lecturing under the auspices of a drug company's speakers' bureau. I can say without hesitation that many, if not all, of the concerns Angell and Bodenheimer raise have merit.
Dr. Angell asks, “Can we really believe that clinical researchers are more immune to self-interest than other people?” My experience suggests that the opposite is true. I think clinical researchers are especially vulnerable to the fame and fortune offered in the private sector. The medical community has been openly concerned about shrinking reimbursements, and the financial benefits of working with pharmaceutical companies are well known. I have been approached many times by lecture attendees with specific questions about financial remuneration for industry-sponsored presentations. In addition, the need for prestige is especially strong among doctors and is manifested as part of the reward system from premedical education through university professorships. The opportunity to include “distinguished guest speaker” on one's curriculum vitae may be sought by physicians who have not been able to find similar titles and accolades elsewhere (and ironically by some who have). The conflicts are obvious to everyone in the field. Who has sat through a company-sponsored presentation by a well-known colleague without squirming a little at the obvious bias in the discussion?
I applaud the Journal' s courage in bringing this debate to the stage of mainstream medical discourse.

Stephen A. Young, M.D.
20 Kingfisher Ln., Key West, FL 33040
1 Reference

To the Editor:

Many institutions now require that academic researchers “justify” their salaries. If they wish to devote the majority of their time to research, they must obtain grants that cover both salary and expenses. If their expenses are not covered, physicians are expected to make up for this deficit by increasing their clinical load or finding other means of funding. The new Medicare laws, the influence of managed care on medicine, and the new, corporate mentality that now pervades medicine have all fueled this arrangement. The situation is further exacerbated by the distribution of government funding. Although funding is readily available to the top 50 medical schools, the majority of schools are in a less competitive position for obtaining government grants. According to Moy et al., the National Institutes of Health awarded medical schools a total of $5 billion in research grants and contracts in 1997.1 An estimated $3.3 billion of drug-company money is available for clinical trials alone, ready for the taking.2
I agree that there is a potential conflict of interest when physicians in the research community are financed by the pharmaceutical industry. However, there is a certain irony when Dr. Angell suggests that the very institutions that encourage such relationships should be the ones to restrict these relationships, especially when many of these institutions are actively recruiting faculty members to run for-profit, clinical drug trials sponsored by the pharmaceutical industry.2

Jonathan Lebowitz, M.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 15213
2 References

To the Editor:

. . . To maintain neutrality in the research endeavor, more neutral funding is needed. Much to the chagrin of those who advocate a reduction in federal spending, there does not appear to be a more reasonable solution than that of increasing federal support of academic medical centers.

Gregory B. Leong, M.D.
Western State Hospital, Tacoma, WA 98498-7213
J. Arturo Silva, M.D.
Veterans Affairs Outpatient Clinic, San Jose, CA 95119

To the Editor:

Brava, Dr. Angell. Thank you for your very thoughtful and well-articulated editorial. It clearly addresses the slippery slope of drug-company money and its influence in our profession. I hope doctors take the time to reflect on the direction in which this is taking us.

David C. Dillon, M.D.
97 Elliman Pl., Syosset, NY 11791

To the Editor:

. . . I agree that the quality and credibility of medical research would benefit if consensus guidelines on industry-sponsored research were adopted by major research institutions. However, my experience does not confirm the notion that industry funding poses a threat because it diverts researchers from scientifically important investigations toward those that are commercially expedient. On the contrary, when a novel research program does not fit neatly into one of the well-defended research domains carved out by the National Institutes of Health and related federal agencies, industry may provide the only alternative funding.
. . . The availability of a variety of funding sources, including private industry, is essential to scientific opportunity. Narrowing the funding options will neither upgrade the quality of medical research nor promote scientific innovation.

Janine Jagger, M.P.H., Ph.D.
University of Virginia School of Medicine, Charlottesville, VA 22908-0764

To the Editor:

. . . Given the essential role of physicians in developing technological innovations, it is important to evaluate carefully the way in which corporate financial incentives influence scientific validity. Financial incentives, however, are just one form of bias. Conflicts of interest from consulting fees or stock options can be trivial in comparison to the potential bias caused by desires for academic productivity, a faculty promotion, a large clinical-referral base, a grant from the National Institutes of Health, fame, or the Nobel prize. These sources of bias, unrelated to relationships with industry, have not been seen as black marks on research requiring public disclosure, despite their remarkable ability to lead to unethical behavior.
A subtle but disturbing implication of Dr. Angell's editorial is the idea that since corporations “are pledged to increase the value of their investors' stock,” industry-related research is more likely than other research to result in dishonest or biased scientific results. We would argue just the opposite. The shareholders of these corporations wish to profit by investing in companies that bring innovations to patients in order to improve their health and the quality of their lives. To these ends, of what value is a falsified result or a biased clinical trial? . . .

Andrew D. Firlik, M.D., M.B.A.
David W. Lowry, M.D., M.B.A.
University of Pittsburgh Medical Center, Pittsburgh, PA 15213

To the Editor:

Is academic medicine for sale? These days, everything is for sale.

Catherine Diamond, M.D., M.P.H.
University of California, Irvine, Medical Center, Orange, CA 92868

To the Editor:

Is academic medicine for sale? No. The current owner is very happy with it.

Thomas J. Ruane, M.D.
200 Riverfront, Apt. 20K, Detroit, MI 48226

To the Editor:

It seems ironic that Dr. Angell's editorial criticizing industry sponsorship of lectures to residents and medical students is surrounded by dozens of advertisements in the Journal. I wonder whether the advertising department is not going to be speaking to the editorial department for a while?

Brian M. Hagan, M.D.
Gundersen–Lutheran Medical Center, LaCrosse, WI 54601

To the Editor:

If Dr. Angell truly believes what she states, then the Journal will eliminate its pharmaceutical advertising. If not, I would raise the question, is the Journal for sale?

Paul D. Miller, M.D.
Colorado Center for Bone Research, Lakewood, CO 80227

Dr. Angell replies:
I thank Dr. Ross for calling attention to an important point I neglected in my editorial. Drs. Norton, Young, Lebowitz, and Leong and Silva also highlight important aspects of the issue.
Dr. Jagger believes that industry funding of clinical research is a plus. I have no quarrel with drug companies funding research, only with the terms. There should be no strings attached. Researchers should also have no other financial connections with the companies whose products they are studying. I disagree with Jagger that industry funding promotes scientific balance. I believe it instead leads to an overemphasis on drug research.
Drs. Firlik and Lowry imply that financial conflicts of interest are not a problem, since there are other sorts of bias that may be at least as great. I find it illogical to justify one conflict of interest on the basis of another. Are two better than one? Furthermore, the other conflicts Firlik and Lowry mention (e.g., the desire for fame) cannot be eliminated. Financial conflicts can.
Firlik and Lowry also assert that shareholders “wish to profit by investing in companies that bring innovations to patients in order to improve their health and the quality of their lives.” I doubt that. Most shareholders simply wish to profit, and they neither know nor care whether the product is innovative or notably beneficial. There is considerable evidence that industry-sponsored research is indeed more likely to be biased than other research,1 but I am unaware of evidence that the work is more likely to be intentionally dishonest.
Drs. Hagan and Miller raise a sensitive issue. The Journal has carried advertisements throughout most of its 188-year existence. Although previous editors and I have had authority over the type of advertisements, we have had no control over whether to have them. In response to Dr. Hagan: the advertising department speaks to the editorial department very little, and that is the way it should be. There is a fire wall between the two — of the sort I recommend for the administration of research grants from industry. The advertising department does not see what we publish before publication, and the editors do not see the advertisements (unless there is some question about their appropriateness). The fact that there are many advertisers protects us from being vulnerable to any one. Whether the high marketing expenditures of drug companies are justifiable, given that they add to the prices of drugs, is a different question, which I addressed in another editorial.2 In answer to Dr. Miller:yes, the Journal' s subscriptions, reprints, and advertising space are for sale. But its editorial standards and policies are not, and I trust they never will be.

Marcia Angell, M.D.
2 References