Conflicts of interest pose a greater problem to the integrity of a profession than most of us imagine. As editor, I ask everyone who submits anything for publication to sign a conflict of interest statement. Most authors honestly believe they can handle it and quickly note that they have no conflict and no bias. Yet they acknowledge, “This is a problem for others to manage.” Many years ago while in my first few years of practice, I participated in an advisory panel for a major appliance manufacturer along with another 15 or 20 clinicians. We regularly received products—new adhesives, brackets, and wires—to evaluate in our practices. Once a year, we were flown at company expense to a nice resort where we met with dental materials engineers and marketing employees of the company to dream of new products that they might consider developing. Before I became editor of The Angle Orthodontist, I dropped out of the group, realizing that I could no longer occupy such a position for a company that I had come to believe in. In fact, over the years, even though I was never paid a stipend and lectured for the company only twice internationally, I believed that it could do no harm. I trusted this company because of the good people it had employed over the years and the great products they developed. Whether or not I was prepared to admit it, I had developed a strong bias favoring this company and its products.
Looking at another area where conflicts can develop, consider 1 dilemma of conducting university research: it can be difficult to manage loyalty to a large manufacturer when it makes quarterly payments to support your research project. Some of these research contracts state that no articles reporting outcomes of a study can be submitted for publication without approval of the company. If you are the professor whose job as corresponding author is to write the conclusions to a multi-year study, knowing that the next quarterly check for $200,000 should be arriving within the next few weeks, every word you write is very carefully weighed. That is the kind of pressure that makes grown men sweat. I mention these real life “conflict of interest” experiences before disclosing the heart of this editorial as it is now being reflected in the news media.
In 2006, Stanford University developed a policy that prohibits faculty members from participating in industry speakers’ bureaus in which drug and medical-device makers pay speakers to give company-prepared talks to doctors about the company’s medical products. It also prohibits Stanford faculty members from accepting gifts, including drug samples for patients. Recently, the 660 community physicians who volunteer their time to teach at Stanford were asked to abide by the same policy—or give up their Stanford titles. Stanford is not the only university reconsidering how it interacts with the pharmaceutical and health care industries. Even so, Dr Pizzo of Stanford said that the leading academic medical centers must set a new standard for engaging the public trust in medicine.
Then, as reported last June in the New York Times , the University of Michigan Medical School became the first to decide that it will no longer take any money from drug and device makers to pay for continuing medical education. The practice of offering credits for meetings and courses sponsored by proprietary entities has come under increasing scrutiny from academics, ethicists, and lawmakers because of the potential to promote products over patient interests. Noted Dr James Woolliscroft, dean of the medical school, “leading faculty members wanted education to be free from bias, to be based on the best evidence with a balanced view of the topic under discussion.” Spending on continuing education programs for medical professionals reached a peak in 2007. Commercial interests, including drug companies, paid for a large proportion of these programs.
More than 25 years ago, the Pacific Coast Society of Orthodontists adopted a new policy making it mandatory for every participant in our scientific meetings to declare whether they had a financial or personal conflict of interest in the lecture topic. The board went a step further and made it clear that such a conflict would be noted in the printed program, and the moderator of the meeting would announce this fact in the introduction. This was a matter of policy for years, and, in many circles, it has been assumed to be the policy for every scientific meeting held in medicine and dentistry. But is that really happening, and if not, why not?
Although the American Association of Orthodontists made this its policy several years ago, it seems like a game at times to count the speakers with well-known commercial ties who show up on the annual session program with no description of the relationship noted when they are introduced. To suggest that this just happened to “slip the attention of the moderator” begs the question: is this policy really taken seriously? This year I have participated in a number of major international congresses and have been surprised at the lack of policy regarding conflicts of interest for most participants. I am well aware of the reason that more proprietary speakers are invited to speak at many of our meetings. It saves the organization money—it’s as simple as that. But is there a downside? I have observed a great deal of confusion regarding the types of presentations being made. Some proprietary speakers are knowledgeable and quite entertaining. At the same time, some of these speakers are slow to report data from current studies and are quick to discount anyone else who tries. What can we learn from the medical profession in this regard? It has a long history of struggling with the issue of financial conflicts of interest and how well self-regulation has or, perhaps I should say, has not, worked. They seem to be learning the hard way that there is no free lunch.
I think it is time for dentistry and its specialties to join medicine in working toward greater transparency in its long-valued ties with both large manufacturers and small proprietary businesses, to accomplish the following:
Enact and enforce association polices to disclose the nature of the speaker’s relationship with each commercial interest for the purpose of reducing bias and making lectures more transparent.
Support proposals for new restrictions on industry involvement in continuing dental education or face the loss of continuing education credits for attending meetings that feature industry employees interpreting product research.