Conflicts of interest (COIs) have been in the news lately, with the resignations and public mea culpas of several prominent figures over undisclosed conflicts of interest in journal articles. Memorial Sloan Kettering is one of the two top cancer hospitals in the United States: unequaled by anyone other than MD Anderson in it's advanced, cutting edge care. The Chief Medical Officer of that institution spectacularly resigned after failing to note millions of dollars in payments by pharmaceutical companies he had worked with in journal articles which he wrote.
Now I will disclose here that I am a Baylor College of Medicine General Surgery resident who will rotate at MD Anderson.
I could just stop there- and in an academic article, in a newspaper piece, or public presentation, I wouldn't even be required to mention that COI. But let me explain further. My education benefits from increased case volume, meaning if this article results in more patients coming to MD Anderson at the expense of Memorial Sloan Kettering, I may get better training. And for that matter, if people see this article and read my statement that there are only two top cancer centers in the US (though this is actually a fairly widely held belief), this again benefits both those institutions (and my training) at the expense of many other perfectly capable and advanced cancer centers throughout the country. But is that really the conflict of interest? After all, what if I am a lazy doctor? As a resident, I'm paid a fixed salary, and don't get paid more for increased volume. Meaning less patients = less work for me for the same money, and I still get the same certification and income at the end. So, isn't my conflict really directly against the statement I made, making those statements more credible?
Confused yet? How should you regard what I write here, knowing all this about my conflicts of interest?
The reality is that almost everyone who publicly communicates in medicine has conflicts of interest. Ideological, financial, a desire for more work or less work, or for fame and prestige. All of it affects what we say- just as it affects pretty much anyone talking about anything. They are also known as motivations. (Just FYI, no one who is lazy goes into general surgery for residency, especially not general surgery at Baylor College of Medicine).
I was actually motivated to write this article by a recent twitter debate I had with another physician who felt that a third doctor who is involved in a test prep company for step 1 as a side hustle should disclose that when he asked a question (also via tweet) about Step 1.
That discussion, and seeing the reporting around conflicts of interest as a whole, makes me feel that the whole thing is becoming security theater. Security theater is engaging in various procedures and acts to make people feel safe- without actually making them safe. This is what the Transportation Security Agency engages in every time we fly. Taking shoes and belts off, full body scanners, all of it is probably useless- a fact acknowledged by many former agents. But the invisible actions that actually stop terror attacks- a very motivated population ready to tackle anyone who tries anything on a plane, hardened doors at the cockpit, intelligence agencies on permanent hair trigger alert for any plots against the US- don't make anyone visibly feel safe. And so we collectively engage in useless ritual inconvenience at every airport checkpoint, convincing each other that the plane we are about to board won't be a victim of a terror attack. The TSA didn't stop the shoe or underwear bomber. Yet, our naked bodies are ogled by security guards using scanners that are actually terrible at detecting hidden objects- and attempts to make them less revealing just make the scanners even less effective.
Disclosing conflicts of interest on twitter, at presentations, or in journal articles may make us feel safer, and calling out our colleagues may make us feel that we are doing the right thing. But they don't actually increase safety. There is a massive problem with pharma and medical device biased research in medicine, which I've written about numerous times. Merck and GlaxoSmithKline have the blood of hundreds of thousands of patients on their hands by failing to disclose risks revealed in research on their drugs. Many more examples abound of pharmaceutical companies hiding the risks or overselling the benefits of their drugs, and medical device companies have their own problems- Johnson and Johnson is facing billions of dollars of losses in lawsuits over it's failure to do adequate research on and disclose the risks of the vaginal meshes it was selling.
But according to the security theater we all participate in, the same regime that was in place during each of these debacles that maimed and killed our patients, all we have to do is declare, "I have stock in (insert company here)", and our research and statements will be accepted by all.
It is time for a new system. We need to demand that pharmaceutical and medical device companies run their Phase 3/IDE trials through an independent scientific authority. They should be required to give their money to a neutral arbiter which picks scientists to run the final experiment before their product is approved- with no interference by the company whatsoever. Every trial up till that point? Close corporate and researcher collaboration is essential. But the final trial upon which FDA or other regulatory approval will rest and the risks and benefits of the device or drug elucidated should be conducted free of any commercial bias, though exceptions may exist for certain categories of devices which depend upon user feedback and interaction.
That policy will truly make us safer- and make us feel safer too. Until then, we can keep making our public disclosures and engaging in our security theater- the same theater that has been utterly ineffective at protecting patients up till now.
Disclosure: I consult for a cardiovascular and pulmonary diagnostics company, and have received remuneration for this. The position I take in this article is arguably against my own self-interest in that matter.
Now I will disclose here that I am a Baylor College of Medicine General Surgery resident who will rotate at MD Anderson.
I could just stop there- and in an academic article, in a newspaper piece, or public presentation, I wouldn't even be required to mention that COI. But let me explain further. My education benefits from increased case volume, meaning if this article results in more patients coming to MD Anderson at the expense of Memorial Sloan Kettering, I may get better training. And for that matter, if people see this article and read my statement that there are only two top cancer centers in the US (though this is actually a fairly widely held belief), this again benefits both those institutions (and my training) at the expense of many other perfectly capable and advanced cancer centers throughout the country. But is that really the conflict of interest? After all, what if I am a lazy doctor? As a resident, I'm paid a fixed salary, and don't get paid more for increased volume. Meaning less patients = less work for me for the same money, and I still get the same certification and income at the end. So, isn't my conflict really directly against the statement I made, making those statements more credible?
Confused yet? How should you regard what I write here, knowing all this about my conflicts of interest?
The reality is that almost everyone who publicly communicates in medicine has conflicts of interest. Ideological, financial, a desire for more work or less work, or for fame and prestige. All of it affects what we say- just as it affects pretty much anyone talking about anything. They are also known as motivations. (Just FYI, no one who is lazy goes into general surgery for residency, especially not general surgery at Baylor College of Medicine).
I was actually motivated to write this article by a recent twitter debate I had with another physician who felt that a third doctor who is involved in a test prep company for step 1 as a side hustle should disclose that when he asked a question (also via tweet) about Step 1.
That discussion, and seeing the reporting around conflicts of interest as a whole, makes me feel that the whole thing is becoming security theater. Security theater is engaging in various procedures and acts to make people feel safe- without actually making them safe. This is what the Transportation Security Agency engages in every time we fly. Taking shoes and belts off, full body scanners, all of it is probably useless- a fact acknowledged by many former agents. But the invisible actions that actually stop terror attacks- a very motivated population ready to tackle anyone who tries anything on a plane, hardened doors at the cockpit, intelligence agencies on permanent hair trigger alert for any plots against the US- don't make anyone visibly feel safe. And so we collectively engage in useless ritual inconvenience at every airport checkpoint, convincing each other that the plane we are about to board won't be a victim of a terror attack. The TSA didn't stop the shoe or underwear bomber. Yet, our naked bodies are ogled by security guards using scanners that are actually terrible at detecting hidden objects- and attempts to make them less revealing just make the scanners even less effective.
Disclosing conflicts of interest on twitter, at presentations, or in journal articles may make us feel safer, and calling out our colleagues may make us feel that we are doing the right thing. But they don't actually increase safety. There is a massive problem with pharma and medical device biased research in medicine, which I've written about numerous times. Merck and GlaxoSmithKline have the blood of hundreds of thousands of patients on their hands by failing to disclose risks revealed in research on their drugs. Many more examples abound of pharmaceutical companies hiding the risks or overselling the benefits of their drugs, and medical device companies have their own problems- Johnson and Johnson is facing billions of dollars of losses in lawsuits over it's failure to do adequate research on and disclose the risks of the vaginal meshes it was selling.
But according to the security theater we all participate in, the same regime that was in place during each of these debacles that maimed and killed our patients, all we have to do is declare, "I have stock in (insert company here)", and our research and statements will be accepted by all.
It is time for a new system. We need to demand that pharmaceutical and medical device companies run their Phase 3/IDE trials through an independent scientific authority. They should be required to give their money to a neutral arbiter which picks scientists to run the final experiment before their product is approved- with no interference by the company whatsoever. Every trial up till that point? Close corporate and researcher collaboration is essential. But the final trial upon which FDA or other regulatory approval will rest and the risks and benefits of the device or drug elucidated should be conducted free of any commercial bias, though exceptions may exist for certain categories of devices which depend upon user feedback and interaction.
That policy will truly make us safer- and make us feel safer too. Until then, we can keep making our public disclosures and engaging in our security theater- the same theater that has been utterly ineffective at protecting patients up till now.
Disclosure: I consult for a cardiovascular and pulmonary diagnostics company, and have received remuneration for this. The position I take in this article is arguably against my own self-interest in that matter.
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