An April 1 JAMA article by David J. Rothman, PhD, and colleagues on the support of professional medical associations (PMAs) by monies from the pharmaceutical and device industries concluded with a “proposal for controlling conflict of interest.”
The authors assert that “PMAs should work toward a complete ban ($0) on pharmaceutical and medical device industry funding, except for income from journal advertising and exhibit hall fees.” Recognizing the financial hardship that such a policy would create, Dr. Rothman and his co-authors modified their assertion to “restrict[ing] total support to no more than 25 percent of [the] operating budget”. A number of other recommendations were also made restricting industry support of all PMA programs, journals and officers.
DOES THE AAN MEET THE PROPOSAL'S RECOMMENDATIONS?
In 2008, support from industry (apart from journal advertisements and exhibitor fees) was 13 percent — well below the 25 percent of operating budget proposed by Dr. Rothman, et al. On the other hand, the amount of such industry support has been increasing — from 7 percent in 2006 to 12 percent in 2007.
Moreover, the AAN annual meeting allows distribution of company-branded items; invites support by unrestricted grants for educational courses; and invites industry-sponsored therapy programs.
In addition industry monies support the AAN Palatucci Advocacy Leadership Forum; contribute to the AAN Foundation, which funds research and training fellowships; and support Neurology journal supplements — all listed by the JAMA authors as conflicts of interest that should be eliminated.
Finally Dr. Rothman, et al., assert that all PMA officers must be “conflict free” (0 percent funding) with no pharma or device industry support during their tenure. Both I as AAN president, and Stephen Sergay, MD, past president, have sought and continue to seek industry support of clinical trials for neurological disease. Thus, the AAN has both policies and leadership that violate the letter and spirit of the proposal.
IS INDUSTRY FUNDING OF THE AAN MEETING AND OTHER ACTIVITIES AND OF OFFICER ACTIVITIES THE PROBLEM?
The JAMA article implies that funding of meetings or research by industry will bias physicians in leadership positions to make decisions that are adverse to the practice of medicine. It ignores the much larger and more important issues of bias introduced by other sources of funding — pointed out by Steven T. Schwid, MD, and Robert A. Gross, MD, in a 2005 article in Neurology — for example, NIH grants, testing in tort litigation, and indeed the private practice of medicine where physicians are paid for the performance of the services that they recommend. Moreover, in choosing to exclude journal advertising from their recommendations (when one of the co-author's journal receives millions of dollars in revenues), the authors sound a discordant note: Advertising in supplements is deemed too conflicting, but advertisements within journals is not, presumably reflecting the authors' opinion that these are not meant to influence physicians or are not sufficiently influential.
IS THE ROTHMAN ET AL FOCUS ON PROFESSIONAL MEDICAL ASSOCIATIONS JUSTIFIED?
PMAs and their funding have become convenient targets for criticism by politicians and now academicians. However, the potential for bias of information presented by industry or in programs supported by industry is self-evident and needs a counter-balance. One such counter-influence is that physicians are trained in scientific methods and have a career-long obligation to sift truth from error, fact from fiction
Much more pernicious to me is the direct-to-consumer and direct-to-patient advertising that focuses on a public without the scientific training of physicians. When the US is the only country in the world that continues to allow this practice, I consider our priorities misplaced. Moreover, the emphasis on conflict of interest disclosures that has become increasingly onerous for journal editors and authors has astonishingly not extended to the authors of text books that potentially naïve medical students use and often memorize.
Our conclusions: While two, three, or more other wrongs don't necessarily make accepting PMA support for the AAN right, they do suggest that placing a priority on $0 industry support for the AAN is misplaced, unlikely to occur and possibly counterproductive.
I take exception to a proposal that would more than double the dues neurologists would pay to support the organization that provides their continuing education, practice guidelines, and leading journal, and which advocates to correct the current imbalance of reimbursement.
I do not retain any monies given to me by industry for chairing a data monitoring committee, for giving lectures, or serving on advisory boards. However, the development of new treatments for neurological disease has been a career-long commitment for me. I firmly believe that this commitment and the fact that I am willing and interested in working with the pharmaceutical industry to pursue this goal is of importance to my presidency and leadership of the AAN. New treatments will depend on the pharmaceutical and device industries.
THE AAN RESPONSE
At a time when neurologists' income is declining and the income of procedural-focused specialties continues to climb, should the AAN revise its policies regarding industry support? The AAN Board of Directors and the AAN Ethics, Law and Humanities Committee are continually reviewing conflict of interest policies, and the board approved a comprehensive policy, Principles Governing AAN Relationships with External Sources of Support in 2004 and substantially amended the Policy on Conflicts of Interest in 2008.
In the context of the recent JAMA article but with the broader issues of bias in mind, I have appointed an independent task force to be chaired by James Bernat, MD, to review AAN conflict of interest policies and make recommendations. Others on the task force include Corey Fehnel, MD; Daniel Larriviere, MD, JD; Timothy Pedley, MD; Christine Phelps; Bernard Ravina, MD; Murray Sagsveen, JD; Thomas Swift, MD; and John Hutchins, JD (staff liaison). Their report to the board of directors, expected early in 2010, will guide AAN policy decisions.