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Managing Conflicts of Interest in Clinical Care: The “Race to the Middle” at U.S. Medical Schools

Chimonas, Susan PhD; Evarts, Susanna D.; Littlehale, Sarah K.; Rothman, David J. PhD

doi: 10.1097/ACM.0b013e3182a2e204
Research Reports

Purpose National recommendations specify how medical schools should manage clinical conflicts of interest (CCOIs), including gifts and payments to physicians from pharmaceutical companies. A 2008 study showed that few schools had policies in keeping with the recommendations. The authors conducted a follow-up study in 2011 to assess possible improvements.

Method To obtain policies in 12 areas of CCOI, the authors searched the Web sites of all 133 medical schools existing in July 2011 and contacted schools that had no online policies. Policies were scored as no policy, permissive, moderate, or stringent, based on published recommendations; each school’s scores were averaged to assess overall policy strength. Changes since 2008 were evaluated. The authors also collected information on schools’ public/private status, hospital ownership/affiliation, and National Institutes of Health (NIH) funding to determine whether these characteristics were associated with differences in policy strength.

Results Policies were obtained for a representative sample of 127 (95%) medical schools. The frequency of stringent policies increased from 2008 to 2011 in all CCOI areas, and medical schools’ overall policy strength more than doubled. However, less than stringent policies remained the norm for all areas except ghostwriting. Greater NIH funding was associated with stronger policies in five areas and with higher overall policy strength.

Conclusions Schools have made great progress toward national standards, yet room for improvement remains: The data reveal not a race to the top but a shift from the bottom to the middle. Follow-up research should explore whether stronger policies emerge in the future.

Supplemental Digital Content is available in the text.

Dr. Chimonas is research scholar, Center on Medicine as a Profession, Columbia University, New York, New York.

Ms. Evarts is research associate, Center on Medicine as a Profession, Columbia University, New York, New York.

Ms. Littlehale is research associate, Center on Medicine as a Profession, Columbia University, New York, New York.

Dr. Rothman is professor, Center on Medicine as a Profession, Columbia University, New York, New York.

Acknowledgments: The authors are pleased to acknowledge Jessica Greenberg’s research assistance and Kevin McManemin’s technical and communications expertise. Ms. Greenberg and Mr. McManemin were compensated for their contributions by the Center on Medicine as a Profession, College of Physicians and Surgeons, Columbia University, New York, New York. The authors also benefited from the methodological guidance of Patrick Moynihan, PhD, methodologist, Office of Opinion Research, U.S. Department of State, Washington DC.

Funding/Support: This study was made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin. This research was also funded by the Institute on Medicine as a Profession (IMAP), which supports the Center on Medicine as a Profession (CMAP) at Columbia University.

Other disclosures: Dr. Chimonas, Ms. Littlehale, and Ms. Evarts have no competing interests to report. Dr. Rothman served as a consultant to the state of Texas in its litigation against Johnson & Johnson for Medicaid fraud. He is president of IMAP and director of CMAP, and he had a direct role in all aspects of the study. Dr. Rothman is a board member of IMAP and has received travel reimbursements from IMAP. CMAP, which employs all authors, received a grant from IMAP to support this work. No financial incentives were offered for participation in this study.

Ethical approval: This study received approval from the institutional review board of Columbia University.

Previous presentations: An earlier version of the data was presented at the 7th China–U.S. Conference on Medical Professionalism, October 8 to 9, 2012, Beijing, China.

Supplemental digital content for this article is available at

Correspondence should be addressed to Dr. Chimonas, 630 W. 168th St., P&S Box 11, New York, NY 10032; telephone: (212) 305-6914; fax: (212) 305-6416; e-mail:

© 2013 by the Association of American Medical Colleges