Conflicts of Interest in the Healthcare Industry are Both Financial and Non-financial
When your doctor prescribes a new medication for you, of course you want to believe that they have made the choice of which drug to prescribe based on science and your individual needs. When you read a scientific paper giving the results of a study to evaluate a new intervention for a disease, it is expected that all the benefits and risks discovered in the study have been accurately and completely described. When you go online seeking guidance from a patient advocacy organization about how to approach treatment for an illness, it is your assumption that the information you will see on the nonprofit’s website is unbiased and reflects up-to-date science on the topic.
A study published last fall in the medical journal the BMJ tells us, however, that those beliefs, expectations, and assumptions must be tempered by a consideration of a considerable web of potential conflicts of interests. To come to that conclusion, the authors did a thorough—in technical terms, a “scoping” –review of the literature and obtained input from “an international panel of experts with broad expertise in industry ties and deep knowledge of specific parties and activities.” They looked at ties of manufacturers of drugs and medical devices with a variety of players in the healthcare industry, including researchers, practitioners, and non-profit organizations, and considered both financial and non-financial incentives. As such, this is perhaps the most comprehensive examination of potential conflicts of interest in the healthcare field that we have yet seen.
Tangled Web of Relationships
What they found is sobering. If you look at figures one, two, and three from their publication (which is available for free online), you will see a tangled web of relationships between the medical product industry and what they call the healthcare ecosystem. It is relatively easy to trace payments made from pharmaceutical companies to medical schools in the form of research grants and then to refer to the long literature that shows that reports of the results of such research tend to emphasize benefits of the company’s products and minimize risks. It is also now straightforward to identify payments from drug and medical device companies to individual physicians because these are covered under various sunshine laws that mandate public disclosure. There is also a long literature documenting that paying doctors to give lectures or attend dinners influences what they prescribe.
Perhaps we are less likely to consider the ways that pharmaceutical industry funding affects consumers directly, but we have only to remember the advertisements that the companies regularly place about their medications to see that they are influencing us as well. Studies show that these direct to consumer (DTC) advertisements affect how we understand the risks and benefits of drugs, sometimes in subtle and not always accurate ways.
We may not always realize that non-profit organizations that serve as patient advocates and educators also receive money from drug and device manufacturers. There is much less known about whether these payments adversely affect the advice these organizations give us and the work that they do.
Non-Financial Incentives Are Also Found
An important feature of the BMJ study is that it considers non-financial incentives as well as financial ones. A medical scientist might be included as a co-author of a paper about a study that was funded by a pharmaceutical company without receiving any actual money themself. Even though no money changes hands in this case between scientists and drug companies, the potential for the scientist to be biased about the study results is potentially present. Here is how the authors of the paper describe the financial and non-financial ties they looked at:
Many medical product industry ties to these parties are financial, involving money or items of financial value, as when companies negotiate prices with supply chain agents; purchase reprints from journals; make contributions to public officials for campaigns; provide consultancy, speaking, or key opinion leader payments to healthcare professionals; or financially support government agencies, healthcare organizations, and nonprofit entities through donations, grants, or fees. Other ties are non-financial, as in companies’ direct-to-consumer advertising to patients, advertising and detailing of prescribers, unpaid professional consultancy work, or the offer of data, authorship, and other professional opportunities to clinicians and researchers. All party types have financial ties to medical product companies. Only payers and distribution agents lack additional, non-financial ties.
These potential conflicts of interest all involve the medical product industry, and they are extensive. Yet, there is more. The paper does not address potential conflicts of interest that do not involve industry. There are also instances in which a long career of advocating for a particular intervention may bias a scientist in how they talk and write about new studies. Let us say for example that an investigator has written several papers showing that a particular type of psychotherapy is good for treating headaches. That scientist’s career and reputation come to be associated with the benefits of the therapy, so when the results of a new study the scientist conducts do not replicate previously found benefits, the scientist could feel conflicted about reporting those results. That is why replication of studies by independent groups is always necessary before we conclude that a finding is solid.
There is some oversight now of direct pharmaceutical industry payments to researchers and prescribers, but much less to non-profit organizations, the BMJ paper noted. And when it comes to potential non-financial conflicts of interest, including those that do not involve industry, it is hard to know what kind of oversight could be implemented.
Incentives Do Influence Behavior
It would be easy to dismiss what the BMJ study found by noting that these conflicts of interest are always expressed with the modifier term “potential.” That is, a financial or non-financial relationship between industry and an individual or organization in healthcare does not automatically translate into actual behaviors. Many doctors we know insist that they can go to pharmaceutical industry-sponsored continuing medical education courses without coming away feeling more favorable about the drug the company makes or going on to prescribing it more often. Many medical journals now take great care to ensure that research studies supported by drug companies include balanced reporting of benefits and adverse side effects and even publish studies in which the company’s drug did not work.
As we noted above, however, there is ample, recent literature attesting to the fact that incentives influence the behavior of scientists, clinicians, and consumers. For example, one recent study showed that physicians were more likely to implant cardioverter-defibrillator devices made by manufacturers who had paid them the most money. Although the proportion of physicians who receive payments from industry seems to be decreasing, a study showed that 45.0% took some form of payment in 2018. A second example comes from a study published last year in the Journal of the National Comprehensive Cancer Network. An analysis of editorials in oncology journals showed that 74% had at least one author with a disclosed conflict of interest with a pharmaceutical company, 39% had a direct conflict of interest with the company whose drug was being discussed in the editorial, and 12% of the editorials were judged as “unfairly favorable” to the product being discussed, of which a majority fell into the direct conflict of interest category.
These are just two examples in which conflicts of interest with industry seem to directly influence behavior, one involving what doctors prescribe and the other what medical scientists write in scientific journals. There are many more of these kinds of studies, leaving little doubt that the money the drug companies spend has a real effect on how their products are used. Again, that does not necessarily mean patients are being harmed. The drug that a doctor who has taken money from a drug company prescribes may be exactly the best one for an individual patient. The study paid for by a pharmaceutical or medical device company may really show that its product is beneficial and has a tolerable adverse side effect profile. All too often we see commentators go in the opposite direction on this and try to claim that any amount of money that changes hands between companies and the healthcare system automatically invalidates the results.
We need to be wary, however, about how medical industry money influences every aspect of the healthcare system. If you accept help with a co-pay for a drug from the company that makes it, be certain you and your doctor really think it is the best one for you. Be very skeptical about ads for drugs—that seemingly endless recitation of adverse side effects that is always accompanied by cheerful music and video representations of happy people does not really tell you much about how the drug will affect you. It is fair game to look up your doctor on one of the publicly available search engines to see if they accepted any money recently from a pharmaceutical company. Whenever a paper lists a company as a sponsor of a study, read it carefully for signs that benefits are being magnified and adverse events minimized. Before donating money to a non-profit healthcare organization or accepting its advice, inquire about donations they receive from industry sources.
Much harder is screening for non-financial conflicts of interest, both the kinds the BMJ paper was able to uncover and the ones that are much harder to detect, like the emotional attachment an investigator has to their findings. Keeping an eye out for inflated language is one way to watch for bias. If findings are described as “breakthroughs” or “major,” remember that those assessments are usually in the eye of the person who ran the study. When a paper has the phrase “we have previously shown,” ask yourself if anyone else has also shown it.
Without going to the extreme of reflexively rejecting anything that has a connection to a financial or non-financial incentive, it is important to recognize the web of influence that engulfs our healthcare system. Every one of us needs to be on guard for the insidious presence of bias.