No free lunch

Sandy Buchman

Transparency is well and good, but accuracy and objectivity are even better. Wall Street doesn’t have to keep confessing its sins. It just has to stop committing them.¹

It’s lunchtime. Your pharma rep is setting up a wonderful spread of wraps, salads, and sweets. Colleagues and staff gather to watch an interesting, educational video on a new product. Good discussion ensues; drug samples are left. You head back to your patients with a satisfied tummy and the sense that you learned something, your staff got a treat, and it didn’t cost anything! Or did it?

What about those novel birth control pill samples you’re handing out to women who can’t otherwise afford them, rationalizing that you’re contributing to the public good by preventing unwanted pregnancy? You know that the next patient who can afford them will get a prescription for novel birth control because, well, it’s the least you can do for the rep for leaving the samples and allowing you to feel good about your altruism. You pause—is there really much solid safety evidence behind that new progestogen? But Health Canada has approved it, so it must be alright. And Dr Gyne down the street uses it with all her patients. You then demonstrate to your medical student how to insert an intrauterine device using a terrific anatomic model of a female pelvis with said pharma company’s logo on it.

A slight unease comes over you. You believe you are a trustworthy physician, offering your patients the best evidence-supported treatments. You know you are a credible teacher for your students, demonstrating objectivity in your clinical decision making. But can you truly not be influenced by these outside forces that primarily have shareholders’—not patients’—best interests at heart? Most of us think we are not influenced, but the evidence is increasingly to the contrary. We are wired for social reciprocity.

Just as individual physicians might experience personal conflicts of interest (COIs) in their relationships with the pharmaceutical, medical device, and health supply industry, so might professional health care organizations such as the College of Family Physicians of Canada (CFPC) experience “organizational COIs.” Industry-supported awards and educational programs permeate our discipline and our College activities. Are our legitimacy and scientific credibility as an organization compromised by this relationship?

The CFPC had a dilemma. Given that family physicians are widely trusted by their patients and communities, that both doctors and organizations occupy roles in society where trust and credibility are paramount, that our commitment to patient and public health is not just a legal but a moral duty, shouldn’t family physicians be represented by an organization that fully reflects those high ethical commitments and standards? And have we been doing that to the extent that we and our members expect? Are we sufficiently objective and transparent?

How do we deal with potential COIs in our financial relationship with industry, and do we “manage” our relationship or do we divest completely? We paused for reflection and decided we could do better. So in October 2010, the CFPC established a task force to examine this relationship. The task force includes practising family physicians; representatives with expertise in research, teaching, and ethics; a public member of the CFPC Board; university leadership; and CFPC senior and executive staff.

At a CFPC leaders’ summit in 2009, 31% of participants thought that physicians and medical organizations should not have any programs or activities supported by the pharmaceutical industry. The converse of this is, of course, that 69% supported some degree of involvement.

We looked at the potential effects of our involvement with industry. On the one hand, through involvement with industry the CFPC could lose credibility as an independent voice with our members, colleagues, sister organizations, regulatory authorities, government, and, of course, the public. The COIs that taint the credibility of our educational offerings risk losing us the support of our voluntary members and the revenue stream they provide. If we divest completely from our involvement with industry, however, we lose another important revenue source.

So we brainstormed principles to form the foundation for our policy. The initial draft states that our relationship will be based on transparency, independence, accountability, and trust. As we aspire to put patients first, we must ensure that the CFPC independently determines the content of all our activities and educational programs based on the best available evidence. This year we will develop our policy further and will report to the Board of Directors.

As you might guess, the examples of personal COIs above belong to yours truly. As I reflect and learn about these issues and try to be accountable and transparent in my own life, I will lead, as CFPC President and task force Chair, to find principle- and evidence-based answers to our dilemma. I hope increased individual and collective awareness of this issue will lead to a balanced solution. As always, input and comments are welcome. Write or drop by the CFPC—but if you do drop by, please bring your own lunch.