A Review of Canadian Medical School Conflict of Interest Policies

doi:10.4236/ce.2013.43032

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Creative Education

2013. Vol.4, No.3, 217-222

Published Online March 2013 in SciRes (http://www.scirp.org/journal/ce) DOI:10.4236/ce.2013.43032

A Review of Canadian Medical School Conflict of Interest

Policies

Michael G. R. Beyaert, Jatinder Takhar*, David Dixon, Margaret Steele,

Leanna Isserlin, Carla Garcia, Ian J. Pereira, Jason Eadie

Continuing Professional Development , Schulich School of Medi c i n e and Dentistry,

The University of Wes te rn Ontario, London, Canada

Email: *[email protected]

Received January 3rd, 2013; revised February 8th, 2013; accepted February 19th, 2013

Background: Growing evidence of behavioral bias has caused a surge of interest in the area of Conflict

of Interest (COI) within the medical community. The present study sought to evaluate the landscape of

Faculty of Medicine COI policies among Canadian medical schools using an evaluation system adapted

from the AMSA PharmFree Scorecard. Methods: The authors contacted leaders at the CPD/CME offices

of all 17 Canadian medical schools in 2011 to determine how many had formal policies guiding interac-

tion with the pharmaceutical industry. Existing policies were evaluated based on 16 criteria developed by

a steering committee. A Policy Score was calculated and a letter grade assigned for each of the existing

policies. Results: At the time of review, roughly 35% of the Canadian medical schools had faculty-wide

COI policy/guidelines, half of which had been implemented. Other policies are currently in development.

Policy Scores ranged from 25.00% to 70.83% with a Mean Policy Score of 52.08%. Policies that were

implemented all scored higher than those that were not implemented. Additionally, several strengths and

weaknesses among policies were identified. Conclusions: Canadian schools have recognized that COI

and bias have become a serious issue and are taking steps toward its management. The authors propose that

the CMFS employ a system similar to the AMSA Scorecard to evaluate progress in a longitudinal study.

Keywords: Conflict of Interest; Policy Evaluation; Continuing Medical Education; Continuing

Professional Development; Quality Control

Introduction

Conflict of Interest (COIs) are becoming increasingly rele-

vant to the medical field. A COI may be defined as “a set of

conditions in which professional judgment concerning a pri-

mary interest (such as a patient’s welfare or the validity of re-

search) tends to be unduly influenced by a secondary interest

(such as financial gain)” (Thompson, 1999). Interactions with

the pharmaceutical industry begin early during medical educa-

tion, shaping behaviour that continues well into practice

(Wazana, 2000; Institute of Medicine, 2009). Residents ex-

posed to pharmaceutical representatives during training are

more likely to be skewed towards industry values (Zipkin &

Steinman, 2005) and are more likely to recall misinformation

about the company’s and its competitors’ products (Wazana,

2000). However, these biases may be attenuated by the intro-

duction of more stringent policies. A Canadian study demon-

strated that residents trained under policies that restricted inter-

action with pharmaceutical representatives were more skeptical

about information provided by pharmaceutical representatives

compared to residents trained under non-restrictive policies

(McCormick et al., 2001).

Although the majority of practicing physicians dismiss the

notion that interaction with the industry introduces bias, their

behaviour is influenced in a number of ways. Notably, physic-

cians and their organizations are more likely to prescribe a

company’s products for up to two years following a direct in-

teraction (Wazana, 2000). COI among authors of popular North

American and European clinical practice guidelines are preva-

lent (Choudry et al., 2002; Neuman et al., 2011), and many

guidelines recommend products sold by the companies with

which authors have ties (Choudry et al., 2002). Gifts may also

alter physicians’ abilities to weigh information (Dana &

Loewenstein, 2003). Although drug samples are considered by

many to be the most appropriate incentive from industry (Mor-

gan et al., 2006), it has been demonstrated that a correlation

exists between access to drug samples and prescription rates of

that product (Adair & Holmgren, 2005).

Conflict of interest extends beyond clinical practice. Nearly

one quarter of medical research performed at academic institu-

tions is at least partially funded by the pharmaceutical industry

(Bekelman et al., 2003). Industry funding influences study de-

sign, execution, reporting, access to data, and publication of

results (Lexchin et al., 2008). Industry-sponsored research de-

sign tends to be less objective (Rochon et al., 2011) and is more

likely to yield results favouring the sponsor (Bekelman et al.,

2003; Lexchin et al., 2003). Among Canadian academic medi-

cal centers, definitions of what constitutes a COI in research is

variable with many potential conflicts often being excluded

(Lexchin et a l., 2008).

It has been estimated that industry spent $57.7 billion Ame-

rican dollars on promotion in 2004. This figure represents near-

ly 25% of industry sales and double the amount spent on re-

search and development. Perhaps more alarming is that 80% of

promotional spending was spent marketing to physicians (Gan-

*Corresponding autho r.

M. G. R. BEYAERT E T AL.

gon & Lexchin, 2008). Of large concern is that COIs are often

self-reported. A recent study found that physicians disclose

only 20.7% of directly related payments from industry and

50.0% of indirectly related payments (Okike et al., 2009).

In an attempt to persuade academic medical centers to ma-

nage COI, a number of American groups have published re-

commendations for more stringent regulation of physician-in-

dustry relationships (Brennan et al., 2006; AAMC, 2008;

AMSA, 2012). In 2008, the American Association of Medical

Colleges (AAMC) Task Force released an assessment of COI

policies from academic medical centers across America and

made recommendations for improvements (AAMC, 2008).

Using similar criteria, the American Medical Student Asso-

ciation (AMSA) continues to monitor and grade COI policies of

academic medical centers in the United States using their

PharmFree Scorecard. Criteria from six COI domains (Gifts

and Individual Financial Relationships with Industry; Pharma-

ceutical Samples; Purchasing and Formularies; Industry Sales

Representatives; Education; and Enforcement) are given scores

ranging from 1 (weak or no policy) to 3 (strong policy). The

cumulative score of these domains, excluding Enforcement, is

used to determine a percentage score out of a maximum 15

points. The 2011-2012 report concluded that 67% of American

medical schools have policies scoring A (score of 85% or

higher) or B (score of 70% or higher). This is a significant im-

provement from 19%, 30% and 51% of schools in 2008, 2009,

and 2010, respectively (AMSA, 2012). It is conceivable that

implementation of the AMSA scorecard has raised awareness

about the issue of COI and contributed to improvements in

medical school COI policies. However, Chimonas et al. evalua-

ted American medical school COI policies using their own

method and found that half of those surveyed had poor or

non-existent COI policies (Chimonas et al., 2011).

In Canada, physicians are encouraged to follow Canadian

Medical Association (CMA)’s “Guidelines for Physicians in

Interactions with Industry” (CMA, 2007). These guidelines

apply to all physicians, residents, and medical organizations in

Canada, including the College of Family Physicians of Canada

(CFPC) and the Royal College of Physicians and Surgeons of

Canada (RCPSC). Although the Association of Faculties of

Medicine of Canada (AFMC) has not issued its own policy

guiding interactions between industry and Canadian medical

schools, it endorsed the AAMC report on “Industry Funding of

Medical Education” (AAMC, 2008).

To address the issue of COI in Canadian medical education,

the AMFC created the Standing Committee on Continuing

Professional Development (SCCPD). This committee brought

leaders from the 17 Canadian medical schools’ Continuing

Professional Development (CPD)/Continuing Medical Educa-

tion (CME) offices together at a national meeting to discuss

relations between industry and CPD/CME. The SCCPD Work-

ing Group on Industry Relations issued a position paper urging

Canadian medical schools to develop individual COI policies,

and provided consensus statements to help guide the creation of

such policies (SCCPD, 2010). The Canadian Federation of

Medical Students (CFMS) has also called upon Canadian

medical schools to develop policies in collaboration with their

medical student societies and educate medical students about

appropriate industry relationships. Their report briefly ad-

dresses COI policies and guidelines from a number of organiza-

tions, including the CMA and the Faculties of Medicine at the

University of Toronto and the University of Ottawa (CFMS,

2011).

As a result of these initiatives, increasing attention has been

paid to COI documents among Canadian universities. In 2008,

Williams-Jones and MacDonald evaluated COI policies from

thirteen of Canada’s largest and most prominent universities for

readability and content. The authors found that most schools'

policies had low readability, using complex legal language to

focus on prohibitions and mitigate institutional liability, rather

than providing readers with clear definitions of COI, examples

of what constitutes COI, and procedures for addressing COI

(Williams-Jones & MacDonald, 2008). More recently in 2012,

Mathieu et al. applied a modified version of the AMSA Pharm-

Free Scorecard to COI policies from Canadian universities with

medical schools. The authors found that Canadian universities

studied scored very poorly, with all but one receiving overall

grades of D or F. However, it is important to note that this

study evaluated university-wide COI policies from univer-

sities with medical schools rather than investigating policies

specific to the Faculties of Medicine. Many of the weaknesses

in policies could be attributed to evaluation of general univer-

sity-wide COI policies using AMSA’s grading scheme, which

was developed specifically for medical school COI policies

(Mathieu et al., 2012).

To the best of our knowledge, no comprehensive assessment

of Faculty of Medicine COI policies from all 17 Canadian

medical schools has been performed. The present study sought

to raise awareness about this issue by evaluating the landscape

of medical school COI policies in Canada using a scoring sys-

tem similar to the AMSA PharmFree Scorecard.

Methods

The associate and vice deans of CPD/CME offices of all 17

Canadian medical schools were contacted in August 2011 to

determine which schools had developed formal COI policies

and whether these policies had been implemented. CPD/CME

leaders were contacted because they are currently taking the

lead on these issues as the majority of policies are vetted

through these offices.

Existing policies, which were all available within the public

domain, were obtained from each Faculty of Medicine’s web-

site for evaluation. University-wide policies were excluded

from analysis because they were not developed specifically for

the physician community. Once policies were obtained, a

steering committee was formed to discuss policy evaluation.

This committee consisted of the Associate Dean of CPD, the

Vice Dean of Hospital and Interfaculty Relations, educators

from various disciplines within the Schulich School of Medi-

cine, a resident representative, and a medical student represen-

tative. The committee created criteria and a scoring system for

policy evaluation based on relevant COI criteria commonly

found in the literature. The criteria selected for evaluation in-

cluded all areas of the AMSA PharmFree Scorecard as well as

additional areas deemed important by the committee (Chimonas

et al., 2011; AMSA, 2012; Mathieu et al., 2012).

Policies were reviewed and graded by a single scorer and

calculations were verified independently by a second reviewer.

The scorer was not blinded to the identities of medical schools.

Each policy was evaluated based on the strength of each crite-

rion using a four-point scale reported by Mathieu et al. (2012),

which was adapted from the AMSA PharmFree Scorecard

(AMSA, 2012). The scoring scale was follows: 0 points for a

218

M. G. R. BEYAERT ET AL.

policy element that was absent; 1 point for a policy element that

was only partially addressed or for which the reader was di-

rected to another institutional policy; 2 points for a policy ele-

ment that was addressed, but the policy was incomplete or

weak; and 3 points for a policy element that was considered

complete and strong.

were implemented, while Medical Schools D through F had not

yet implemented theirs.

Policy Scores ranged from 25.00% (Medical School F) to

70.83% (Medical Schools B and C), corresponding to letter

grades of F and B, respectively. When taken together, the ave-

rage Policy Score for all six schools was 52.08%, which corre-

sponds to a letter grade of D. However, when implemented and

non-implemented policies were considered separately, there

appeared to be some differences. The average Policy Score

among implemented policies was 69.44% (corresponding to a

letter grade of C), while the average Policy Score among

non-implemented policies was 34.72% (corresponding to a

letter grade of F).

A raw score was determined for each COI policy by cal-

culating the sum of scores for each criterion within that policy.

This was then used to express each school’s Policy Score as a

percentage of the highest possible score, or 48 points. Each

school’s policy was assigned a letter grade based on its policy

score percentage according to the cutoffs used for AMSA’s

PharmFree Scorecard (AMSA, 2012): A for a policy with a

score of 85% or higher; B for a policy with a score of 70% or

higher; C for a policy with a score of 60% or higher; D for a

policy with a score of 40% or higher; and F for a policy with a

score below 40%. Additionally, an Average Criterion Strength

was determined for each criterion by calculating the mean score

for that criterion from all six policies.

Results

The presence of COI policies among Canadian medical

schools can be seen in Figure 1. In August 2011, six of the 17

Canadian medical schools (35.2%) had completed their facul-

ty-wide policies on physician interaction with industry, while

the remaining 11 schools had not (64.7%). Among schools with

existing policies, three had been implemented at the time of

review (17.6%). The other three existing policies had not been

implemented (17.6%), but will be in the near future.

Results from the evaluation of the six existing policies are

shown in Figure 2. For reporting purposes, medical schools

were assigned an identifier based on the implementation status

of their policy. Medical Schools A through C had policies that

Figure 1.

Status of COI policies among all 17 Canadian medi-

cal schools.

Figure 2.

Grading of Canadian medical schools’ COI policies using a modified AMSA PharmFree Scorecard. *Indicates policies that were implemented at the

time of revi ew.

M. G. R. BEYAERT E T AL.

Given these differences in quality between implemented and

non-implemented policies, it is difficult to make meaningful

comparisons of Average Criterion Strength, especially because

several criteria that were present in at least two out of the three

implemented policies were absent in at least two out of the

three non-implemented policies. Nevertheless, the Average

Criterion Strength was still useful for identifying general

strengths and weaknesses of policies. Strengths were consid-

ered criteria with an Average Criterion Strength of 2.00 or

greater: Gifts and Meals (2.50), Support for Educational Pro-

grams (2.33), Support for Research (2.33), and Industry Access

to Faculty, Trainees, and Students (2.17). Weaknesses were

considered criteria with an Average Criterion Strength of 1.00

or lower: Guidelines for Compensation (1.00), Ghost-writing

(1.00), Purchasing (1.00), COI Training (1.00), and

Off-Campus Events (0.83).

Discussion

The new reality is that interactions between industry and

physicians will continue to be pervasive throughout a phy-

sician’s career. The current study provides new insight into how

the medical profession recognized this potential for bias and

produced accreditation policies and procedures to assure that

medical education is not biased due to commercial support.

In addition, organizations like the AFMC have taken the ini-

tiative to bring key leaders in education to the table for dis-

cussion and standardization since 2010. The Brief Report of

Highlights of the AFMC Hosted 2nd National COI Meeting

alluded to the following challenges: disclosure requirements,

buy-in from faculty, definition of what constitutes a COI, need

for education, alignment with local health care facilities, and

the reliance on industry support for Continuing Professional

Development (CPD). The CFMS has taken a stand towards

raising awareness and education in the early part of training.

Canadian schools have recognized that the management of COI

and bias is a serious issue needing new policy direction and

innovative practices. Our finding that 35% of Canadian medical

schools responded by creating formal policies indicates that

schools are taking appropriate steps to address COI. It is also

encouraging that half of existing policies have been imple-

mented and the remaining policies will be implemented in the

near future. However, there are still major steps to be taken

moving forward as 11 schools (roughly 65%) still do not have

formal COI policies.

Our results indicate that the strength of existing policies var-

ied substantially, with Policies Scores ranging from 25.00% to

70.83% and a Mean Policy Score of 52.08%. However, our

results also indicate differences between policies that have been

implemented and those that have not, particularly in terms of

overall policy strength. All implemented policies scored higher

than non-implemented policies in our evaluation, and had Poli-

cy Scores ranging from 66.67% to 70.83%. These scores cor-

respond to letter grades of C and B using AMSA’s PharmFree

Scorecard cutoffs. In contrast, Policy Scores of non-imple-

mented policies ranged from 25.00% to 43.75%, or letter grades

of F and D, respectively.

While implemented policies tended to address more criteria

than non-implemented policies (14.3 vs. 10.7, respectively),

this was not the only contributing factor to the difference in

Policy Scores. Only one criterion from all three non-imple-

mented policies received an ideal score of 3, compared to 21

criteria that received a score of 3 among implemented policies.

Therefore, implemented policies not only covered a broader

range of criteria, they also had stronger content.

Using the AMSA scoring system to evaluate similar criteria,

the strength of university-wide COI policies ranged from 30%

to 55% among Canadian universities with medical schools,

with a mean score of 44% (Mathieu et al., 2012). However, it

must be noted that the authors evaluated university-wide poli-

cies, whereas the present study evaluated policies specific to

Canadian Faculties of Medicine. Therefore many of the weak-

nesses in university-wide COI policies reported by Mathieu et

al. may be a result of evaluating general university-wide poli-

cies using a scoring system developed specifically for medical

schools.

Our results also indicate a number of clear strengths and

weaknesses among existing policies. While it is difficult to

make definitive conclusions given distinct differences in crite-

ria inclusion between implemented and non-implemented

schools, some general observations can be made.

Four criteria had Mean Criterion Strengths greater than 2.00:

Gifts and Meals (2.50); Support for Educational Programs

(2.33); Support for Research (2.33); and Industry Access to

Faculty, Trainees, and Students (2.17). Mathieu et al. also

found that guidelines for research were strong among Canadian

university COI policies and reasoned that this is because all of

Canada’s medical schools are part of research-intensive institu-

tions. In contrast to our findings, Mathieu et al. identified Sup-

port for Education and Industry Access as weaknesses (Mathieu

et al., 2012). As these issues are likely to be more common

within medical education than in other disciplines, it is encoura-

ging that Faculty of Medicine COI policies scored greater in

these areas than university-wide policies. Five criteria had

Mean Criterion Strengths of 1.00 or less: Guidelines for Com-

pensation (1.00); Ghostwriting (1.00); Purchasing (1.00); COI

Training (1.00); and Guidelines for Off-Campus Events (0.83).

Many of these weaknesses were also identified by Mathieu et al.

(Mathieu et al., 2012).

This study does have some inherent limitations. It must be

acknowledged that the present study only evaluated COI poli-

cies from each school’s Faculty of Medicine, although some

criteria may be included in university-wide policies. However

we felt it was important to focus within the context of medical

education, as both the AMFC and CFMS have urged medical

schools to adopt their own COI policies. While Faculties of

Medicine still fall under the jurisdiction of broader univer-

sity-wide policies, it is still critical to develop policies specifi-

cally for the physician community given the unique circum-

stances encountered by this population. Additionally, univer-

sity-wide policies have been previously evaluated from a

medical perspective (Mathieu et al., 2012).

While reviewing these policies does provide insight into their

strength and quality, it does not allow us to assess how knowl-

edgeable individual faculty members are about the policy or

how closely the policies are being followed. Nevertheless, the

development of strong policies is a necessary first step towards

better management of COI among Canadian medical schools.

We believe this environmental scan will help raise awareness

of the importance of this issue to those within the continuum of

education and prepare them for the challenges in the shift from

guideline to policy development and implementation. We hope

that schools will take note of this study and improve the

strength of their policies. We encourage Canadian Faculties of

220

M. G. R. BEYAERT ET AL.

Medicine to learn from the experiences of other schools in the

development and implementation of their COI policies. Addi-

tionally, several excellent suggestions have been provided in

the literature. Notably, Smith and Williams-Jones made exem-

plary recommendations for the development of COI policies in

Canada (Smith & Williams-Jones, 2009).

Our goal is that a similar system to the AMSA PharmFree

Scorecard will be put in place in Canada to grade medical

school COI policies and track the progress in a continuous lon-

gitudinal initiative. AMSA has achieved great success with

their initiative in the US, as the overall quality of medical

school COI policies has improved every year since the introdu-

ction of their scoring system (AMSA, 2012). We believe simi-

lar success can be achieved in Canada. We propose that this

could be done by some of the organizations in the National COI

group such as CFMS, a Canadia n organization similar to AMSA,

in collaboration with academic CME/CPD offices in Canada.

In conclusion there are important lessons learnt from this

early study, that is sharing of experiences in implementing

these policies through education in Canadian medical schools

would be beneficial through a national COI group. There is

ongoing need to identify appropriate management of COI’s and

bias through educational strategies in all academic institutions.

Academic health sciences centers should ensure that any and all

partnerships between themselves and industry serve the best

interest of patients. Using information gleaned from this study

for longitudinal evaluation and continuous quality improvement

in education is the vital next step.

Acknowledgements

The authors are pleased to acknowledge the assistance of

Larissa Husarewy c h in the submission of this manuscript.

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