Clear Thinking About Transparency

Conflicts of interest in medicine have catapulted to the front page recently. Congress and the media have criticized relationships between physicians and the pharmaceutical industry (pharma for short). For reasons that are unclear, much of the attention has focused on psychiatrists and APA, though other medical specialties, specialists, and medical organizations have had similar relationships with industry. Psychiatrists receive money from pharma because they work for pharma, pharma pays them for giving lectures or providing consultation, and pharma supports their research. APA receives money from pharma for advertising in our newspaper and journals and from exhibits at our meetings, leadership training for chief residents and research training for minority residents, industry-supported symposia at our scientific meetings, reprints of articles in our journals, and other activities. We follow all established guidelines, including those APA has developed.

There are arguments for and against the acceptance of funds from pharma.

For: It's a very profitable industry; it should support the educational and research efforts of the field. Other sources of support are insufficient to fund crucial activities such as public education and research training for minority residents. As individuals and as a professional association, we can be trusted to act in the best interests of patients. We make clinical decisions on the basis of the scientific literature.

Against: The evidence indicates that even trivial gifts do affect prescribing patterns. That constitutes a conflict of interest. The receipt of money or gifts causes our patients and the public to question our professional integrity—and undermines the credibility of everything we do.

We tend to forget that we all have conflicts of interest all the time. If we are in fee-for-service practice, we benefit financially from seeing patients more often. If we are salaried, we may have incentives to order fewer tests and see patients less often. When hospitalizing a patient or ordering a laboratory test, we may have conflicts between what is optimal for the patient and what is optimal for protecting ourselves against lawsuits. If we develop expertise in a particular area, we benefit when more patients are diagnosed with “our” disorder or referred for our treatment. Serving as an expert witness to testify that litigants either do or don't have a particular disorder, we have an incentive to define that diagnosis narrowly or broadly. We have a conflict when we recognize the need for data to support the efficacy of a treatment, but hesitate to see a patient randomized into a clinical trial because we feel the treatment would benefit the patient. We have conflicts of interest when we could do more for our patients, students, or research or by staying in the office but choose to go home at the end of the day to take care of ourselves and our families. One could almost say that the most crucial decisions in life involve conflicts of interest.

APA has required disclosure of conflicts of interest for years. The speakers at our professional meetings and the members of our Board, councils, and committees must complete conflict-of-interest forms. At the beginning of each meeting of the Board of Trustees, each member announces any relationships that could be construed to conflict with our fiduciary obligation to APA.

When we began the process of selecting the participants in the DSM-V process, we immediately addressed the conflict-of-interest question. The director of the DSM-V process gave up his pharmaceutical income for the duration. After reviewing the disclosure forms of the federal government and major universities, we developed a disclosure form that takes up to eight hours to complete. There is no established standard; we set a limit of $10,000 a year of pharma income per participant. Since we have had complaints that the limit is both too high and too low, we have probably done the best we could.

Another complaint is that APA (and federal offices and many medical schools) do not verify the accuracy of the disclosures. I cannot think how we could do that. If pharmaceutical companies publish information about all payments to physicians, that would be one source, but how would we know whether it is accurate? And pharmaceutical companies are not the only sources of support that pose conflict-of-interest questions. Is it reasonable to ask APA to go through the tax returns of every DSM participant and every member of every committee, the Assembly, and the Board? Would the tax returns even be sufficient? Money often passes through CME organizations, medical schools, APA district branches, and other intermediaries between its source and its recipient.

I believe we are doing what we can: we require extensive disclosure, publish information about pharma relationships, publicly remove from participation anyone who is shown to have deliberately falsified information, and continue to wrestle openly with this complex issue. ▪