As 2009 plays out, physicians will likely see fewer pens, coffee cups and other trinkets bearing the logos of popular drugs, as new voluntary guidelines from the pharmaceutical industry's trade association take effect. The Pharmaceutical Research and Manufacturers Association (PhRMA), which represents many large drug firms, put a new marketing code into effect on January 1, in response to criticism of the billions of dollars in marketing its members spend to influence physicians' prescribing practices.
But doctors aren't the only ones whose objectivity is under scrutiny. Health journalists also face conflict of interest problems. Journalists working on television, in print and online play a vital role in explaining complex medical research and clinical decisionmaking to consumers, making reporters' credibility and trustworthiness precious both to their own professionalism and to society at large.
But critics say journalists put that trust in jeopardy when they allow themselves to become too close to the industries they cover by using quotes from patients provided by a hospital or drug company, or by participating in industry-sponsored journalism contests with fat cash prizes. It's particularly important for journalists who are writing about controversies around industry influence in medical research to avoid the same conflicts in their own work, they say.
“Any journalist who regularly covers drugs or devices should be familiar and sensitive to conflicts of interest in the sources they are reporting on, and should hold themselves to at least as high a standard,” argues Andrew Holtz, an independent journalist in Portland, OR, who sits on the board of directors of the Association of Health Care Journalists (AHCJ) and is a former CNN correspondent. “You have to look at what's the highest standard out there, and take it a notch higher.”
The Shifting Media Landscape
The problem could become thornier as the very definition of “media” changes by the day. Traditional news organization—major metropolitan newspapers, news magazines and network television news operations–are taking heavy financial hits and laying off large numbers of journalists. At the same time, anyone can become an instant expert online by starting a blog, with no requirement that they have a background in journalistic ethics. “With more reporters working freelance, there may be more wiggle room around conflict of interest standards,” says Steve Woloshin, MD, associate professor of medicine at the Center for Medicine and the Media, Dartmouth Institute for Health Policy and Clinical Practice in Hanover, NH. “With the blogosphere, god knows what protection there is.”
Dr. Woloshin, along with Lisa Schwartz, MD, co-director of the center, and journalist Ray Moynihan, wrote a paper in the November 22, 2008, British Medical Journal raising questions about potential conflicts for health journalists.1
The center's staff holds seminars for journalists on accurately reporting medical research, and in the course of working with reporters would hear stories about how drug companies routinely offer interviews with patients who have positive things to say about using their products, Dr. Woloshin said. Print journalists traditionally avoid the use of quotes from press releases or that are provided by a source with an interest in the outcome of a story, and the practice is discouraged in the 2004 statement of principles adopted by the AHCJ.
The authors decided to catalogue these and other ethical conflicts faced by health journalists. For instance, they questioned the University of North Carolina medical journalism master's degree program, which has accepted pharmaceutical company money to endow a professorship and fund a minority scholarship.
Glaxo Wellcome provided $333,000 toward the Glaxo Wellcome distinguished professorship back in 1996. Tom Linden, MD, a psychiatrist and broadcast medical journalist, was named to the professorship in 1997. Schwartz et al wrote that even if there is no evidence that the drug company influences the curriculum in the medical journalism program, its sponsorship “could send a symbolic message to students and engender a subtle sense of loyalty to the industry.”
The article also questioned a separate Pfizer medical journalism scholarship worth $28,000 per year along with health care benefits.
Dr. Linden and the UNC journalism school dean, Jean Folkerts, wrote a spirited defense of their program on the BMJ's Rapid Response section online, arguing that the authors had “engage(d) in a pernicious form of journalism by invoking guilt by association and innuendo.”2 They noted that Dr. Linden is a salaried employee of the university and does not receive direct funding from any pharmaceutical company. They also said that Pfizer has no input in the selection of the minority scholarship or any of their activities.
“We are not shills for the pharmaceutical industry or any other interest group,” they wrote. “We are aware of the pitfalls of conflict of interest and thwart such with transparency, peer review and conscience.”
Folkerts and Dr. Linden both declined requests to discuss the issue and said by email that their comments on BMJ's Web site adequately address their point of view.
The controversy is reminiscent of similar skirmishes over industry sponsorship of medical education programs. For instance, the American Academy of Dermatology caught fire from some of its members for establishing an industry fund to create dermatology residency spots in 2004. Even though the organization created a mixed pot of money from a variety of industry sponsors so the residents would not feel a connection to any specific firm, some dermatologists saw the move as a conflict.
Where Their Bread is Buttered
Specialists in medical ethics tend to agree, arguing that the residents will clearly know which companies made their educations possible and are more likely to have positive associations with those firms while practicing. “It's commonly done, but we don't like it,” says Susan Chimonas, PhD, associate research scholar at the Institute on Medicine as a Profession at Columbia University College of Physicians and Surgeons in New York. “It's common for trainees and fellows to be branded like that.”
Dr. Chimonas continues: “We really wonder what impact it has for somebody who is a new physician and has their whole career in front of them, that they know their training was made possible because of this company. We would like to see that all end. I would think that the same should apply for journalists.”
Cash Prizes
The BMJ article also criticized journalists who participate in industry-sponsored journalism contests that carry large cash prizes or overseas trips.3 Among others, they cited the Roche international award for obesity journalism, whose 2 winners each receive 7,500 Euros and a trip to an international obesity congress, and the Boehringer Ingelheim Eloquium COPD communication award, which carries a 5,000-Euro prize.
The AHCJ principles urge health journalists to weigh carefully the benefits of participating in such awards contests before entering. Holtz says most journalists avoid award programs sponsored by industry because of the potential for appearing biased. “Journalists can fall into that trap and believe they can make unbiased judgments despite some potential conflicts,” says Holtz. “There are journalists out there who believe they are immune to it and accept these things and think it's fine.”
AHCJ itself has struggled with what types of funding to accept for its own activities, such as an annual conference. The organization chose not to accept funding or sponsorships from pharmaceutical and device makers, and has turned down their offers. However, the health care journalists do accept funding from independent foundations such as the Robert Wood Johnson Foundation, the Kaiser Family Foundation, the Commonwealth Fund and the California Health care Foundation. AHCJ has also accepted funding from nonprofit academic medical centers.
Holtz acknowledged that these organizations may have their own agendas, particularly when it comes to health care policy. But the organization has been careful not to allow any strings to be attached to the money and believes foundations and academic institutions are quite different from for-profit corporations, Holtz says.
Another journalism organization that includes people who write about health and medicine is the National Association of Science Writers, which carries out a smaller yearly conference (1 day versus 4 days for AHCJ) and maintains a much smaller office staff. National Association of Science Writers President Robert Lee Hotz explained in an email that the organization accepts no money from industry, lobbying groups or special interest organizations. The science writers group is supported solely by dues, classified job ads and user fees.
Evolving Medical Ethics
The new scrutiny on both doctors and journalists has gained steam over the past several years as revelations about exactly how drug and device makers have been spending their marketing budgets to influence the way their products are seen and used. Also, research was indicating that gifts, stipends and honoraria from drug companies influenced physicians' treatment decisions.
Over the past several years, medical schools have begun adopting stricter rules for when their doctors can accept gifts and meals from drug companies, and when they can be paid for participating in industry-sponsored continuing education programs. In 2008 the Association of American Medical Colleges approved a series of guidelines on conflict of interest that prohibit all gifts from industry, allow no industry-provided meals, and recommend that product samples be centrally managed. They also propose that funding for continuing medical education be funneled through a central medical center office rather than via individual academic departments.
Despite a lot of trepidation about physicians accepting these changes, they've been adopted with relatively little conflict at medical schools, say Dr. Chimonas, who has carried out interviews at a number of academic medical centers on the topic. “Even people who thought it would be a disaster or unnecessary said it made the institution a cleaner place,” Dr. Chimonas says.
The American College of Emergency Physicians (ACEP) has maintained a policy on gifts to emergency physicians from the biomedical industry since 1992, and has amended it several times, most recently in 2002, with a policy resource and education paper expanding on the topic issued in 2005.
The ACEP policy calls for disclosure of any gifts, and that they should be of minimal value and either benefit patients or serve a genuine educational function. Conference attendees, the policy states, should not accept direct subsidies from industry to pay for meeting costs, and conference faculty should be compensated by industry only for direct costs and the physician's time.
The Ties That Bind
Meanwhile, the financial conflicts issue has made it to Congress, where Senator Charles Grassley (R-Iowa) has focused on physicians and medical researchers' financial ties to industry, uncovering multimillion dollar undisclosed conflicts of several high-level investigators. However, he recently called out Fredrick Goodwin, MD, an influential psychiatrist who was the host of the popular National Public Radio program “The Infinite Mind,” the first news media figure caught up in the scandal. Grassley has proposed the Physician Payment Sunshine Act, which would require disclosure of industry payments to doctors to the Health and Human Services Department.
Such action is less likely for journalists, given that there's no such thing as a license to practice journalism and given the First Amendment, there probably never will be. “I don't see you how could ever license a journalist,” says Holtz. “Everyone should be able to say something in public.”
Still, even some in journalism believe some kind of certification for medical reporters might be appropriate given how important–and difficult–it can be to place medical research and practice into context for the public. As proposed in a 2005 article in the Columbia Journalism Review by University of Minnesota journalism professor Gary Schwitzer, such a certification could help television broadcasters prove that they've been trained to interpret health news, similar to how the American Meteorological Society offers a seal of approval to broadcast meteorologists.4
Schwitzer focused on broadcast reporters because of what he saw as “the quality of health news and information (having) plummeted to a level that makes watching many TV health stories an unhealthy activity.”
At the same time, given the plummeting budgets of local news stations and other parts of the mainstream media, maintaining standards of quality reporting and objectivity may be difficult. Holtz acknowledges that as the media landscape rapidly changes, it can be hard for the public to identify a trustworthy source of information about any topic, including medical information. “I'm hoping that as we move forward, readers will start seeing there is a difference between professional journalism and casual blogging and people who are taking gifts from industry. It's up to every news organization to demonstrate that through what they do.”
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