American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, September 21, 2015

Industry-funded research: conflict or confluence?

The great public health imbroglio disclosed over recent weeks, in which widely, highly-regarded scientists were found to be running on Coca-Cola funding to enlighten the world about calories and energy balance, continues to reverberate through all forms of media. You have no doubt encountered a bounty of commentary, perhaps including my initial reaction, and more recently, the mea culpa and pledge of better methods ahead in the Wall Street Journal by Coke's CEO, Muhtar Kent. I've encountered it, too, and in addition, have heard directly from some of those most intimately involved, on both sides of the divide.

As the allegations, apologies, rebuttals, sanctimony, and snark have all propagated themselves through the Twitterverse, I have come to the conclusion that this particular crisis of trust in public health nutrition is part of a much larger crisis of trust in public health nutrition, which in turn is part of a far larger, sociocultural crisis, never better expressed than in Cool Hand Luke: What we have here is failure to communicate.

We don't, in general, communicate anymore; we vituperate. We adopt some opinion to which we are natively inclined, and propound it into the ether. Somewhere out there in cyberspace, a kindred spirit, who for all we know may be a delusional sociopath, corroborates our world view. A few other voices of unknown pedigree join the chorus, and we have established the absolute truth and correctness of our view. Of course, others with opposing views have done just the same. Welcome to the world of cyberspatial echo chambers, in which everyone seeks and finds only those opinions they already own, and no one listens to any arguments in favor of what they already know to be wrong.

In public health nutrition, this is costing us all dearly, and playing only into the hands of those who profit from din, discord, and perennially benighted procrastination. We have had opportunity for decades to apply a set of fundamental nutrition priorities, time honored, evidence-based, to the addition of years to lives, and life to years. Instead of rallying around this common ground, however, we have carved it all up into diverse nutrient fixations, dug in, hunkered down, and commenced to hurl epithets and disdain.

This devolution of constructive dialogue into competing monologues is culture-wide, and perhaps nowhere better illustrated than in the U.S. Congress. Even as we, the people, are all frustrated by partisan antipathy so intense that a given party will renounce its own core values and favored policies if required to obstruct and stymie the opposition, we propagate the same tendency. We repudiate it, but as far as I can tell, ever more of us practice it, from the sets of television studios to living rooms, from the halls of science to schoolyards; on topics ranging from climate to guns, civil rights to nuclear containment. We are masters of the failure to communicate.

And that, in turn, underlies the debacle, and debacle it is, of Coca-Cola's salient involvement in our education about calories. We have approached the topic of industry-funded research with the customary subtlety of a sledgehammer, allowing for only two positions: It is all good, or all bad. That encourages proponents to invite us to follow where research should never have gone in the first place, as in the current case. It encourages detractors to propound a brand of piety at odds with practical advance in the real world. The tendency fabricates opposing corners, and fails to draw a line. In the absence of a line, signifying propriety, there is no way to say on which side of that line a given venture resides. So here we are, with proponents running amok, and opponents raving mad.

Were we more adept at communication, and the nuance it requires, we might readily draw that missing line. It would differentiate conflict of interest, from confluence.

Before concluding with that distinction and its implications, I humbly offer a reality check to the purists among my colleagues who renounce industry-funded research wholesale in the ostensible service of public health. Well-intended though such protestations may be, they are devoid of nuance, and misguided.

A blithe, dismissive, and undifferentiating contempt for industry funded research is contempt for virtually all advancement in modern pharmacotherapy, immunization, and medical technology, all of which are applied daily to the relief of miseries, and the extension of countless lives. It is contempt for the next, new chemotherapeutic agent that treats a cancer nothing else can. It is contempt for the new antibiotic that works despite multidrug resistance. It is contempt for the incipient vaccine that will prevent HIV, or Ebola, or chikungaya, or Powassan.

We may, in our want of subtlety, be emulating the drama of our policy makers who hone the craft of castigation, and refine the art of disparaging sanctimony. Among the many illustrations of this is the high-profile case of Al Gore. Back in 2009, he was excoriated by critics, climate change deniers salient among them, for deriving profits from his “green economy” investments. The accusation was that Gore was advocating for the work of companies most likely to prove personally profitable. Gore's rebuttal was the obvious one: he had advocated first, invested after. He had done what we have all been advised to do in proverb, as an expression of consistency, commitment, and integrity: put our money where our mouths are. Do more than talk about what matters to us; act on it. If that is wrong, then much of the lore on which we were all raised is wrong, and our parents are a pack of story-telling hypocrites.

Let us, then, give our parents the benefit of the doubt, and allow for the possibility that funds and faithfulness to a cause may genuinely align. And let us return to the case of calories and Coca-Cola, and the opportunity for opposing factions to come together, and draw a line.

I propose that industry-funded research is not the problem; conflict of interest is the problem. And I would propose that confluence of interest is very different from conflict, but the two are routinely conflated.

If there are generally understood or expected health effects of any given product, and an entity with a vested interest, be it a pharmaceutical company, a technology company, or a food company, funds research to explore the particulars of those effects, i.e., how much, how often, for whom, and by what mechanisms, that is a potential confluence, rather than conflict, of interest. To ensure it is so, rules of research engagement must apply. The researchers must be authorized to publish results be they favorable or unfavorable to the company's interests. The researchers must be autonomous; methods must defend against bias; and there can be no quid pro quo. Given suitable, contractual terms, private entities can, and do, participate in advancing our understanding.

If, however, the marketing, messages, and aspirations by any given private entity for its product or service are at odds with the generally understood or expected health effects, then that company is, ipso facto, conflicted with regard to the unvarnished truth. That entity is an unsuitable funder of research, the goal of which must be true understanding, however stuttering the course to that ideal may prove to be.

Examples are rather self-evident. Given the widely recognized health benefits of vegetables and fruits, produce companies or trade groups funding research to explore such effects would be confluent, not conflicting, with the interests of public health. Vested interest, and public interest, could readily commingle. Given the widely recognized health (and weight) detriments of sodas, a soda company cannot possibly approach research on the topic of energy balance without conflict. Coca-Cola's role with the Global Energy Balance Network is the very prototype of conflict.

I humbly suggest that replication of such perilous folly becomes less likely in a world that supplants sequential monologue with actual dialogue, in which nuance is permissible, and in which a failure to communicate is not the national pastime. We will, I think, more reliably identify, and renounce, conflict of interest, when we allow for the occurrence of confluence.

The intersection of interest, and investment, is not invariably conflict, although it certainly can be exactly that. Sometimes, it is a confluence that serves the interest of investor, investigator, and public alike. Differentiating between the 2, just like distinguishing baby from bathwater, is in the interests of us all.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
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One of the most popular anonymous blogs written by an emergency room physician.

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