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Conflict of Interest in Medical Research, Education, and Practice
The opportunities for supporting organizations to exert influence arise in different ways, depending on the roles and authority of the organization. Accrediting organizations set standards for medical schools, residency and fellowship programs, and institutions that provide health care. State agencies establish rules for the licensing and relicensing of individual physicians, and specialty boards design rules to certify and recertify physician specialists. The National Guidelines Clearinghouse sets conditions for the posting of clinical practice guidelines developed by professional societies and other groups. Public and private health insurers use a variety of financial and other incentives to influence the practices of institutions and individual physicians. The U.S. Department of Justice and the Office of Inspector General of the U.S. Department of Health and Human Services enforce antikickback and self-referral laws that prohibit or limit certain conflicts of interest. NIH promotes and oversees adherence to U.S. Public Health Service (PHS) regulations on conflict of interest for grantees. Professional societies and associations of health care and educational institutions articulate norms and ethical standards for their members. (Some professional societies are both organizations in this sense and also institutions that carry out research, education, and practice guideline development.) Although the Pharmaceutical Research and Manufacturers of America (PhRMA) and the Advanced Medical Technology Association (AdvaMed) represent companies, they establish codes of conduct for their members that may indirectly support medical professionals and institutions by discouraging member companies from interactions that create a risk of undue influence. (As described in Chapter 6, PhRMA and AdvaMed have indicated that they will publicly report on the companies that adopt their recently revised codes.)
Previous chapters have identified various shortcomings in the policies and practices of academic and other institutions. For example, as discussed in Chapter 3, some research institutions have been slow to adopt or adequately implement PHS requirements for conflict of interest policies, some academic medical centers have not adopted key AAMC policy recommendations, and some medical journals have not followed recommendations on conflict of interest from WAME and the International Committee of Medical Journal Editors (ICMJE). Furthermore, it may be difficult to determine a particular institution’s policies. Postings on institutional websites may be incomplete or not up to date, and some institutions choose not to reveal their policies. Such a lack of transparency makes it difficult to assess whether an institution’s policies are consistent with regulations or with recommendations of groups such as AAMC and WAME. As a result, opportunities to strengthen the institution’s accountability for conflict of interest policies may be lost. Supporting organizations may promote consensus on the content of policies and also, in some situations, draw attention to the