Learning under the influence

Vet schools developing ethics policies to avoid conflicts of interest
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Woman in sponsors-logoed lab coat holding clipboard and penStep onto any veterinary school or college campus, and if you pay attention, you'll notice a subtle presence throughout. It could be the fliers announcing a nutrition talk by a speaker who mentions only a certain pet food company's products. Or it could be a faculty member who also happens to be a paid consultant for a pharmaceutical company.

But that may be changing. A few veterinary schools and colleges have implemented policies that emphasize transparency and eliminate corporate giveaways and free lunches for students and faculty. Other institutions are considering similar moves.

The Association of American Veterinary Medical Colleges has given further momentum to these changes with its recent approval of an ethics document that provides guiding principles for schools looking to develop their own policies.

Changes in policy

The University of California-Davis School of Veterinary Medicine is one of those institutions that has recently adopted a more stringent ethics policies. The school altered its Health Care Vendor Relations policy in 2010 to reflect more general University of California policies regarding pharmaceutical, medical supply, and pet food companies. 

Health care vendors, for example, may not directly provide food or any other gifts to faculty, staff, or students; however, small items may be provided to those who visit a booth at a university event or who attend a presentation made by the vendor, according to the policy.

In lieu of gifts or food, companies can make a donation to the school, with the funds deposited into a university account. Two accounts have been established, one for unrestricted gifts and one for gifts limited to funding educational activities of the students. Both are managed by the SVM Office of Student Programs.

The University of Wisconsin-Madison School of Veterinary Medicine developed similar guidelines after a university-led effort caused the school to re-evaluate its policies related to conflicts of interest and industry involvement.

The UW-Madison Health Sciences Council, comprising the schools of medicine and public health, pharmacy, nursing, and veterinary medicine, convened a task force this past year to clarify and strengthen policies governing relationships with the health care industry. Associate deans and student representatives from each of the schools formed the working group, which arrived at the final policy statement and gave its approval in April.

It recommended, among other things, the following:

  • Faculty and staff disclosing in their syllabuses any relationships with commercial entities that could constitute a conflict of interest.
  • Faculty, staff, and students being barred from accepting any personal gifts or promotional items from industry.
  • Discouragement of industry sponsorship for student organization events.
  • Not allowing presentations that focus on or promote a commercial entity's product, device, or service.
  • Barring companies from distributing samples of medicines or other products to students.

"It evolved on the basis of concern that has been noted all around the country that the educational process—not just for professional degrees but also continuing education—be developed by faculty, based on the best scientific knowledge at the time without any real biases," said Dr. Daryl D. Buss, dean of the UW-Madison veterinary school.

"It's also to avoid unintentional bias, which is much more likely to be an issue."

When talking with companies, Dean Buss said, their concern has been that all companies be treated the same, "and that's our interest, too; otherwise, we set up our own conflict of interest."

He continued, "We have found that companies that we've worked with are very conscientious and want to operate within the policy, and we want that to happen as well."

Other institutions with ethics policies include the University of Florida, whose faculty developed its own guidelines in October 2008.

AAVMC guidelines

For veterinary schools and colleges that do not have guidelines for interactions with companies, the AAVMC adopted an ethics document at its July 17 meeting. The purpose is not to provide rules but to provide guiding principles for schools as they develop their own policies, said Dr. H. Michael Chaddock, deputy executive director of the AAVMC. The principles pertain not only to industry but also to any external influence that could introduce bias.

Areas the guidelines touch on range from continuing education to use of generic versus brand names in student instruction to maintaining intellectual independence of individuals and the institution.

According to the document, available soon at www.aavmc.org: "Schools and colleges of veterinary medicine hold a public trust, with the expectation that educational, clinical, research and outreach programs will be based on the best, current and unbiased scientific knowledge. That information must be free of biases or inappropriate influences that may result from interactions with external entities, especially with companies that provide goods and services of value within veterinary medicine. ... The institution and the school/college share a responsibility of managing that support in a manner that ensures the integrity and independence of all of its academic programs."

The Colorado State University Professional Veterinary Medical Program, led by associate dean Dr. Peter Hellyer, is developing ethical standards specific to the program, governing corporate gift giving, that will be consistent with the AAVMC guidelines. Dr. Chaddock said he hopes others will follow.

Dean Buss said it's time for veterinary schools to recognize that things such as freebies have been shown to influence behavior and preferences. Plus, the AAVMC believed it was important for schools to be proactive, not because of any big issues or problems, but to ensure that concerns don't arise in the first place.

Activities in human medicine

Data remain scarce on the veterinary side, but research on how industry gifts and representatives influence doctors on the human medicine side can provide some helpful insights.

It has been documented that doctors tend to prescribe drugs that pharmaceutical companies promote to them, and patients may end up paying more but not always getting the most suitable medications. That's according to an analysis of 58 studies that was published in the October 2010 issue of the journal PLoS Medicine.

"Interactions with pharmaceutical representatives increase the likelihood of physicians making formulary requests for drugs with no clear advantage over existing ones, prescribing nonrationally, prescribing costlier drugs, and prescribing fewer generic drugs. All of this, yet, physicians often deny the influence of pharmaceutical promotion," according to the PLoS study.

A national survey specifically looking at medical students revealed that they, too, are just as influenced by drug makers, whether they admit it or not (JAMA 2005;294(9):1034-1042). The study provides information about student experiences and attitudes related to drug company interactions. It showed that most students perceive that they are entitled to gifts. Many also think that sponsored educational events are likely to be biased but are helpful. In addition, most think that their prescribing habits will not likely to be influenced by these interactions, but that their colleagues will be more likely to be influenced.

According to the study's authors, this combination of perceptions, along with the high exposure to these interactions, suggests that as a group, medical students are at risk for unrecognized influence by marketing efforts.

The American Medical Association and the American Medical Student Association developed guidelines or recommendations about drug company–physician interactions and drug company–student interactions years ago to prevent such influence. AMA guidelines state that gifts to physicians must be primarily for patients' benefit and of insubstantial value, with no conditions attached. AMSA recommendations urge physicians and students to not accept gifts from drug companies and urge hospitals and residency programs to discontinue drug company–funded lectures and lunches. In addition, the AMA guidelines oppose the granting of continuing medical education credits for attending drug company–sponsored events.

The AMSA's PharmFree Campaign takes the issue of reducing corporate influence one step further. It's a national movement that aims to reduce conflicts of interest at medical schools by educating and training medical students to interact professionally and ethically with the pharmaceutical industry. The PharmFree Scorecard ranks U.S. medical schools on the basis of the extent to which their policies limit the access and influence of pharmaceutical companies and their representatives at schools.

gift items
Companies often hand out freebies to veterinary students at information fairs, sponsored lunches, and the like throughout students' time in veterinary school. (Photo by R. Scott Nolen)

The AMSA itself has banned pharmaceutical advertising and sponsorships at regional and national conferences; in the AMSA's magazine, The New Physician; and on the organization's website, www.amsa.org.

Veterinary students speak

The Student AVMA decided to weigh in this past summer after chapter presidents asked the organization to do something about the matter. SAVMA House of Delegates members voted July 18 to create a Task Force on Corporate Funding. It will seek to address the extent and appropriateness of corporate funding at veterinary schools and colleges. Then, task force members will develop recommendations for the SAVMA HOD.

SAVMA President Joseph M. Esch said sometimes decisions get made at academic institutions without student input. He's hoping whatever guidelines or recommendations come from the task force will be considered by individual schools or, at the very least, that schools will solicit student input when creating their own policies.

From his own conversations with fellow classmates, Esch said students see value in maintaining interactions with companies one way or another as preparation for their transition to veterinarians.

"This is not human medicine where you have a purchasing department. Here you often have veterinarians deciding on what products to purchase and from which company. You're going to have people coming from companies to make a pitch about a product in practice. ... Interacting with (company representatives) in school is a way to learn how to properly interact with these representatives. If (students) can't do that in school, they'll be at a disadvantage out in practice," Esch said. This way, he said, students can learn how to critically evaluate a product, its efficacy, and the research behind it.

In addition, industry supports a lot of important initiatives at veterinary schools and colleges, from student clubs and organizations to white coat ceremonies to informational lectures supplementing weaker points in the curriculum, he said.

Michelle Dally, JD, views the relationship between students and industry more skeptically. She penned a commentary earlier this year questioning the prevalence of freebies at Colorado State University, where she is a third-year veterinary student (see JAVMA, June 15, 2011).

She admits the article hasn't made her the most popular person amidst her classmates, as she'll be congratulated and teased alternately on her way to class. The reaction she's received outside Colorado has skewed far more positive with many emails—some from as far away as Australia—commending her for bringing the issue up for discussion.

On the one hand, she acknowledges the difficulty in not accepting things such as free or discounted pet food, particularly when veterinary students tend to have more pets or large student loans. On the other hand, her research solidly convinced her of the strong influence that these offerings from companies can have.

Dally saw proof of this phenomenon while writing about politics for more than a decade. She said the constant question in that field is "Whose side are you on?"

"I get to vet school and see gifts, and immediately I think, 'Whose side are you on?' You're supposed to be on the animal's side, only thinking about the pet in front of you and the owner, but if there's corporate influence involved, that can change whose side you're on," she said.

Industry involvement

So, what do the companies think about these policies?

Dr. Christine Jenkins, director of Hill's Pet Nutrition's Academic Affairs, said her company appreciates the intent and importance of the AAVMC's new guidelines. The policy, specifically its definition of ethical practices and avoiding conflicts of interest, is consistent with Hill's own code of conduct and business practices.

Hill's, Iams, and Purina may be best known on veterinary school and college campuses for their college feeding programs. These pet food companies donate their products for fundraising purposes to veterinary schools and student chapters. Proceeds from the sale of these products are meant to pay for educational initiatives, including scholarship programs, tutoring services, and student activities. Dr. Jenkins said the Hill's program "aligns with our mission to help enrich and lengthen the special relationship between people and their pets."

Pharmaceutical companies such as Pfizer and Bayer spend millions annually not only on programs that support educational symposia, veterinary teaching hospitals, and research but also on continuing education, scholarships, and tools for veterinary student education.

Dr. Cristiano von Simson, director of veterinary technical services for Bayer, said the company is on veterinary campuses for many reasons.

"A lot of important scientific information is being generated and shared by the researchers at veterinary schools. Also, some of the best experts are in veterinary schools, and we get involved because we believe we should do our part to help the future veterinarians get the best education possible that will ensure their success in the profession," Dr. von Simson said.

The company doesn't believe any new ethics guidelines would present new challenges or further constrain Bayer from how it already operates.

"The AAVMC guidelines are welcome and will be useful if they can help veterinary schools harmonize their guidelines," he added.

Dr. Michael McFarland, group director of veterinary medical services at Pfizer, said his company has been working with the schools for a number of months as they develop their own codes of conduct to ensure that the company's policies and procedures fit accordingly.

Pfizer and other companies have adapted in a number of ways, from no longer funding student representatives or scholarships at the schools to not donating products such as heartworm medication during heartworm prevention days held on campus.

"At this point, it seems fairly clear that there won't be a consistent or certainly not an identical set of guidelines across all 28 schools in the U.S. This will require some level of customization for each school," Dr. McFarland said. "What we are committed to is working with integrity, and we feel our existing programs do exactly that. It's not an effort to unduly influence. By and large, our efforts are designed to educate."

Ethics reform makes its way to research field

The National Institutes of Health released on Aug. 23 its final conflict-of-interest reporting rule for researchers who receive grants from the agency. Federal officials said the new policy would build public trust in the integrity of biomedical research by strengthening transparency and oversight.

The NIH first proposed the rule in response to concerns expressed by Congress and others that some researchers receiving grant money from the NIH don't disclose the full extent of their financial connections to private companies, such as drug and device manufacturers.

Under the new rule, researchers who receive grants from the NIH will first be required to report to their universities not just about how their financial interests in a company or other entity might affect a particular federal project or grant but also how it might affect all their "institutional responsibilities."

These include NIH-funded research, consulting, and membership on university committees. Excluded from reporting requirements are payments from universities and governments for lectures or other forms of teaching as well as payments from academic teaching hospitals and research institutes affiliated with universities.

Under the old rule, investigators decided which conflicts to report to the university, rather than reporting every potential conflict. The new rule also lowers the dollar threshold—from $10,000 to $5,000—at which researchers must report conflicts of interest to their academic institutions. Plus, universities must now develop plans for managing or reducing such financial conflicts, providing highlights of the plan to the NIH.

The last time the rule was changed was in 1995.