Conflict of Interest Disclosure in Early Education of Medical Students

Abstract

MEDICAL EDUCATION HAS EMBRACED THE transparency movement by shining the light of disclosure on physician-industry interactions. Many medical journals mandate that authors report potential conflicts of interest and publish detailed financial relationship lists with their articles. Likewise, the Accreditation Council for Continuing Medical Education requires disclosure of lecturers’ conflicts before lectures qualifying for continuing medical education (CME) credits. Despite these changes in physician education, disclosure norms have not yet trickled down to the very start of medical education—the preclinical years. Are firstand second-year students justified in expecting conflicts of interest disclosure in their education? The clinicians and researchers who lead preclinical medical education at US medical schools are usually drawn from affiliated medical centers and therefore are likely to have financial ties to industry. In the context of physician education, financial relationships to the subject matter have been shown to induce selective presentation of data or biased interpretations. Nonetheless, the typical rationales for conflict of interest disclosure do not apply in the context of preclinical education. The ultimate justification for disclosure is that biased statements can influence the care patients receive. Because medical students do not prescribe medications and have little patient care responsibility, there is less direct potential for harm. In addition, the first 2 years of medical education are largely spent studying basic biological sciences and pathophysiology. In the context of a CME event, it is easy to see how a speaker’s financial relationship to a specific pharmaceutical company could be relevant to the therapeutic recommendations, such as the best choice for treatment-refractory depression. In an analogous lecture to medical students on the neurobiochemical basis for depression, the mention of specific therapies may only serve as examples to illustrate the underlying scientific concepts. However, these perspectives miss the essential role that disclosure can have in early medical education. For example, as students learn details about anatomy and physiology, they also are beginning to construct a framework for analysis of data and application of data to clinical reasoning they will use as practicing physicians. In this light, a policy that requires disclosure of financial conflicts of interest before the start of any lecture would serve as a powerful reminder to a medical student audience about the potential for bias in the presentation of scientific information and therefore the need to be critical evaluators of the material being taught. Such lessons will be particularly useful when these students later need to weigh the risks and benefits of a new, heavily promoted therapeutic product or analyze the design of clinical trials that led to treatment recommendations. Promoting critical thinking in medical professionals may be easier to accomplish at a time when students’ clinical reasoning skills are just beginning to be developed than trying to create this skill after the students graduate, enter residency training, and subsequently practice. The mere existence of a disclosure policy can also affect students’ professional development. In addition to lessons in the formal curriculum, students are deeply influenced by the behavior of role models, institutional policies, or other characteristics of the learning environment cumulatively known as the “hidden curriculum.” Most students do not enter medical school having reflected on the scope and influence of interactions between physicians and the pharmaceutical and medical device industries; however, the acculturation process can occur rapidly. For example, surveys reveal that students further along in training have more positive attitudes regarding issues such as the appropriateness of accepting gifts from pharmaceutical representatives. The existence of a disclosure policy would communicate that an institution values the integrity of medical education. The practice of disclosure also provides a stimulus for students to begin dialogues with peers and advisers and consider their own ethical views on the controversial topic of