Disclosing Conflicts of Interest (especially in medical research)

I attended a talk this morning by Dr. Patrick McDonald, a Paediatric Neurosurgeon based off of Vancouver, on the topic of disclosing conflicts of interest. He shared a lot of wisdom with the attendees and basically inspired me to write this post. Some of the material I have used and/or mentioned in this post are directly or indirectly related to what he presented during his talk.

A lot of us have very busy schedules. Physicians are normally even busier and this might be the premise behind many physicians and surgeons not wanting to add more to their already busy schedules. Disclosing every conflict of interest they might have in a research paper is time consuming, requires a considerable amount of effort and attention and of course, adds more to their already busy schedules. However, doing that could potentially save a lot of time for the same person and/or their fellow researchers in the long run. It could also lower the burden on the healthcare system, save lives of thousands of people and inspire patients’ trust in the healthcare system.

Conflicts of interest arise in situations where we have diverging secondary interests that affect our primary professional obligation(s). For a physician, the primary professional obligation is to treat patients and protect their wellbeing. For instance, secondary interests might arise when the same physician is reimbursed by a company for research they did on a drug or device developed by that company, or when they serve in a board of a non-profit that believes in a specific set of health-related activities, or when they are a practicing member of a religious community that considers a medical act “sinful.” As you can see, not every conflict of interest is financial in nature and it can take various shapes and forms.

Disclosing any “potential” conflicts of interest has been shown to mitigate a lot of problems. It is also common sense that when I’m reading a research article from a researcher about a drug from a company that has “sponsored” the study, I would make sure to tread carefully, do more research and take things with a grain of salt until I have more (independent) data to prove that what the researcher is saying is factually true and that the secondary interests haven’t influenced their primary obligation in a way that would deem the conclusions of the study incorrect. As another example, suppose a researcher believes in an ideology that considers any non-straight sexual act a sin and they report findings in a research article that a specific non-straight sexual act is a health risk to people involved. Consider the different approaches you would take on this finding when the researcher has disclosed their conflicts of interest and when they haven’t. This is also true in disciplines other than medicine. Suppose an environmentalist is a member of the environmental advisory committee to the government. Their views on the environment could potentially impact the way they propose action and eventually pass laws. In contrast, if the person is a firm believer in climate change being a “hoax,” their proposed approach and policy will potentially be influenced by their views as well.

The US government has introduced legislation and some journals have started processes in order to make the disclosures mandatory and open to public. In 2009, the United States government introduced the so-called Sunshine Act that made it mandatory for all the drug and device manufacturing companies to disclose any payments to the physicians. The Centers for Medicare and Medicaid Services has a website that you can type in a physician’s, hospital’s or company’s name and get the information about the payments transferred between the involved parties. Studies have shown that since the introduction of this piece of legislation, a lot of medical researchers have started to disclose conflicts of interest and the amount of nondisclosures, in most cases, have decreased significantly. Canada and some European countries are following suit, but there is still a lot more work to be done.

Last but not least, it is very important to emphasize again that physicians and medical researchers are in no way the only people with conflicts of interest or the only people whose conflicts of interest could result in dire repercussions, nor are all pharmaceutical companies and their C suite executives thinking of their market cap (as you can probably tell, I’m very pro-business and I don’t hold grudges against big corporations just because). Medical research is under a lot of scrutiny because its results and the results of any (even small) misbehaviours are in the public eye, which is not the case for many other fields whose nondisclosure of conflicts of interest could result in repercussions in the same level of magnitude as the ones caused by nondisclosures in the medical field. Therefore, by all means, let’s ask physicians and medical researchers to disclose their conflicts of interest (and I will try to disclose my conflicts of interest as well), but let’s not discriminate against them as the only people who have to report that information. Hopefully, that will open the doors to more open communication and open data that can give us more confidence in trying to make a decision when it comes to our health (and other aspects of our lives as well).


References and further reading:

  1. The Royal College of Physicians and Surgeons of Canada: http://www.royalcollege.ca/rcsite/bioethics/cases/section-3/personal-conflict-interest-medical-research-e
  2. Industry Financial Relationships in Neurosurgery in 2015: Analysis of the Sunshine Act Open Payments Database: https://www.ncbi.nlm.nih.gov/pubmed/29581013
  3. Conflict of interest policies and disclosure requirements in neurosurgical journals: https://www.ncbi.nlm.nih.gov/pubmed/30117775
  4. US conflict-of-interest case draws attention across continent: http://www.cmaj.ca/content/185/15/1309
  5. Avandia Drug Case: https://www.ucsusa.org/silencing-scientist-who-first-exposed-truth-about-dangers-diabetes-drug-avandia#.XEJdEi3Mx24 and https://www.nejm.org/doi/full/10.1056/NEJMoa072761
  6. The Open Payments Data Website: https://openpaymentsdata.cms.gov

Constructive feedback and criticism

Having been a judge in different fairs and conferences for pre-secondary, secondary and post-secondary students, I have had my fair share of listening to students presenting their work, asking them questions both to clarify what they have said and to evaluate them, scoring them based on their research topic, methods, presentation and expertise, and giving them feedback on how they did and how they could potentially improve or do more. I have always heard from the more experienced judges that the feedback should be constructive, regardless of the student’s level and I have tried to implement that to the best of my ability. The problem with this approach most often is that some of us don’t know what constructive feedback really means!

Let’s start with what constructive feedback is not. Constructive feedback is not necessarily an all-positive feedback. It is also not unduly beating around the bush before getting to a point that might upset the person. It is not faking interest and awe when what you have just heard or seen is not up to the expected level. It does not mean evaluating things you are not supposed to evaluate, either, for instance, how great (or awful, for that matter) the personality of the person is (unless, of course, this is what you are evaluating).

Now, on to the constructive feedback itself. Constructive feedback means that you are paving the way for the person to improve. Hence, commenting on things that the person can actually control and/or change. This also means that you are telling the person what is already up to the standards and what is not. Therefore, it is good to start with the strengths and move on to the things that need improvement and then summarize at the end. Speaking from experiences, students who present their findings don’t do it as a one-time thing only. They are mostly interested in doing that frequently. Therefore, the more constructive feedback they receive the better their presentation will be the next time around and the more they will appreciate your help as they continue presenting.

Last weekend, I was at a fair, judging a few projects that were presented by students who were in elementary or junior high school and I got the chance to give them feedback and see some of the other feedback sheets that they had gotten. To my surprise most of those feedback sheets had some variation of these words on them: “Great job!” and that’s it! As much as a teenager would like to hear that they did a great job, they need to know what can be improved. There is definitely something that needs to be improved and if you can’t see that as a judge, then you should probably work on your judging skills or present some sort of work and get criticized by other judges before judging someone else’s work. When I get comments from supervisors or other fellow researchers on a document I have written, whether it be a poster or a thesis or a scientific manuscript, I would like to see a “great job here” or “this is awesome” somewhere in the comments. This makes me even more inspired to continue this line of work. But, I also need to know where my weaknesses lie so that I can improve my current work or works that follow. I know that an elementary school student might be very happy to see a “Great job!” on the feedback sheet, but they are going to be our next generation of journalists, scientists, engineers, supervisors, etc. and that is why we need them to know how to fact check, how to work with the facts, and how not to give fake information or information that is not backed up by evidence. And the road to that starts from these fairs and the projects that they do during their early ages. We have a big responsibility here and that is to prepare them for all those.

All things considered, I think starting with what they did right and well, pointing out the areas that need improvement and finishing off by summarizing the points is the best way to give constructive feedback, whether we are the parents, the teachers, the fair judges or friends. As for the parts that may upset the person, it is good to follow the “is it true? is it necessary? and is it kind?” rule. If what we are trying to say will help them improve, then, why not? If we can make it less upsetting and make them comfortable before saying it, even better! Let’s bring up a better next generation, a generation that will learn from their mistakes and use what they have learned from their mistakes to improve and prosper.

Communicating research

This has been on my mind for a long time now. Time and time again I have seen news articles about research studies that don’t really correspond to the studies they are supposedly reporting. Sometimes, the title of the news article or the main point it conveys is totally different from the one the research study, itself, tries to communicate. Other times, correlation is interpreted as causation, or a statement is extracted from the research paper without its preceding or succeeding statements that explain the conditions in which these results hold true. As a result, I have seen a lot of us, researchers, complain about the media not reporting exactly what we meant in our papers.

One of the reasons for this, I believe, is that we don’t give the media enough information about research and its settings. Obviously, someone who hasn’t been in that setting and/or doesn’t have a clue as to what it entails will not be able to explain it accurately. Unless our journalists are scientists themselves or they have been in close contact with scientific research, they won’t be able to accurately report/communicate research to the general public.

The second reason for this is that our scientists are being trained on how to do wet lab research or how to analyze a specific type of data in a computer program, but not how to talk to the people outside of their field. We are so used to using jargon in our talks and abbreviating long scientific terms in our writings that we forget that our audience may not be the same each and every time.

Having journalists that have trainings in science or have been in a research setting before could help alleviate the first issue. However, I think I can provide more insight into the second issue. One of the things that I think researchers need to know is that if others are not reporting your research or if they are reporting it wrong, you should be doing something about it: Maybe write a letter, very much like the ones you write to scientific journals about the papers they have published, albeit using a different language, to the journalist or the corresponding media outlet. You could also work on your lay-person summary skills and write your own version of what your research entails. Another avenue of action could be to volunteer to train journalists about what it is you do in the dark rooms of your lab every day from dawn to dusk.

All in all, we have to make sure the people that are most often our end product users, know what we are doing about the problems they face everyday. We might even be able to raise money to fund our next project by informing donors about the studies we undertake. I know I’m going to start enriching the tutorial section of my website with related articles and will occasionally write about my research, what it entails and how it can benefit the general public. Let’s make science and research information available to everyone!