How To Really Take Medical Conflicts Of Interest Seriously

If we’re going to have a central database of conflict of interest disclosures in medicine—and there is one, created by law—it’s high time that people start using it.

This weekend, the New York Times, working with the nonprofit ProPublica, reported on its front page that Jose Baselga, one of the world’s top oncologists and the chief medical officer of Memorial Sloan Kettering Cancer Center, failed to disclose financial conflicts of interest when he wrote articles for medical journals including the New England Journal of Medicine. That includes more than $3 million dollars Baselga made when Roche bought Seragon, a startup that had paid him in stock.

The big message is that most people don’t realize that doctors can be paid large sums of money by drug companies, and that making sure these sums are disclosed is important if one doesn’t want the whole enterprise of developing drugs to appear crooked. That’s why the a 2010 law called the Physician Payments Sunshine Act—which makes the highly unusual decision that a whole class of people (doctors) should have no right to privacy over payments made to them by drug companies—exists.

“If you do science (some of it taxpayer funded, others intended to influence decisions of regulatory agencies), lead a not-for-profit academic institute, lead a professional society, then having to tell the world about your related financial interest is the price you pay for the privilege of being allowed to hold those interests in the first place,” tweeted Steven Joffe,the Emanuel and Robert Hart Professor of Medical Ethics and Health Policy at the University of Pennsylvania.

The Times story was arguably not fair to Baselga in some ways. It blurred the line between a consulting payment (what doctors usually get from drug companies) and the Roche’s purchase of stock he owned. Consulting payments create the expectation of an ongoing relationship. Purchasing a company is different, and may create gratitude, but doesn’t hold out a future incentive for Baselga to be nice to Roche. He already has the money. It is a conflict, but the distinction is worth making. Without the Seragon stake, the dramatic statement that Baselga withheld "millions" would not be true.

The article also stretches to portray comments in which he called a drug's effect modest but said that was still scientifically exciting as positive spin.

But there's no question Baselga should have disclosed the payment. It's baffling that he didn't, and shows how cavalier many physicians are about disclosure.

To quote from a New England Journal disclosure form: “You should disclose interactions with ANY entity that could be considered broadly relevant to the work.” An entity paid you three million bucks? Seems broadly relevant.

This leads to deeper questions: How is it that a medical journal would allow a physician not to disclose a payment that exists in a public database? How is it that Memorial Sloan Kettering isn’t checking to be sure that Baselga bent over backward to make a relevant disclosure?

The obvious solution: have a public database that includes all those conflicts, and use it.

The one created by the Sunshine Act is a start, and medical journals should  check disclosure forms against it.

But it doesn’t include corporate boards (Baselga is on the boards of Varian and Bristol-Myers Squibb) or companies whose drugs or medical devices are not yet marketed. In the meantime, physicians and their employers should start thinking about disclosing potential conflicts not as an embarrassment to be avoided but as an inoculation against the risk of someone else pointing out those conflicts for them.

As Baselga found out, once someone has beat you at a game of "gotcha!" a defense can be pretty hard to mount.

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