Cardiology strikes back: Bove, Lewin, Weber & Black defend ties to industry

In the wake of numerous congressional investigations,  an influential report on conflict of interest from the IOM, a JAMA special communication by Rothman et al advocating that medical groups sever most of their ties to industry, and many other calls for wholesale reform, several groups of influential and powerful physicians are striking back and defending academic ties to industry.

The most visible example of this reaction against reform will take place tomorrow when the first meeting of the Association of Clinical Researchers and Educators (ACRE) will take place at Brigham & Women’s Hospital in Boston. ACRE, in its own words, is

an organization of medical professionals dedicated to the advancement of patient care through productive collaboration with industry and its counterparts. ACRE seeks to define and promote balanced policies at academic medical centers and within government that will enhance rather than interfere with our highly valued collaboration.

Among the leaders of ACRE, in addition to Harvard cancer expert Thomas Stossel, are two well known hypertension experts, Michael Weber and Henry Black. You can read a detailed news article about ACRE at Inside Higher Ed.

Another example of this reaction against reform is in the July 7 issue of JACC, in which ACC president Alfred Bove wrote a heated attack on the JAMA special communication and defended the benefits of industry support for professional medical associations like the ACC. In sharp contrast to the numerous critics of the current system, Bove argued that that the current relationship between industry and the medical profession is “a system that works.”  Bove’s position hinges on the professional responsibility and trustworthiness of medical professionals:

Any proposal to create proper relations with industry must be based on the assumption that we are personally responsible for the best interest of our patients and can work with industry while maintaining that goal. Responsibility is the key word. To assume that all physicians would act irresponsibly in relation to industry gifts or payments is inappropriate.

Bove’s remarks drew heavy fire in the blogosphere, most remarkably a scathing attack on Bove’s logic, and the deep financial conflicts within the ACC itself, by Roy Poses on the Health Care Renewal blog. Poses points out, among other things, that Bove never engages the actual points made in the JAMA communication. Instead, Poses argues, Bove refutes a series of straw man arguments, and argues that physicians should be trusted because “physicians are among the most responsible professionals.” Writes Poses:

So Dr Bove ended up by warning that the suggestions Rothman et al made about reducing institutional conflicts of interest affecting professional medical societies, and individual conflicts of interest affecting their leaders would “destroy the best of what we have in our science and industry,” that is, destroy biomedical and clinical science, and lead to nationalization of important forms of medical production. None of that was suggested or implied by Rothman et al. After positing this dire future, Dr Bove then asserted that professional societies ought to be entitled to money from industry limited only by their “professionalism.” Thus, “industry should be able to support unbiased programs aimed at educating physicians and other health care providers about the therapies available for the care of their patients. Professional societies should be able to receive unconditional educational grants to provide up-to-date information to their members on medical therapies.” Furthermore, “the proper relationships should allow us to work with industry and allow our professional societies to receive undesignated funds from industry to foster better patient care.” So, Dr Bove wound up where he started, asserting that doctors and professional societies are inherently virtuous, and thus should be trusted to do whatever they think is right, without any external scrutiny or accountability. Yet he never demonstrated the virtue of the ACC under his leadership, or of PMAs in general, or showed why they should be trusted.

Poses then reported that in 2007 the ACC received over $35 million from industry, which constitues 38% of its total revenue. In 2007 the ACC also paid its president $147,750, while other officers and board members were also paid substantial sums.  Poses notes the unusual circumstances, as well as the inherent conflict of interest:

To my knowledge, it is unusual for a professional society to pay salaries to its voluntary officers (as opposed to full-time, hired managers.) However, given that the ACC does, it seems that were the organization to foreswear industry revenue, its officers’ personal income might be threatened to some extent.

Poses also reports that the ACC’s CEO, Jack Lewin, received $534,452 in total compensation in 2007. It should be noted that  Lewin, on his own blog,  called Bove’s remarks a “responsible rebuttal of the recent JAMA editorial.” Lewin said that Bove’s response “got a lot of play outside cardiology this week,” but Lewin didn’t mention or respond to Poses detailed critique, and he ignored another detailed criticism of Bove’s editorial by Howard Brody. The only response Lewin did cite was a highly admiring one on the Policy and Medicine website, which is not, as its name implies, a site run by an objective, or at least unconflicted, observer. Rather, Policy and Medicine is written by Thomas Sullivan, who is the the president and founder of Rockpointe Corporation, which specializes in producing CME programs funded by industry.

Here’s something else Lewin didn’t mention about Sullivan: a visit to the Rockpointe website turns up the listing for a CME program, Emerging Concepts in Aggressive Lipid Lowering, produced by Rockpointe and webcast in 2005. The “sponsor” was the American College of Cardiology Foundation and the “supporter” was Merck-Schering-Plough.

Finally, one additional strand helps tie all the all the loose ends into a neat knot: in a separate post on the same blog Sullivan wrote a glowing endorsement of ACRE. In that blog posting, Sullivan somehow forgot to mention the fact that he’s a leader and founder of ACRE. And, according to PharmaGossip, the ACRE meeting will be “logistically managed by Rockpointe.”

Comment: Despite  the above remarks, I think many of Bove’s and ACRE’s points deserve to be taken seriously. It is important that people on all sides of the debate refrain from demonizing their opponents. We all know that there have been egregious abuses of the system, and undoubtedly there will be more examples to come, but the vast majority of people who work in industry, and the vast majority of academics and other medical professionals, are just trying to do their best within an imperfect system. Academics who exist in an “eat what you kill” ecosystem can hardly be blamed for not being pacifist vegetarians. Even Jim Stein, the University of Wisconsin cardiologist who has renounced almost all ties to industry, acknowledges how difficult it is for younger academics to establish their careers without industry support.

Clearly there are no easy or instantaneous solutions to these problems, and I don’t pretend to know how the complex relationships between industry and medicine should be arranged. But I do think one principle is paramount: transparency. The absence of transparency is an invitation to abuse. The presence of transparency doesn’t guarantee that there will be no more problems, but it does help ensure that everyone is working to solve the same problem.

The fact that the ACC and its officers receive a great deal of money from industry, or that the ACC has worked with commercial CME companies, isn’t necessarily wrong (nor is it necessarily right). But it is wrong to blithely insist that nothing is wrong and that we have “a system that works” and at the same time conceal key details of that system. If there’s nothing wrong, and if it works, then there should be nothing to hide.

CardioBrief hopes to return to this story after the inaugural ACRE meeting on Thursday. We’ll be happy to receive any reports from the meeting from anyone able to attend.

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