The potential bias introduced into research, medical education, and individual clinician judgment by relationships with commercial entities is a perennial and serious issue in medicine, including the veterinary field. While critics of mainstream veterinary medicine frequently raise this issue when challenging the claims made for conventional diets, medications, and other healthcare interventions (e.g. 1, 2), alterative practitioners and organizations are no less involved with industry (e.g. 3). While financial bias is only one potential influence on the judgments and practices of veterinarians, and by no means the biggest problem we face, it is a source of bias that can be limited and monitored through transparency and rules concerning the kinds of interactions between veterinarians and industry.
The American Association of Veterinary Medical Colleges (AAVMC) has published a new set of guidelines addressing this issue specifically for veterinary schools, and it provides a sensible list of principles for minimizing the potential bias created by relations between industry and academia: Guiding Principles and Considerations: Ethical Interactions Between Schools/Colleges of Veterinary Medicine and External Entities. Though the document is not intended to be comprehensive, and AAVMC specifically recommends each institution develop their own rules appropriate to their unique circumstances, these guidelines identify many of the key areas in which inappropriate industry influence can arise, and they make reasonable suggestions for preventing this.
AAVMC begins 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 same should, of course, be true for private practices. While it is clear that research and the development of new and better therapies cannot happen without the resources provided by commercial organizations, it is equally clear that it is all too easy for these organizations to inappropriately influence the content and outcome of research and the practice of individual veterinarians, and strict ethical guidelines are needed to control for this source of bias.
The document then details many of the ways in which industry can attempt to influence the veterinary profession through veterinary medical schools, including:
- Gifts of goods and service to students, faculty and staff.
- Gifts to individuals in the form of scholarships, research grants, and other forms of financial support.
- Gifts to the institutions themselves, in the form of money, products, services, land, etc.
- Remuneration for speaking, consulting, and other activities.
- Funding and organization by commercial entities of educational events.
One of the key principles identified in this document, and often not clearly understood, is that the size or specific nature of gifts from commercial organizations to individuals is not relevant to the potential for such gifts to introduce bias. It is not simply a case of crass, direct buying of influence. Sales representatives, who often genuinely believe in the products they are marketing, build relationships and trust and a sense of personal rapport, which subtly bias the decisions of their customers through a sense of personal obligation, through a greater awareness of the products one is most frequently reminded of, and other mechanisms not requiring any malfeasance on any individual’s part. Pens and coffee cups and pizzas are laughable as bribes, and most individual veterinarians are ethical and not likely to accept deliberate bribes anyway, yet the evidence from studies of physicians shows quite clearly that interactions involving even such trivial gifts do influence the behavior of recipients even when those recipients don’t believe it does.
The principles suggested by the AAVMC for minimizing the bias introduced by relationships between industry and academia are not very detailed, but they do touch on a couple of key elements in such an effort.
- Transparency and the disclosure of any and all relationships with commercial entities, regardless of how trivial or legitimate they may seem.
- Managing any and all gifts to the schools, financial or otherwise, centrally so that individual faculty, students, and staff are not directly receiving such gifts from commercial organizations.
Specific rules promulgated by individual schools will need to be considerably more specific. And in many cases, it seems to me that it would be appropriate to ban outright many of the gifts students and faculty receive from commercial entities, including food, medicine, sponsorship of events, and all the innumerable trinkets marketing departments devise. If industry wishes to contribute resources to the advancement of veterinary medicine, financial support filtered through the school administration, or better yet through independent non-profit organizations supporting research and education, would be more useful and ethically less problematic than these sorts of gifts.
What is more, similar ethics policies would be appropriate for private practices as well. I personally no longer attend continuing education dinners and other such events provided to our practice by vendors of veterinary products and services because I have come to believe the risks of such relationships outweigh the benefits, even though I personally have no influence on the product choices made by the management where I work. And while I cannot see how most clinical research could happen in veterinary medicine without industry funding, since government and private non-profit funds for small animal research are incredibly scarce, I would love to see industry support such research indirectly, through grants made to independent organizations which distributed such funds according to pre-defined and transparent criteria of scientific merit. This would allow industry to continue to support the development of needed therapies without such a risk of biasing the outcome of research studies. Such would be a truly philanthropic activity, rather than just a form of marketing.
I would like to see doctor groups such as the ama and avma stop taking money from corporations.
Art Malernee dvm
So I assume then that vets will quit selling ‘junk’ rx foods such as Science Diet feline KIBBLE…(?)
So I assume then that vets will quit selling ‘junk’ rx foods such as Science Diet feline KIBBLE…(?)>>>>
funny you should mention Hills. When I checked out evidence based alternative to the AVMA it was the way Hills, the science diet maker, was using its association with that evidence based veterinary group to promote evidence based food that kept me from joining the group. I think we need a evidence based alternative veterinary group that does not take money from corporations. I find after I am full of cheese cake and liquor, all paid for by these corporations at required by state law continuing education courses, its hard even for me to stand up with my belly full of dinner and be critical of all the quackery being promoted by the dinner meeting speaker paid to speak by these big corporations. Hills in my opinion does make some good food that may or may not be over priced but the FDA needs to pass some laws that would make promoted evidence based foods supported by good prospective randomized trials. Every time Hills comes out with a new so called “RX” food I keep hoping their promotions are supported by evidence based studies rather than corporate donations to vet groups that then help them promote it to veterinarians. Hills has a new food for treating hyperthyroid disease they may be able to produce prospective studies to support.
art malernee dvm
fla lic 1820
With all this kvetching about Hill’s I wonder if any of you have any evidence that there is a problem with the foods they make, or even a rational definition of what a “junk” food. It sounds like a meaningless term used to imply something bad without saying anything detailed or substantive about it.
As for the “evidence-based alternative to the AVMA,” are you referring to the EBVMA? If you are then 1) It is not in any sense intended to be an alternative to the AVMA, whatever tat might be. It is a single issue advocacy and educational group devoted to promoting and facilitating evidence-based medicine, both the principles and then methods. And the EBVMA does not have corporate sponsors in general, though there have been some contributions made to fund having the biennial symposium. If you would like the group to be independant of industry, consider joining or offering to help fund their activities yourself. Or perhaps you have another concrete suggestion for how to fund educational or outreach activity that is less problematic? It is a question I know the group is actively exploring, but no simple answers have yet appeared.
Was Hills funding the symposium in the early beginnings of ebvma? Did the ebvma allow its name to be linked in any way with food studies Hills promoted as evidence based such as publishing them or allowing Hills to refer to evidence based food studies in the literature of the ebvma. Were evidence based hills food courses offered at the symposiums? if so I would promote that Hills so called evidence based food studies and courses are not evidence based and should not be linked to a doctor group having evidence based in it’s name that takes donations from hills. Note hills is part of a even larger corporation
Art Malernee dvm
Art Malernee dvm
I believe Hill’s was one of 3 corporate sponsors for the 4th EBVMA Symposium in 2010, contributing some portion of the couple thousand dollars of corporate sponsorship received. I was not associated with the organization before then, so I don’t know whether previous symposia have had such sponsorship.
I don’t believe Hill’s has ever referred to the EBVMA in any of its marketing materials, and I don’t believe the EBVMA has ever promoted Hill’s products or mentioned the company at all beyond acknowledging sponsorship of the symposium. There were no lectures or workshops at the 2010 symposium concerning nutrition, but I believe there have been such lectures by nutritionists employed at Hill’s at previous symposia (though I don’t know whether any of these meeting had Hill’s or other coroporate sponsorship).
As the ethical guidelines I wrote about indicated, transparency about such relationships is a good thing. But you seem to be implying that any financial association between industry and research or CE events is inherently wrong and should be forbidden. Apart from the obvious question of whether such an extreme position is based on any evidence that sponsorship renders such events entirely useless and illegitimate, this position is easy to take when you make no effort to suggest how else research and education are to be funded. If your response to establishing ethical guidelines for coroporate financial relationships and research partnerships with veterinarians is to say no such relationships are acceptable, then you ought to explain how you’re going to replace the resources you feel should not be used.
The whole point of the scientific method is to control for bias, and if you believe it has any efficacy at all, then you ought to accept that the potential biases involved in the sources of funding for research and education can be mitigated by such methods. If the methods are useless at controlling bias, then what is the point of scientific evidence at all? Are the CAM folks right when they say that nothing you or I say is worth anything because we get paid to practice medicine and so have a bias?
Let us not try to make the perfect the enemy of the good and end up with everyone free to do whatever they like because we cannot generate any evidence or teach students and veterinarians about evidence-based medicine because we are phobic about utilizing any money generated bby selling veterinary goods and services. A middle ground between laissez-faire promiscuity and total abstinence had better be possible or we have no chance of improving the profession.
http://www.ebvma.org/?q=node/7
a google find using ebvma and hills as search words after my last post.
Someone from hills in 04 is telling the group what ebm is. Was ebvma taking money from hills for the symposium in 04? If so how do you get up after hills pays for the symposium and the first speaker works for hills and ask the speaker why hills does not properly blind it’s evidence based food studies? And the answer to what do i suggest? I am totally happy with ebvma if they only took money from members. But I do realize the reason why more doctors do not support ebm is because it’s difficult to make a living practicing it. So I understand the difficulty not getting in line when corporations are handing out money to dr groups
Art Malernee dvm
Art Malernee dvm
Fla lic 1820
So no nutritionist can say anything about evidence-based medicine or nutrition if they work for a company that makes food? And none of the content at a symposium is valid if any of the speakers work in industry or any company sponsors the symposium? Bit of a dream world, IMHO.
If you suggest that more independant funding is needed for the work of the EBVMA to be legitimate (and bear in mind in mind that member dues fund about 3/4 of the budget), perhaps you should join or contribute or otherwise get involved in funding an alternative organization? The reality is that such criticism is easy, but the work of influencing the profession is harder, and while I agree that bias is an issue, your approach seems unrealistic and less than helpful. As well as this blog, I do all of my work for the EBVMA completely independantly, without any compensation or funding and in my spare time on my own dime. I guess it irks me a bit for you to dismiss it so blithly as meaningless because the organization was unable to have an educational event without industry funds and allows veterinarians wh work for corporations, not just universities and private business, to participate. If you are aware of some alternative funding source, I’m happy to investigate it, but if your only suggestion is to disband the organization and give up our efforts because they are tainted by this, then I don’t see how that helps the cause of EBVM.
Have you polled the ebvma members and see if they would be willing to pay a 1/4 dues increase to avoid needing corporate sponsorship? Am I the only vet that has given corporate sponsorship as a reason for not joining the ebvma? I would never join and donate to a political party that took corporate donations. Maybe I have been reading to many Ralph Nader newsletters to be open minded about corporate sponsorship of doctor groups.
Art Malernee dvm
http://www.ebvma.org/?q=node/702
Looks to me ,from the link above ,the ebvma was co sponsoring food studies with Hills. Mark Morris started Hills. Hills donates to the ebvma.
Art Malernee dvm
Fla lic 1820
Speaking of bias, you have clearly filtered this through your own. The EBVMA donated $3000 of member dues to Morris Animal Foundation to sponsor a university research study on IMHA. It has nothing to do with food or Hill’s and in fact is exactly the kind of independant funding necessary to avoid potential industry bias, non-profit groups pooling resources and coordinating donations to fund research rather than having industry conduct such research or fund it directly.
looks to me like Hills is moving its money to to the EBVMA. The EBVMA then puts its evidence based name to the money and gives it back to Hills to fund the study done by Hills. This the trend I’ve noticed of other papers — largely related to products or concepts products are intended to fill a need for — often diets — with titles such as, “An Evidence Based Approach to (Fill in the blank)” . My stomach becomes sickened by the abuses and bastardization of our literature and the well-meaning concept we hold out as pure — EBVM.
Art Malernee dvm
fla lic 1820
This is a completely inaccurate fantasy. Hill’s sponsored part of a conference having nothing to do with nutrition in 2010. In 2011, EBVMA donated some money to Morris Animal Foundation to sponsor research on IMHA done at a university. None of this has anything to do with Hill’s products, nutrition research or anything else. You are making this stuff up to suit your own imaginary narrative.
Art, why pick on just Hill’s? How about every other pet food manufacturer, since, by your logic, they are all guilty. Save for a few dozen or so of the “holistic”, “natural”, et al variety. How about going after them, and actually demanding real evidence for THEIR bogus claims? If anything is so far removed from EBVM in nutrition, it is the quackery in the above noted pet food diets. Don’t you think challenging the above mentioned is much more worthwhile than attacking a major pet food manufacturer whom, to their credit, actually helps fund research in other areas?
Art, why pick on just Hill’s?>>> I see Hills trying to add evidence based veterinary medicine to “Science” diet and “Prescription” Diet marketing.
art malernee dvm
Art, and other pet food manufacturers aren’t doing the same thing?
At least a few of the major manufacturers actually attempt to do the research and studies. Much more than you could say for many other manufacturers who have absolutely nothing to back up their claims.
Hills has the words science diet and prescription diet trademarked. At least the FDA does not allow those words to be trademarked for human cereal. At least the physician does not have prescription and science diet cereal to sell out of his office. There is a new problem with royal canin, The people who make it, mars candy bars, also own the vet hospital and pet shop where it’s promoted and sold as better than other food used for treating diseases.
Art Malernee dvm