- © 2008 Canadian Medical Association
Although there's widespread variation in the policies that Canadian medical schools have toward pharmaceutical and medical devices industry handouts for medical education and in some cases, seemingly no policies at all, administrators say there is no need for restrictive guidelines like those recently adopted in the United States because the level of abuse isn't as severe north of the 49th parallel.
There's little justification for following America's lead by limiting industry support for continuing medical education services, or prohibiting financial payments, travel junkets and other goodies from industry to physicians, faculty, residents and students at medical schools and teaching hospitals, the administrators say.
Such subsidies and handouts are “not of the [same] order of magnitude” in Canada as in the United States, says Dr. Gavin Stuart, dean of medicine at the University of British Columbia, which appears to have the most restrictive industry handouts policy of the nation's 17 medical schools in that it caps financial payments at 20% of a faculty member's salary.
There's little political pressure, internal or external, to adopt stricter policies like those approved in June 2008 by the Association of American Medical College's executive-council, adds Queen's University Senior Associate Dean (Medical Education) Dr. Lewis Tomalty. “My sense is that we don't see abuses in the system so that we're comfortable where we are at.”
Furthermore, Canadian medical schools would be resentful if the Association of Faculties of Medicine of Canada adopted a similar “top-down” approach, adds Dr. David McKnight, associate dean of equity and professionalism at the University of Toronto medical department. “If you impose things on people that they resent, they look for ways around them. If you can get a consensus as to what is a reasonable limitation, then it works better.”
“Each university likes to keep its individuality,” he adds.
By contrast, concerns that industry handouts are influencing therapeutic decisions and severely compromising the medical profession's reputation prompted the American association to formally adopt wide-ranging guidelines recommended by an internal Task Force on Industry Funding of Medical Education (CMAJ 2008;178[13]:1651-2). Several American institutions, including Yale and Stanford, have already moved to ban industry goodies.
The American Medical Association, meanwhile, deflected a proposal by its Council on Ethical and Judicial Affairs to entirely eliminate industry funding from medical education. The proposal was prevented from reaching the floor of the Association's annual general meeting in June when its Reference Committee sent the matter back to the Council for further input from stakeholders.
In general, Canadian medical schools appear similarly loathe to adopt anything like a prohibition on handouts, primarily because they now rely entirely on registration fees or industry subsidies to pay for continuing medical education programs. As Tomalty says, “we're all cost recovery.”
Administrators at several other schools, speaking on condition of anonymity, said they simply “could not afford” to wean themselves of industry monies for continuing medical education, or wouldn't dare to do so, for fear of a physician backlash. “Have you ever tried to separate a doctor from the income to which he feels entitled?” asked one Ontario administrator.
Other institutions flatly refused to even disclose whether they have policies governing industry handouts or like McGill University and the University of Ottawa, indicated only that they are in the midst of reviews.
Still others, like the University of Western Ontario, offer written guidelines to their faculty, oft-times of a very general nature. Western's guidelines, for example, say there's no restriction on participation in industry-organized events, like speaker's bureaus, other than an obligation on the part of the faculty member to “ensure that the representation of their involvement does not confuse participation with endorsement of a particular product or enterprise.”
Many schools indicated their faculties are now primarily guided by the recently revised Canadian Medical Association's guidelines for physicians in interactions with industry (policybase.cma.ca), which essentially say that “significant” gifts from industry should be declined.
“But the CMA guidelines didn't go as far as many of us wanted them to go,” Tomalty notes, adding that there's also a significant nationwide variation in the extent to which institutions actually monitor, and audit, the activities of their faculty.
The Canadian administrators are also universally agreed that the level of industry handouts to Canadian physicians, and industry support for education programs, pales in comparison to the financial handouts received by Americans, which the Association of American Medical Colleges estimates are in the billions of dollars annually.
An Association of Faculties of Medicine of Canada survey conducted earlier this year indicated that about 20%-30% of continuing education budgets come from industry sponsorship, Tomalty says.
Overall, UBC's guidelines appear the most rigorous, requiring annual disclosure and approval by senior administrators. No faculty member is entitled to spend more than 52 days per year or earn more than 20% of their salary through external activities like speaker's bureaus. “It's a fairly robust system,” Stuart says, adding that there seems to be a general consensus among deans across the nation “that this is the direction that one has to go.”
Anything in the way of formal guidelines don't seem imminent, although Dalhousie University Assistant Director of Finance and Administration for CME Dr. Eileen MacDougall says the Association of Faculties of Medicine of Canada working group on continuing medical education will likely review the issue of industry handouts in the wake of the American crackdown to see if there's an inclination to develop a consensus, national approach.
Even if guidelines were developed, there'd still be a problem of enforcement, adds University of Alberta Dean of Medicine Dr. Tom Marrie. “The system is based on trust,” he says. “I would favour a system wherein industry payments to physicians are directed to a fund to provide support for health care in developing countries and funds to allow medical students to obtain an experience in such countries.”