Organized medicine has come a long way since the founding of the American Medical Association (AMA) in 1847. For conflicts of interest, the journey has been downhill.
When it was created, the AMA said it was “unlawful” for doctors to attest to the effectiveness of patented drugs or in any way promote their use. Holding a patent for any drug or surgical device was “derogatory to professional character” for doctors. Accepting shill money for industrial patent holders was a violation of ethics.
Beginning in the 1920s, organized medicine, including hundreds of specialty societies, abandoned this fierce disregard for commercialism for careful collaboration and, eventually, full adherence to supporting the pharmaceutical and medical device industries.
Today, the threadbare remnant of organized medicine’s original position is a weak principle of “transparency” about the flow of money and influence from industry to medical practice. But organized medicine does not even hold itself to this flimsy standard.
Anyone can now visit the federal government’s Open Payments website to see what individual doctors are getting from the industry. And from 2022, what medical assistants and specialist nurses get is also exposed to the sun’s purported disinfectant properties. Even money flowing from industry to academic medical centers is reported – but not so for their professional societies. Why not?
The human and economic costs of medicine’s commercial entanglements are enormous: overdiagnosis, overuse, overmedicalization – and so the potential harmful effects. As medical companies actively contribute to the burgeoning business of continuing medical education, promulgate clinical guidelines, and publish educational materials on drug therapies and devices, they potentially share responsibility for overpriced drugs. and often misleading, often used for poorly researched off-label applications. indications, contributing to clinical risks and massive wastage.
The most egregious example of economically compromised organized medicine was revealed in the 2017 US Senate investigation into the opioid epidemic. The public learned how Purdue Pharma and Johnson & Johnson spent nearly $9 million between 2012 and 2017 on physician and patient organizations (like the American Pain Society) who together aired the baseless claim that opioids prescribed for pain were rarely addictive.
The laser focus of the medical-industrial complex on drug therapies and expensive surgical procedures means the neglect of prevention and the social causes of disease in the educational and lobbying activities of medical organizations. For example, of approximately 300 scientific sessions at the upcoming 2022 meeting of the American College of Cardiology (ACC), only seven relate to lifestyle and other non-drug prevention methods. In contrast, at least 38 sessions sponsored by pharmaceutical and medical device companies on the clinical uses of their products are planned.
From arm’s length to ready embrace
The opioid crisis has exposed only the outrageous tip of a deep-seated problem that has been slow to develop.
At the beginning of the 20th century, the executive of the AMA and JAMA editor George H. Simmons treated the drug companies “with suspicion and grave doubt, like diplomats working on an armistice”. Simmons told his successor, Morris Fishbein, that negotiating with pharmaceutical manufacturers to clean up their specious publicity was “much the same as Faust trying to make a deal with Mephistopheles”.
Under Simmons, the AMA succeeded in imposing certain ethical standards for industry access to JAMAthe advertising pages of. He actively lobbied for passage of the Pure Food and Drugs Act of 1906. But after 1924, under Fishbein, the downfall began. In 1938, the AMA passively watched as secular forces pushed for another major drug law reform, the Federal Food, Drug, and Cosmetic Act, which required proof of safety before marketing.
In the early 1940s, Fishbein helped raise $1 million for a massive “National Physicians’ Committee” campaign to fight National Health Insurance and thus preserve the “American System of Medicine”. But the committee was mislabeled – about 90% of its funding came from Hoffman-Laroche and other big pharma.
“Captive and beholden”
In the 1950s, the AMA and the pharmaceutical industry became completely intertwined. JAMA relaxed its control over advertising to increase its revenue. A revolving door opened between the two. The Pharmaceutical Association of America (PMA) awarded Austin Smith, who had succeeded Fishbein in 1949, with its presidency. In 1963, after Smith moved to a more lucrative position as President of Parke-Davis, the PMA replaced him with C. Joseph Stetler, Executive Vice President of the AMA.
The money has circled. In the early 1960s, 17 of the largest pharmaceutical companies gave nearly a million dollars to the lobbying arm of the AMA to help it fight Medicare, in part out of fear of federal drug price controls. medications.
In 1962, the AMA testified with the PMA against a proposed amendment to the Food and Drugs Act of 1906 that required new drugs to show efficacy, not just safety, in clinical studies controlled. The AMA argued that individual clinicians did not need government advice on what worked and what did not. He also backed the pharmaceutical industry’s successful objections to the provisions breaking its monopoly pricing power.
The unholy alliance was cemented in the early 1970s. In 1971, the AMA removed from its code of ethics its historic disapproval of drug patents held by doctors. The following year it closed its semi-independent Medicines Council which had issued advice on hundreds of products on the market to help bewildered clinicians separate the good from the useless – or worse – drugs. The board had condemned many cost-effective drugs as “not recommended” or even “irrational”.
In 1973, John Adriani, the now-disbanded chairman of the board, indignantly explained to Congress that the AMA was “captive and beholden to the pharmaceutical industry.”
The ties have only grown closer. Over the past 40 years, medical specialty societies have eclipsed the AMA in terms of global importance and political power.
Much of their revenue and business growth has been industry funded. In a 2008 Medscape article, Lawrence Grouse, a disaffected insider in the ranks of organized medicine, estimated that many specialty companies receive almost 80% of their industry income in the form of grants, project grants , educational enterprises, donations to their spin-off foundations and in-kind contributions. He had to estimate because of the secrecy of the organizations.
Since then, nothing has changed. In 2019, for example, membership dues accounted for only about 13% of the nearly $150 million that the CCA and its foundation collected. The fact that most of the remaining revenue came from industry can be inferred from the fact that in 2018, 22 of ACC’s 26 executives had financial ties to industry totaling nearly $23 million. In fact, about 80% of executives at companies specializing in the 10 most expensive medical fields, including cardiology, had financial ties to industry. For those with links, the median reward was around $30,000. For American Society of Clinical Oncology leaders with such ties, the median was just over $500,000.
What remains today of the 19th century AMA ethos against entanglement with medical industries? Nothing but a lukewarm endorsement of the need for transparency about which doctors get what from whom. Tellingly, the forceful implementation of this principle had to be pushed by a coalition of organized medical outsiders, including powerful politicians, in the form of the Physician Payments Sunshine Act, which was passed in 2010 as part of of the Affordable Care Act.
Of course, keeping money out of medicine is impossible and probably not even desirable, given the relative scarcity of federal funding for medical research, continuing medical education, and the formulation of clinical guidelines. But we have to do something to bring the system back into balance.
Medical reformers have offered various solutions to organized medicine’s pervasive conflicts of interest, including a complete divorce from industry. These will be late in coming. A middle ground, though insufficient, would be for the law to subject entanglements to critical scrutiny by the public and the medical profession as a whole.
But given the likely opposition to forced reporting and public disclosure, even new federal regulations or congressional action will be hard to come by. Between 1998 and 2021, the AMA was the fourth largest spender on federal lobbying among trade associations and major corporations, doling out more than $462 million during that time. Without a countervailing alliance of secular forces and reformist doctors to force disclosure, the armada of specialty corporations and industrial powers will continue to wield unchecked power and political influence. And that’s a prescription for the wrong medicine.
Peter A. Swenson, PhD, is the CM Saden Professor of Political Science at Yale University, New Haven, Connecticut, and an award-winning author on the political history of health care and the welfare state. His latest book is Trouble: A History of Reform, Reaction, and Money in American Medicine (Yale University Press, 2021).
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