Conflict of Interest Disclosure in Early Education of Medical Students

Medical education has embraced the transparency movement by shining the light of disclosure on physician-industry interactions. Many medical journals mandate that authors report potential conflicts of interest and publish detailed financial relationship lists with their articles.¹ Likewise, the Accreditation Council for Continuing Medical Education requires disclosure of lecturers' conflicts before lectures qualifying for continuing medical education (CME) credits.²

Despite these changes in physician education, disclosure norms have not yet trickled down to the very start of medical education—the preclinical years. Are first- and second-year students justified in expecting conflicts of interest disclosure in their education?

The clinicians and researchers who lead preclinical medical education at US medical schools are usually drawn from affiliated medical centers and therefore are likely to have financial ties to industry.³ In the context of physician education, financial relationships to the subject matter have been shown to induce selective presentation of data or biased interpretations.³ Nonetheless, the typical rationales for conflict of interest disclosure do not apply in the context of preclinical education. The ultimate justification for disclosure is that biased statements can influence the care patients receive. Because medical students do not prescribe medications and have little patient care responsibility, there is less direct potential for harm. In addition, the first 2 years of medical education are largely spent studying basic biological sciences and pathophysiology. In the context of a CME event, it is easy to see how a speaker's financial relationship to a specific pharmaceutical company could be relevant to the therapeutic recommendations, such as the best choice for treatment-refractory depression. In an analogous lecture to medical students on the neurobiochemical basis for depression, the mention of specific therapies may only serve as examples to illustrate the underlying scientific concepts.

However, these perspectives miss the essential role that disclosure can have in early medical education. For example, as students learn details about anatomy and physiology, they also are beginning to construct a framework for analysis of data and application of data to clinical reasoning they will use as practicing physicians. In this light, a policy that requires disclosure of financial conflicts of interest before the start of any lecture would serve as a powerful reminder to a medical student audience about the potential for bias in the presentation of scientific information and therefore the need to be critical evaluators of the material being taught. Such lessons will be particularly useful when these students later need to weigh the risks and benefits of a new, heavily promoted therapeutic product or analyze the design of clinical trials that led to treatment recommendations. Promoting critical thinking in medical professionals may be easier to accomplish at a time when students' clinical reasoning skills are just beginning to be developed than trying to create this skill after the students graduate, enter residency training, and subsequently practice.

The mere existence of a disclosure policy can also affect students' professional development. In addition to lessons in the formal curriculum, students are deeply influenced by the behavior of role models, institutional policies, or other characteristics of the learning environment cumulatively known as the “hidden curriculum.”⁴ Most students do not enter medical school having reflected on the scope and influence of interactions between physicians and the pharmaceutical and medical device industries; however, the acculturation process can occur rapidly. For example, surveys reveal that students further along in training have more positive attitudes regarding issues such as the appropriateness of accepting gifts from pharmaceutical representatives.⁵ The existence of a disclosure policy would communicate that an institution values the integrity of medical education. The practice of disclosure also provides a stimulus for students to begin dialogues with peers and advisers and consider their own ethical views on the controversial topic of physician-industry relations without the pressure of conforming to the behaviors exhibited by residents and attending physicians who oversee and grade their clinical rotations. Students may then form their own opinions about these interactions instead of simply adopting those of role models and peers and, dialectically, students could be better motivated to value and promote the acquisition of evidence-based medical knowledge.

As a practical matter, disclosure also prepares trainees for the realities of their upcoming medical career. Introducing first- and second-year medical students to disclosure of industry ties helps reinforce this professional norm. Numerous examples exist of physicians failing to comply with the disclosure policies of medical journals or their academic institutions.⁶ Introducing medical students to this now widespread practice may help immunize against these ethical breaches.

Moreover, a system of prelecture disclosure can also complement curricular time devoted to issues in professionalism such as physician-industry interactions. According to the 2010 American Medical Student Association scorecard, approximately half of US medical schools currently provide specific education to first- and second-year medical students about the topic of conflicts of interest.⁷ Such formal curricular efforts should be universally implemented and empirically studied to identify and disseminate highly effective teaching strategies.⁸ A prelecture disclosure policy may enhance the benefits of these teaching sessions by demonstrating relevance of the topic to medical students and engaging them as active participants in their own medical training.

The ideal format and content of disclosure to medical students remain unknown. Requiring comprehensive disclosure of 36 months' worth of financial relationships (as suggested by the ICMJE¹ ) may unnecessarily distract students. Recently, students and staff at Harvard Medical School crafted a more concise disclosure policy that serves as an example. Every lecture to the first- and second-year classes must include, as the second slide of the presentation, 1 of 3 standardized disclosures ([1] no financial relationships with commercial entities producing health care–related products and/or services; [2] financial relationships with commercial entities that are not relevant to lecture content; or [3] disclosure of relevant conflicts with basic details) that provide information about the professor's financial relationships with health care–related companies and entities. Course directors are tasked with ensuring that lecturers are informed about this second slide policy.

Certainly, a more active posture toward conflict of interest disclosure in medical school should continue once students enter their clinical rotations. That environment will require additional strategies because more teaching occurs informally and in small groups. For example, some hospitals have taken steps to make physicians' financial relationships publicly available and accessible to students.⁹

It may be argued that disclosure is an inadequate response regardless of the educational setting. Other strategies that eliminate or regulate conflicts of interest among medical school instructors may be necessary, such as restricting certain types of gifts or requiring institutional oversight of faculty members' consulting arrangements with industry.³ Still, as the medical profession moves slowly toward these goals, prelecture disclosure can be a valuable first step in introducing the issue to the newest members of the profession.

Even though disclosure may not repair the problem of bias produced by conflicts of interest,¹⁰ improving transparency about financial relationships of faculty members involved in the preclinical medical curriculum can have important benefits for the professional development of medical students, even early in their training. Introducing first- and second-year medical students to the concept of disclosure could be implemented as part of a comprehensive strategy to manage conflicts of interest. As many medical schools are now redrafting their policies on industry interactions, students and faculty should discuss adopting a second slide policy, or some other type of mandatory disclosure, as part of their curricula.