Drug firms to fund residency slots in dermatology pilot program
■ Ethicists express concerns about inherent conflicts of interest in such a relationship.
By Myrle Croasdale — Posted July 18, 2005
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Faced with a work-force shortage and no new federal funding for resident training, the American Academy of Dermatology is expanding residency slots by using pharmaceutical company donations.
AAD leaders say enough safeguards are in place to prevent conflicts of interest that could arise from the relationship, but critics say such funding compromises the medical profession and leaves it beholden to for-profit corporations.
The academy's goal is to increase dermatology resident positions by up to 10% -- about 30 new slots -- per year. A pilot program will fund an initial 10 slots at $60,000 per slot per year for three years starting in July 2006.
Corporate sponsors contributing to the $1.8 million needed to fund the pilot are 3M Pharmaceuticals, Amgen and Wyeth Pharmaceuticals, Delasco Dermatologic Lab and Supply Inc., Galderma Laboratories and OrthoNeutrogena. The AAD also committed to contributing $1 million annually to the fund if pharmaceutical gifts fall short but declined to say how much of its own funds, if any, were being invested in the pilot.
David Pariser, MD, an AAD board member and chair of the pilot task force, detailed the measures the academy is taking to nip possible conflicts of interest in the bud. Members of the Assn. of Professors of Dermatology vetted the pilot and helped draw up guidelines. Corporate contributions are combined in a general fund, and the grants are assigned to specific programs to avoid having individual residents singled out as beneficiaries.
The APD and AAD jointly selected 10 institutions for the pilot from 24 applicants. Pharmaceutical donors were excluded from the selection process. Dr. Pariser said the pilot will not be expanded until the AAD evaluates the results.
According to the AAD, one-third of the 9,000 practicing dermatologists would like to hire additional dermatologists, but only 290 graduate each year.
Nationwide, the average wait for an appointment is one month, the academy said, and in some regions the wait is three to six months.
To ease this shortage, programs that were chosen for the additional resident slots have a track record of producing physicians willing to practice in underserved areas.
Concerns about reciprocity
The pilot is not without its critics. Jerome Kassirer, MD, former editor of the New England Journal of Medicine and author of a book documenting conflicts of interest in the medical profession, is one of them.
"It's a disgrace," he said of the pilot. "There are all kinds of issues to worry about. One of the important questions for me is how often unrestricted grants are truly unencumbered. It's hard to imagine the drug companies are interested only in the education of dermatologists."
Such relationships create feelings of reciprocity, he said. "Will they [the physicians] say nicer things about the company's drugs? Will they tend to prescribe their drugs more?"
Pharmaceutical funding is like a balloon, Dr. Kassirer said. When it's pushed in one place, it pops out in another. "Instead of CME, they're funding GME," Dr. Kassirer said. "Maybe soon we'll have the Merck medical student. Is this simply a ploy by the pharmaceutical industry to increase the supply of physicians who are prescribing expensive drugs?"
Arthur Caplan, PhD, director of the Center for Bioethics at the University of Pennsylvania, also is critical.
"There is a huge issue when you have residents underwritten by pharmaceutical companies," he said. "You create both the appearance of a conflict of interest and the reality of a conflict. The doctors absolutely know whether Merck or Pfizer paid for their residencies."
In the end, the public should decide whether there is a conflict and whether it matters, Dr. Caplan said.
"To be fair to the dermatologists, what do Americans want?" he said. "Do they want their doctors' education paid for by companies who have a direct interest in medical products?"
Harry Jonas, MD, chair of the reference committee that considered medical education issues at the AMA Annual Meeting in June, said he understands the dermatologists' difficult position. He has firsthand experience of the shortage, through his wife's struggle to get appointments to remove melanomas.
"There's no question in my mind that we need more dermatologists, but where is the funding going to come from?" he said. "The federal and state government won't fund it."
Ethical issues have to be considered, he said. Standards like those seeking to keep drug marketing out of CME should be applied to graduate medical education, he said.
Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, said the pharmaceutical industry has a long history of supporting young scientists.
"We think it's important to have bright, young scientists conducting research and clinical work," Trewhitt said. He said whether to fund graduate medical education is a matter for individual companies to decide.
Individual residency programs have pursued corporate sponsorship on a smaller scale, and Alfred Lane, MD, service chief and adult dermatology professor at Stanford University School of Medicine, has firsthand experience.
Connectics Corp., which creates new delivery systems for generic drug compounds, contributes $160,000 over the three-year dermatology residency cycle at Stanford. The money covers research electives, and residents are free to determine how their elective month is spent, according to Dr. Lane.
Connectics comes to campus once a year to present optional elective opportunities at the company.
While residents benefit from research and clinical-trials experience, Connectics benefits from having young doctors around, he said.
"[Connectics] gets a new, excited, young physician's time and ideas," Dr. Lane said. "Also, when they're looking for a new medical director, they'll know five or 10 of our residents personally."
Samantha Wyatt, MD, a Stanford dermatology resident, said she enjoyed her elective at Connectics.
"I feel there's no conflict of interest at all," Dr. Wyatt said. "It's an unrestricted educational grant, and it's been very beneficial for residents."