Surgeon-industry conflict of interest: survey of opinions regarding industry-sponsored educational events and surgeon teaching

Clinical article

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Object

Conflict of interest (COI) as it applies to medical education and training has become a source of considerable interest, debate, and regulation in the last decade. Companies often pay surgeons as faculty for educational events and often sponsor and give financial support to major professional society meetings. Professional medical societies, industry, and legislators have attempted to regulate potential COI without consideration for public opinion. The practice of evidence-based medicine requires the inclusion of patient opinion along with best available evidence and expert opinion. The primary goal of this study was to assess the opinion of the general population regarding surgeon-industry COI for education-related events.

Methods

A Web-based survey was administered, with special emphasis on the surgeon's role in industry-sponsored education and support of professional societies. A survey was constructed to sample opinions on reimbursement, disclosure, and funding sources for educational events.

Results

There were 501 completed surveys available for analysis. More than 90% of respondents believed that industry funding for surgeons' tuition and travel for either industry-sponsored or professional society educational meetings would either not affect the quality of care delivered or would cause it to improve. Similar results were generated for opinions on surgeons being paid by industry to teach other surgeons. Moreover, the majority of respondents believed it was ethical or had no opinion if surgeons had such a relationship with industry. Respondents were also generally in favor of educational conferences for surgeons regardless of funding source. Disclosures of a surgeon-industry relationship, especially if it involves specific devices that may be used in their surgery, appears to be important to respondents.

Conclusions

The vast majority of respondents in this study do not believe that the quality of their care will be diminished due to industry funding of educational events, for surgeon tuition, and/or travel expenses. The results of this study should help form the basis of policy and continued efforts at surgeon-industry COI management.

Abbreviations used in this paper:ASIA = American Spinal Injury Association; CME = continuing medical education; COI = conflict of interest.

Abstract

Object

Conflict of interest (COI) as it applies to medical education and training has become a source of considerable interest, debate, and regulation in the last decade. Companies often pay surgeons as faculty for educational events and often sponsor and give financial support to major professional society meetings. Professional medical societies, industry, and legislators have attempted to regulate potential COI without consideration for public opinion. The practice of evidence-based medicine requires the inclusion of patient opinion along with best available evidence and expert opinion. The primary goal of this study was to assess the opinion of the general population regarding surgeon-industry COI for education-related events.

Methods

A Web-based survey was administered, with special emphasis on the surgeon's role in industry-sponsored education and support of professional societies. A survey was constructed to sample opinions on reimbursement, disclosure, and funding sources for educational events.

Results

There were 501 completed surveys available for analysis. More than 90% of respondents believed that industry funding for surgeons' tuition and travel for either industry-sponsored or professional society educational meetings would either not affect the quality of care delivered or would cause it to improve. Similar results were generated for opinions on surgeons being paid by industry to teach other surgeons. Moreover, the majority of respondents believed it was ethical or had no opinion if surgeons had such a relationship with industry. Respondents were also generally in favor of educational conferences for surgeons regardless of funding source. Disclosures of a surgeon-industry relationship, especially if it involves specific devices that may be used in their surgery, appears to be important to respondents.

Conclusions

The vast majority of respondents in this study do not believe that the quality of their care will be diminished due to industry funding of educational events, for surgeon tuition, and/or travel expenses. The results of this study should help form the basis of policy and continued efforts at surgeon-industry COI management.

Continuing education is a well-accepted and essential component of physician best practice. This may occur in settings ranging from structured courses to more casual interactions at professional society meetings. Whatever method is used, the process of learning does not occur without external influences. Of particular concern is the role of medical companies in the dissemination of this knowledge. Corporate interest may underpin decisions to support the education of the medical community financially. Although conflict of interest (COI) does not inherently equate to bias, it has the potential to detract from best patient care if unrecognized.12 This is certainly a current concern for industry-sponsored research,1 but also for industry support of continuing medical education (CME). As stated by the American Medical Association Council on Ethical and Judicial Affairs: CME activities should be developed without industry support and without the participation of teachers or program planners who have financial interests in the subject matter.10 Is this a realistic goal?

Physicians are often paid by companies to teach about the appropriate indications and techniques for applications of their products.9 These physicians offer clinical insight and technical expertise that is unparalleled. Despite the potential positive effects, this component of industry-funded surgeon education may lead to the delivery of biased information in favor of the company sponsor.

Surgical device manufacturing companies also play a substantial role in the funding and sponsoring of most major professional society meetings. Were it not for medical device company sponsorship of spine academic conferences, they would not exist in their current magnitude; a former president of the American Spinal Injury Association (ASIA) and former chairman of the “Annual Contemporary Update on Disorders of the Spine” course estimated that at least 50% of the budget to run the annual ASIA meeting is attributed to industry sponsorship. The privately organized academic “Annual Contemporary Update on Disorders of the Spine” course relied on a 3:1 ratio of industry funding to registration fee income (G. Rechtine, personal communication, 2008).

Industry-funded educational conferences present potentially biased arrangements. Companies invest resources to sponsor professional society meetings. They require a visible presence to advertise their products; the degree of visibility is often related to the magnitude of support. This generates potential industry bias. The upside is that industry-funded medical education offers platforms where physicians can routinely share information and teach each other how to apply new and existing medical technology.5

Despite clearly defined government regulation and physician/industry self-regulation, the opinion of the general population on COI in education is not well defined. The development of evidence-based recommendations requires the inclusion of patient choice and opinion along with best available evidence and expert opinion in the decision making process.4

The goal of this study was to determine the opinions of people in the general public regarding surgeon-industry relationships in the setting of education. Surgeon reimbursement, industry sponsorship of surgical educational conferences, and the perceived effect of surgeon-industry relationships on quality of care, disclosure, and ethics were explored to help refine “evidence-based medicine” guidelines for surgeon-industry COI regulation.

Methods

Survey Design

After institutional ethics approval was obtained, a survey was developed by the authors to test the key components of surgeon-industry COI as it pertains to medical education and teaching. Multiple iterations of the survey were generated to ensure question clarity and inclusion of relevant content. A pilot study of each rendition was conducted on small samples of the general population. The final survey is referenced in Appendix 1.

Survey Administration

Participants were visitors to the website www.spineuniverse.com who agreed to complete the Web-based survey. By way of access, 80% of site traffic arose from search engine inquiries regarding spine health questions. There was no financial incentive or reward offered to respondents. As an incentive for survey completion, respondents were entered into a random drawing to win a portable media device.

There was no financial connection between the authors or industry and the hosting website. The site is independently owned by a medical communications company with no ties to any industry entities. The highest possible website standards were observed by the site including, but not limited to: membership of the HONcode (stipulating standards), separation of editorial and advertising arms, and full financial transparency. Visitors to the website were not allowed to see the survey until they registered and agreed to proceed. The survey was available on the website for a 2-week time period, and responses were aggregated for analysis.

Statistical Methods

Demographic and general survey results were summarized as a percentage for each answer and expressed as a 95% CI. Six descriptors (age, sex, level of education, insurance status, employment status, and patient status [that is, currently seeking or has received treatment for a condition that requires surgery with an implantable device]) were selected for subgroup analyses in an attempt to identify variables that predispose respondents to certain opinions. Subgroup analyses were conducted by performing logistic regression for each question. Subcategories within each subgroup for each question were analyzed and statistical significance was set at p < 0.05.

Sample Generalizability

Demographic data were examined and expressed as percentages of key demographic variables as listed in Table 1. These data were compared with US census data in Appendix 2. Sample weight was calculated for each respondent to construct a weighted sample that had the same marginal proportions as the target population on the following factors: sex, age, and level of education. After weighting the sample, response proportions were tallied and compared with the unweighted sample.

TABLE 1:

Demographic data in 501 COI survey respondents*

DescriptionCount (%)Missing
age
 18–2939 (7.8)
 30–49235 (46.9)
 50–59131 (26.1)
 60+96 (19.2)
sex
 female317 (63.3)
 male184 (36.7)
education
 less than high school8 (1.6)
 high school103 (20.6)
 technical school126 (25.1)
 4-yr college135 (26.9)
 graduate129 (25.7)
insurance status
 MSP/Medicare126 (25.5)6
 private268 (54.1)
 other101 (20.4)
employment status
 homemaker/student80 (16.0)
 employed270 (53.9)
 unemployed59 (11.8)
 retired92 (18.4)
patient
 yes192 (38.4)1
 no308 (61.6)

“Missing” refers to the number of incomplete respondent records for the particular subgroup. MSP = Medical Services Plan (name for Canadian-issued government health plan).

“Technical school” means that at least a 2-year associate degree was achieved, and “college” denotes completion of a 4-year college degree.

“Patient” refers to respondents who identified themselves as either having had surgery or who were possibly planning to have surgery that involves an implantable device.

Results

Survey Responses, Demographic Data, and Subgroup Analysis

There were 541 surveys initiated, of which 40 were removed due to incomplete responses, leaving 501 completed surveys for analysis. A SpineUniverse administrative query yielded 25,736 visits per day. The survey was administered over a 2-week period in the month of February 2009. Over 14 days, this amounts to 360,302 total visits. Due to the constraints of privacy protection we were unable to identify how many “hits” represented repeat visits; therefore, this number cannot be construed as an accurate estimate of the actual number of people who visited the site. Rather, the number of visits per day represents the number of times the site was visited.

Respondents believed that their care would improve or not be affected if their surgeon 1) attended industry-funded conferences to learn about particular clinical topics; 2) attended a course that was organized by a medical company to learn how to use surgical instrumentation; or 3) if their surgeon was being paid to teach at these conferences (94.4%, 93%, and 93.4%, respectively; Table 2, questions C1a, C2a, and C3a). More than 60% of respondents thought it was ethical or had no opinion if surgeons were to receive travel and lodging compensation from the medical industry to attend company-sponsored conferences (61.5%, 63%, respectively; Table 2 questions C1b, C2b). A higher proportion of respondents (68.9%) believed that it was ethical or had no opinion if surgeons received compensation for fees and travel expenses incurred for professional society meetings (question C1c). More than three-quarters (77.4%) of respondents thought that surgeons should disclose company financial relationships to their patients if the surgery they recommend would involve implantation of the device that they were paid to teach about. Views were mixed when asked whether surgeons should disclose these relationships to all patients (42.1% yes vs 38.9% no). The respondents overall (86%) believed that their care would either be positively affected or not affected if company funding provided the majority of sponsorship for CME events. More than 80% thought that the greater the number of CME events, regardless of funding, the better off patient care would be.

TABLE 2:

Surgeon teaching and CME funding survey responses and analysis

Question*Answer Choices%95% CI
C1a. Imagine your surgeon went to a training/education seminar that was organized & funded by a medical company that updated the surgeon on a particular topic such as the treatment of low back pain. How do you feel it will affect the quality of your care?Care will be worse5.63.6–7.6
Care will improve69.365.2–73.3
Care will not be affected25.121.3–29.0
C1b. Is it ethical for him/her to be reimbursed by the medical company for travel expenses, meals, & lodging?No38.534.2–42.8
No opinion12.89.8–15.7
Yes48.744.3–53.1
C1c. Is it ethical for a company to pay for a surgeon to attend a professional society meeting if the surgeon that presents research is associated w/ a university & not affiliated with any company?No31.127.1–35.2
No opinion16.613.3–19.8
Yes52.347.9–56.7
C2a. Your surgeon attends a course that is organized & funded by a medical company. At the course, he/she learns about a topic such as in question 1 & also is shown how to use approved surgical devices that are made by the company. How do you feel it will affect the quality of your care?Care will be worse7.04.8–9.2
Care will improve66.462.2–70.6
Care will not be affected26.622.7–30.5
C2b. Is it ethical for him/her to be reimbursed by the medical company for travel expenses, meals, & lodging?No37.032.8–41.2
No opinion13.010.0–16.0
Yes50.045.6–54.4
C3a. Imagine your surgeon is paid by a company to teach other surgeons through lectures & courses about how to use an approved device that will be used in your surgery: How do you feel it will affect the quality of your care?Care will be worse6.64.4–8.8
Care will improve66.762.5–70.8
Care will not be affected26.722.9–30.6
C3b. Should he/she explain this teaching job to patients who may receive the device during their surgery?No9.06.5–11.5
No opinion13.610.6–16.6
Yes77.473.8–81.1
C3c. Should he/she explain this teaching job to ALL of his/her patients?No38.934.6–43.2
No opinion19.015.5–22.4
Yes42.137.8–46.5
C4. If medical companies are the main funding source for most CME courses, how will that affect the quality of your care?Care will be worse14.010.9–17.1
Care will improve38.233.9–42.5
Care will not be affected47.843.4–52.2
C5. The more CME events that exist & forums for research exchange, regardless of funding source, the better it is for patientsAgree81.878.4–85.2
Disagree5.63.6–7.6
No opinion12.69.7–15.5

This table abbreviates the actual survey questions for the purpose of clarity, so that abridged questions could be displayed with the tabular formatted answers and statistical analysis for easy reference. Full-length questions and complete survey are available in Appendix 1.

The associations among the 8 pairs of questions demonstrated correlation among all pairs, as demonstrated by p values of < 0.0001 (Table 3). The magnitude of correlation was noted by correlation coefficients. Questions that were constructed and worded in a similar fashion showed the highest degree of correlation. For instance, respondents who answered in the affirmative for question C1a (“care will improve”) also tended to answer in the affirmative for question C2a (r = 0.61). Respondents who answered in the affirmative for question C1b about ethics tended to answer in the affirmative for question C1c (r = 0.51). Responses for question C2a versus C3a were highly correlated as well (r = 0.61). The remaining pairs generated “r values” in the range of 0.04–0.47. These tended to occur with questions that were written in differing formats.

TABLE 3:

Question pairings for test of consistency in responses to COI survey*

Response 1Response 2r (correlation coefficient)p Value
C1aC1b0.0517<0.0001
C1c0.0428<0.0001
C2a0.6141<0.0001
C3a0.4715<0.0001
C1bC1c0.5140<0.0001
C2aC2b0.0761<0.0001
C3a0.6069<0.0001
C3aC2b0.0061<0.0001

Correlation analysis of responses to paired questions. Responses to questions listed in column 1 were analyzed against each paired question in column 2. There were 8 pairs total. Correlations between responses were assessed with the Rao-Scott modified chi-square test and a Pearson correlation coefficient (“r”) was assigned. Questions that were designed with similar response types (that is, perception of quality of care) tended to have the best correlation in responses. For instance, participants who answered in the affirmative for question C1a tended to answer in the affirmative for question C2a.

The subgroup analysis of question responses is summarized in Table 4. Overall, there were very few significant differences in opinion based on stratification of the assigned subgroups. The “patient status” category generated the greatest proportion of significant differences in responses. Generally people who were “patients” (defined as those respondents who identified themselves as either having had surgery or as possibly planning to have surgery that involves an implantable device) generally responded in the affirmative for questions that asked about how quality of care would be affected. Patients were generally in favor of disclosure and more likely to think that the given scenarios were ethical, compared with nonpatients, who tended to think that the scenarios presented were more likely not to have an influence one way or the other.

TABLE 4:

Classification of opinion differences in COI survey based on subgroup analysis*

VariableAgeSexEducationInsurance StatusEmploymentPatient Status
C1a0.4620.8720.3330.5120.2050.046
C1b0.0090.3470.9140.2760.0310.017
C1c0.2410.2580.3870.8420.8160.029
C2a0.1240.5900.6720.1540.2580.018
C2b0.1170.1430.4330.0270.1120.023
C3a0.3490.4160.7930.5070.6770.013
C3b0.9700.9850.8690.3250.9970.027
C3c0.8830.6540.2380.1310.6230.034
C40.7200.0200.9330.8160.1350.059
C50.4220.3500.1700.5980.5920.009

Subgroup analysis results are expressed as p values. Overall there were very few significant differences in opinion based on subgroup analysis, with the exception of patient status. If people had or were planning to undergo an operation that involved implantation of a surgical device, they were designated as “patients.” These respondents tended to believe that company-funded educational events were ethical and would help improve quality of care.

Statistically significant difference (p < 0.05).

Sample Generalizability

The sample has a higher proportion of women and more highly educated people than the comparable US general population data (Appendix 2). We have attempted to make these data more generalizable to the North American population by weighting the survey respondent sample to approximate the US population data more closely and to calculate a set of “weighted responses.” This theoretically represents what the responses to our survey would be if a true cross-section of the American population had answered it. Table 5 allows a comparison of the “unweighted” (true responses) to the “weighted” (postulated responses based on US census data) and shows that there are very few percentage differences. This analysis yielded a range of 0.1%–4.9% difference in response types. This suggests that our data are generalizable to the population as a whole, despite the demographic discrepancies of our sample when compared with the overall US population.

TABLE 5:

Unweighted and weighted sample comparison of responses to COI survey

QuestionAnswerUnweighted Sample*Weighted SampleDifference (%)
%95% CI%95% CI
C1acare will be worse5.63.6–7.66.01.7–10.40.4
care will improve69.365.2–73.367.259.9–74.52.1
care will not be affected25.121.3–29.026.719.9–33.61.6
C1bno38.534.2–42.838.231.1–45.20.3
no opinion12.89.8–15.712.08.4–15.60.8
yes48.744.3–53.149.842.6–57.11.1
C1cno31.127.1–35.229.022.4–35.62.1
no opinion16.613.3–19.816.912.2–21.60.3
yes52.347.9–56.754.146.9–61.31.8
C2acare will be worse7.04.8–9.25.83.0–8.61.2
care will improve66.462.2–70.663.155.5–70.63.3
care will not be affected26.622.7–30.531.123.5–38.74.5
C2bno37.032.8–41.235.628.6–42.61.4
no opinion13.010.0–16.012.28.4–16.00.8
yes50.045.6–54.452.244.9–59.42.2
C3acare will be worse6.64.4–8.86.03.0–8.90.6
care will improve66.762.5–70.867.160.3–73.90.4
care will not be affected26.722.9–30.627.020.4–33.50.3
C3bno9.06.5–11.510.85.8–15.81.8
no opinion13.610.6–16.612.68.9–16.41.0
yes77.473.8–81.176.670.7–82.40.8
C3cno38.934.6–43.234.027.8–40.14.9
no opinion19.015.5–22.420.514.7–26.31.5
yes42.137.8–46.545.538.1–53.03.4
C4care will be worse14.010.9–17.111.98.1–15.72.1
care will improve38.233.9–42.540.533.5–47.52.3
care will not be affected47.843.4–52.247.640.2–55.00.2
C5agree81.878.4–85.280.274.5–85.91.6
disagree5.63.6–7.65.72.6–8.70.1
no opinion12.69.7–15.514.19.0–19.21.5

“Unweighted sample” represents the true responses of the survey.

“Weighted sample” represents the postulated proportions of responses based on weighting the sample to reflect the demographics of the US population more closely. This is in essence a control for the skewed nature of the sample population that responded to the survey (which was typically more female and more highly educated than a representative cross-section of the US population). There was very little difference in projected responses for the weighted sample compared to the unweighted sample.

Discussion

More than 94% of respondents to our survey believed that the quality of their care would either improve or be unaffected if doctors were to attend or teach at medical conferences or professional society meetings with the aid of industry funding for tuition or salary, food, and travel expenses. Although approximately 37% thought that this industry compensation was not ethical, this did not seem to impact people's opinion about how the quality of their care would be affected. It was noteworthy that more respondents were in favor of surgeons receiving industry funding to attend professional society meetings compared with a purely industry-run seminar.

Surgical device manufacturers run their own educational seminars and pay surgeons to teach at them. These conferences are probably a high-yield marketing tool; this is where potential for COI develops. The boundary between education and marketing can be blurry. However, surgeon “opinion leaders” are best equipped to teach not only about proper technical device usage, but also about indications and complication management. In some instances the US FDA has mandated that surgeons be properly trained by company employees to be certified in the usage of particular surgical devices.7 Having surgeons teach at industry seminars may be a legally protective step so that attendees are educated on properly approved indications for the devices. Companies have the freedom to choose the most qualified personnel to provide the teaching. These teaching services have a monetary value based on the time spent and the knowledge of the teacher. The majority of respondents to our survey believed that the quality of care would improve if their surgeon got paid to teach other doctors about certain surgical devices that a company makes. Less than 7% of respondents believed that the fact that surgeons were getting paid by companies to teach other surgeons would have a negative impact on quality of care. The survey did not query opinions on specific dollar amounts for reimbursements due to the limitations of space and time for the subject matter.

Manufacturers of surgical devices provide a tremendous amount of funding for professional society meetings and surgeon research conferences. Between 1998 and 2007, CME conferences showed a dramatic increase in funding from industry, of more than 300%.7 Professional society meetings may typically derive approximately 50% of their funding from industry. It is unlikely, but certainly desirable, that the current number and magnitude of meetings could affordably be orchestrated without industry funding. This funding provides support for administrative duties, venue, committee member meetings, fellowships, and awards for papers, to name a few.

The respondents to our survey overwhelmingly agreed that industry sponsorship of these events would not be detrimental to the quality of their care (85%). More than 80% believed that more educational conferences, regardless of funding sources, result in better outcomes for patients. The general public perception of this topic is critical as we enter an era of increasing governmental regulation. The surgical industry has recently been targeted as new taxes are levied in a US federal health reform bill. Also, state laws are limiting the type and extent of surgeon-industry relationships.7 Because companies fear sanctions or any appearance of impropriety, they are beginning to restrict funding for educational and professional activities for physicians, to avoid legal threats to their very existence. As part of this protectionist strategy, some funds for educational events may not be offered if the meetings do not comply with potentially unrealistic course schedule requirements. Based on our study, the general public would not favor this scenario and perhaps views the “regulation pendulum” as having swung too far.

Interestingly, respondents to this survey seem to approve surgeon involvement in industry-sponsored research,3 in industry consulting relationships, and in industry-sponsored educational events. A majority of them do not see a potential detrimental impact to the quality of their care with any of these aspects of surgeon-industry COI. This appears to be in contrast to what is circulated in the medical community and lay press about COI. Why such a perceptual dichotomy? Are our patients and the public well informed of all the unethical behaviors that have arisen from surgeon-industry COI?

Khan et al.6 found that approximately 72% of patients in their office wanted to know if the surgeon would be using a device during the surgery that he or she had helped design. This seems to indicate that surgeon disclosure is important to patients with respect to their own surgeries. More than 75% of respondents believed that doctors should explain their teaching job (disclosure) to patients if the device might be used in their surgery. Respondents appeared split on the role of disclosure if patients were not receiving the device that the surgeon teaches about. Disclosure of physician-industry relationships has become a standard for the proper handling of COI. Major spine societies have already implemented self-regulated disclosure policies.2,8 Disclosure allows the parties involved to be informed, to help assess the risk/benefit of a given COI scenario.11 It would appear that public opinion agrees with expert opinion on this issue. Disclosure of physician-industry relationships has been recommended for the informed consent process as the proper method for handling COI.12 The mere act of disclosing a physician-industry relationship does not eliminate bias, but respondents in our study appeared to value disclosure especially if it involved devices that surgeons were paid to teach about.

Many questions remain unanswered. For instance, does disclosure of surgeon-industry relationships at research and teaching conferences make a difference in the perception and usage of the information presented? Does the presentation's type (that is, verbal vs written) and duration (that is, a single slide that may be shown rapidly as part of a larger presentation) make a difference? Currently, there are more than 7 accreditation councils or boards and multiple state licensing bodies that oversee CME.7 Almost every professional society or meeting has its own method of requesting disclosure. How do patients want to have this information disclosed to them? Perhaps disclosure for CME events and professional society meetings should be unified in a standard process so that a single group could manage all disclosure listings, and this would serve as a standard reference that is intended to be updated and responsibly managed by surgeons.

This study has multiple strengths. By making the survey Web based, we were able to reach a broader population than only patients who presented to a doctor's office (as in the study by Khan et al.6), while minimizing the doctor-patient expectation bias. In our study 541 surveys were completed and 501 were usable, which is more than twice the number in the study by Khan et al. Although it may seem important to survey as representative a sample of the general population as possible, there are strengths to limiting our study population to those who are visiting a website seeking medical information, such as www.spineuniverse.com. If policy and regulatory guidelines are to be developed based on people's opinions, it may be most suitable to poll those who have the most interest in the subject and who therefore have the greatest stake in the issue. Based on the respondent demographics in this study, and in comparison with data obtained from the US Census Bureau (http://www.census.gov/prod/www/decennial.html; see also Appendix 2), it appears that our population was older on average than those represented in the US census data; however, these people are more likely to use the health care system. There were approximately 10% more women, and our population was more likely to have attained a higher level of education. Our respondents were also more likely to have had or planned to have surgery that involved implantation of a device. Those with experience dealing with the health care system because of personal or family health issues may be more aware of how the COI reporting system should be shaped.

There are some inherent weaknesses in this study that stem mainly from the population of respondents. First, we were unable to account for the demographics and number of those who saw the survey but elected not to complete it. There is also an inherent bias in administration of our surveys on a website that people visit for medical information. Second, it is unlikely that our study represents a true cross-section of North Americans or US citizens older than 18 years of age. Almost 40% of our respondents had a history of or planned to have surgery that involved an implantable device. Khan et al.6 had more than 60% of respondents planning for or with a history of surgery, so our population is closer to the general population. Third, use of the Web in general compared with other conventional methods of surveying may bias toward certain demographic segments of the population, such as those with Internet access and certain educational levels or motivation to seek medical information. It appears that the educational level of our respondents, on average, was higher than that of the typical American citizen. Finally, 3 of the authors (C.D., M.D., and C.F.) have consulting agreements with medical device companies.

Conclusions

The data provided by this study offer evidence of society's opinions with regard to the complex issue of surgeon-industry COI in education as it pertains to surgeons being paid to be educators by medical companies. It also sheds light on people's perception of how funding sources for CME affect patient care. Industry-education relationships clearly generate potential biases and may have untoward consequences. Most of us are aware of powerful anecdotes about this subject, but it is important that we ask sound questions and support decision making with evidence. It is a challenge to craft policy recommendations that strike the right balance between addressing egregious cases and creating burdens that stifle relationships that advance the goals of professionalism and generate knowledge to benefit society.7 This survey suggests that the public trusts that surgeons can act as clinicians, educators, and students in conjunction with surgical industry, and that it is unlikely to affect the quality of their care. Furthermore, we are at a point in time where the source of funding for CME may become limited and it is important to know how our potential patients view this. Based on this study, the public supports more conferences for CME, regardless of funding source.

The opinion of the public is a critical and necessary component, along with expert opinion and best available evidence, to allow politicians and other health care regulators to form appropriate COI guidelines in education. Hopefully these guidelines will guarantee continued or improved access to ongoing high-level medical education in a transparent, objective setting that will ensure that the highest standard of care is provided to patients.

Acknowledgments

We acknowledge Jeremy Longhurst and Kamiah Walker from www.spineuniverse.com for their generous assistance in survey preparation, testing, distribution, and data management. We also acknowledge Juliet Batke for assistance with manuscript preparation, formatting, and submission.

Disclosure

No financial connection or services were rendered or exist between any of the authors and the personnel of www.spineuniverse.com. Dr. DiPaola is a consultant for Allen Medical, and also receives support for a nonstudy-related research effort that he oversees (Safe Passage Neuromonitoring; unrestricted grant). Dr. Dvorak is a consultant for Medtronic. Dr. Fisher is a consultant for Medtronic and NuVasive.

Author contributions to the study and manuscript preparation include the following. Conception and design: Fisher, DiPaola, Lee. Acquisition of data: Fisher, DiPaola, Lee. Analysis and interpretation of data: Fisher, DiPaola, Dvorak, Lee. Drafting the article: Fisher, DiPaola, Dea, Lee. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Fisher. Administrative/technical/material support: Fisher, Dvorak.

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    Carragee EJHurwitz ELWeiner BKBono CMRothman DJ: Future directions for The Spine Journal: managing and reporting conflict of interest issues. Spine J 11:6956972011

  • 3

    Fisher CGDiPaola CPNoonan VKBailey CDvorak MF: Physician-industry conflict of interest: public opinion regarding industry-sponsored research. Clinical article. J Neurosurg Spine 17:1102012

  • 4

    Fisher CGWood KB: Introduction to and techniques of evidence-based medicine. Spine 32:19 SupplS66S722007

  • 5

    Jaquet GJ: Industry CEOs: relationships with surgeons are vital. AAOS Now June2009. (http://www.aaos.org/news/aaosnow/jun09/cover2.asp) [Accessed November 11 2013]

  • 6

    Khan MHLee JYRihn JACassinelli EHLim MRKang JD: The surgeon as a consultant for medical device manufacturers: what do our patients think?. Spine (Phila Pa 1976) 32:261626192007

  • 7

    Lo BField MJ: Conflict of Interest in Medical Research Education and Practice Washington, DCThe National Academies Press2009

  • 8

    Schofferman JAEskay-Auerbach MLSawyer LSHerring SAArnold PMMuehlbauer EJ: Conflict of interest and professional medical associations: the North American Spine Society experience. Spine J 13:9749792013

  • 9

    Shah RVAlbert TJBruegel-Sanchez VVaccaro ARHilibrand ASGrauer JN: Industry support and correlation to study outcome for papers published in spine. Spine (Phila Pa 1976) 30:109911052005

  • 10

    Steinman MALandefeld CSBaron RB: Industry support of CME—are we at the tipping point?. N Engl J Med 366:106910712012

  • 11

    Thompson DF: Understanding financial conflicts of interest. N Engl J Med 329:5735761993

  • 12

    White APVaccaro ARZdeblick T: Counterpoint: physician-industry relationships can be ethically established, and conflicts of interest can be ethically managed. Spine (Phila Pa 1976) 32:11 SupplS53S572007

Appendix 1: Survey on Education

Does medical company funding of educational conferences for surgeons affect your care?

It is estimated that 50–75% of funding for Continuing Medical Education (CME) events comes from medical companies. Although the involvement of companies in these events is very strictly regulated, there remains concern that some of the educational content may be commercially biased. However, if companies could not provide financial support for these events, many such educational meetings could not continue, and there would be fewer opportunities for physicians to receive ongoing education.

Companies will also fund surgeons to attend these meetings to improve surgeon education, and to build relationships with surgeons and possibly gain the surgeon's business.

In light of this concern, many surgeons, medical companies, and even governments want to understand how patients perceive surgeons' relationships with medical companies. You can help them understand by answering the following questions.

  1. Imagine your surgeon went to a training/education seminar that was organized and funded by a medical company that updated the surgeon on a particular topic, such as the treatment of low back pain:

    • How do you feel it will affect the quality of your care?

      • Care will improve ( )

      • Not affect your care ( )

      • Care will be worse ( )

    • Is it ethical for him/her to be reimbursed by the medical company for travel expenses, meals, and lodging?

      • Yes

      • No

    • Is it ethical for a company to pay for a surgeon to attend a professional society meeting (such as the American Academy of Orthopaedic Surgery) if the surgeon or researchers that present are associated with a university and not affiliated with any company.

      • Yes

      • No

  2. Your surgeon attends a course that is organized and funded by a medical company. At the course, he/she learns about a topic as in question one, but also is shown how to use approved surgical devices that are made by the company.

    • How do you feel it will affect the quality of your care?

      • Care will improve ( )

      • Not affect your care ( )

      • Care will be worse ( )

    • Is it ethical for him/her to be reimbursed by the medical company for travel expenses, meals, and lodging?

      • Yes

      • No

  3. Imagine your surgeon is paid by a company to teach other surgeons through lectures and courses about how to use an approved device that will be used in your surgery:

    • How do you feel it will affect the quality of your care?

      • Care will improve ( )

      • Not affect your care ( )

      • Care will be worse ( )

    • Should he/she explain this teaching job to patients who may receive the device during their surgery?

      • Yes ( )

      • No ( )

      • No opinion ( )

    • Should he/she explain this teaching job to ALL of his/her patients?

      • Yes ( )

      • No ( )

      • No opinion ( )

      How do you feel about the following statements?

  4. If medical companies are the main funding source for most CME courses, how will that affect the quality of your care?

    • Care will improve ( )

    • Not affect your care ( )

    • Care will be worse ( )

  5. The more Continuing Medical Education (CME) events that exist and forums for research exchange, regardless of funding source, the better it is for patients:

    • Agree ( )

    • No opinion ( )

    • Disagree ( )

Your Background

  1. How old are you?

    • 18–29 ( )

    • 30–39 ( )

    • 40–49 ( )

    • 50–59 ( )

    • 60 or older ( )

  2. What is your gender?

    • Male ( )

    • Female ( )

  3. What is your highest level of education?

    • Less than high school ( )

    • High school diploma or GED ( )

    • Technical school or Associate's degree ( )

    • 4-year college degree ( )

    • Graduate or professional degree ( )

  4. Where do you live?

    • USA ( )

    • Canada ( )

    • Other ( )

  5. What type of medical insurance do you have?

    • Private ( )

    • Medicaid ( )

    • Medicare ( )

    • Worker's Compensation ( )

    • Medical Service Plan/Provincial ( )

    • No coverage ( )

    • Other ( )

  6. Are you:

    • A student ( )

    • A homemaker ( )

    • Employed ( )

    • Unemployed ( )

    • Retired ( )

  7. Have you ever or do you plan to have a surgery which involves implanting a medical device (such as an artificial hip, screws, plates, or rods)?

    • Yes ( )

    • No ( )

Appendix 2:

Demographic data for people > 18 years of age in the general US population*

Characteristic%
sex
 male49.1
 female50.9
age in yrs
 20–2919
 30–4942.7
 50–5915.5
 ≥6022
highest level of education
 less than high school14.2
 high school diploma or GED30.9
 technical school or associate degree18
 4-yr college degree17.8
 graduate or professional degree9

Data derived from Thompson.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Address correspondence to: Charles G. Fisher, M.D., Blusson Spinal Cord Centre, 6th Floor, 818 W. 10th Ave., Vancouver, BC V5Z 1M9, Canada. email: charles.fisher@vch.ca.

Please include this information when citing this paper: published online December 20, 2013; DOI: 10.3171/2013.11.SPINE13168.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Bailey CSFehlings MGRampersaud YRHall HWai EKFisher CG: Industry and evidence-based medicine: believable or conflicted? A systematic review of the surgical literature. Can J Surg 54:3213262011

2

Carragee EJHurwitz ELWeiner BKBono CMRothman DJ: Future directions for The Spine Journal: managing and reporting conflict of interest issues. Spine J 11:6956972011

3

Fisher CGDiPaola CPNoonan VKBailey CDvorak MF: Physician-industry conflict of interest: public opinion regarding industry-sponsored research. Clinical article. J Neurosurg Spine 17:1102012

4

Fisher CGWood KB: Introduction to and techniques of evidence-based medicine. Spine 32:19 SupplS66S722007

5

Jaquet GJ: Industry CEOs: relationships with surgeons are vital. AAOS Now June2009. (http://www.aaos.org/news/aaosnow/jun09/cover2.asp) [Accessed November 11 2013]

6

Khan MHLee JYRihn JACassinelli EHLim MRKang JD: The surgeon as a consultant for medical device manufacturers: what do our patients think?. Spine (Phila Pa 1976) 32:261626192007

7

Lo BField MJ: Conflict of Interest in Medical Research Education and Practice Washington, DCThe National Academies Press2009

8

Schofferman JAEskay-Auerbach MLSawyer LSHerring SAArnold PMMuehlbauer EJ: Conflict of interest and professional medical associations: the North American Spine Society experience. Spine J 13:9749792013

9

Shah RVAlbert TJBruegel-Sanchez VVaccaro ARHilibrand ASGrauer JN: Industry support and correlation to study outcome for papers published in spine. Spine (Phila Pa 1976) 30:109911052005

10

Steinman MALandefeld CSBaron RB: Industry support of CME—are we at the tipping point?. N Engl J Med 366:106910712012

11

Thompson DF: Understanding financial conflicts of interest. N Engl J Med 329:5735761993

12

White APVaccaro ARZdeblick T: Counterpoint: physician-industry relationships can be ethically established, and conflicts of interest can be ethically managed. Spine (Phila Pa 1976) 32:11 SupplS53S572007

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