Competing interests and undergraduate medical education: time for transparency

Conflicts of Interest of Canadian Medical School Deans: A Cross-Sectional Study

Background

Medical school deans wield considerable influence over research, clinical and educational missions at their institutions. This study investigates conflict of interest (COI) of Canadian medical school deans.

Method

The websites of all 17 Canadian medical schools were searched for any mention of relationships between deans and pharmaceutical or medical device companies.

Results

No COIs were discovered for 11 of the deans. Six had COIs, including participating in research funded by pharmaceutical companies and received consulting and speaker fees.

Discussion

A minority of deans had COIs with healthcare industry companies. Whether deans' COIs affect policies at the medical schools they lead should be the subject of further investigation.

Cost, Usability, Credibility, Fairness, Accountability, Transparency, and Explainability Framework for Safe and Effective Large Language Models in Medical Education: Narrative Review and Qualitative Study

BACKGROUND

The world has witnessed increased adoption of large language models (LLMs) in the last year. Although the products developed using LLMs have the potential to solve accessibility and efficiency problems in health care, there is a lack of available guidelines for developing LLMs for health care, especially for medical education.

OBJECTIVE

The aim of this study was to identify and prioritize the enablers for developing successful LLMs for medical education. We further evaluated the relationships among these identified enablers.

METHODS

A narrative review of the extant literature was first performed to identify the key enablers for LLM development. We additionally gathered the opinions of LLM users to determine the relative importance of these enablers using an analytical hierarchy process (AHP), which is a multicriteria decision-making method. Further, total interpretive structural modeling (TISM) was used to analyze the perspectives of product developers and ascertain the relationships and hierarchy among these enablers. Finally, the cross-impact matrix-based multiplication applied to a classification (MICMAC) approach was used to determine the relative driving and dependence powers of these enablers. A nonprobabilistic purposive sampling approach was used for recruitment of focus groups.

RESULTS

The AHP demonstrated that the most important enabler for LLMs was credibility, with a priority weight of 0.37, followed by accountability (0.27642) and fairness (0.10572). In contrast, usability, with a priority weight of 0.04, showed negligible importance. The results of TISM concurred with the findings of the AHP. The only striking difference between expert perspectives and user preference evaluation was that the product developers indicated that cost has the least importance as a potential enabler. The MICMAC analysis suggested that cost has a strong influence on other enablers. The inputs of the focus group were found to be reliable, with a consistency ratio less than 0.1 (0.084).

CONCLUSIONS

This study is the first to identify, prioritize, and analyze the relationships of enablers of effective LLMs for medical education. Based on the results of this study, we developed a comprehendible prescriptive framework, named CUC-FATE (Cost, Usability, Credibility, Fairness, Accountability, Transparency, and Explainability), for evaluating the enablers of LLMs in medical education. The study findings are useful for health care professionals, health technology experts, medical technology regulators, and policy makers.

Conflict of interest policies at Belgian medical faculties: Cross-sectional study indicates little oversight

BACKGROUND

Medical students encounter pharmaceutical promotion from the very start of their training. Medical schools have an important role to play in educating medical students regarding the interactions between healthcare professionals (HCPs) and industry and in protecting them from commercial influence and conflict of interest (COI). In 2019, medical student associations in Belgium and abroad called for more preparation in dealing with COI and for a more independent medical training. As little information is available on the situation in our country, we undertook an assessment of conflict of interest policies at Belgium's medical schools. We relied on a methodology already used in studies from USA, Canada, Australia, France and Germany and adapted it to the Belgian context.

METHODS

We identified 10 medical schools in Belgium. We searched the website of each medical school in November 2019 with standardized keywords for COI policies and learning activities on COI in the curriculum. The deans of medicine were invited to participate by sending us information that we could have overlooked during our web-based searches. We also consulted personal contacts within faculties among students and teachers. Based on a list of 15 criteria adapted from North American and French studies, we calculated a total for each faculty of medicine with a maximum score of 30 points.

RESULTS

By December 2019, we had gathered a set of written documents for four faculties of medicine (40%) containing policies with varying degrees of precision and relevance to our survey. We found elements of the curriculum addressing the COI issue for one faculty (10%). In all cases, these policies consisted of "moderate" initiatives with little or no "restrictive" elements. Only one faculty showed interest in our study by providing us with relevant information (10%). Half of the faculty notified us of their refusal to participate in the study (50%) and the other faculties either did not respond or did not provide us with any information (40%). The maximum score obtained was 3 out of 30 points with six faculties scoring 0 (60%).

CONCLUSION

There is little transparency regarding interactions between medical students and pharmaceutical companies at Belgian medical faculties, which may create COI issues. Initiatives to protect students from pharmaceutical promotion and to train them to manage their future interaction with pharmaceutical companies have a limited scope and are isolated. This is inconsistent with international recommendations from Health Action International, World Health Organization or the American Medical Students' Association. The Belgian government has legislated in favor of more transparency in the relation between HCPs and pharmaceutical industry. Indeed, it made the disclosure of benefits granted by the industry compulsory and limited their value. Our results show that there is still some way to go to ensure an independent medical training for future Belgian physicians.

Conflict of Interest Policies at French Medical Schools: Starting from the Bottom

BACKGROUND

Medical faculties have a role in ensuring that their students are protected from undue commercial influence during their training, and are educated about professional-industry interactions. In North America, many medical faculties have introduced more stringent conflict of interest (COI) policies during the last decade. We asked whether similar steps had been taken in France. We hypothesized that such policies may have been introduced following a 2009-2010 drug safety scandal (benfluorex, Mediator) in which COIs in medicine received prominent press attention.

METHODS

We searched the websites of all 37 French Faculties of Medicine in May 2015 for COI policies and curriculum, using standardized keyword searches. We also surveyed all deans of medicine on institutional COI policies and curriculum, based on criteria developed in similar US and Canadian surveys. Personal contacts were also consulted. We calculated a summary score per faculty based on 13 criteria. [range 0-26; higher scores denoting stronger policies].

RESULTS

In total, we found that 9/37 (24%) of French medical schools had either introduced related curriculum or implemented a COI-related policy. Of these, only 1 (2.5%) had restrictive policies for any category. No official COI policies were found at any of the schools. However, at 2 (5%), informal policies were reported. The maximum score per faculty was 5/26, with 28 (76%) scoring 0.

CONCLUSION

This is the first survey in France to examine COI policies at medical faculties. We found little evidence that protection of medical students from undue commercial influence is a priority, either through institutional policies or education. This is despite national transparency legislation on industry financing of health professionals and limits on gifts. The French National Medical Students Association (ANEMF) has called for more attention to COI in medical education; our results strongly support such a call.

Teaching Conflict: Professionalism and Medical Education

Resistance by physicians, medical researchers, medical educators, and medical students to pharmaceutical industry influence in medicine is often based on the notion that physicians (guided by the ethics of their profession) and the industry (guided by profit) are in conflict. This criticism has taken the form of a professional movement opposing conflict of interest (COI) in medicine and medical education and has resulted in policies and guidelines that frame COI as the problem and outline measures to address this problem. In this paper, I offer a critique of this focus on COI that is grounded in a broader critique of neo-liberalism, arguing it individualizes the relationship between physicians and industry, too neatly delineates between the two entities, and reduces the network of social, economic, and political relations to this one dilemma.

Money makes the (medical assessment) world go round: The cost of components of a summative final year Objective Structured Clinical Examination (OSCE)

INTRODUCTION

The widely used Objective Structured Clinical Examination (OSCE) is undoubtedly expensive. Cost-effectiveness is one of the components of the assessment utility index defining its usefulness. Our current financial climate demands increased transparency in the costs associated with medical education and it is now vital to ascertain how much is spent on assessments, such as the OSCE, and in particular costs associated with the different types of stations within the OSCE.

METHODS

A retrospective case-study approach was used to identify all costs associated with the development, production, administration and post-examination phases of the 2013 final year MBChB OSCE at the University of Aberdeen, Scotland. This 15 station OSCE was held over 2 days for 185 students.

RESULTS

This OSCE cost £65,328 to run. Costs per station ranged from £3108 (prescribing) to £6577 (eye examination). The cost per student was £355.

DISCUSSION

The costs of a "high stakes" OSCE are sobering. The bulk of costs identified are not modifiable in light of what is currently known about the metrics of OSCE utility, particularly reliability and validity.

CONCLUSION

Providers, and funders, of medical education must be prepared to assign significant resource to OSCE assessment and centres should be encouraged to calculate precise costs associated with assessment to inform resource allocation decisions.

Too few, too weak: conflict of interest policies at Canadian medical schools

Introduction

The education of medical students should be based on the best clinical information available, rather than on commercial interests. Previous research looking at university-wide conflict of interest (COI) policies used in Canadian medical schools has shown very poor regulation. An analysis of COI policies was undertaken to document the current policy environment in all 17 Canadian medical schools.

Methods

A web search was used to initially locate COI policies supplemented by additional information from the deans of each medical school. Strength of policies was rated on a scale of 0 to 2 in 12 categories and also on the presence of enforcement measures. For each school, we report scores for all 12 categories, enforcement measures, and summative scores.

Results

COI policies received summative scores that ranged from 0 to 19, with 0 the lowest possible score obtainable and 24 the maximum. The highest mean scores per category were for disclosure and ghostwriting (0.9) and for gifts and scholarships (0.8).

Discussion

This study provides the first comprehensive evaluation of all 17 Canadian medical school-specific COI policies. Our results suggest that the COI policy environment at Canadian medical schools is generally permissive. Policy development is a dynamic process. We therefore encourage all Canadian medical schools to develop restrictive COI policies to ensure that their medical students are educated based on the best clinical evidence available, free of industry biases and COI relationships that may influence the future medical thinking and prescribing practices of medical students in Canada once they graduate.