Creative Education
2013. Vol.4, No.3, 217-222
Published Online March 2013 in SciRes ( DOI:10.4236/ce.2013.43032
A Review of Canadian Medical School Conflict of Interest
Michael G. R. Beyaert, Jatinder Takhar*, David Dixon, Margaret Steele,
Leanna Isserlin, Carla Garcia, Ian J. Pereira, Jason Eadie
Continuing Professional Development , Schulich School of Medi c i n e and Dentistry,
The University of Wes te rn Ontario, London, Canada
Email: *
Received January 3rd, 2013; revised February 8th, 2013; accepted February 19th, 2013
Background: Growing evidence of behavioral bias has caused a surge of interest in the area of Conflict
of Interest (COI) within the medical community. The present study sought to evaluate the landscape of
Faculty of Medicine COI policies among Canadian medical schools using an evaluation system adapted
from the AMSA PharmFree Scorecard. Methods: The authors contacted leaders at the CPD/CME offices
of all 17 Canadian medical schools in 2011 to determine how many had formal policies guiding interac-
tion with the pharmaceutical industry. Existing policies were evaluated based on 16 criteria developed by
a steering committee. A Policy Score was calculated and a letter grade assigned for each of the existing
policies. Results: At the time of review, roughly 35% of the Canadian medical schools had faculty-wide
COI policy/guidelines, half of which had been implemented. Other policies are currently in development.
Policy Scores ranged from 25.00% to 70.83% with a Mean Policy Score of 52.08%. Policies that were
implemented all scored higher than those that were not implemented. Additionally, several strengths and
weaknesses among policies were identified. Conclusions: Canadian schools have recognized that COI
and bias have become a serious issue and are taking steps toward its management. The authors propose that
the CMFS employ a system similar to the AMSA Scorecard to evaluate progress in a longitudinal study.
Keywords: Conflict of Interest; Policy Evaluation; Continuing Medical Education; Continuing
Professional Development; Quality Control
Conflict of Interest (COIs) are becoming increasingly rele-
vant to the medical field. A COI may be defined as “a set of
conditions in which professional judgment concerning a pri-
mary interest (such as a patient’s welfare or the validity of re-
search) tends to be unduly influenced by a secondary interest
(such as financial gain)” (Thompson, 1999). Interactions with
the pharmaceutical industry begin early during medical educa-
tion, shaping behaviour that continues well into practice
(Wazana, 2000; Institute of Medicine, 2009). Residents ex-
posed to pharmaceutical representatives during training are
more likely to be skewed towards industry values (Zipkin &
Steinman, 2005) and are more likely to recall misinformation
about the company’s and its competitors’ products (Wazana,
2000). However, these biases may be attenuated by the intro-
duction of more stringent policies. A Canadian study demon-
strated that residents trained under policies that restricted inter-
action with pharmaceutical representatives were more skeptical
about information provided by pharmaceutical representatives
compared to residents trained under non-restrictive policies
(McCormick et al., 2001).
Although the majority of practicing physicians dismiss the
notion that interaction with the industry introduces bias, their
behaviour is influenced in a number of ways. Notably, physic-
cians and their organizations are more likely to prescribe a
company’s products for up to two years following a direct in-
teraction (Wazana, 2000). COI among authors of popular North
American and European clinical practice guidelines are preva-
lent (Choudry et al., 2002; Neuman et al., 2011), and many
guidelines recommend products sold by the companies with
which authors have ties (Choudry et al., 2002). Gifts may also
alter physicians’ abilities to weigh information (Dana &
Loewenstein, 2003). Although drug samples are considered by
many to be the most appropriate incentive from industry (Mor-
gan et al., 2006), it has been demonstrated that a correlation
exists between access to drug samples and prescription rates of
that product (Adair & Holmgren, 2005).
Conflict of interest extends beyond clinical practice. Nearly
one quarter of medical research performed at academic institu-
tions is at least partially funded by the pharmaceutical industry
(Bekelman et al., 2003). Industry funding influences study de-
sign, execution, reporting, access to data, and publication of
results (Lexchin et al., 2008). Industry-sponsored research de-
sign tends to be less objective (Rochon et al., 2011) and is more
likely to yield results favouring the sponsor (Bekelman et al.,
2003; Lexchin et al., 2003). Among Canadian academic medi-
cal centers, definitions of what constitutes a COI in research is
variable with many potential conflicts often being excluded
(Lexchin et a l., 2008).
It has been estimated that industry spent $57.7 billion Ame-
rican dollars on promotion in 2004. This figure represents near-
ly 25% of industry sales and double the amount spent on re-
search and development. Perhaps more alarming is that 80% of
promotional spending was spent marketing to physicians (Gan-
*Corresponding autho r.
Copyright © 2013 SciRe s . 217
gon & Lexchin, 2008). Of large concern is that COIs are often
self-reported. A recent study found that physicians disclose
only 20.7% of directly related payments from industry and
50.0% of indirectly related payments (Okike et al., 2009).
In an attempt to persuade academic medical centers to ma-
nage COI, a number of American groups have published re-
commendations for more stringent regulation of physician-in-
dustry relationships (Brennan et al., 2006; AAMC, 2008;
AMSA, 2012). In 2008, the American Association of Medical
Colleges (AAMC) Task Force released an assessment of COI
policies from academic medical centers across America and
made recommendations for improvements (AAMC, 2008).
Using similar criteria, the American Medical Student Asso-
ciation (AMSA) continues to monitor and grade COI policies of
academic medical centers in the United States using their
PharmFree Scorecard. Criteria from six COI domains (Gifts
and Individual Financial Relationships with Industry; Pharma-
ceutical Samples; Purchasing and Formularies; Industry Sales
Representatives; Education; and Enforcement) are given scores
ranging from 1 (weak or no policy) to 3 (strong policy). The
cumulative score of these domains, excluding Enforcement, is
used to determine a percentage score out of a maximum 15
points. The 2011-2012 report concluded that 67% of American
medical schools have policies scoring A (score of 85% or
higher) or B (score of 70% or higher). This is a significant im-
provement from 19%, 30% and 51% of schools in 2008, 2009,
and 2010, respectively (AMSA, 2012). It is conceivable that
implementation of the AMSA scorecard has raised awareness
about the issue of COI and contributed to improvements in
medical school COI policies. However, Chimonas et al. evalua-
ted American medical school COI policies using their own
method and found that half of those surveyed had poor or
non-existent COI policies (Chimonas et al., 2011).
In Canada, physicians are encouraged to follow Canadian
Medical Association (CMA)’s “Guidelines for Physicians in
Interactions with Industry” (CMA, 2007). These guidelines
apply to all physicians, residents, and medical organizations in
Canada, including the College of Family Physicians of Canada
(CFPC) and the Royal College of Physicians and Surgeons of
Canada (RCPSC). Although the Association of Faculties of
Medicine of Canada (AFMC) has not issued its own policy
guiding interactions between industry and Canadian medical
schools, it endorsed the AAMC report on “Industry Funding of
Medical Education” (AAMC, 2008).
To address the issue of COI in Canadian medical education,
the AMFC created the Standing Committee on Continuing
Professional Development (SCCPD). This committee brought
leaders from the 17 Canadian medical schools’ Continuing
Professional Development (CPD)/Continuing Medical Educa-
tion (CME) offices together at a national meeting to discuss
relations between industry and CPD/CME. The SCCPD Work-
ing Group on Industry Relations issued a position paper urging
Canadian medical schools to develop individual COI policies,
and provided consensus statements to help guide the creation of
such policies (SCCPD, 2010). The Canadian Federation of
Medical Students (CFMS) has also called upon Canadian
medical schools to develop policies in collaboration with their
medical student societies and educate medical students about
appropriate industry relationships. Their report briefly ad-
dresses COI policies and guidelines from a number of organiza-
tions, including the CMA and the Faculties of Medicine at the
University of Toronto and the University of Ottawa (CFMS,
As a result of these initiatives, increasing attention has been
paid to COI documents among Canadian universities. In 2008,
Williams-Jones and MacDonald evaluated COI policies from
thirteen of Canada’s largest and most prominent universities for
readability and content. The authors found that most schools'
policies had low readability, using complex legal language to
focus on prohibitions and mitigate institutional liability, rather
than providing readers with clear definitions of COI, examples
of what constitutes COI, and procedures for addressing COI
(Williams-Jones & MacDonald, 2008). More recently in 2012,
Mathieu et al. applied a modified version of the AMSA Pharm-
Free Scorecard to COI policies from Canadian universities with
medical schools. The authors found that Canadian universities
studied scored very poorly, with all but one receiving overall
grades of D or F. However, it is important to note that this
study evaluated university-wide COI policies from univer-
sities with medical schools rather than investigating policies
specific to the Faculties of Medicine. Many of the weaknesses
in policies could be attributed to evaluation of general univer-
sity-wide COI policies using AMSA’s grading scheme, which
was developed specifically for medical school COI policies
(Mathieu et al., 2012).
To the best of our knowledge, no comprehensive assessment
of Faculty of Medicine COI policies from all 17 Canadian
medical schools has been performed. The present study sought
to raise awareness about this issue by evaluating the landscape
of medical school COI policies in Canada using a scoring sys-
tem similar to the AMSA PharmFree Scorecard.
The associate and vice deans of CPD/CME offices of all 17
Canadian medical schools were contacted in August 2011 to
determine which schools had developed formal COI policies
and whether these policies had been implemented. CPD/CME
leaders were contacted because they are currently taking the
lead on these issues as the majority of policies are vetted
through these offices.
Existing policies, which were all available within the public
domain, were obtained from each Faculty of Medicine’s web-
site for evaluation. University-wide policies were excluded
from analysis because they were not developed specifically for
the physician community. Once policies were obtained, a
steering committee was formed to discuss policy evaluation.
This committee consisted of the Associate Dean of CPD, the
Vice Dean of Hospital and Interfaculty Relations, educators
from various disciplines within the Schulich School of Medi-
cine, a resident representative, and a medical student represen-
tative. The committee created criteria and a scoring system for
policy evaluation based on relevant COI criteria commonly
found in the literature. The criteria selected for evaluation in-
cluded all areas of the AMSA PharmFree Scorecard as well as
additional areas deemed important by the committee (Chimonas
et al., 2011; AMSA, 2012; Mathieu et al., 2012).
Policies were reviewed and graded by a single scorer and
calculations were verified independently by a second reviewer.
The scorer was not blinded to the identities of medical schools.
Each policy was evaluated based on the strength of each crite-
rion using a four-point scale reported by Mathieu et al. (2012),
which was adapted from the AMSA PharmFree Scorecard
(AMSA, 2012). The scoring scale was follows: 0 points for a
Copyright © 2013 SciRe s .
Copyright © 2013 SciRe s . 219
policy element that was absent; 1 point for a policy element that
was only partially addressed or for which the reader was di-
rected to another institutional policy; 2 points for a policy ele-
ment that was addressed, but the policy was incomplete or
weak; and 3 points for a policy element that was considered
complete and strong.
were implemented, while Medical Schools D through F had not
yet implemented theirs.
Policy Scores ranged from 25.00% (Medical School F) to
70.83% (Medical Schools B and C), corresponding to letter
grades of F and B, respectively. When taken together, the ave-
rage Policy Score for all six schools was 52.08%, which corre-
sponds to a letter grade of D. However, when implemented and
non-implemented policies were considered separately, there
appeared to be some differences. The average Policy Score
among implemented policies was 69.44% (corresponding to a
letter grade of C), while the average Policy Score among
non-implemented policies was 34.72% (corresponding to a
letter grade of F).
A raw score was determined for each COI policy by cal-
culating the sum of scores for each criterion within that policy.
This was then used to express each school’s Policy Score as a
percentage of the highest possible score, or 48 points. Each
school’s policy was assigned a letter grade based on its policy
score percentage according to the cutoffs used for AMSA’s
PharmFree Scorecard (AMSA, 2012): A for a policy with a
score of 85% or higher; B for a policy with a score of 70% or
higher; C for a policy with a score of 60% or higher; D for a
policy with a score of 40% or higher; and F for a policy with a
score below 40%. Additionally, an Average Criterion Strength
was determined for each criterion by calculating the mean score
for that criterion from all six policies.
The presence of COI policies among Canadian medical
schools can be seen in Figure 1. In August 2011, six of the 17
Canadian medical schools (35.2%) had completed their facul-
ty-wide policies on physician interaction with industry, while
the remaining 11 schools had not (64.7%). Among schools with
existing policies, three had been implemented at the time of
review (17.6%). The other three existing policies had not been
implemented (17.6%), but will be in the near future.
Results from the evaluation of the six existing policies are
shown in Figure 2. For reporting purposes, medical schools
were assigned an identifier based on the implementation status
of their policy. Medical Schools A through C had policies that
Figure 1.
Status of COI policies among all 17 Canadian medi-
cal schools.
Figure 2.
Grading of Canadian medical schools’ COI policies using a modified AMSA PharmFree Scorecard. *Indicates policies that were implemented at the
time of revi ew.
Given these differences in quality between implemented and
non-implemented policies, it is difficult to make meaningful
comparisons of Average Criterion Strength, especially because
several criteria that were present in at least two out of the three
implemented policies were absent in at least two out of the
three non-implemented policies. Nevertheless, the Average
Criterion Strength was still useful for identifying general
strengths and weaknesses of policies. Strengths were consid-
ered criteria with an Average Criterion Strength of 2.00 or
greater: Gifts and Meals (2.50), Support for Educational Pro-
grams (2.33), Support for Research (2.33), and Industry Access
to Faculty, Trainees, and Students (2.17). Weaknesses were
considered criteria with an Average Criterion Strength of 1.00
or lower: Guidelines for Compensation (1.00), Ghost-writing
(1.00), Purchasing (1.00), COI Training (1.00), and
Off-Campus Events (0.83).
The new reality is that interactions between industry and
physicians will continue to be pervasive throughout a phy-
sician’s career. The current study provides new insight into how
the medical profession recognized this potential for bias and
produced accreditation policies and procedures to assure that
medical education is not biased due to commercial support.
In addition, organizations like the AFMC have taken the ini-
tiative to bring key leaders in education to the table for dis-
cussion and standardization since 2010. The Brief Report of
Highlights of the AFMC Hosted 2nd National COI Meeting
alluded to the following challenges: disclosure requirements,
buy-in from faculty, definition of what constitutes a COI, need
for education, alignment with local health care facilities, and
the reliance on industry support for Continuing Professional
Development (CPD). The CFMS has taken a stand towards
raising awareness and education in the early part of training.
Canadian schools have recognized that the management of COI
and bias is a serious issue needing new policy direction and
innovative practices. Our finding that 35% of Canadian medical
schools responded by creating formal policies indicates that
schools are taking appropriate steps to address COI. It is also
encouraging that half of existing policies have been imple-
mented and the remaining policies will be implemented in the
near future. However, there are still major steps to be taken
moving forward as 11 schools (roughly 65%) still do not have
formal COI policies.
Our results indicate that the strength of existing policies var-
ied substantially, with Policies Scores ranging from 25.00% to
70.83% and a Mean Policy Score of 52.08%. However, our
results also indicate differences between policies that have been
implemented and those that have not, particularly in terms of
overall policy strength. All implemented policies scored higher
than non-implemented policies in our evaluation, and had Poli-
cy Scores ranging from 66.67% to 70.83%. These scores cor-
respond to letter grades of C and B using AMSA’s PharmFree
Scorecard cutoffs. In contrast, Policy Scores of non-imple-
mented policies ranged from 25.00% to 43.75%, or letter grades
of F and D, respectively.
While implemented policies tended to address more criteria
than non-implemented policies (14.3 vs. 10.7, respectively),
this was not the only contributing factor to the difference in
Policy Scores. Only one criterion from all three non-imple-
mented policies received an ideal score of 3, compared to 21
criteria that received a score of 3 among implemented policies.
Therefore, implemented policies not only covered a broader
range of criteria, they also had stronger content.
Using the AMSA scoring system to evaluate similar criteria,
the strength of university-wide COI policies ranged from 30%
to 55% among Canadian universities with medical schools,
with a mean score of 44% (Mathieu et al., 2012). However, it
must be noted that the authors evaluated university-wide poli-
cies, whereas the present study evaluated policies specific to
Canadian Faculties of Medicine. Therefore many of the weak-
nesses in university-wide COI policies reported by Mathieu et
al. may be a result of evaluating general university-wide poli-
cies using a scoring system developed specifically for medical
Our results also indicate a number of clear strengths and
weaknesses among existing policies. While it is difficult to
make definitive conclusions given distinct differences in crite-
ria inclusion between implemented and non-implemented
schools, some general observations can be made.
Four criteria had Mean Criterion Strengths greater than 2.00:
Gifts and Meals (2.50); Support for Educational Programs
(2.33); Support for Research (2.33); and Industry Access to
Faculty, Trainees, and Students (2.17). Mathieu et al. also
found that guidelines for research were strong among Canadian
university COI policies and reasoned that this is because all of
Canada’s medical schools are part of research-intensive institu-
tions. In contrast to our findings, Mathieu et al. identified Sup-
port for Education and Industry Access as weaknesses (Mathieu
et al., 2012). As these issues are likely to be more common
within medical education than in other disciplines, it is encoura-
ging that Faculty of Medicine COI policies scored greater in
these areas than university-wide policies. Five criteria had
Mean Criterion Strengths of 1.00 or less: Guidelines for Com-
pensation (1.00); Ghostwriting (1.00); Purchasing (1.00); COI
Training (1.00); and Guidelines for Off-Campus Events (0.83).
Many of these weaknesses were also identified by Mathieu et al.
(Mathieu et al., 2012).
This study does have some inherent limitations. It must be
acknowledged that the present study only evaluated COI poli-
cies from each school’s Faculty of Medicine, although some
criteria may be included in university-wide policies. However
we felt it was important to focus within the context of medical
education, as both the AMFC and CFMS have urged medical
schools to adopt their own COI policies. While Faculties of
Medicine still fall under the jurisdiction of broader univer-
sity-wide policies, it is still critical to develop policies specifi-
cally for the physician community given the unique circum-
stances encountered by this population. Additionally, univer-
sity-wide policies have been previously evaluated from a
medical perspective (Mathieu et al., 2012).
While reviewing these policies does provide insight into their
strength and quality, it does not allow us to assess how knowl-
edgeable individual faculty members are about the policy or
how closely the policies are being followed. Nevertheless, the
development of strong policies is a necessary first step towards
better management of COI among Canadian medical schools.
We believe this environmental scan will help raise awareness
of the importance of this issue to those within the continuum of
education and prepare them for the challenges in the shift from
guideline to policy development and implementation. We hope
that schools will take note of this study and improve the
strength of their policies. We encourage Canadian Faculties of
Copyright © 2013 SciRe s .
Medicine to learn from the experiences of other schools in the
development and implementation of their COI policies. Addi-
tionally, several excellent suggestions have been provided in
the literature. Notably, Smith and Williams-Jones made exem-
plary recommendations for the development of COI policies in
Canada (Smith & Williams-Jones, 2009).
Our goal is that a similar system to the AMSA PharmFree
Scorecard will be put in place in Canada to grade medical
school COI policies and track the progress in a continuous lon-
gitudinal initiative. AMSA has achieved great success with
their initiative in the US, as the overall quality of medical
school COI policies has improved every year since the introdu-
ction of their scoring system (AMSA, 2012). We believe simi-
lar success can be achieved in Canada. We propose that this
could be done by some of the organizations in the National COI
group such as CFMS, a Canadia n organization similar to AMSA,
in collaboration with academic CME/CPD offices in Canada.
In conclusion there are important lessons learnt from this
early study, that is sharing of experiences in implementing
these policies through education in Canadian medical schools
would be beneficial through a national COI group. There is
ongoing need to identify appropriate management of COI’s and
bias through educational strategies in all academic institutions.
Academic health sciences centers should ensure that any and all
partnerships between themselves and industry serve the best
interest of patients. Using information gleaned from this study
for longitudinal evaluation and continuous quality improvement
in education is the vital next step.
The authors are pleased to acknowledge the assistance of
Larissa Husarewy c h in the submission of this manuscript.
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