the hidden curriculum (i.e., institutional practices and culture) (see, e.g., Hafferty [1998], Ratanawongsa et al. [2005], Cottingham et al. [2008], and Haidet [2008]). Ideally, these two elements convey messages that are consistent with the formal curriculum, but in practice they may not. For example, the formal curriculum might include course work on medical ethics, research methodology, and appropriate relationships with industry. Concurrently, the informal and hidden curricula might be characterized by disparaging faculty comments on their institution’s conflict of interest policies and the failure of institutions to adopt and implement sound policies.

Unfortunately, some aspects of each curriculum may contribute to undesirable attitudes or practices. The Association of American Medical Colleges (AAMC) observed in a 2008 report that the conflicts created by a range of common interactions with industry can “[f]or medicine generally, and for academic medicine in particular … have a corrosive effect on three core principles of medical professionalism: autonomy, objectivity, and altruism” (AAMC, 2008c, p. 4). Members of the U.S. Congress have also expressed concern about commercial relationships in medical education, primarily continuing medical education (see, e.g., Finance Committee, U.S. Senate [2007]). In contrast to the requirements for recipients of U.S. Public Health Service research awards, the federal government does not require the recipients of direct or indirect funds for medical education to establish and administer conflict of interest policies.

This chapter next provides a brief background on the current context of medical education. It then examines the literature on conflict of interest issues and responses in the learning environments of undergraduate, graduate, and continuing medical education. The discussion covers access to educational environments by sales representatives of medical product companies (e.g., drug detailing, which is a visit to a doctor by a sales representative for a pharmaceutical company), the provision of drug samples and other gifts to faculty and students, and industry-sponsored scholarships and fellowships. A separate section considers a concern that cuts across all phases of education: intellectual independence in presentations and publications and the risks associated with speakers bureaus and ghostwritten publications. (Chapter 4 discussed concerns about how researcher conflicts of interest might affect their advice or supervision involving the research of medical students, residents, fellows, and junior faculty.)

The committee concluded that, in general, industry financial relationships do not benefit the educational missions of medical institutions in ways that offset the risks created. The chapter thus ends with recommendations that are intended to protect the integrity and limit the potential for undue industry influence in medical education. As explained in Chapter 1, the committee focused on conflicts of interest involving physicians and biomedical researchers; but much of the core rationale for the recommendations



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