industry. For example, in an analysis of marketing literature and interactions between physicians and industry representatives, Roughead and colleagues (1998) noted that “[r]eciprocity is one of the norms by which society abides.… The provision of gifts by sales personnel encourages an automatic response of indebtedness on the part of the receiver who will then look for ways to make repayment” (p. 307). Other research has documented the importance of unconscious bias (see Appendix D).

Since 2000, a number of private and public groups have issued reports on conflict of interest in aspects of medical research, education, or practice. Table 1-2 lists some of the more prominent reports, several of which are discussed in later chapters of this report. Most reports have focused on research. Most have recognized the value of legitimate and properly designed research, educational, and technical relationships; but several have recommended some restrictions on other types of relationships and the more effective implementation of policies. In addition, the Pharmaceutical Research and Manufacturers of America (PhRMA) revised its voluntary Code on Interactions with Healthcare Professionals (effective January 2009) to more strongly discourage noninformational gifts, such as providing tickets to sporting events and token consulting arrangements (PhRMA, 2008). The Advanced Medical Technology Association has also revised its Code of Ethics for medical device manufacturers (effective July 2009) to include generally similar provisions (AdvaMed, 2008). (Other countries also have industry codes on relationships between the pharmaceutical industry and physicians [Jost, 2009].)

The recommendations in the reports listed in Table 1-2 are often similar (but not entirely consistent) in calling for more accountability and openness and more effective implementation. The policies of particular institutions vary, and some individuals may be subject to multiple policies that apply to their different roles and activities. To the extent that the adoption and implementation of policy recommendations have been evaluated, the results are mixed, as discussed in Chapter 3.

Evolution of Other Strategies to Limit Bias in Medical Research, Education, and Practice

At the same time that policy makers, universities, professional groups, and others were responding to concerns about conflict of interest, methodologists, statisticians, and scientists were working to develop and refine methods for designing and conducting research and analyzing data in ways that limit bias—whatever the source—during all stages of scientific investigation, from protocol design through the reporting of the results (see Chapter 4). In addition, academic medical centers have instituted education on evidence-based medicine to instruct future physicians on how to evaluate



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