Guns, society, and medicine.

Given the 96 incidents of firearm violence on school campuses since Sandy Hook and the ongoing toll on lives and health, the lack of relevant data and a research pipeline in this area should be anathema to all physicians.

Internal medicine residency redesign: proposal of the Internal Medicine Working Group.

Concerned with the quality of internal medicine training, many leaders in the field assembled to assess the state of the residency, evaluate the decline in interest in the specialty, and create a framework for invigorating the discipline. Although many external factors are responsible, we also found ourselves culpable: allowing senior role models to opt out of important training activities, ignoring a progressive atrophy of bedside skills, and focusing on lock-step curricula, lectures, and compiled diagnostic and therapeutic strategies. The group affirmed its commitment to a vision of internal medicine rooted in science and learned with mentors at the bedside. Key factors for new emphasis include patient-centered small group teaching, greater incorporation of clinical epidemiology and health services research, and better schedule control for trainees. Because previous proposals were weakened by lack of evidence, we propose to organize the Cooperative Educational Studies Group, a pool of training programs that will collect a common data set describing their programs, design interventions to be tested rigorously in multi-methodological approaches, and at the same time produce knowledge about high-quality practice.

Commentary: Disclosure's failings: what is the alternative?

Failure to disclose all sources of financial support in biomedical publications has been the focus of media critiques of authors, journals, and professional societies. In this issue, David Resnik properly calls attention to the need in many cases for an archaeological dig to discover all the companies that fund a particular research project. Disclosure is widely considered the best disinfectant for relationships between investigators and industry, but even though disclosure is necessary and all funding sources should be exposed, disclosure is not a real solution to dealing with conflicts of interest. Here the author calls attention to the more dangerous problem--namely, the existence and persistence of the financial conflict even despite full disclosure. The author makes the point that the vast attention paid to failure to disclose is misplaced, and that more attention must be focused on the financial conflicts themselves and their consequences. He avers that the best approach to financial conflicts is to have none, and that those individuals who are free of financial ties to industry should be the ones appointed to major decision-making roles in journals, clinical practice guideline committees, FDA panels, and professional societies.

No more free drug samples?

Susan Chimonas and Jerome Kassirer argue that giving out "free" drug samples is not effective in improving drug access for the indigent, does not promote rational drug use, and raises the cost of care.

Professional societies and industry support: what is the quid pro quo?

Professional medical societies have become increasingly dependent on pharmaceutical, device, and biotechnology companies for ongoing support of their programs, but the internal influence of this financial largesse on medical societies' practices is well hidden. Many examples exist in which societies' educational products, including clinical practice guidelines and professional publications, have been tainted by involvement by industry-paid individuals. These examples show that professional judgments of organizations can be affected in ways that are not in the best interests of our patients. Society leaders should develop policies that leave critical decisions, especially those that affect patient care, in the hands of members without financial ties to industry. Society leaders should not accept funds designated for specific industry-recommended projects unless such programs are already part of their planned agenda. These leaders, who typically serve for only a year or two, should delve into arrangements that salaried society executives make with industry, and insure that no promises are made that compromise an organization's professional goals. Professional societies should also find ways of reducing the vast, embarrassing industry involvement at their national meetings, especially the vulgar circus-like displays and the drug company-sponsored symposia. We must reduce commercialism and restore professionalism to our medical meetings.

When physician-industry interactions go awry.

Financial connections between members of the profession and professional organizations and the pharmaceutical, device, and biotechnology industries are increasingly common and can lead to biased medical decision making, higher costs of care, and decline in the public's trust of the profession. To preserve its reputation and its autonomy over medical decisions, the profession must begin to police itself.

Health industry practices that create conflicts of interest: a policy proposal for academic medical centers.

Conflicts of interest between physicians' commitment to patient care and the desire of pharmaceutical companies and their representatives to sell their products pose challenges to the principles of medical professionalism. These conflicts occur when physicians have motives or are in situations for which reasonable observers could conclude that the moral requirements of the physician's roles are or will be compromised. Although physician groups, the manufacturers, and the federal government have instituted self-regulation of marketing, research in the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts. We propose a policy under which academic medical centers would take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry.