By Ronald Sherman MD, MSC, DTM&H
I am seeing more and more expert lecturers being disqualified from speaking at wound care conferences, simply because their qualifications include significant positions or associations in the corporate world. When did these speakers' qualifications become disqualifications? I believe it began when conference organizers and accreditation committees decided that it was no longer worth their time to ensure that lectures were unbiased. The practices that I am about to describe are not universal, but as accreditation committees increasingly adopt such practices, and as conference organizers increasingly accept such practices as the status quo, we may soon find ourselves with drastic changes in our educational programs. I believe it is worth considering the following thoughts and observations.
What Qualifies a Field Expert in Wound Care?
From whom would you prefer to learn about fixing a flat tire: an assistant professor of automotive mechanics, who recently edited a book entitled: The History of the Wheel, or the owner of a tire-repair shop who has been fixing flat tires for over 30 years? If you are like me, you would prefer to hear about tire repair from the tire repair expert. His or her successful tire repair business is a qualification for giving the lecture. If you were attending a conference on car maintenance, the conference organizers would probably see it the same way, and select the tire expert to give the lecture. If this were a medical conference, however, it is increasingly likely that the professional tire repair person would not be allowed to lecture because his/her shop ownership is also a commercial conflict of interest. The academic, on the other hand, is considered not to have significant conflicts of interest --- well, at least there are no commercial conflicts of interest --- and that means that his/her lecture does not need to be vetted for bias. Really?
During the past year I have been un-invited to speak about maggot therapy at two conferences (Symposium for Advanced Wound Care, and the Annual Conference of the Academy of Physicians in Wound Healing) as a result of my corporate affiliations (conflicts of interest). I know of several colleagues whose lectures were also recently deemed "un-accreditable." Two years ago, the same conflicts of interest were managed simply by requiring that I, like other speakers, avoid mentioning brand names, and that we provide an advanced copy of our lecture slides for review. Other methods of mitigating commercial bias included reviewing participants' lecture evaluations and having members of the conference organizing committee monitor the lectures during the conference. Although these methods are still acceptable today (according to the Accreditation Council for Continuing Medical Education, or ACCME), more and more conference organizers and accrediting committees appear to be passing over many prospective speakers with "significant" commercial conflicts of interest rather than taking the effort to review the lectures for evidence of bias.
But what constitutes a "significant" conflict of interest? Doesn't every speaker have a conflict of interest? After all, speaking at a conference brings respectability and notoriety, not to mention an honorarium. Ironically, those with the greatest conflicts of interest may actually be university faculty, who usually get a free ride through the speaker vetting process. Speaking at conferences has a direct impact on the professional status of university faculty: their tenure, rank, pay, and ability to secure grant funding all depend on the frequency of conference lecturing. I should know, for I used to lecture at wound care conferences when I was still on the faculty of the University of California. At that time, I gave nearly the same disclosures as I give now, plus I listed my faculty position as a potential conflict of interest. Despite my disclosures, the conference literature (and many of my scientific publications) often simply read: "Dr. Sherman has no conflicts of interest to report." These conflicts of interest were apparently not considered significant, because they were not commercial conflicts.
The advantage of categorizing conflicts of interest as "significant" or "insignificant" is that it dramatically eases the burden of controlling lecture content and bias. When commercial conflicts such as business ownership or spousal employment are considered egregious and un-mitigable, then potential lecturers can be disqualified without further review. When non-commercial conflicts like grant access, academic advancement and job security are considered minor conflicts, then potential lecturers with only these conflicts of interest can be allowed to speak without further review. Indeed, it is much more time efficient and economical to select a conference faculty on the basis of declared conflicts of interest than it is to ensure educational quality by reviewing the actual content of each lecture.
Commercial vs. Non-Commercial Conflicts of Interest
When I lived within the ivory tower of academic medicine, I, too, believed that commercial conflicts of interest were far more serious than non-commercial conflicts. But once I walked outside, I saw the walls of the ivory tower to be just as dirty and stained as any industrial edifice. In fact, with increasing frequency, we are hearing of academic investigators whose research, publications, and advancements were based, at least in part, on altered or fabricated data. I have now come to believe that conflicts of interest are universal, and should be handled more equitably.
If the concern is that qualified speakers who are deemed to have "significant" commercial conflicts of interest might inject their biases into a conference lecture, then what are the solutions? As already described, the increasingly popular solution is to find an alternative speaker without such conflicts (albeit sometimes without equivalent qualifications). I have heard many complaints from conference attendees who have heard well-respected but inexperienced speakers make inaccurate statements like: "Maggot therapy never causes any pain"; "medicinal maggots do not turn into flies because they are sterile"; "the FDA has determined that maggots contained in bags are equally effective as free range maggots." I am sure that similar misinformation abounds in other fields, and I am equally sure that such "unbiased misinformation" should be considered no more accreditable than biased information.
The solution I propose is that we continue to follow the time-proven methods still promoted by AACME: require that speakers not only declare all conflicts of interest but also mitigate them, and require that conference organizers and/or accreditation committees ensure that this is being done. For the speaker, eliminating commercial bias is usually as simple as not promoting off-label use of commercial products, avoiding brand names, and/or giving equal time to most or all similar products whenever brand names are appropriate. For their part, conference organizers and accreditation committees should make sure that lectures are free of bias by reviewing the lecture and lecture slides in advance. They could also review critiques from prior conferences by requiring that prospective lecturers submit not only their curriculum vitae, but also their attendee’s reviews. Lecture monitors are also a valid method of ensuring that there is no commercial bias, according to ACCME. In short, accreditation should be about the lecture content and quality, not about a speaker's potential conflicts of interest. Arbitrarily ranking the severity of threat posed by various conflicts of interest is inherently flawed because a significant conflict of interest to one person may be an easily mitigated conflict to another. It is not usually the conflict, but rather the effort and methods of conflict resolution, that determine whether or not an educational program will be both instructional and void of commercial bias.
Dr. Ronald Sherman discloses that he officially retired from the University of California, Irvine, in 2008. In 2005, his medicinal maggot laboratory at the university was privatized as Monarch Labs, for which he remains Co-Founder and Laboratory Director. Dr. Sherman's wife has worked in his laboratory for nearly 30 years, and has been paid for her services for the past 9 years. Dr. Sherman is also on the Board of Directors of the not-for-profit BioTherapeutics, Education and Research (BTER) Foundation, which supports patient care, education and research in biotherapy, including maggot therapy. Since 2003, he has also functioned as the Director of the Foundation. To minimize his conflicts of interest, Dr. Sherman earns his living working 2 days/week as an HIV doctor for the Orange County Health Care Agency (health department). Dr. Sherman does not accept salary support for his work for Monarch Labs, nor for the BTER Foundation, and he insists that any speaking honoraria that may come his way are donated to the BTER Foundation or some other charity.
About The Author
Ronald Sherman MD, MSC, DTM&H has led a long career at the forefront of biotherapy, pioneering the development of medicinal maggots for over 25 years. He is now retired from his faculty position at the University of California, but continues to volunteer as Director and Board Chair of the BTER Foundation, and as Laboratory Director of Monarch Labs.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.