Conflicts of interest (COI) in medicine — relationships between physicians and for-profit companies that may influence the delivery of patient care and outcomes — have existed for centuries. COI are well known to affect prescribing. Even gifts as small as a $20 meal have been associated with increased prescribing of a promoted medication over a generic alternative.Reference DeJong ¹ However, in the last decade, the visibility of COI in the US has changed dramatically. After Congress passed the Sunshine Act, financial relationships between clinicians and pharmaceutical or device manufacturers have been documented through the Centers for Medicare and Medicaid Services’ (CMS) Open Payments database since 2013.

A major insight from the Open Payments database has been the prevalence of COI in academic medical environments where medical training occurs. Using data from 2018, one study found that hospitals with major medical school affiliation were about 2.5 times more likely to receive over $100,000 in nonroyalty payments compared to unaffiliated hospitals.Reference Anderson ² At the same time, medical education is increasingly embedded in corporate health systems for which financial imperatives shape the daily experiences of learners. Students are socialized within institutions where industry relationships and financial productivity pressures are part of daily patient care. It is an important time to reevaluate COI education and policy in medical schools.

The last major wave of COI reform in medical education occurred more than a decade ago. The Association of American Medical Colleges (AAMC) issued its first guidance on institutional COI related to research in 2001. ³ By 2008, it reported that only 38% of medical schools had adopted formal policies meeting its recommendations, though a larger proportion had policies for specific officials such as institutional review board members.Reference Ehringhaus ⁴ The last report from the AAMC on COI was published in 2008. It called for enhanced regulation of industry relationships on medical school campuses. ⁵

The American Medical Student Association (AMSA) launched a Medical School Scorecard in 2007, publicly grading schools on the strength of their COI policies and curriculum. Based on that scorecard, 17% of US medical schools were found to have policies stronger than those recommended in the AAMC’s 2008 guidance.Reference Carlat ⁶ However, the scorecard faced criticism. A 2015 article in the New England Journal of Medicine argued that COI reform was driven by moral outrage rather than empirical evidence, characterizing the movement as reactive and unscientific.Reference Rosenbaum ⁷ The AMSA Medical School Scorecard was discontinued the following year. Now, a decade later, medical school COI policies may have become less stringent: just 38% of US medical schools explicitly prohibit faculty participation in industry-sponsored speakers’ bureaus, down from 50% in 2014.Reference Wieberdink ⁸

What trainees observe and practice in medical school shapes their sense of professional norms and sets their baseline for future practice. A systematic review evaluating the extent of medical student exposure to pharmaceutical marketing reported that 40–100% of medical students had some form of interaction with drug manufacturers, and 89–98% of clinical students had accepted food.Reference Austad, Avorn and Kesselheim ⁹ The review also found that increased interaction with industry during medical school was associated with more favorable views of drug manufacturers and greater skepticism toward critiques of pharmaceutical marketing. In a randomized experiment, even small promotional items — a branded clipboard and notepad used briefly during sign-in for the study — altered implicit attitudes among fourth-year students, with effects differing between schools depending on the degree of strictness of COI policies.Reference Grande ¹⁰

Since its creation, Open Payments has documented billions of dollars transferred annually from drug and device manufacturers to physicians, starting during training.Reference Cuomo ¹¹ In 2020–2021, 12% of trainees reportedly received industry payments totaling more than $6 million — almost certainly an underestimate, given that promotional funding enjoyed by residents is not subject to the same reporting requirements as that directed at fellows and attending physicians.Reference Hogan ¹²

At multiple stages of training, there is evidence showing that exposure to industry payments influences the likelihood of continuing such interactions. A 2015 survey found that students with more exposure to drug manufacturers were more likely to plan to interact with them during residency.Reference Sierles ¹³ A study of cardiology fellows and recent cardiology program graduates found that cardiologists who received payments during fellowship were more likely to continue receiving payments after graduating.Reference Dhruva ¹⁴

A substantial body of research has also shown that industry payments are associated with increased prescribing and use of the drugs and devices linked to those payments.Reference Perlis, Perlis, Annapureddy and Mitchell ¹⁵ When financial relationships shape clinical decisions, they affect patients and the professional norms that students carry into practice. When medical students, at the earliest stage of their medical training, are exposed to industry marketing, these interactions can influence the habits that they bring to patient care, research, and their own careers as educators, introducing conflicts of interest — from subtle to explicit — in all aspects of their careers.

To create the unbiased and conflict-free learning environment that students deserve, it is the responsibility of medical schools and their governing bodies to implement and enforce meaningful COI policies. Meeting the AAMC recommendations would be an important start. Indeed, the Liaison Committee on Medical Education (LCME), the accrediting body for medical schools in the US, should require that schools meet the AAMC policies for annual accreditation. Research curriculum should include a discussion of different funding sources and how they impact study design and development. In addition, discussion of the role of funding sources should be part of all critical appraisals of research in small groups or journal clubs. Teaching about the evidence that receiving payments is correlated with increased prescribing of associated drugs and devices, and the impact on patient care and safety should be part of all medical school curriculum.Reference Mitchell ¹⁶ The Open Payments Program from CMS serves as a vital tool for monitoring the enforcement of these policies, and we encourage all to become familiar with this database. Strengthening and enforcing COI policies will help ensure that medical students learn in environments where patient-centered, evidence-based medicine guides decision-making.