Dr. Bruce Psaty of University of Washington in Seattle knows how easy it can be to fall under the spell of a friendly relationship with drug companies.
As an assistant professor, he published an article on using beta-blockers to treat high blood pressure that caught the attention of the pharmaceutical industry.
"My family and I were invited to a first-class resort, where I presented the results at a sponsored conference," Psaty wrote in a commentary this week in the Journal of the American Medical Association.
He agreed to help develop a set of slides on beta-blockers and soon found himself suggesting that the drug company's studies be featured, in part because he felt "a kind of social duty to reciprocate both the kindness and the investment made by the sponsor in the slide set."
Psaty said his own story illustrates the subtleties of conflicts of interest. He is dissatisfied with the current debate among doctors, spurred by reports last year by Iowa Republican Senator Charles Grassley that a prominent Harvard psychiatrist failed to fully disclose hefty payments from drug companies.
"The debate has not been terribly fruitful," Psaty said in a telephone interview. He said conflicts are sometimes hard to recognize, pointing to the work of Dan Ariely, a behavioral economist at Duke University in North Carolina.
Ariely's research suggests that most people are comfortable with just a little bit of cheating, without considering themselves dishonest. He says subtle conflicts of interest often color decision making, yet most people — especially doctors — think they are immune.
"It's human instinct," Ariely said in a telephone interview. "If someone does something nice — gives you $5 million in a research grant — don't you want to do something nice back to them?"
Ariely said return favors could come in the form of excluding a sicker patient from a clinical trial, which might affect the study results. "Not on purpose, but I'm trying to help my friends, just a little bit."
Several states including Massachusetts, Minnesota and Vermont are tightening restrictions on gifts to doctors in the hopes of preventing such conflicts.
And a bill introduced by Senators Grassley and Wisconsin Democrat Herb Kohl would compel doctors to disclose their financial ties with drug companies or face stiff fines.
Psaty said such laws may curb some financial conflicts, but a bigger challenge will be addressing the influence drugmakers have over company-funded research supporting the safety and effectiveness of the drugs they make.
Psaty said he accepts no funding from drug companies for his research, but short of having all clinical trials funded with public money, he suggests doctors look for red flags in studies that might indicate bias.
"Was the question a good question? Did they set the study up right? Did they use the weakest possible comparator to make a drug look good in a trial?" he said.
And when a medical journal editorial disagrees with the primary interpretation of the author, "that is a potential marker of a study where there may been some bias from conflict of interest," he said.