The Cleveland Clinic ranks among the best-known hospitals in the nation, joining institutions such as Johns Hopkins Hospital and the Mayo Clinic among healthcare's aristocracy.
But the elite institution is now struggling with ethical issues that have triggered an uncomfortable self-examination over potential conflicts in its business practices and the cozy relationships that exist between top officials, physicians and the high-tech vendors that sell products to the clinic.
Yet, despite the self-analysis and outside criticism, the brash Cleveland Clinic announced plans to co-sponsor a new educational track with a local university to better train future healthcare industry leaders (See sidebar).
Toby Cosgrove, the hospital's president and chief executive officer, asked for an independent review of conflict-of-interest policies just days after news reports in mid-December 2005 detailed his role as a board member of a medical-device company that the clinic helped found through a venture-capital partnership. The clinic reportedly owns about $7 million worth of stock in AtriCure, whose products are used by clinic doctors to correct atrial fibrillation.
Cosgrove, a well-known cardiac surgeon, invested in the venture-capital fund and served as a general partner until he cut his ties about late last year.
The well-publicized controversy at the famous hospital could trigger soul-searching at other institutions grappling with this potentially volatile mixture of private industry, academic research, patient care and profits.
For example, revelations of the Cleveland Clinic's arrangements with vendors led to a critical reappraisal of the 3-year-old conflict-of-interest policy at the Johns Hopkins University School of Medicine in Baltimore, says Julie Gottlieb, assistant dean for policy coordination.
"I think many institutions are evaluating what policies and procedures they have in place to capture and manage or eliminate conflicts of interest," Gottlieb says. "This (situation with the clinic) is a very high-profile case. It's a strong reminder to all of us in this business that we need to make sure we have robust policies."
To some, the case is another example of the blurred ethical lines in an industry where drug companies lavish gifts on doctors to prescribe their costly medicines, and peer-reviewed medical studies are conducted by researchers with ties to drug companies.
Late last year, the Journal of Thoracic and Cardiovascular Surgery announced a new policy that will bar authors who fail to disclose financial ties to industry. The tough new guidelines stemmed from the failure of two authors, including Cleveland Clinic heart surgeon Mark Gillinov, to disclose their financial ties to AtriCure in a September 2005 article that cast the company in a positive light.
Meanwhile, it has become more routine for doctors and healthcare executives to sit on the boards of directors of for-profit vendors that do business with their institutions, a situation that can generate at least the perception of a conflict of interest.
In February 2005, the National Institutes of Health unveiled a strict policy prohibiting all employees from taking drug-company money in the aftermath of news reports that raised questions about those relationships.
And just last month, an article published in the Jan. 25 Journal of the American Medical Association calls for rigid guidelines that would prohibit drug companies from providing physicians with gifts of any kind, saying that long-standing financial ties between the medical profession and pharmaceutical industry erode research integrity and hurt patient care. "No matter what you are told by any physician or administrator, these gifts--no matter how small--influence doctors' behavior," says David Rothman, president of the Institute on Medicine as a Profession in New York.
The think tank at the Columbia University College of Physicians and Surgeons helped fund the report by a group of about a dozen medical experts who urged academic medical centers to take the lead in abolishing gifts of any size, including meals, payment for travel or for participating in continuing medical-education programs, and to strictly regulate ties between doctors and drug companies.
Other recommendations include: replacing direct drug samples with a system of vouchers for low-income patients and insulating continuing medical education from industry influence by requiring companies to contribute to a central academic office that would disperse funds to individual programs.
"There's kind of a tsunami of trouble out there for healthcare in terms of these kinds of conflicts," says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. "The situation with the Cleveland Clinic may be a big wave, but it's just one of many. It definitely gives the clinic a black eye. I think they're going to have some work to do to rebuild their reputation."
Like Gottlieb, Caplan says he thinks the harsh media attention focused on the Cleveland Clinic sends a "strong message" to other institutions that "You'd better re-examine policies and stances on conflicts of interest." While he suggests that the industry "doesn't know or have an agreement on how to manage conflicts of interest," he says the simple formula boils down to two key principles: "One: Where there are conflicts, disclose them; and, two: Don't study what you own.
"I think the biggest lesson from the Cleveland Clinic situation is that no institution-even our best-has figured out a way to manage conflicts of interest."