A Bright Future

In her shortlisted essay for the 2017 John Henahan Writing Prize, 
Dr Meena Arunakirinathan looks at the relationship between 
industry, clinical practice and academics

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Three years as a young ophthalmologist in training, five years having sworn the Hippocratic Oath during my medical graduation, and only of late have I fully considered how commercial interest may affect my career. As medical students we relished sponsored lunches, eyes glazed over listening to sales pitches. As a freshly graduated doctor, I watched slideshows emblazoned with names of industry greats, and attended continuing medical education seminars and lavish dinners hosted by industry representatives who always picked up the hefty bill. I began to view these few interactions with them as the secret perks of being a medic – no one in the public seemed to know and no one seemed to judge. Whilst organising a course for doctors I struggled to remain cost neutral. Having extended an invitation to a well-known company, I secured sponsorship. To my relief, the attendees were spoiled with lunch and stalls laden with goodies. I struggled to comprehend why they sponsored us. We had no power of influence, no professional opinion to solicit and no authority over the formulary. Was there simply a surplus of cash to throw around or were my colleagues and I a vehicle for something bigger? This was the day commercial interests began to affect my career. What other doors could commercial interests open? I discovered a myriad of industry-funded fellowships, grants and wetlab courses, their credibility affirmed by involving prominent ophthalmologists whom I had admired from afar in conferences, videos and textbooks. PROPHECIES Industry-funded bursaries facilitated my training, as I would otherwise struggle bearing the financial brunt of many other courses. I practised scleral flaps and releasable sutures in specimens and grooved endlessly in model eyes spilling egg yolk vitreous under the watchful eye of the attendings. Contrary to my preconceptions, I was not bombarded with merchandise and prophecies of emerging therapeutics and miracle devices. Instead, I was provided with models to practise my surgical skills. Representative of the instruments I used in the operating theatre, handling these devices allowed me to build muscle memory and develop dexterity. My research moved from basic sciences to minimally invasive glaucoma surgical devices, for which I won a prize. The awarding body, a leading academic institution, funded me to present my research on an international platform. Funds were derived from a company, albeit one with no interest in my research. I fretted about affiliating myself with their company, and paying lip service to their sales pitch. However, I was wrong - there was no expectation of my involvement in promotional aspects, only the caveat that I should declare this. I stopped viewing commercial interests through rose-tinted glasses when my proposal for an educational article in a leading medical journal was refused due to my supervisor’s competing interests. Despite our best appeals, highlighting that ties to industry were not driven by financial gain nor malign motives, we were rejected. My colleagues trivialised the need for declarations and even regarded this as a form of McCarthyism. I myself felt dejected. This response felt like prohibition. I wanted to cut my own ties with industry at this stage of my career as I needed to publish not perish. I reviewed the mounting evidence in high-impact journals of the influence of competing interests on the conclusions reported. I began to notice negative results published in lesser journals and author declarations written in the finest of print as if their admission could somehow be overlooked. Bias, like a subtle veil, clouds judgement. So are clinicians truly immune? My primary interests were the best interests of my patients. At this point in my career I had no care for secondary interests and shunned any further collaboration industry. I could not be tempted by what I now regarded as forbidden fruit. Through professional networks I was granted an interview with an industry physician. He shed light on strengthening ties with industry that helped bring plans for new drugs and devices to fruition in ‘innovation hubs’ and investigator-initiated studies. He reminded me of the bias working with certain academic institutions conferred irrespective of industry affiliations, and highlighted how frequently industry could be misconstrued as ‘big bad pharma’ by society and the media. Delving into the world of an industry physician helped me understand my own: generous donations from industry topped up our drug supplies, provided samples for the indigent and funded training for doctors and nurses – vital resources that would otherwise have been a struggle to finance within the budget of the National Health Service. Brexit’s aftermath poses a risk of delayed access to novel therapeutics due to changes in licensing regimes. A strengthened union with industry can surely be one option to fend these challenges off? Day in, day out we work with industry perhaps more than any other specialty, as evidenced by the novel therapeutics and devices in use around us. The real conflict of interest rests within my own my mind. Can I recognise the risk of influence and instead harness the opportunities industry provides for the greater good of my patients? Only time will tell as I gain experience. At the brink of a career in ophthalmology, I hope to see a future where industry, academic and clinical practice work synergistically, with a mutual understanding of their respective motivations maintaining transparency at its heart. Where once there were muddied waters they begin to run clear, and as aspiring leaders, clinicians and researchers, we can forge stronger collaborative partnerships. Dr Meena Arunakirinathan is a Resident in her third year of ophthalmic training at Moorfields Eye Hospital, London, UK