Timing of revenue streams from newly recruited faculty: implications for faculty retention.

PURPOSE: To determine the timing and magnitude of revenues generated by newly recruited faculty, to facilitate configuration of recruitment packages appropriately matched to expected financial returns. METHOD: The aggregate of all positive cash flows to central college of medicine administration -- from research, clinical care, tuition, philanthropy, and royalties and patents, from all faculty newly recruited to the University of Arizona College of Medicine between 1998 and 2004 -- was quantified using the net present value (npv) methodology, which incorporates the time value of money. RESULTS: Tenure-track faculty and, in particular, those with laboratory research programs, generated the highest positive central cash flows. The npv for positive cash flows (npv[+]) during 6 and 10 years for newly recruited assistant professors with laboratory research programs were $118,600 and $255,400, respectively, and, for professors with laboratory research programs, $172,600 and $298,000, respectively (associate professors were not analyzed because of limited numbers). Faculty whose appointments at the University of Arizona College of Medicine exceeded 15 years in duration were the most productive in central revenue generation, far in excess of their numbers proportionate to the total. CONCLUSIONS: The results emphasize the critical importance of faculty retention, because even those newly recruited faculty who are most successful in central revenue generation (tenure track with laboratory research programs) must be retained for periods well in excess of 10 years to recoup the initial central investment required for their recruitment.     

Overcoming a perfect storm: an academic cardiology section's story of survival.

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.     

The metrics process: Baylor's development of a "report card" for faculty and departments.

In 1996, Baylor College of Medicine began the first year of its "metrics process," collecting, analyzing, and reporting data on the performance of each individual faculty member and each department in achieving the school's missions of education, patient care, research, service, and finance. This article is a report of the first two years of the process, with updates about the 1999 process, future plans, and lessons learned. The primary goal of the metrics process is to provide meaningful data to assess and improve the performance of faculty and departments across all missions. The authors (1) indicate the categories chosen, within each mission of the school, for measuring faculty time and effort (e.g., patient care, with or without learners) and state the measures chosen (e.g., percentage of time); (2) describe the development of questionnaires in 1996 and 1997 to acquire data from faculty, in the chosen categories and measures, about the time and effort they spent; and (3) report highlights of the resulting departmental data that were gathered in 1997. Among the key categories and units of measure chosen for measuring faculty (and departmental) time and effort are research grant dollars (total and per research full-time equivalent, or FTE); basic research grant dollars per square foot of laboratory space; percentage of faculty who spend at least 50% of their time in research who are National Institutes of Health principal investigators; numbers of inpatient and outpatient visits per evaluation and management FTE; total relative value units (RVUs) per patient-care FTE; patient-care income/RVU and expense/RVU for total faculty and support staff; percentage of faculty with at least one leadership position in a state or national organization; and income in excess of expense, by mission (e.g., patient care). Results of comparing data from the first two years of the metrics process demonstrate marked improvements in performance for most research measures (i.e., items of measurement agreed upon for the metrics process). The process is continually being redeveloped; the ultimate challenge is to place the objective measurements in a context where less objective qualities (e.g., innovation) also figure importantly in the evaluation and fostering of excellence. The metrics process is providing important management data, encouraging significant discussions among faculty and chairs about performance and accountability, and aiding greatly in departmental goal-setting and ultimately in determining the overall performance of the school.     

Primary care teaching physicians' losses of productivity and revenue at three ambulatory-care centers

This study reports two years of basic data concerning University of Illinois clerkship students, their teaching faculty, and their patients at three community health centers. Students from four classes (1985, 1986, 1987, and 1988) were studied in 1985 and 1986. The faculty were family physicians, internists, and pediatricians who provided 20% of the undergraduate medical education for the last 30 months of a four-year curriculum. The study's goal was to develop estimates of the primary care teaching physicians' productivity, to compare them with the productivity of physicians not involved in teaching, and to provide estimates of revenue shortfalls that occurred for the physicians who were teaching. The estimated productivity of the teaching physicians, working 29 hours a week in ambulatory-care settings, was lower by 30-40% when they were teaching medical students than the productivity of nonteaching physicians regionally and nationally. The average patient-care revenue loss for a full-time-equivalent faculty member per full-time-equivalent student for 1985 was estimated to be $27,531 (regional comparison) or $21,143 (national comparison). The corresponding figures for 1986 were $24,294 and $21,525, respectively. The study's results should be useful to those who are planning to establish ambulatory-care delivery systems and also to directors of existing ambulatory-care delivery systems who may be contemplating accepting medical students.     

Developing a new faculty practice plan with a model for funds flow between the hospital and the plan.

The majority of academic health centers are experiencing significant difficulties balancing their research, teaching, and clinical missions while maintaining adequate financial performance. One of the major areas under intense scrutiny is the specific financial relationship between the hospital and the full-time faculty. A realignment of the funds flow between these two entities is becoming essential to the future viability and ultimate survival of many health systems. The authors describe a model that evolved as part of the integration of the faculty practice plans of their institutions when they merged into a single health system, and that provides a framework that specifically addresses these issues of funds flow. The model includes (1) a strong partnership between the hospital and the full-time faculty; (2) a governance model of chairmen, faculty, and administration; (3) flexibility for the department chairs to set salaries and make significant financial decisions relative to their departmental performances; (4) a specific formula for funds flow for graduate medical education dollars from the hospital to the clinical departments; (5) local front-end charge capture and back-end central collections; and (6) clear and consistent definitions of revenue and expense items for both partners.     

An instrument for determining the amount of NIH support for clinical investigations at one academic health center.

PURPOSE: Although interest in supporting clinical investigators is increasing, information regarding the quantity, spectrum, and specific types of clinical research performed in academic health centers (AHCs) is generally not available. The authors report on an instrument to quantify the National Institutes of Health (NIH)-funded component of clinical research at one institution. METHOD: A systematic review of all NIH grants awarded to Massachusetts General Hospital (MGH) in fiscal year (FY) 1997-98 was performed using public information from two NIH Internet sources. Research abstracts from all 487 grants were reviewed and the percentage and type of clinical research activity within each was estimated and compared with estimates provided by a subset of principal investigators. RESULTS: During FY 1997-98, the MGH received $134 million in total NIH funding; $39.9 million (30%) supported the broadest definition of clinical research (that using human materials). When the definition of clinical research was narrowed to direct interaction between investigator and patient for investigative purposes (patient-oriented research), the total for clinical research was $18.2 million. These numbers significantly exceeded the institution's previous estimates of $.6 million for NIH-sponsored clinical trials and $2.2 million for population-based studies. CONCLUSIONS: Clinical investigation is an important component of AHCs' research portfolios from several perspectives, not the least of which is financial. Data on the clinical component of an institution's research effort should be collected prospectively and nationally to inform the optimal allocation of research resources and the alignment of the AHC's infrastructure.     

A comprehensive study of the direct and indirect costs of adult asthma

BACKGROUND: Asthma is a common and costly health condition, but most estimates of its economic effect have relied on secondary sources with limited condition-specific detail. OBJECTIVE: We sought to estimate the magnitude of direct and indirect costs of adult asthma from the perspective of society. METHODS: We used cross-sectional survey data from an ongoing community-based panel study of 401 adults with asthma originally derived from random samples of northern California pulmonologists, allergist-immunologists, and family practitioners to assess health care use for asthma, to assess purchase of items to assist with asthma care, and to measure work and other productivity losses. Unit costs derived from public-use and proprietary data sources were then assigned to the survey items. RESULTS: Total per-person annual costs of asthma averaged $4912 US dollars, with direct and indirect costs accounting for $3180 US dollars (65%) and $1732 US dollars (35%), respectively. The largest components within direct costs were pharmaceuticals ($1605 US dollars [50%]), hospital admissions ($463 US dollars[15%]), and non-emergency department ambulatory visits ($342 US dollars [11%]). Within indirect costs, total cessation of work accounted for $1062 US dollars (61%), and the loss of entire work days among those remaining employed accounted for another $486 US dollars (28%). Total per-person costs were $2646, $4530, and $12,813 US dollars for persons self-reporting mild, moderate, and severe asthma, respectively (P <.0001, 1-way ANOVA). CONCLUSION: Asthma-related costs are substantial and are driven largely by pharmaceuticals and work loss.     

Measuring the direct costs of graduate medical education training in Minnesota.

PURPOSE: To demonstrate the usefulness of self-reported cost-accounting data from the sponsors of training programs for estimating the direct costs of graduate medical education (GME). The study also assesses the relative contributions of resident, faculty, and administrative costs to primary care, surgery, and the combined programs of radiology, emergency medicine, anesthesiology, and pathology (REAP). METHOD: The data were the FY97 direct costs of clinical education reported to Minnesota's Department of Health by eight sponsors of 117 accredited medical education programs, representing 394 sites of training (both hospital- and community-based) and 2,084 full-time-equivalent trainees (both residents and fellows). Average costs of clinical training were calculated as residency, faculty, and administrative costs. Preliminary analysis showed average costs by type of training programs, comparing the cost components for surgery, primary care, and REAP. RESULTS: The average direct cost of clinical training in FY97 was $130,843. Faculty costs were 52%, resident costs were 26%, and administrative costs were 20% of the total. Primary care programs' average costs were lower than were those of either surgery or REAP programs, but proportionally they included more administrative costs. CONCLUSIONS: As policymakers assess government subsidies for GME, more detailed cost information will be required. Self-reported data are more cost-effective and efficient than are the more detailed and costly time-and-motion studies. This data-collection study also revealed that faculty costs, driven by faculty hours and base salaries, represent a higher proportion of direct costs of GME than studies have shown in the past.     

The cost and diagnostic yield of exome sequencing for children with suspected genetic disorders: a benchmarking study

PurposeThis study aimed to generate benchmark estimates for the cost, diagnostic yield, and cost per positive diagnosis of diagnostic exome sequencing (ES) in heterogeneous pediatric patient populations and to illustrate how the design of an ES service can influence its cost and yield.MethodsA literature review and Monte Carlo simulations were used to generate benchmark estimates for singleton and trio ES. A cost model for the Clinical Assessment of the Utility of Sequencing and Evaluation as a Service (CAUSES) study, which is testing a proposed delivery model for diagnostic ES in British Columbia, is used to illustrate the potential effects of changing the service design.ResultsThe benchmark diagnostic yield was 34.3% (95% confidence interval (CI): 23.2–46.5) for trio ES and 26.5% (95% CI: 12.9–42.9) for singleton ES. The benchmark cost of delivery was C$6,437 (95% CI: $5,305–$7,704) in 2016 Canadian dollars (US$4,859; 4,391€) for trio ES and C$2,576 (95% CI: $1,993–$3,270) (US$1,944; 1,757€) for singleton ES. Scenario models for CAUSES suggest that alternative service designs could reduce costs but might lead to a higher cost per diagnosis due to lower yields.ConclusionBroad conclusions about the cost-effectiveness of ES should be drawn with caution when relying on studies that use cost or yield assumptions that lie at the extremes of the benchmark ranges.     

Measuring contributions to the clinical mission of medical schools and teaching hospitals.

This is the final report of a panel convened as part of the Association of American Medical College's (AAMC's) Mission-based Management Program to examine the use of metrics (i.e., measures) in assessing faculty and departmental contributions to the clinical mission. The authors begin by focusing on methods employed to estimate clinical effort and calculate a "clinical full-time equivalent," a prerequisite to comparing productivity among faculty members and departments. They then identify commonly used metrics, including relative-value units, total patient-care gross charges, total net patient fee-for-service revenue, total volume per CPT (current procedural terminologies) code by service category and number of patients per physician, discussing their advantages and disadvantages. These measures reflect the "twin pillars" of measurement criteria, those based on financial or revenue information, and those based on measured activity. In addition, the authors urge that the assessment of quality of care become more highly developed and integrated into an institution's measurement criteria. The authors acknowledge the various ways users of clinical metrics can develop standards against which to benchmark performance. They identify organizations that are sources of information about external national standards, acknowledge various factors that confound the interpretation of productivity data, and urge schools to identify and measure secondary service indicators to assist with interpretation and provide a fuller picture of performance. Finally, they discuss other, non-patient-care, activities that contribute to the clinical mission, information about which should be incorporated into the overall assessment. In summary, the authors encourage the use of clinical productivity metrics as an integral part of a comprehensive evaluation process based upon clearly articulated and agreed-upon goals and objectives. When carefully designed, these measurement systems can provide critical information that will enable institutional leaders to recognize and reward faculty and departmental performance in fulfillment of the clinical mission.     

The decreasing cost of telemedicine and telehealth

The teleoncology practice based at the University of Kansas Medical Center (KUMC) in Kansas City, Kansas, is one of the longest running practices of its kind worldwide. The practice began in 1995 and connected an oncologist at KUMC with a rural medical center in Hays, Kansas. Fifteen years later, the practice continues to thrive at Hays Medical Center and has also expanded to include two additional sites within the state-the Northeast Kansas Center for Health and Wellness in Horton and Goodland Regional Medical Center in Goodland-that offer regularly scheduled teleoncology clinics. While the KUMC practice has witnessed an expansion in service sites throughout its history, the practice has seen a significant decrease in the costs associated with providing such services since its inception. The cost decrease can, in part, be attributed to an increase in the number of teleoncology visits conducted through the practice since it began. In Fiscal Year 1995 (FY 1995), 103 teleoncology visits resulted in a cost per visit of $812. Five years later, the FY 2000 $410 per visit cost for 121 visits was almost half the cost identified in the initial cost analysis. The FY 2003 cost per visit for 219 visits saw another decrease to $401, and the most recent FY 2005 cost analysis yielded another decrease to $251 per visit for 235 visits. The data reported below are likely to be the best now available to track time trends in the cost of providing telemedicine or telehealth consultations. The Conclusion and Policy Recommendations at the end of this article will focus on both the cost-time profile and some other challenges and lessons learned.     

Geographical distribution of publications in Human Reproduction and Fertility and Sterility in the 1990s

Curious about the geographical distribution of publications in reproductive medicine, we compared the numbers of publications in Human Reproduction (HR) and Fertility and Sterility (F&S). The annual number of publications from the individual countries was obtained by searching the Medline database using the internet provider PubMed. The data were analysed and normalized to population size, gross domestic product (GDP) and total number of Medline publications. The 8511 publications of both journals in the 1990s came from 56 countries. The number of publications per year was increasing in HR and remained constant in F&S. In absolute numbers, the UK produced the most publications in HR (21%) and the USA in F&S (45%) as well as in both journals together (28%). Relatively, Israel was the most productive country per million inhabitants (8.4 +/- 2.1 publications/year), per billion US dollars GDP (0.85 +/- 0.21 publications/year) and per 1000 Medline publications (15 +/- 4 publications/year). Europe was the most productive world region in absolute numbers (54%) and Australia/New Zealand in relative numbers per million inhabitants and per 1000 billion US dollars GDP. Almost 87% of all publications in HR and F&S came from the 18 countries with a GDP per capita of >10 000 US dollars. In conclusion, the geographical distribution of publications in HR and F&S follows the pattern of the distribution of publications in general biomedical research. Most publications come from affluent countries. Although the USA and the UK appear to be the most productive countries in absolute numbers, smaller affluent countries like Israel and Belgium are more productive when the numbers are normalized to population or GDP.     

The impact of a program for systematically recognizing and rewarding academic performance.

PURPOSE: To describe an academic performance incentive system (APIS) and faculty perception of it; explore the impacts of incentive level, faculty rank, clinical practice volume, and administrative responsibility on academic productivity; and describe the APIS's use in maintaining congruence between department mission and activities. METHOD: A list of teaching, research, and academic service activities was developed, which full-time faculty (n = 33) used to report activities. Clinical faculty members received incentive income based on credits earned. APIS initially distributed 1% of practice plan receipts (subsequently increased to 3% and then 5%). Productivity was measured by differences in APIS points achieved. Satisfaction of all faculty participants was measured by survey. RESULTS: Faculty members (n = 20) who participated throughout averaged 22 credits per month (nine to 42 credits), and quarterly incentive bonuses ranged from 145 US dollars to 6,128 US dollars. Average credits earned per month were 24 for the 1% incentive, 23 for the 3% incentive, and 20 for the 5% incentive. Faculty members with administrative responsibilities were as productive academically as were their non-administrative counterparts. Senior faculty members were as productive as junior faculty. Faculty members who were more productive clinically were more productive academically. Seventy percent of respondents reported they were either very satisfied or somewhat satisfied with the APIS. Seventy-eight percent felt that the APIS accurately reflected their academic productivity. Most respondents (81%) felt that the amount of money allocated to the incentive system was appropriate (15% felt it should be increased and one respondent recommended reduction). CONCLUSIONS: The APIS system has been well accepted by faculty and allows for data-driven discussion of the department's mission and activities.     

Analysis of downstream revenue to an academic medical center from a primary care network.

PURPOSE: Many academic medical centers (i.e., teaching hospitals) have established primary care networks for not only assuring a referral base but also for educating students in the primary care setting. Such networks generally are not profitable when analyzed on an individual facility basis. However, revenues generated at the medical center in terms of inpatient admissions, laboratory testing etc., usually are much larger than generated on site. In this study, the downstream revenue from 18 practice sites was evaluated at The Ohio State University Medical Center. METHOD: Revenues in fiscal year July 1, 2003, to June 30, 2004, were broken down into four streams, including inpatient and outpatient charges and collections for both network and specialist physicians. A fifth stream evaluated specialist professional fees. The authors developed a novel conservative weighting system to capture the concept that not all revenues generated from network patients were actually dependent on the use of the network. RESULTS: Findings included that the downstream direct contribution margin of US dollars 14 million just from the admissions and outpatient tests and procedures directly generated by network physicians alone was nearly twice the US dollars 8.3 million network operating loss. The total downstream net revenue of nearly US dollars 115 million was more than 6 times the US dollars 18.9 million net revenue to the network. The downstream direct contribution margin of US dollars 52 million was 6.3 times the network loss. Total downstream gross revenue (charges) to the medical center was over US dollars 250 million and over US dollars 300 million when the specialist gross revenues were included. CONCLUSIONS: This study demonstrates that a primary care network can generate significant financial support for an academic medical center.     

The case for interdepartmental research in primary care.

Research problems in human biology, clinical medicine, and health services delivery are complex, and increasingly require collaborative approaches. Despite the commitment of general internists, general pediatricians, and family physicians to comprehensive, coordinated, and longitudinal care, their substantial overlap in research topics, methods, and data sources, and their shared emphasis on research conducted in community-based settings, the three primary care disciplines rarely collaborate in research. The research enterprises of most primary care departments and divisions in the United States are small "cottage industries," while interdepartmental research units are rare. Interdepartmental research units can develop and maintain the critical mass of investigators, trainees, and staff that is necessary for an intellectually vibrant and financially sound primary care research enterprise. The University of Colorado Health Sciences Center School of Medicine has developed a successful interdepartmental research effort in primary care that includes joint fellowship training and faculty development programs and a Primary Care Research Unit that supports the analysis of secondary databases, practice-based research networks, and interdisciplinary research projects. Key elements of this collaboration include shared projects among faculty and trainees, proactive negotiation about resources, and shared research space, staff, and faculty. Such a collaboration provides the breadth of perspectives necessary to address complex health care problems, and the pragmatic infrastructure necessary to sustain research themes and careers.     

The rising cost of NIH-funded biomedical research?

During the last decade, total appropriations for the NIH have grown in current as well as constant dollars. Constant dollar expenditures for indirect costs and research project grants have increased, as also has the number of the latter, while such expenditures for research centers, training, and research contracts have shrunk. The most impressive redistribution in emphasis has been toward traditional research project grants (R01s). The size of the average R01 award, discounted for inflation, has grown at an annual rate of 1.1% during the last decade and 1.3% since fiscal year (FY) 1970; that of the average research program project (P01) has declined over the same periods, after a slight rise in the early 1970s. Factors contributing to the modest rise in the real (constant-dollar) size of the average R01 are explored. The regularity with which current-services-requirements estimates for the NIH exceed inflation reflects real growth in the program, particularly in the category of research project grants; the artifact of basing calculations on the post-rather than pre-"negotiated" levels of awards in the "current" year; and the extent to which the project periods of awards have been extended. The effect of lengthening project periods is slow to become manifest, but inexorably swells the pool of non-competing awards; decisions in this area undertaken in 1985, and continued at least through FY 1988, could very significantly increase current services requirements in FYs 1991 and 1992.     

Strategies for defining financial benchmarks for the research mission in academic health centers.

Valid financial benchmarks are needed for the research mission in academic health centers (AHCs). Databases listing institutional success in obtaining sponsored research funding are publicly available. However, these databases are generally not adjusted for AHC size, confounding useful comparisons between institutions. The authors suggest simple strategies, which depend on a form of ratio analysis, to circumvent this limitation. Annual rates of growth (rates of return, R(f)) are determined for total National Institutes of Health research grant dollars, number of research grants, and average dollars per research grant for 15 U.S. AHCs. Selected institutions are compared to one another and to the total pool of medical school funding. Performance is evaluated over a ten-year period (1992-2001) to illustrate the advantages, limitations, and applications of the ratio analysis approach. Alternative strategies are suggested for individual AHCs to evaluate their departmental and organizational performance, again without regard to institution size, and also dependent on ratios. Application of these strategies, especially when individualized to the particular AHC, permits more accurate assessment of past performance and more accurate and effective planning for future growth.     

Should medical school faculty see assessments of students made by previous teachers?

Whether medical school faculty should be provided with assessments of students made by previous teachers remains controversial. To document which schools have implemented policies that address this issue and to characterize the specific features of these policies, in 1998 the authors conducted a direct mail survey of deans of student affairs and medical education at 144 medical schools in the United States, Canada, and Puerto Rico. Replies were received from 129 (90%) of the 144 medical schools. Of those schools, 72 (56%) reported having policies that address this issue. The policies permit the sharing of information in 38 (53%) of the 72 schools that had policies; therefore, at the time of this study, 29% of the 129 medical schools that responded to the survey had a policy that permits the sharing of assessment information. The policies permit the sharing of information related to problems with academic performance (35%), professional conduct (35%), physical health (25%), and miscellaneous circumstances, such as learning disability (5%). Information may be shared with clerkship coordinators (44%), course directors (35%), faculty mentors (11%), clinical faculty supervisors (8%), and resident supervisors (3%). The findings show that there is considerable diversity in the format and content of policies that address the issue of whether medical school faculty should be provided with information about students' assessments made by previous teachers. The authors explain why policies that require the provision of such information are helpful to medical school faculty, and offer recommendations based on the survey findings.     

Conflict-of-interest policies for investigators in clinical trials

BACKGROUND: There is substantial concern that financial conflicts of interest on the part of investigators conducting clinical trials may compromise the well-being of research subjects. METHODS: We analyzed policies governing conflicts of interest at the 10 medical schools in the United States that receive the largest amount of research funding from the National Institutes of Health. These institutions are Baylor College of Medicine, Columbia University College of Physicians and Surgeons, Harvard Medical School, Johns Hopkins University School of Medicine, the University of Pennsylvania School of Medicine, the University of California at Los Angeles School of Medicine, the University of California at San Francisco School of Medicine, the University of Washington School of Medicine, Washington University School of Medicine at St. Louis, and Yale University School of Medicine. RESULTS: All 10 universities required that faculty members disclose financial interests to university officials. Only four required disclosure by all members of the research staff. Five universities required disclosure of all financial interests, even though federal regulations specify a threshold for disclosure. Six universities required disclosure to the institutional review board as well as to a committee on conflicts of interest or a university official. Four universities had stricter requirements for investigators conducting clinical trials than required by federal regulations. One university prohibited investigators from having stock, stock options, consulting agreements, or decision-making positions involving a company that sponsored the research. A second university prohibited researchers from trading stock or stock options in a company that sponsored the research or sold the product or device under study. Two universities ordinarily did not allow faculty members to participate in clinical research if they had what federal regulations refer to as a "significant" financial interest in the company owning the product or device being studied, but exceptions were allowed. CONCLUSIONS: Policies governing conflicts of interest at leading medical schools in the United States vary widely. We suggest that university-based investigators and research staff be prohibited from holding stock, stock options, or decision-making positions in a company that may reasonably appear to be affected by the results of their clinical research. Of the 10 medical schools we studied, only 1 had a policy that was close to this standard.