¹Harvard Medical School, and Translational Medicine Division and Hematology Division, Brigham & Women's Hospital, Boston, Massachusetts, USA.

Correspondence: Dr Thomas Peter Stossel, Hematology Division, Brigham & Women's Hospital, 1 Blackfan Circle, Karp 6, Boston, Massachusetts 02115, USA. E-mail: tstossel@partners.org

Acta Dermatologica Venereologica recently published a special report that summarizes a workshop held in Finland by the European Academy of Dermato-Venereology celebrating the elevation to higher consciousness of "conflicts of interest (COI)" in cutaneous medicine (Williams et al., 2006). The report first defines COI metaphorically: dermatologists with COI have metamorphosed into dogs and other dermatologists and patients into cats. Not all dogs chase cats, but, because some do, cats must take notice. Through disclosure by journals, professional meetings, and educational events, the cats can be wary of the dogs. Evidently they are, because the report cites two British Medical Journal studies that polled readers to determine their enthusiasm for a paper describing a clinical study in which half the respondents were told that the study's authors had financial conflicts and half that they did not. The readers rated the fictionally unconflicted version slightly (but statistically significantly) more interesting, important, and believable than the conflicted one. The report echoes editors of high-profile general medical journals in decrying "a cycle of dependency between physicians, academic opinion leaders, patient's organizations, researchers and industrial interests," citing a dismal litany of deceptive industry-based "disease-mongering" and marketing practices. It calls for adherence to medical journal editors' demands for prospective trial preregistration, since industry-sponsored research publications sometimes give rosier views of products than FDA filings and package inserts. It indicts "ghost writing" of papers, whether by academic or company employees, and praises recently toughened disclosure policies of the Journal of the American Medical Association.

The report concludes by expressing "a ray of hope" that now disease-mongering and ghost writing are part of the dermatologist's vocabulary and asks for "unbiased summaries" to evaluate clinical trials. It endorses a proposal to curtail sharply the presence of companies in academic health centers by banning gifts, samples, and meals and by collectivizing corporate support of research and education. The aim is not to "discourage a flourishing and innovative healthcare industry" but to prevent dermatologists from losing "values on which the ... profession is built."

Given that 20 years of unopposed airtime has sensationally covered real and alleged industrial transgressions and popularized COI, the idea that dermatologists have somehow failed to recognize it hitherto seems strange. Space does not permit addressing all the workshop's points in detail, so I have selected a few.

The canine–feline depiction of COI illustrates two important points. First, it shows how COI has escalated from its dictionary definition—a conflict—to an outcome—a potentially predatory situation. Second, I have no idea what percentage of dogs chase cats, but I imagine that it is high, far higher than that of documented cases in which COI have adversely affected dermatologic practice. Disclosure and transparency are reasonable goals to a point. However, all disclaimers to the contrary, disclosure has actually become a disrespectful ad hominem assault, meant primarily not to honor sponsorship but to discount scholars' word and work. The empiric studies reported in the BMJ bring this point home. The prurient focus on who pays whom how much, rather than on the scientific data, is characteristic of the COI literature. A bizarre aspect of the current COI disclosure requirements is that they exempt medical financial interactions that do not involve drug or device companies—around 85% of total health-care expenditures.

We want scientific rigor in dermatology, but the arguments to make the case for the damages of COI violate such rigor. Based on anecdotes, they lack context, namely a comparison of adverse outcomes or bias concerns to noncommercial interactions of physicians and scientists (Stossel, 2005). Finally, the real damage inflicted by the ambient obsession with COI has been the prevention of company startups by overly restrictive university COI regulations and a total consulting ban inflicted since 2005 on intramural NIH researchers, which adversely affects retention and recruitment of researchers and prevents companies from getting the best advice. The idea that "objective" guidelines somehow can relieve dermatologists from the uncertainties they face making difficult clinical decisions is a conceit. "Unconflicted" usually means less competent, and advisories composed of such individuals empirically make bad recommendations. For example, an unconflicted Institute of Medicine panel recommended removal of mercurial preservatives from vaccines because of litigious claims unsupported by numerous comprehensive studies that they contributed to autism. The recommendation caused deaths due to failure to vaccinate and a reduction in commercial vaccine production (Stratton et al., 2001).

Finally, the risks of economic incentives and COI summarized in the workshop are distortions. The uncontestable fact is that medicine in general and dermatology in particular improve steadily, not because of medical ethics and professionalism but because of products developed by private companies, capitalizing to some extent on knowledge acquired from academic research. What is far more important for dermatologists to understand than the inflated risks of COI are the mechanisms by which industry accomplishes these feats and the difficulties it must address to do so (Epstein, 2006), factors that the critics have no experience with and therefore treat dismissively. The greater presence of business in medicine today is not a commercial conspiracy but an evolutionary adaptation to opportunity (Stossel, 2007). The monies that industry contributes to education and research mean more of these activities take place. If dermatologists cannot sort out promotion from substance, it is the fault of their character, their training programs, or both—not of companies.