The 17 Canadian medical schools received scores that ranged from 0 to 19 out of a possible maximum score of 24. The score of 0 was received by NOSM. This low score may reflect, in part, the fact that the school was only established in 2005. Western University received the highest score of 19. Of the 17 medical schools in Canada, over half (10) received summative scores of 5 or less out of 24, indicating that in most of the categories they had either no policy or a permissive policy. No single category managed to achieve an average score of 1 or more.
Fourteen (82%) of the schools received a rating of 0 (no policy or permissive policy) for samples. Samples have been shown to influence medical residents’ prescribing practices, with negative implications both for costs and prescribing appropriateness. Adair and Holmgren have shown that access to drug samples increases the likelihood that physicians will prescribe heavily advertised and more costly drugs as opposed to cheaper or over-the-counter drugs. 
We also found that most medical faculties (70%) had permissive policies or no policy concerning faculty involvement in companies’ speakers’ bureaus. The United States (US) Institute of Medicine’s recent report on COI recommended banning such relationships 
because speakers’ bureaus represent part of a company’s promotional activities and the content is often under the company’s control. 
Similarly, 70% of medical faculties had permissive or no policies concerning interactions with sales representatives. Sales representatives have been found to negatively influence prescribing practices, e.g., to lead to more frequent and expensive prescribing and poorer prescribing quality. 
In a comparative study, recently graduated internists who had studied in a program that restricted contact with sales representatives were more critical of the information they provided and saw sales representatives less often than internists from a medical school without such restrictions. 
Most schools (70%) also failed to cover conflicts of interest or drug promotion in the curriculum. This gap has important implications for students’ abilities to understand the context within which promotional activities occur and to weigh their own responses to ethical challenges that might arise. 
Finally, nearly all schools had a party responsible for enforcing their policies (15/17) and the majority had sanctions for violations (10/17), but we do not have information on how often these sanctions are applied or how effective they are.
We found that COI policies were most stringent in the areas of disclosure, ghostwriting, gifts, (considered to be the easiest to prohibit 
) and scholarships. These results parallel findings that AMSA obtained in its annual reviews of policies in US medical and osteopathic schools. Its 2012 analysis found that the policy areas that received the highest ratings were those that addressed scholarships, off-campus continuing medical education, purchasing, and gifts. 
The importance of restricting gifts is emphasized in a review of COI policies at 14 American medical schools that found that exposure to a gift restriction policy during medical school was associated with reduced prescribing of two out of three newly introduced psychotropic medications. 
Our findings on ghostwriting are consistent with those of Chimonas and colleagues, even though their rating scale separated out no policy (score
0) and permissive policies (score
They found that, although existing ghostwriting policies at American medical schools were among the most stringent of all of the policy areas, ghostwriting was also the most neglected policy area. Furthermore, other work has shown that meaningful sanctions for academic fraud are generally absent. 
Because universities reward academic faculty for their publication records, limited enforcement can mean that faculty may find themselves complicit in ghostwriting activities, in spite of policies prohibiting them.
A similar study of Australian medical schools found that their COI policies were even weaker than those at Canadian schools. Eleven out of 15 schools received less than 50% of the maximum possible number of points and only one barely exceeded 66%. All schools either had no policies or had policies that were unlikely to have a substantial effect on behavior in the areas of on- and off-campus educational activities. Lastly, policies on consulting relationships and disclosure had mean scores below 50%. 
Our study, in conjunction with the ongoing AMSA survey, the analyses of the US schools by Chimonas and colleagues, and the results from the Australian schools, clearly establishes that the poor control of COI at medical schools is not confined to a single country, but is an issue that needs to be addressed at both national and international levels. One effort to engage medical students in these issues has come from a collaboration between the World Health Organization and Health Action International that has resulted in a manual to teach medical students about pharmaceutical promotion 
. The manual is available in English, French, Russian and Spanish, and has been distributed across a wide range of countries.
This study has some limitations. Two schools did not respond to our initial request for any policies that we might have missed in our web search. Six medical schools failed to review our ratings despite repeat requests; their input could have validated, or alternatively, contradicted our findings. Furthermore, only medical schools’ COI policies were within the scope of our study, so we did not consider the policies of affiliated teaching hospitals (e.g., on samples or sales representatives). Hospitals may have had more restrictive policies, but this is unlikely based on previous research. 
Policy development is a dynamic process, and some Canadian medical schools have introduced new policies since September 2011, while others continue to revise their policies. It is important for medical schools to continue to develop and improve their COI policies to mitigate institution-industry relationships and to address the ways in which those relationships may affect the information that is taught to, and the attitudes of, medical students. Policies must also continue to develop, especially since the role of industry within universities continues to evolve. 
Practices that were once entrenched into medical culture, including the receipt of gifts, food, and drug samples, in addition to faculty consulting and speaking engagements with industry, 
should no longer play direct or indirect roles in the education of medical students. Student-industry interactions can influence students’ education. 
Students who have more contact with industry tend to have more favorable attitudes towards these types of interactions. 
It has been reported that students who receive gifts from industry feel obliged to rely on industry representatives for information on medications. 
More stringent policies are not the only answer for helping to ensure medical education is free from faculty COI, but such policies have been shown to limit the acceptability of promotional items. 
Medical schools across Canada are encouraged to achieve the most effective and stringent policies to regulate industry relations with both faculty and students.