Angell on drug money: Just say No

Marcia Angell makes it plain:

The fact that drug companies pay prescribers to be "educated" underscores the true nature of the transaction. Students generally pay teachers, not the reverse. The real intent is to influence prescribing habits, through selection of the information provided and through the warm feelings induced by bribery. Prescribers join in the pretence that drug companies provide education because it is lucrative to do so. Even free samples are meant to hook doctors and patients on the newest, most expensive drugs, when older drugs -- or no drug at all -- might be better for the patient.

This is from an essay in a special issue of BMJ dedicated to the relationship between pharma and doctors. In another essay, BMJ editor Fiona Godlee takes doctors to task for consenting to the huge influence pharma has had on medical research and practice. She starts with a quote from health services researchers and Cochrane Collaboration co-founder Iain Chalmers:

"I do not blame industry for trying to get away with anything that is normally considered to be its primary purpose, which is to make profits and look after its shareholders' interests. It is our profession that has colluded in all of this and been prepared to go along with it--we are the people to blame because we need not have stood for it."

By "all of this" I assume Chalmers means the many ways in which drugs are promoted in the guise of science, education, and information: the misreporting of industry funded research, the use of ghost writers and key opinion leaders, the provision of free courses and conferences. His words echo Suzanne Fletcher's in the BMJ last year (2008;337:a1023, doi:10.1136/bmj.a1023). For these practices to flourish, doctors have had to at least acquiesce, if not actively take part, as researchers, guest authors, paid opinion leaders, and recipients of gifts and hospitality.

As our cover image shows, it takes two to tango. It's time for the profession to take a lead. This means saying no to gifts and hospitality, ensuring that research and clinical collaborations are transparent and unbiased in their design and reporting, refusing to be a guest or ghost author, declining the role of paid opinion leader, paying our way for information and education, and refusing industry support unless it is entirely transparent and in patients' or the public's best interests.

Some thoughtful, well-informed examinations of the troubled spot medicine and many doctors feel themselves in right now. Many of the essays are, refreshingly, free.


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Of course, none of this would even be happening if doctors were educating themselves. But fact is that's hard work and takes time, and it takes time away from patient turnover, which is THE key factor in most health systems, alas.

There are some more structural problems in the assessment.

First of all, the assessment overlooks that plenty of conferences, honest to god scientific conferences, would plainly not exist without industry support. Contrary to the spiel "big, powerful industry here, intimidated, obedient doctor there", the situation is quite different. Academic societies have an immense influence and can generate through word-of-mouth, guidelines etc. a considerable amount of damage for corporations. I know for a fact that at least in the diagnostic industry, companies have been blackmailed to participate at conferences by threat of bad word-of-mouth. Why? Because the fees for booths, workshops etc. are humongous and essential for paying the costs of the conference which often could not be covered by registration fees alone - all the more in times were travel budgets in the public sector and with them conference attendance receive more and more scrutiny. And why, do you ask, would a company not want to present itself at a conference of experts? Because a company is interested in the cost/benefit ratio. If the cost of being at the conference is higher than the sales generated through the conference, it's just not worth being there - except for the consequences of not being there through bad word of mouth, both deliberately, as in the blackmailing, and coincidentally ("Oh, XYZ is not here this year, they really must be in dire straits..." or "...their pipeline is probably dead so they do not have anything to present").

This leads us to "refusing industry support unless it is entirely transparent and in patients' or the public's best interests." Well, what IS "entirely transparent"? For one person, it is clear as day that a lunch symposium, for all its informational character, is a marketing event. For the other, it's not. Where's the borderline?

Plenty of academic journals are full of advertisements. Should doctors stop reading them for fear of being influenced? After all, they do profit financially, since what the publishers gain from advertisements is not put on the subscription fee.

Likewise, the problem with the generalized lambasting of key opinion leaders. Having dealt with this issue on a consistent level, I can tell you that again, the vision of the gullible, corruptible KOL is a cliché, if a powerful one. There's plenty of people that charge companies an arm and a leg and have no hesitation to have their laundry for a two- or three-day trip done by the hotel and add it to the bill. If I ask them for an expert opinion on an issue, I'd have to pay them. But I doubt anyone expects people to abolish expert opinions in general. So the issue is who pays, because that might influence the recipient. Does it? Yes, if he a)expects follow-up engagements and b)expects WHAT he says to influence the probability of said engagements. In other words, as it was said above, it takes two to tango. Dishonesty doesn't arrive out of such an arrangement alone, but out of one side seeking a way to "spread the news" and the other finding a welcome opportunity to milk a cash cow. But even then, this is not a guaranteed result. Just because both sides have found a welcome partner doesn't mean that the outcome is garbage. This MAY be the result and the credibility may be lower, but there is no guarantee that the result isn't, at the least, accurate.

For all the sweet lure of cash, the real solution is not the radical solution suggested above, not just because it is a generalizing cliché but because it is simply not practical. The real solution is translating scientific credibility into cash value. The moment honesty, transparency and credibility translate into cold, hard, cash, all or at least most companies will make them their goal.

Real life is rarely black and white. Far too often, situations are way more complex than cliché would make us believe. There is no doubt corruption going on. But the answer is hardly a disingeneous prohibition which will only lead to even more corruption and in fact less transparency as the necessary deals will continue, just much less openly. The real solution is looking at each person and each interaction individually and looking at the merits of the case. Then again, that's hard work and takes time, and we already talked about that. Everybody wants to have his cake and eat it, too.