Pity the poor pharmaceutical industry, much maligned by those concerned about marketing-based medicine. Ray Moynihan is one of the most vocal watchdogs of the industry. He’s the Australia-based co-author with Alan Cassels of a compelling book called Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients.
His work on disease-mongering has intrigued me for years, and now he offers these handy hints for physicians on how to get along with your friendly neighbourhood drug or medical device company. These hints are in response to a British guideline for physicians written by a multinational stakeholder group, including the Association of the British Pharmaceutical Industry (ABPI). Neither the group’s membership nor funding is declared in the guidelines or on the ABPI website.
Here’s Moynihan’s cheeky advice* in the British Medical Journal for doctors who are reading this guidance:
“If you haven’t read the recent guidance on doctor-industry relationships, it’s certainly worth a look.1
“Endorsed by leading professional groups, this guide argues that promising collaboration with industry “may be missed or even rejected” because of “misconceptions” arising from historical practices or rogue individuals. To set the record straight, the guide emphasises the value of seeing sales representatives, the benefits of industry sponsored education, and the critical importance of health professionals serving on companies’ advisory boards.
“To drive home its message, the guidance spells out some DOs and DON’Ts for doctors, and this is where it starts to sound just a tad defensive, not least because of the use of BOLD CAPITALS. First among the DOs is the instruction to treat industry as a partner and to get involved with company funded trials and education. The DON’Ts feel like the desperate pleas of a lover fearing that a long term affair may be on the rocks: “Don’t establish blanket policies denying interaction with industry,” and “Don’t be tempted to accept the negative myths about cooperating with industry.”
“Given the slightly shrill tone, it might be helpful to strengthen the guidance with a few more DON’Ts for doctors, offered here with respect and humility.
“First, don’t read the 2010 systematic review that concluded, “With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations.”2 Secondly, don’t read salacious whistleblower testimony describing how one of Pfizer’s top selling reps boasted of using strip clubs to help boost sales of sildenafil (Viagra) and other products.3
“To maintain an enthusiasm for attending company sponsored gatherings, definitely don’t read the 2008 report of the Josiah Macy Foundation. This found that the responsibilities of the industry and of professionals were “fundamentally incompatible,” that bias had become “woven into the very fabric of continuing education,” and that all sponsorship from drug and device makers should be phased out.4 Also, don’t even peek at the 2009 JAMA editorial from a host of heavy hitters suggesting that professional medical associations work towards “a complete ban on pharmaceutical and medical device industry funding, except for income from journal advertising and exhibit hall fees.”5
“For those who like to help drug companies evaluate their own products, it’ll probably be best if you don’t look at the systematic review published in the BMJ in 2003.6 It famously found that company-funded studies were four times more likely than other studies to have outcomes favouring the sponsor’s products. Just to be safe, it may be best not to browse any of the more than 1000 articles that have subsequently cited that systematic review. And if you’d rather avoid reading something more up to date, don’t read any of the literature calling for more independent ways of running medical research, including the 2012 JAMA article stating that asking a drug company to fund a trial of its own product “is like asking a painter to judge his or her own painting so as to receive an award.”7
Key opinion leaders
“For those young guns who hope one day to work as a company funded “key opinion leader,” don’t read the 2010 BMJ systematic review that found a strong association between authors’ positions on a controversial anti-diabetes drug and their acceptance of money from the drug’s manufacturer.8 At the same time, don’t read the 2009 BMJ editor’s choice column suggesting that health professionals should decline the role of paid opinion leaders, start paying their own way for education, and enter only those research or clinical collaborations that are unbiased and transparent.9
Renewing the relationship
“There’s no dispute that drugs extend lives and ameliorate suffering, and that the industry is populated by many people of good will. What is increasingly in dispute is the value of the industry evaluating its own products and then disseminating demonstrably biased evidence through sophisticated networks of sponsored education and paid opinion leaders.
“To dismiss the mountain of independently generated evidence about the myriad ways in which marketing distorts the care of patients as “misconceptions” and “negative myths” is an insult to science, and to suggest that the problems are a thing of the past is a dangerous fiction.
“While enhancing transparency of collaborations and industry-sponsored data, the current UK drug industry code of practice still fully endorses:
- doctors seeing sales representatives
- the giving of small gifts, including notepads and memory sticks at conferences
- sponsoring of education, hospitality, travel, and accommodation
- paying senior doctors to speak at promotional events 10 without any provisions for mandatory naming of recipients, as is required by the Sunshine Act being implemented in the United States.11
“Long overdue public scrutiny of influence peddling is accompanied by growing attention to the harm and waste caused by the unhealthy use of health-giving therapies. Many doctors are starting to close the door on drug company salespeople and politely decline the role of paid key opinion leaders.12
“Fearing a longer term loss of direct access to the clinical coalface, the industry is attempting an audacious repositioning: as a partner with health services in the provision of patient care rather than the supplier of one element of it.13
“This latest guidance on collaboration is extremely welcome, not as a guide to practice, but as an Orwellian insight into a desperate attempt to defend the indefensible.”
© 2012 British Medical Journal Ray Moynihan
Ethical Standards in Health & Life Sciences Group. “Guidance on collaboration between healthcare professionals and the pharmaceutical industry”.
Moynihan R, Mintzes B. Sex, lies and pharmaceuticals. Allen and Unwin, 2010:95.
Fletcher S. “Continuing education in the health professions: improving healthcare through lifelong learning: chairman’s summary of the conference”. Josiah Macy Jr Foundation, 2008.
Rothman D, McDonald W, Berkowitz C, Chimonas S, DeAngelis C, Hale R, et al. “Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest”. JAMA2009;301:1367-72. Free Full Text
Lexchin J, Bero LA, Djulbegovic B, Clark O. “Pharmaceutical industry sponsorship and research outcome and quality: systematic review”. BMJ2003;326:1167-70. Free Full Text
Prasad V, Cifu A, Ioannidis J. “Reversals of established medical practices: evidence to abandon ship”. JAMA2012;307:37-8. Free Full Text
Wang A, McCoy C, Murad M, Montori V. “Association between industry affiliation and position on cardiovascular risk with rosiglitazone: cross sectional systematic review”. BMJ2010;340:c1344. Free Full Text
Godlee F. “Doctors, patients, and the drug industry”. BMJ2009;338:b463. Free Full Text
Association of the British Pharmaceutical Industry. “Code of practice for the pharmaceutical industry 2012”.
Moynihan R. “U.S. drug manufacturers will have to disclose payments to doctors”. BMJ2010;340;c1648.
Cutting Edge Information. Key opinion leaders (PH 122): relationship management and segmentation data.
YouTube. “Promoting positive collaboration to improve patient health: interview with Simon Jose from Association of the British Pharmaceutical Industry”.