It seems that there are enough physicians out there who aren’t even a tiny bit embarrassed about referring to themselves out loud as “Thought Leaders” or “Key Opinion Leaders” to keep Canada’s Dr. Sergio Sismondo busy writing about them.
I first wrote about his work in A Philosopher’s Take on Big Pharma Marketing. Focusing on what he calls the pharmaceutical industry’s “corruption of medical knowledge”, the Queen’s University professor now has a new paper in The Journal of Law, Medicine & Ethics.
In it, he warns us about physicians and academic researchers who willingly become financially enmeshed in Big Pharma’s marketing efforts:(1)
“The issue here, as in many other cases of institutional corruption, is that a few actors have accumulated the power to shape the information on which many others base their decisions.
“Partly due to the use of these Key Opinion Leaders or KOLs, companies with well-defined and narrow interests have inordinate influence over how medical knowledge is produced, circulated, and consumed.”
How this translates for people like me, a dull-witted heart attack survivor who now takes a fistful of cardiac meds every day, is that these physicians – oops, I mean Key Opinion Leaders – are approached by their friendly neighbourhood drug rep to accept money from the drug company in exchange for telling their peers about whatever expensive drug the drug company wants them to endorse. Other doctors hear these paid talks or read the clinical practice guidelines they write – and prescribing habits are actually impacted. Big Pharma’s Speakers Bureau hired docs are so effective at increasing product sales that, as Dr. Sismondo notes, 15-25% of total Big Pharma marketing budgets go just to pay KOLs to do these speaking events.
I wrote here a few years ago about a revealing National Public Radio report called Drug Company Flattery Wins Docs, Influences Prescriptions. For example, the report examines how doctors become KOLs in the first place:
“To get a doctor to write more prescriptions, a drug rep asks the doctor to become a speaker on the company’s Speakers Bureau.
I’m guessing it feels pretty darned good to be considered a Thought Leader or a Key Opinion Leader. The titles seem to have incredible psychological power, according to the NPR report. But many drug reps interviewed had a more cynical view of why drug companies choose the doctors they end up choosing to be Speakers Bureau members. It’s not about how well-respected the doctor is, they say, but it’s about how many drug prescriptions he/she writes. One rep reported:
“A ‘thought leader’ or ‘Key Opinion Leader’ is defined as a physician with a large patient population who can write a lot of prescriptions. Period.“
The KOL, as further defined by bioethicist, author and professor Dr. Carl Elliott in his compelling essay called The Secret Lives of Big Pharma’s ‘Thought Leaders‘, is “a combination of celebrity spokesperson, neighborhood gossip, and the popular kid in high school.”
For a first-person perspective on what a KOL is, just try asking one. That’s what Dr. David Healy used to be. The Cardiff University professor of psychiatry and prominent drug industry critic worked for many years as a KOL himself before his industry relationships began to go sour, explains Dr. Elliott, who quotes Healy’s unvarnished opinions on the intellectual abilities of KOLs:
“If you look at these Opinion Leaders, the guys in the field are not stellar geniuses. The field moves forward by virtue of the fact that people cooperate.
“It’s not that anybody has a particularly brilliant insight, or that these guys are really awfully bright, but the Opinion Leaders who work with Pharma are actually the least bright.
“These guys get made by industry. They get money, they get status, and they knew they wouldn’t be anything if it weren’t for this.”
And when Ray Moynihan wrote in the British Medical Journal about the role of these influential “experts” paid by industry to help “educate” the medical profession, he cited the experience of one Kimberly Elliott.(2) She’d been a drug company sales rep for almost two decades with pharmaceutical companies like SmithKline Beecham and Novartis. Part of her job was developing relationships with these hired Thought Leaders, to whom she paid $2,500 for each drug lecture they gave to their peers. She revealed:
“Key Opinion Leaders were salespeople for us, and we would routinely measure the return on our investment by tracking prescriptions before and after their presentations. If that speaker didn’t make the impact the company was looking for, then you wouldn’t invite them back.”
This marketing strategy generally works spectacularly well for drug and medical device companies. Consider this example: the drug giant GlaxoSmithKline, like most other drug companies, hires doctors to speak to other doctors as part of their Speakers Bureau marketing efforts.*
One of the GSK drugs that these paid Key Opinion Leaders talk about to their peers is called Avodart, a drug prescribed to treat enlarged prostates. Over a single five-year period of its paid Speakers Bureau marketing efforts, Avodart sales more than quadrupled and its market share doubled. Thank you, hired Key Opinion Leaders.
GlaxoSmithKline insists that it chooses its KOLs by selecting “highly qualified experts in their field, well-respected by their peers and good presenters.”
But the Pulitzer-prize winning online newsroom ProPublica found that some top speakers are “experts” mainly because the companies have deemed them so.
Many KOLs acknowledge, for example, that they are regularly called upon to speak because they are willing to speak when, where and how the companies need them to, and to use company-produced slides and presentation material – and not to veer from that product material. They are usually accompanied by drug company staff who monitor the speaker’s presentations to make sure the opinions of the Key Opinion Leaders are ones they approve.
Dr. Howard Brody is a self-described “pharmascold” and author of Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry. He is blunt in his disdain for these KOLs. For example, he notes his reaction to Dr. Sismondo’s observation that the number-one requirement specified by KOLs to their Big Pharma masters is:
‘Protect my reputation!’
This requirement apparently evolved over time because KOLs desperately want to avoid the “appearance of being an industry ‘sell-out.'” But Dr. Brody believes that it’s too late: Key Opinion Leaders in medicine are, indeed, industry sell-outs, he says.
He suggests that a public outing within medicine and biomedical science to thus shame these physicians could have a significant impact on the general level of professional behaviour.
Dr. Sismondo is unsure that this type of naming-and-shaming campaign would work, explaining:
“The medical profession has been corrupted because a small number of companies with well-defined and narrow interests have inordinate influence over how medical knowledge is produced, circulated, and finally used by physicians to make decisions concerning their patients.
“Most physicians see the companies as playing legitimate roles when the companies promote products in clinics, when they create and distribute medical research, and when they fund and provide continuing medical education.”
So even if KOLs personally wish to avoid looking like sell-outs to industry, Dr. Sismondo claims that the larger medical profession, in fact, seems quite blasé about whether or not these docs have actually sold out.
To address this apathy, Dr. Sismondo favours a clear separation between pharmaceutical research and development on one hand and pharmaceutical marketing on the other, to help break up the “perverse financial incentives” that arise when drug marketing gets mixed up with medical research.
But acknowledging that this separation isn’t about to happen anytime soon, his temporary backup plan is this:
“Ban physicians speaking on behalf of drug companies.”
Dr. Brody proposes that this ban could actually happen “. . . if only physicians would grow an ethical spine and simply refuse to attend company-sponsored talks.”
While patients are waiting for docs to grow this ethical spine, the bottom line reality is that we may very well be putting powerful drugs into our bodies each day that were prescribed for us precisely because pharmaceutical companies and their KOL hired help convinced our physicians that these expensive drugs are safe and effective and superior to any other existing form of treatment – whether or not that’s true.
But how do we know now which ones we can trust — and which ones we shouldn’t?
Sadly, not even our doctors can know this.
This was also picked up as a guest post by Dr. Joe Today, November 5, 2013.
(1) Sismondo, S. “Key Opinion Leaders and the Corruption of Medical Knowledge: What the Sunshine Act Will and Won’t Cast Light On”. May 31, 2013. Journal of Law, Medicine, Ethics, Vol. 14, No. 3, 2013
(2) Moynihan, R. “Key opinion leaders: independent experts or drug representatives in disguise?” BMJ 2008; 336:1402 doi: 19 June 2008
* UPDATE: December 17, 2013: GlaxoSmithKline To Stop Paying Doctors to Pump Its Drugs
- Doctor’s kiss and tell tale: “My 1-Year Career as a Wyeth Drug Rep”
- Nice work if you can get it: same talk, same slides, week in, week out – at $1,500 a pop
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- How Big Pharma spends $20 billion a year on marketing their drugs to you
- A Philosopher’s Take on Big Pharma Marketing
And let us include medical device manufacturers along with Pharma. I once knew an orthopedist who alternated his months as a surgeon with months as a company rep. All over the world, he went.
Oh, good point, Kathleen. Dr. Sismondo’s study focused on Pharma, but KOLs exist everywhere industry needs MDs to help boost product sales. More on this at: Surgeons Make Millions on Medtronic Payroll or Is Your Surgeon Able to Understand Simple Instructions?
Thank you, Carolyn. I just did. Fascinating. Especially the non-disclosure study. I don’t have a hard time understanding that.
That orthopedist was entirely upfront about his other job, btw, but it never occurred to me that it might influence my own result.
And that’s the scary part. Lots of research out there confirming that such financial relationships will OF COURSE influence decisions that doctors make, despite their protests to the contrary. That’s why I believe that conflict of interest disclosure requirements are just the tip of a very big iceberg. The fact that so many docs seem to actually believe there’s nothing wrong with being on the take from drug/device manufacturers is the real issue here. We’d be outraged if a judge was taking money from the defense attorney, or if a baseball ump was taking money from one of the teams playing – so why do we turn a blind eye when docs are taking money directly from those who clearly have a stake in their medical decisions? Yet docs now seem to think that as long as they “disclose” the relationship, it’s no big deal.
Though the fact that such a large proportion do not disclose (or did not in the study) argues that they are at least uneasy about appearances. Resentful, perhaps, that others might make a judgment they would consider completely inappropriate, but uneasy enough to lie about it.
Our doctors CAN “know this”. I am one of them and it is EASY to know. Brody and Moynihan are heroes and are exactly right. And so are very many others whom you don’t hear about because we have no funding. The key, I think, is to seek out objective sources of non-financially conflicted “opinion leaders”. BMJ compiled a list of them but I don’t believe I’ve seen it published.
Thank you for shedding light on this subject. If you are a patient and want to know if your doctor is accepting money, use the ProPublica site you mention. (I think it was funded by moneys from the large Tobacco settlement). Therein, you can look up any doctor and appropriately shame them into changing.
Thank you Mark – what a joy it is to hear from docs like you. Besides ProPublica’s Dollars For Docs site, another resource to check who’s taking money from industry is the Integrity in Science project funded by the Center for Science in the Public Interest.
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Yes this is a major problem in medicine. When we combine this with ghostwriting and no publishing of “negative” studies, it gets worse. Plus the recent review which showed 12 out of 14 panel heads on committees to do with disease definition and treatments had conflicts of interest.
And the humble GP (family physician) is castigated for daring to question the “best practice” that money can buy.
Thanks for sharing your perspective, Dr. Joe. This is indeed what your Australian countryman Dr. Peter Parry and his U.S. colleague Dr. Glen Spielmans reported in the Journal of Bioethical Inquiry: “While evidence-based medicine is a noble ideal, marketing-based medicine is the current reality.” Pretty frightening if you’re a patient…
Don’t patients want the latest medicines? If drug rep activity and paying doctors to speak increases prescriptions, then that is more patients being treated. Not always a good thing, e.g. statins, but sometimes is, e.g. cancer drugs.
As long as doctors compare the options (Let’s assume all published research is equally biased, for simplicity) after a drug rep visit, as a patient, I am fine with that. People learn differently (visual, auditory, auditory-digital), right?
Saying that, I wouldn’t be happy with unethical marketing by drug reps and its a lot harder to monitor than, say, advertising.
Thanks for your comment. In any other field, we would simply never allow this practice as it exists when doctors are on the take from industry. Sports referees don’t take money from team owners. Judges don’t take money from defendants’ lawyers. Professionals are not allowed to profit financially when a clear conflict of interest exists – why would we think physicians and other drug prescribers should get away with this? Side note: the drug giant GlaxoSmithKline has announced it will no longer pay docs to help sell their products, following the massive bribery scandal in its China operations.
You’re right and the closest I can think of is Independent Financial Advisors, who can no longer be paid by their industry (costing individuals more). With the end user being separate from the payer and from the prescriber, is there even another industry that we can compare to?
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