E-drug: Drug company payments to doctors
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The following was published in the Guardian newspaper UK.
Warning signs on doctors' roadshow
While the NHS is strapped for cash, the pharmaceutical companies have money
to woo
Sarah Boseley, health editor
Guardian
Thursday February 15, 2001
There is a group of eminent British cardiologists who are referred to, by a
certain drug company's sales reps in irreverent moments in the pub, as the
Roadshow. They spend a considerable amount of time travelling around the UK
and abroad, promoting the company's heart drugs. Some of them earn more
from this than their annual salary from their hospital or university.
It may well be that these consultants are totally convinced of the value of
the medicines and would do it out of conviction even if they were not
sometimes paid as much as �3,000-�5,000 a time for an evening lecture
which lasts around an hour. But the fact that they receive such large
payments
undermines the credibility of their opinions.
Peter Wilmshurst, consultant cardiologist at the Royal Shrewsbury hospital
who has been a constant critic of the relationship between drug companies
and doctors, believes the huge sums of money washing around have the
potential to skew people's judgments.
"Some members of the Roadshow have spoken fortnightly for the company ..
some also receive fees from other companies. It would be naive to imagine
that the size of fees do not affect the statements of opinion leaders," he
wrote in a letter to the Lancet last summer.
There is no suggestion that doctors will promote a drug that will do any
harm, but they may persuade themselves to promote one drug over another
that is just as good.
There are always going to be tensions between the altruism inherent in
healing the sick and the baser human imperative that drives the
pharmaceutical industry to make money. But there are those who say that in
parts of British medicine today, the one is being distorted by the other.
While the NHS is strapped for cash, the pharmaceutical firms have billions
to invest in research and marketing. Doctors from early in their career are
under subtle pressure to accept the financial support of the industry. Many
see nothing wrong, others feel uncomfortable but shrug it off as the
prevailing culture, and some consider that there is a real conflict of
interest.
Dr Wilmshurst's eyes were opened to the potential for abuse when he was a
relatively junior doctor involved in the clinical trials of a new drug for
heart failure called amrinone. His team at St Thomas's hospital in London
found some patients suffered gastrointestinal disturbances, liver failure
and problems with their immune system. "The company asked us not to publish
our adverse findings. Then when we said we had to publish, they threatened
us with legal action," he says. "When you are threatened by a multinational
with infinite amounts of money, some people might find that a good reason
not to go ahead."
His team published. Others with similar results did not, he says, after
senior cardiologists told them their findings were out of line with
everyone else's. The drug was withdrawn on safety grounds in 1984, but was
sold over the counter in the Philippines and Africa until 1986.
Dr Wilmshurst believes little has changed and that the largesse of the drug
companies is a malign influence on doctors. "I don't think it is the
majority of the medical profession, but the big problem is often with the
big earners. The big earners are offered the biggest amounts of money."
The Association for the British Pharmaceutical Industry (ABPI) disagrees.
Doctors, often those who have run trials on a drug, are certainly asked to
speak and are paid for it, said spokesman Richard Lay. "I think that is
right and proper. What we do not control is what they actually say."
He claims it is not unusual for a doctor to dissent from the company line.
"Companies are not in the position of paying doctors to say what they want
them to say. These are top people in their field. I would be astonished to
hear that people like that are going to give misleading information to an
audience of professionals who are intelligent and well-informed in their
area."
Few academic departments could keep going without the revenues from drug
company clinical trials. But the money, power and influence games are most
noticeable at medical conferences. On the micro level there are corporate
logos, ring binders, notepads, pens and bags in which to keep the
literature. But that is not all. "The whole system of paying for doctors to
go to conferences by drug companies is corrupt, because a company will not
only pay for the air fare, the hotel and the registration fee but also for
all the entertainment during the conference," says Richard Horton, editor
of the Lancet.
"The payback is that they will make sure that doctor goes to all the
symposia that promote their drugs. At the major cardiology conferences,
almost no doctor will ever pay for any of those things him or herself. It
is all paid for by the industry. The whole thing is one massive promotion."
The ABPI points to its code of practice which says hospitality must be a
subsidiary part of a bona fide meeting. "If there is any suggestion that it
is just a good jolly, that is not allowed," says Mr Lay.
Even so, Dr Horton is concerned by the growing number of these symposia at
medical conferences. A study of the published articles that came out of
symposia, carried out by Lisa Bero and colleagues in 1992, found that they
had "strong promotional attributes" and warned that readers should
"approach symposium issues that are sponsored by a single pharmaceutical
company with scepticism".
It is hard to step out of line and those who do, such as Dr Wilmshurst,
find their careers take a slide. "You wouldn't get money to do clinical
trials if you didn't go along with it," says Dr Horton, "but you are making
a Faustian pact by doing so.
"The days of pharmaceutical companies taking doctors out on holiday are
over. You can't do that any more - it's been banned. But the way it is done
now is very, very heavy."
Those at the very top of the profession, whose work is readily funded by
the Medical Research Council or the Wellcome Trust, do not have to depend
on the generosity of drug companies, he says. "But for people in the middle
rank it is very difficult. It starts very young. They are junior doctors
and along comes a friendly drug company rep who takes them out to dinner
every week. Immediately you become very sympathetic to industry."
He does not think the UK is any different from America. "I think it is in
some ways worse. The reason is that when you are working in a bit of a
downtrodden NHS and along comes the rich company that will take you to
wonderful cities at the weekend, you become very susceptible. It is just
too easy. It is sad."
In his recent book, "Don't Tell the Patient", Professor Bill Inman, who
started the NHS "yellow card" scheme for doctors to report to the
Department of Health the side effects of the medicines they prescribe and
later founded the Drug Safety Unit at Southampton, alleges that drug
company "post marketing surveillance" schemes, where GPs are paid for
filling in forms on the side effects experienced by patients on a new drug,
are nothing more than covert marketing.
As a result of his campaigning, industry guidelines called Samm (safety
assessment of marketed medicines) were agreed, stipulating that no
inducement must be offered to a GP. But, says Prof Inman, he has seen a
letter from one company doing a so-called Samm study for angina, offering a
doctor �275 to treat four patients with the new drug to be compared with
two given the old one. The letter says GPs may enrol up to 18 on the new
drug "but the ratio[new drug to old] will be maintained".
Prof Inman believes it is wrong that the Committee on the Safety of
Medicines, the government advisory body responsible for drug safety in the
UK, should have so many members with links to industry. So does Charles
Medawar of the watchdog body Social Audit. "I to some extent buy the
argument that it is difficult to recruit top people who don't at least have
indirect interests," he said, "but the scale is distinctly unhealthy." In
the latest declaration of interests from the CSM, 15 out of 36 had either
shareholdings, fees or paid consultancies from drug companies.
"The very fact that they insist the chairman should have no ties indicates
that they think it is significant," he said. The present chairman, Alastair
Breckenridge, resigned from the advisory board of SmithKline Beecham to
take the job.
Members leave the room when a drug from a company they have interests in is
being discussed. But Joe Collier, professor of medicines policy at St
George's hospital school of medicine, says there is "institutional bias" -
so many on the committee are close to drug companies they cannot help but
take an industry point of view.
regards,
Peter
Dr Peter Mansfield
GP and consultant on marketing and appropriate therapeutics
peter.mansfield@flinders.edu.au
www.malam.asn.au
PO Box 172 Daw Pk SA 5041 Australia
ph/fax +61 8 8374 2245
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