Australian drug industry gives details of money spent
courting doctors
&
Doctors' education: the invisible influence of drug company sponsorship
Australian drug industry gives details of money spent courting
doctors
BMJ 2008;336:742 (5 April), doi:10.1136/bmj.39535.488299.DB
http://www.bmj.com/cgi/content/full/336/7647/742-a
News
Bob Burton
1 Hobart
Australia's drug industry has said that in the last six months of 2007 alone it
organised more than 14 633 "educational events" for the benefit of medical
professionals. Detailed monthly reports by 43
companies show that they spent more than $A31m (£14.3m; 18.1m; $28m) and
attracted 385 221 people to the events.
Although many meetings were held in hospitals and
attracted attendances of only about two dozen,
others were more elaborate affairs. Amgen
Australia, for example, spent $328 206 on food,
alcohol, travel, and accommodation at a Sydney
hotel for a two day clinical haematology
symposium attended by 142 haematologists and
trainees. Amgen sells a range of haematology drugs.
In July 2006 the Australian Competition and
Consumer Commission, a government regulatory
agency, reauthorised the self regulatory code of
conduct developed by Medicines Australia, the major drug industry group.
However, the commission required member companies
to submit monthly reports detailing each event
for medical professionals, the venue, the purpose
of the event, the nature of the hospitality
provided, the number attending, and the total
cost of the function (bmj.com, News extra, doi:
10.1136/bmj.333.7562.278-b
<http://www.bmj.com/cgi/doi/10.1136/bmj.333.7562.278-b>
).
A legal appeal by Medicines Australia against the
condition was dismissed by the Australian Competition Tribunal.
Before the release of the reports the industry
took out full page advertisements in medical
publications seeking to reassure doctors that
individuals would not be identified and that
attendance at such events "does not imply that
the provision of timely information by
pharmaceutical companies to your profession is in any way improper."
Ian Chalmers, chief executive of Medicines
Australia, said that the industry had "listened
to community anxiety about what goes on behind
closed doors between doctors and drug companies"
and embraced the new reporting requirement.
"Transparency is intrinsically valuable," he
said. However, he would not be drawn on whether
the industry internationally should emulate the
new Australian disclosure standard.
Rosanna Capolingua, president of the Australian
Medical Association, defended drug industry
events as keeping doctors informed on new
treatments. She said, "Doctors don't get a cut
for prescribing one drug over another . . . We
have never looked at this through a conflict of interest frame."
Peter Mansfield, a spokesman for the drug
industry watchdog group Healthy Skepticism, said
that the reports are "useful for telling us the
scale of the problem but will have no impact on
solving the problem of drug companies influencing
doctors' prescribing habits."
Simply by attending such events, he said,
"doctors compromise their ability to give
patients unbiased advice . . . Drug companies
don't sponsor these events to 'educate' doctors
on the best treatment but to sell their drugs."
Federal minister for health Nicola Roxon did not
respond to a request for comment. But in a
response to an earlier article in the BMJ about
sponsorship of medical education (BMJ
2008;336:416-7; doi: 10.1136/bmj.39496.430336.DB
<http://www.bmj.com/cgi/doi/10.1136/bmj.39496.430336.DB>
), she said that prescribing should not be
"influenced by any sponsorship arrangements of
education" and that "complete transparency" was
desirable. But she also made it clear that the
federal government would not act to curb the
involvement of sponsors in doctors' education.
________________________________
The member company reports are available at
www.medicinesaustralia.com.au/pages/page155.asp.
http://www.bmj.com/cgi/content/full/336/7641/416
BMJ 2008;336:416-417 (23 February), doi:10.1136/bmj.39496.430336.DB
Feature
Doctors' education: the invisible influence of drug company
sponsorship
Ray Moynihan, conjoint lecturer, University of
Newcastle, New South Wales, and visiting editor, BMJ
Ray.Moynihan@newcastle.edu.au
As calls to end drug companies' direct
sponsorship of doctors' education echo round the
world, an investigation in Australia reveals
sponsor involvement in the education of thousands
of general practitioners, writes Ray Moynihan
We've all been there-the educational seminars,
the medical symposiums, and the scientific
conferences generously sponsored by big drug
companies. The visible signs of sponsorship at
these events are obvious: the smiling drug
company representatives, the colourful company
logos, and the high tech stalls in the exhibit
halls. But what about inside lecture theatres,
where high quality education is delivered to
doctors by respected speakers? Surely the
sponsors have no input into those sacred places of independent education?
It seems that invisible influence may be flowing
through these sponsored seminars-even those
accredited by august associations-far more often
than many of us realise. In a rare look behind
the scenes of sponsored medical education, the
Australian Broadcasting Corporation's Background
Briefing programme
(www.abc.net.au/rn/backgroundbriefing/)
will this
weekend show that it is not uncommon for drug
company sponsors to suggest speakers at sessions
that are assumed by the thousands of general
practitioners who attend them to be totally
independent. Drug industry representatives have
confirmed that similar practices take place in
the United Kingdom, where roughly half of all
education for doctors is sponsored by drug companies.
In the case of one popular Australian provider of
medical education, HealthEd, leaked documents and
emails from a range of sources show drug company
sponsors having input into the selection of some
speakers at seminars held in recent years,
despite the fact that these have been
aggressively sold to general practitioners in
brochures claiming that "all content is independent of industry influence."
Doctors in the dark about sponsorship?
In an email to the drug giant Sanofi-Aventis,
HealthEd asks, "Could you please suggest a couple
of speakers for our scientific committee's
approval?" The drug company emails back: "Please
find attached our suggested speakers." One of the
speakers suggested by the drug company sponsor is
subsequently accepted and delivers a presentation
at a HealthEd seminar. Doctors attending that
seminar, held at a university, were not verbally
informed of the sponsor's role in suggesting speakers.
Another set of leaked emails features
communications between the same educational
provider and CSL, the company that markets the
analgesic tramadol (Tramal) in Australia. While
negotiating sponsorship arrangements with the
provider, for a planned session on headache, a
CSL representative writes that the company would
like HealthEd to "determine the speaker's opinion
re: Tramal as I would like to ensure he positions
it appropriately." HealthEd replies that it "will
reconfirm opinion of headache speaker re: Tramal
to ensure balanced presentation."
In another email the drug company Organon, now
part of Schering-Plough, writes that "we would
like to put forward the following two doctors for
consideration" as speakers for a seminar on
women's health. The educational provider replies,
"We will do our best to accommodate your
request." The drug company's suggested speakers
are ultimately accepted, provoking this grateful
response to the educational provider: "I would
like to again sincerely thank you for the
political help . . . in respect of orchestrating
the favourable consideration of the proposed topic and speaker."
When asked about its sponsorship arrangements
with HealthEd, Schering-Plough's managing
director in Australia, Shaju Backer, said that
"as part of the sponsorship, [drug] companies are
allowed to suggest speakers and topics," which,
he added, then undergo a peer review process to
see which are suitable. Schering-Plough also made
public an extract from an email sent to it by
HealthEd, which stated that top level "platinum"
sponsors were routinely offered the chance to
"work with us to determine a speaker and topic
for the programme," subject to conditions that
the speaker be authoritative and scientifically
balanced and that the content be evidence based.
The drug company said it sponsored such meetings
to help ensure that drugs are used appropriately
in Australia. It stressed that no guarantee is
given that the topics or speakers nominated by
sponsors will be chosen and that this is not a condition of sponsorship.
Industry suggestions are "filtered"
In an extended interview about sponsorship,
HealthEd convenor Ramesh Manocha repeatedly and
strenuously defended the content of his seminars
as totally independent. He said that suggestions
from the industry for speakers were "filtered"
through his company's working groups or
scientific committees, which commonly include two
or three doctors, including himself, and which
make decisions entirely independently of industry
sponsors. "We filter the suggestions that come from the industry," he said.
In relation to the material in the leaked emails
Dr Manocha said they dated back to 2006 and that
in all cases decisions about content were made by
HealthEd and its working groups, not the industry
sponsors. He did, however, concede that measures
were not at that time tight enough in relation to
the demands of sponsors. "We have accordingly
tightened up and established guidelines to
prevent them from making these kinds of demands
from us." Moreover, he said it was "standard
industry practice for sponsors to be involved" in
the running of independent educational seminars.
Reacting to specific emails, Dr Manocha said that
the speaker suggested by Sanofi-Aventis had been
cross checked with independent sources before
being accepted and that in the case of the CSL
request he admitted talking to the prospective
speaker about his presentation but brought no
pressure to bear on him. In the case of Organon
Dr Manocha agreed that he had asked his
scientific committee to accept the speaker
suggested by the drug company because he "felt
that speaker was a person who was capable of
presenting on the topic without being influenced."
Another document that shines light on the
relationships between sponsors and educational
providers is a 2008 HealthEd brochure that the
educational provider had used to seek sponsorship
from drug companies. That brochure states that
"at each seminar as a platinum sponsor your
company can . . . work with us to determine a
topic that is on message for your product area."
Platinum sponsors typically pay the educational
provider around $A10 000 (£4700; 6200; $9100) to
be a sponsor at a one day seminar and receive
many entitlements, including stalls in the
exhibit area and free passes for their favourite general practitioners.
When asked about the 2008 sponsorship brochure
(which the BMJ obtained from a drug company
sponsor this month) Ramesh Manocha said that the
brochure was no longer used and that the wording
should have been changed. He did, however, say
that for up to 25% of the sessions at his most
recent seminars-specifically the sessions
relating to new products-he had sought a list of
suggestions from the sponsoring drug company for potential speakers.
Sponsors suggesting speakers is "not unusual"
The drug industry's representative body Medicines
Australia has confirmed that the practice of
inviting input from sponsors into the selection
of speakers is by no means uncommon. Its chief
executive, Ian Chalmers, said, "It's not unusual
in a sponsored professional event for
pharmaceutical companies to be offered the
opportunity of suggesting speakers."
In an interview with the BMJ last week the
medical director of the Association of the
British Pharmaceutical Industry, Richard Tiner,
confirmed that the practice of sponsors
suggesting speakers for accredited events also
occurred in the UK, where, he said, drug
companies fund roughly half of all postgraduate
education of general practitioners.
Dr Tiner said that the organisers of educational
meetings might ask their drug company sponsors,
"Who would you suggest we invite to talk about
this topic?" Drug company sponsorship would then
provide funding to bring speakers from outside
the local area, so by accepting the sponsors'
suggestions for speakers the educational
providers "would often get access to speakers
they were not able to invite themselves," he said.
The view from the drug industry is that allowing
sponsors to suggest speakers does not compromise
the independence of medical education, as the
educational providers have ultimate control over
who speaks. However, research for the
investigation in Australia reveals several
examples where sponsors' suggestions were
embraced by the company providing supposedly
independent education. Doctors attending those
seminars were not told of this invisible sponsor
influence, although during the period when the
research was being conducted for this
investigation HealthEd made changes to its
website, saying that in some cases sponsors are
offered a chance to suggest speakers, subject to
a list of conditions.1
<http://www.bmj.com/cgi/content/full/336/7641/416#REF1>
Disclosure or disentanglement?
Industry representatives in Australia and the UK
strongly argue that, in the interests of
transparency, doctors attending educational
sessions should be fully and explicitly informed
if sponsors have suggested speakers for
educational sessions. Dr Tiner told the BMJ that
his personal view was that he would "have
absolutely no problem making it clear, if a
sponsor has had input into suggesting speakers-I
would have no problem with that whatsoever."
Such a degree of disclosure could radically
change perceptions of the content of accredited
education, which many doctors believe to be
independent of sponsor influence. While welcoming
the call for more transparency, Des Spence, of
the pressure group No Free Lunch, says that in
practice this sort of disclosure would not
happen. Dr Spence says that in his view these
sponsored events are "marketing masquerading as
education" and that "it isn't appropriate that
industry should be sponsoring education."
The evidence, such as it is, tentatively
indicates that the prescribing habits of doctors
may be affected by attending sponsored
educational events, albeit only in the short
term. A survey of doctors who attended courses
funded by single drug company sponsors found that
after the course "overall the sponsoring drug
company's products were favored."2
<http://www.bmj.com/cgi/content/full/336/7641/416#REF2>
A review of the evidence on interactions between
doctors and drug companies, published in 2000,
found that drug company sponsored educational
events "preferentially highlighted the sponsor's
drug(s) compared with other . . . programs."3
<http://www.bmj.com/cgi/content/full/336/7641/416#REF3>
An earlier review of the evidence published in
1993 suggested that "company-sponsored . . .
courses may have a commercial bias even if
conducted under guidelines designed to ensure the
independence of the event."4
<http://www.bmj.com/cgi/content/full/336/7641/416#REF4>
Although all these findings may have limited
applicability to contemporary circumstances, they
suggest that sponsorship of educational events
may well result in an increase in sales of the sponsor's products.
Harvard professor David Blumenthal, an
internationally recognised authority on
relationships between doctors and drug companies,
says that the industry is certainly looking for a
return on its investment in medical education.
"Why would for-profit companies, in this country
at least (the United States), pour more than a
billion dollars a year into continuing medical
education without the expectation of gaining anything from it?" he asks.
The obvious problem with allowing sponsors to
suggest speakers is that they will tend to select
speakers who will at best, from the company's
viewpoint, favour their drug or, at least, not
contradict the sponsor's marketing messages. The
problem is not that individual speakers will
change their presentations according to sponsor's
wishes; the problem is that doctors attending
these sponsored sessions may not be getting the
full range of views, in an educational setting
supposedly free of industry influence.
In a landmark paper in 2006 Professor Blumenthal
and colleagues called on academic medical centres
in the US to end the direct drug company
sponsorship of continuing medical education
events (also known as continuing professional
development). In its place they suggested the
creation of some sort of blind trust to fund
education at an institution level.5
<http://www.bmj.com/cgi/content/full/336/7641/416#REF5>
Others, such as Peter Mansfield from
HealthySkepticism, a group critical of
pharmaceutical marketing, have called for medical
education to be funded by the taxpayer through a system of competitive grants.
Oversight of these educational events is
currently a self-regulatory affair, and medical
associations everywhere seem uninterested, at
this stage, in guaranteeing genuine independence
from industry influence. Perhaps the recent
revelations from Australia-and confirmation from
the industry itself that it is "not unusual" for
sponsors to suggest speakers-will sharpen the
lines of debate about how to achieve more
independent education or at least greater transparency.
________________________________
RM thanks Wendy Carlisle and Miranda Burne for research assistance.
Competing interests: None declared.
CSL and Sanofi-Aventis declined to comment.
References
1. HealthEd. HealthEd's educational content.
www.healthed.com.au/epages/dynamicwebcsoln.storefront/?ObjectPath=/Shops/HealthED/Categories/about
(accessed 15 February 2008).
2. Bowman MA, Pearle DL. Changes in drug
prescribing patterns related to commercial
company funding of continuing medical education.
Journal of Continuing Education in the Health
Professions 1988;8:13-20.[CrossRef]
<http://www.bmj.com/cgi/external_ref?access_num=10.1002/chp.4750080104&link_type=DOI>
[Medline]
<http://www.bmj.com/cgi/external_ref?access_num=10294441&link_type=MED>
3. Wazana A. Physicians and the
pharmaceutical industry: is a gift ever just a
gift? JAMA 2000;283:373-80.[Abstract/Free Full
Text]
<http://www.bmj.com/cgi/ijlink?linkType=ABST&journalCode=jama&resid=283/3/373>
4. Lexchin J. Interactions between
physicians and the pharmaceutical industry: what
does the literature say? CMAJ
1993;149:1401-7.[Abstract]
<http://www.bmj.com/cgi/ijlink?linkType=ABST&journalCode=cmaj&resid=149/10/1401>
5. Brennan TA, Rothman DJ, Blank L,
Blumenthal D, Chimonas SC, Cohen JJ, et al.
Health industry practices that create conflicts
of interest: a policy proposal for academic
medical centers. JAMA
2006;295:429-33.[Abstract/Free Full Text]
<http://www.bmj.com/cgi/ijlink?linkType=ABST&journalCode=jama&resid=295/4/429>