It's only fair to share…

Some interesting figures have been posted on the Medicines Australia website. In the six months to September 30, 2011 37 pharmaceutical companies spent AUD$ 40 million on 18,174 educational events which attracted 423,516 attendees. The average cost per head re event was $96.20.

At first this may look like a lot of money. To put it into perspective currently one company is negotiating a billion dollar plus settlement with the FDA over marketing of one product. Forty million by 37 companies is small change.

There has been a lot of debate about conflicts of interest in medicine and how much the gift of a pen or a dinner out influences the prescribing habits of a doctor. Indeed there have been restrictions placed on both gifts and “entertainment”. As part of a move to greater transparency the information about spending on educational events is now publicly available.

According to a poll done for GSK (published in medical Observer) a majority of people were happy for doctors to receive payments from pharmaceutical companies if the payments were transparent. Some 90% viewed payments to health practitioners negatively, but 79% supported pharmaceutical funded research.

A survey of doctors in the USA showed 65% supported transparency. My guess is that this figure may be similar in Australia if someone did the survey.

The arguments over pens and dinners miss the main point. The big money is in research and advisory board decisions. The FDA currently has to re-examine the safety of a contraceptive called Yaz after it emerged that four panelists had ties to the manufacturer. Four is a significant number as the vote in favour of the drug was 15-11. The vote would be reversed if four people had voted differently.

At the height of the swine flu, panic recommendations were made to governments about buying swine flu vaccines for the entire population. It emerged that 64% of the people on advisory panels had potential conflicts of interest that were not disclosed and 13% did not even have conflict of issue forms filed – which of itself should have barred them from being involved.

In a recent medical journal on page three was an article about the warning of diabetes being a possible side effect of cholesterol lowering (statin) medications. Two professors were quoted in the article being fairy dismissive regards the risk and prompting the benefits of the drug. At the bottom of the article was a disclaimer that the professors had “… previously disclosed accepting fees from statin makers.”

Within the next 14 pages were four full page ads for a statin and there was an insert of an ad promoting an online video from “leading specialists” about cholesterol. One of the leading specialists was quoted in the page three article. A statin manufacturer supported the video.

Amongst other questions one could ask how “previous” were the fees

The Medicines Australia website states “No one knows medicines as well as those who make them.” This is quite true. Those who make them also have the most to gain by selling them. It is analogous to saying that no one knows a car better than the manufacturer.

Would we feel that an opinion on a car from the maker was unbiased? Probably not. Should we expect the maker of any product to be unbiased? I don’t think so.

So here is the real issue. It is perfectly legitimate for doctors to be paid to do research for pharmaceutical companies. We need research and people are absolutely entitled to earn a living doing so. However these same people cannot be unbiased when it comes to the products they have helped develop. Neither can doctors who are paid to talk on behalf of companies (and flown around the country and put up at fancy hotels) be unbiased. The money involved here is far greater than $96.20 per head.

In the USA some doctors have earned over a million dollars a year in consultancies to industry. Much of this is for speaking roles at educational events and research. The propublica website has a database of payments made by 12 companies to doctors. So far $761 million has been disclosed. The US government is moving to mandate disclosure of all payments for travel research speaking and consulting.

In sport, the umpire is not drawn from the ranks of the playing team. Panels considering pharmaceuticals, advising governments or making guidelines are like umpires. They cannot include people from an applicant “team”.

Yet currently some 69% of doctors on the DSM-5 task force have drug maker ties!

Neither can “leading specialists” be promoted as experts on a topic without it being made clear that they are being paid to be experts. I am not suggesting that anyone says something they don’t believe. It is very easy to find doctors of a certain opinion and “cultivate” them.

Transparency is more than just making publically available an aggregate figure on how much has been spent on education. It is beyond little footers at the base of articles. It is about how “experts” are presented. When paid to present they should be promoted as company spokespeople – which is essentially what they are.

Doctors cannot wear two hats. Either they can work for industry or sit on panels advising health authorities. They cannot do both.