BMJ  2008;336 (5 January), doi:10.1136/bmj.39444.472708.47

Editor's Choice

Doctors and the drug industry

The Royal College of Physicians is looking at relations between doctors and the drug industry and wants to hear from you (doi: 10.1136/bmj.39428.617431.DB). In case you need them, here are some pointers from this week’s BMJ.

Firstly, should we fear for the integrity of medical research because clinical trials are overwhelmingly funded by industry? Yes, says Paulo Bruzzi (doi 10.1136/bmj.39416.559942.BE). Industry designs trials mainly to get new drugs registered as soon as possible, preferably with an unrestricted indication. The best trials for this—in large unselected populations—often leave key questions unanswered and, because of ethical constraints on subsequent trials, unanswerable.

Bruzzi is only slightly reassured by evidence from Louise Berendt and colleagues (doi: 10.1136/bmj.39401.470648.BE) that independent trials have survived the imposition of rules for good clinical practice. He says the medical research community must rethink the terms of cooperation with industry: "Our health systems risk bankruptcy for the skyrocketing costs of drugs that were developed on their own patients using strategies that ignore the patients’ needs and priorities."

Secondly, what of industry’s influence on prescribers? Nothing new here except, I would like to think, a growing sense of outrage. Writing recently in the New York Times, Daniel Carlat, an academic psychiatrist in Boston, has exposed his journey from industry funded speaker to penitent giver of "un-drug talks." As Jeanne Lenzer and Shannon Brownlee describe (doi: 10.1136/bmj.39437.473576.0F), Carlat feels he must pay his dues for the overprescribing he has caused. He wants other doctors to join him in kicking the addiction to drug company money.

Paid opinion leaders are not unique to psychiatry, of course. In 2002, the New England Journal of Medicine reversed its 12 year old policy of precluding anyone with financial ties to industry from writing editorials or review articles. It couldn’t find enough authors with no financial ties. The NEJM can still claim to have the most stringent policy of the major general medical journals.

On the face of it, this is a pragmatic response to the world we live in. But looked at another way it’s an indictment of medicine’s culture. The evidence that industry funding biases the design and reporting of clinical research is overwhelming. So too is the evidence that paid opinion leaders increase prescription of the sponsor’s drug. Why else would industry pay them? Surely we must create a better system. Giovanni Fava, editor of World Psychiatry, may have come up with one. As well as enforcing declaration of conflicts of interest, he suggests rewarding those who choose to remain independent—by giving them priority for public research funding, guideline panels, and journal editorships (World Psychiatry 2007;6:19-24). If enough of us dropped our links with industry, it could mean not only less bias but also less money spent on marketing and more on doing trials that address the important questions. Drugs might be cheaper, too.

Ultimately, says Carlat, our professionalism is at stake. The Royal College of Physicians is giving the profession the chance to speak with one voice and to come up with a better way of doing things. Send it (pharma{at}rcplondon.ac.uk) and us (bmj.com) your views.

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