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HEAD TO HEAD: Charlie Buckwell Should the drug industry work with key opinion leaders? Yes BMJ 2008; 336: 1404 [Full text]

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KOLs and pharma – mutual beneficiaries, but at whose expense?

Jon N Jureidini, Joel Lexchin   (20 June 2008)

Re: KOLs and pharma – mutual beneficiaries, but at whose expense?

Paul K Morrish   (21 June 2008)

Maintaining the stus quo

Peter O'Loughlin   (21 June 2008)

How it really works

Bernard J. Carroll   (24 June 2008)

KOLs and pharma – mutual beneficiaries, but at whose expense? 20 June 2008
Jon N Jureidini, Chair, Healthy Skepticism Women's and Children's Hospital, North Adelaide, South Australia, 5006, Joel Lexchin Send response to journal: Re: KOLs and pharma – mutual beneficiaries, but at whose expense?	Charlie Buckwell argues that as long as the relationship between KOLs and drug industry is transparent, ‘there is much benefit to be gained on both sides’. We have no doubt that both parties have much to gain; but what about patients, who might well be losing? Buckwell argues there is nothing wrong with KOLs providing ‘analysis and guidance to other doctors regarding the appropriate placement of a drug in clinical practice’. But Buckwell appears to ignore evidence that shows that analysis is likely to be biased if it comes from pharma. KOLs may not recognise this bias, since doctors who recognise the possible influence of drug company generosity on others nevertheless regard themselves as immune from such influence. Buckwell’s claim that ‘It is not in the interest of the industry to have its products used incorrectly or in the wrong patients' is not supported with evidence. We have not seen Merck’s balance sheets, but even taking into account their subsequent legal costs, it is likely that they profited from their continued marketing of refocoxib after they knew it was killing patients. Under our current system of paying for medications pharmaceutical companies profit regardless of whether a medication is used correctly or incorrectly. When sales are large enough incorrect use is not only tolerated but encouraged. We need only look at the examples of fen-phen for weight reduction or troglitazone for diabetes to see that sales trump safety. We dispute the fact that it is primarily ‘focusing on the right decision for patients and maintaining their independence’ that makes individuals opinion leaders; the patronage of drug companies greatly increases an expert’s profile. The relationship between a KOL and industry is generally unequal, with KOLs made to feel important and valued in the process, while being intensively studied and scrutinised by the companies retaining them. Even where a well-paid KOL earns tens of thousands of dollars from the company, this spending is potentially dwarfed by the benefit in the influence the KOL exerts over prescription habits of other doctors. So we must be wary of claims that it is a good thing to ensure that KOLs ‘are supported in having the loudest voice possible’. There is no support for the claim that transparency solves the problem of conflict of interest. Declaring an interest is a necessary first step but it is not sufficient. Transparency can actually make listeners more accepting of false statements coming from KOLs. If there is a conflict, it is not adequate just to announce it, it needs to be eliminated. Competing interests: None declared
Re: KOLs and pharma – mutual beneficiaries, but at whose expense? 21 June 2008
Paul K Morrish, Consultant Neurologist Gloucester Send response to journal: Re: Re: KOLs and pharma – mutual beneficiaries, but at whose expense?	The question is surely "should key opinion leaders use the drug industry?" as it is the morality of the opinion leaders, not the drug industry, that is in doubt. The opinion leaders can, after all, turn down the offer. Whilst we might expect fellow medical professionals to question which opinion is being paid for, and by whom, the attraction of an expenses-paid meal or overseas conference frequently seems to get in the way. Competing interests: None declared
Maintaining the stus quo 21 June 2008
Peter O'Loughlin, Principal. Eden Lodge PracticeBeckenham BR3 3AT Send response to journal: Re: Maintaining the stus quo	Judging by history, I was of the opinion they already did. " On the appearance of any new drug an interesting cycle of events may often be observed. A trickle of favourable reports develop into a stream, and the drug becomes fashionable. Then the stream of favourable reports dries up. The drug falls into relative disrepute, and its use may even be abandoned"(1) 1 Medawar Charles: Citing british Medical Journal 1956 in Power and Dependence: Social audit on the safety of medicines: Social Audit 1992. Bath Press. Competing interests: Alcohol and Drug Addiction Recovery
How it really works 24 June 2008
Bernard J. Carroll, Consultant Pacific Behavioral Research Foundation, P.O. Box 223040, Carmel, California 93922-3040, USA Send response to journal: Re: How it really works	Charlie Buckwell (YES) pleads for an idealized state of transparent relations between the industry and KOLs. Would that it were so. His tone is similar to that of George Lundberg, editor in chief of the commercial medical information company Medscape a few days ago, making the case that the “educational” output of Medscape through KOLs is clean, transparent, and in the interests of patients (see http://hcrenewal.blogspot.com/2008/06/medscapes-cme-ethics-part-ii.html#links). This link also provides a case study of how inappropriate KOL behavior can become, with the collusion of outlets that survive by skimming corporate dollars while laundering honoraria to KOLs. The reality is different. Here is a description from an internationally recognized clinical scientist about his experience with the industry. Here I respect his confidentiality and that of the corporation. My colleague’s experience is not atypical. "When [the company] first began trumpeting the success of [their drug], I was asked to be on their speaker's bureau. In a large audience … I departed from the script I was given for the published data to note that the effect size … was significantly lower than the [alternative treatments]. Since most [of the audience] had no idea what "effect size" is, I gave a brief explanation. That evening I received a phone call in my hotel room from [the company’s] director of the program. He chastised me for being off message and warned me not to make these intrusive statements. I told him that I did not work for [the company], and that presumably I was asked to give these talks because I was a respected researcher in the field and had participated in some of the early trials of their drug, including meetings to develop a protocol for their FDA submissions. I repeated my performance the next day, and was never asked to talk for them again." For myself, over the years I cheerfully gave many talks sponsored by corporations, but I gave my talk, using my slides, and choosing my topic. These presentations were designed for educational impact, and the company’s drugs were never the central focus. They were extremely popular. About 5 years ago I was informed that henceforth I must use the company’s topics and slides, with no deviations allowed. The corporate material provided was mediocre in quality and infomercial in tone. That is when I stopped giving company-sponsored lectures in the US. Competing interests: None declared