Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Drug promotion: An octopus for prescribing
- Shazia Qasim Jamshed, Zaheer-ud-din Babar, Mohamed Izham Mohamed Ibrahim (15 August 2008)
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Who else will fund the Medical education ?
- Dr Malaki O Ramogi (19 August 2008)
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It's not drug companies but doctors that are the problem
- Simon Hatcher (20 August 2008)
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Good drugs is the priority
- Anwar Jawdat Jawdat (20 August 2008)
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Industry and learning: Comforting caress or brutal stranglehold?
- Joseph L. Mathew (20 August 2008)
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Drug (company) addiction
- David J Brookman (1 September 2008)
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Covert social conditioning or a matter of choice?
- Saliha Nazir, BR6 7WF (2 September 2008)
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education without tears
- David T Reilly (2 September 2008)
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...If Only!
- David G Tucker (7 September 2008)
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Some progress in UK psychiatry
- Joanna Moncrieff, Philip Thomas, Rhodri Huws (16 September 2008)
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PHARMS;The Physician's Best Friend.
- Alexander FRANKLIN (21 September 2008)
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Alligator Tears
- David J Reinhardt (27 September 2008)
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Ethical Training For Medical Students Needed
- Salique Miah (4 October 2008)
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Shazia Qasim Jamshed, PhD scholar Social Pharmacy, Universiti Sains Malaysia, Zaheer-ud-din Babar, Mohamed Izham Mohamed Ibrahim
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Drug Promotion-An octopus for prescribing In “Is the relationship between pharma and medical education on the rocks?” Ray Moynihan has beautifully highlighted the pharmaceutical marketing gimmicks with evidences. We all know since decades that pharmaceutical manufacturers are the most skillful composers in carving, instituting, and estimating promotional journeys. Their keenly penetrative and tailor made plans are equipped with attentive assistance in the form of target groups and preliminary studies. Pharmaceutical promotion is a chain reaction which is smooth sailing since decades, incorporated silently and entwining our prescribing pattern like an octopus. Pharmaceutical manufacturers hit the psyche of the prescriber (whomsoever he or she is) by showering them with gifts which can be even of negligible value as simple as pen (1). With the aim of accelerating their sales, disease mongering is a robust attempt on the part of pharmaceutical companies i.e. to simply promote and give public hype to relatively minor incompetent health states such as male-type baldness (2). A study was conducted to investigate the 'gift-relationship' between pharmaceutical companies and doctors at the school of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales Australia. This study outlined guidelines on gifts from pharmaceutical companies and differing standards applying to gifts and grants for travel. Although most of them are in concordance with the professional and pharmaceutical industry guidelines but some such as personal gifts, tickets to sporting events, entertainment and travel expenses for specialists' partners did not comply with the stated guidelines (3). In a developing country like India, Glaxo is in liaison with 2, 30,000 doctors with a strong grip through symposiums, medical journals and mailers, 3-12 times per year; thus contributing in holding the number one status in India. In one of the study conducted over 20 years doctors have ascertained the role of medical representatives as one of the prime informers (4). Obviously these are few of the bitter facts which cannot be looked down upon but the prescribing habits should be relied upon careful thought which caters to patient's need in the best clinical interest. It is not a matter of what being asked or offered. One must hear the voice from within. As per US psychologist Price Pritchett, writer & entrepreneur, sometimes we are submerged in between our ethical "shoulds" and selfish "wants" but it is better to strive and come up with ethics of excellence. References 1.Halperin EC, Hutchison P, Barrier RC Jr. A population-based study of the prevalence and influence of gifts to radiation oncologists from pharmaceutical companies and medical equipment manufacturers. Int J Radiat Oncol Biol Phys 2004; 59: 1477-83. 2.Shankar PR, Subish P. Disease mongering. Singapore Med J 2007; 48:275-80. 3.McNeill PM, Kerridge IH, Henry DA, Stokes B, Hill SR, Newby D, Macdonald GJ, Day RO, Maguire J, Henderson KM. Giving and receiving of gifts between pharmaceutical companies and medical specialists in Australia.Intern Med J 2006; 36:571-8. 4.Srivastava RK. Emotive marketing can generate prescriptions Wednesday, August 15, 2007 accessed at http://www.pharmabiz.com/article/detnews.asp?articleid=39376§ioni=46 Competing interests: None declared |
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Dr Malaki O Ramogi, Spr Genitourinary Medicine Nottingham University Hospital NHS Trust
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Current medical training lays alot of emphasis on attending accredited external teachings, seminars , workshops and conferences as part of continous professional development.All doctors must earn a minimum number of CPD per annum to be eligible for recertification. A trainee doctor in the united Kingdom has an annual training allowance of about £700 per annum ,which is insufficient to cover a two day course in a big city. Sadly enough, very few accredited teachings are taking place in the hospitals. Alot of commercial courses ran by trainers in conjuction with pharmaceutical companies have mushroomed to replace the good old hospital teachings in clinical settings. Without the support of pharmaceutical companies , most trainee doctors will be unable to attend these meetings. With no alternative source of funding in sight the pharmaceutical companies will still have a major role in physicians education.Hence more emphasis should be on educating doctors about their ethical and moral duty and to have the best interest of their patients when recommending any treatment. Competing interests: None declared |
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Simon Hatcher, Senior Lecturer in Psychiatry University of Auckland
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Dear Editor I'm on the organising committee of the 2010 Australian and New Zealand College of Psychiatrists Congress in Auckland. We too have been concerned about the role of drug company sponsorship and their role in this event. Having seen what happened in Adelaide and the response of the College we felt that we couldn't ban drug company sponsorship. However there is another way of looking at this issue. If large multinational companies want to give us money that is not a problem. Given that the function of these companies is to maximise returns to their shareholders by encouraging use of their products we should expect nothing less. Drug companies are not "evil" they are just doing what they are set up to do. The difficulty arises with doctors and how they relate to the drug companies. This is both a challenge and an opportunity as we have far more influence over what doctors do than drug companies. So when it comes to organising conferences we'll accept money from anyone (especially if it means we can sponsor the attendance of mental health workers from the Asia -Pacific region including some of the Pacific islands). What we are paying attention to however are the "strings" attached to the receipt of any monies. At the very least we would like to see these made transparent. I would also like to see a wider range of "trade stands" including booths promoting the use of non drug treatments and a place for "No free lunch" at this congress. How we negotiate this remains to be seen...... Yours Dr. Simon Hatcher Competing interests: I am on the organising committee of the 2010 Australian and New Zealand Congress. The views are my personal views and not necessarily those of the committee. I do not receive any pharmaceutical funding or attend sponsored drug company meals. |
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Anwar Jawdat Jawdat, ENT surgeon AL Hakeem Hospital Najaf IRAQ
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How does continuing medical education cause adverse effects on the education of doctors? Does continuing medical education increase the prices of drugs ? How can famous drug companies with very good products have unreliable continuing medical education? I want to prescribe drugs of good quality , with appropriate prices for every patient and can be stored in appropriate environment. Competing interests: None declared |
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Joseph L. Mathew, Assistant Professor Advanced Pediatrics Centre, PGIMER, Chandigarh, India
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Dear Sir, The recent debate on the role of industry in the continuing education of medical professionals prompts the following considerations. 1. Industry has successfully determined what professionals (will/can) learn (and otherwise) during conferences/ meetings/ workshops, through 'sponsored sessions' and the associated glitz/glamour that go with them. This is a major departure from the practice of Scientific Commitees determining the academic content and programme. Thus professionals are exposed to education that may not be required, warranted, accurate or appropriate. Imagine if school/college education involved such practices; there would be an instant uproar! 2. The practice of 'sponsored sessions' has gained considerable 'legitimacy' through open declaration in the programmes of conferences. However, this 'legitimacy/legality' does not replace the issue of whether it is ethical and /or moral. The latter aspect has not been considered in depth. 3. Industry is capable of 'hiring' eminent speakers who deliver presentations and are paid a fee. Declaration of funding sources again settles the issue of legitimacy; but the ethical and moral components often remain open to question. Such practice is often no different from 'advertising'. 4. Industry participation certainly adds to the elegance, comfort and glamour of conferences, but professionals need to determine whether these should be permitted at the cost of academic independence. 5. As there are no free lunches anywhere; the ultimate cost of these expensive 'learning exercises' is borne by society, in particular those who are already suffering. This is another aspect that needs careful consideration. Joseph L. Mathew Competing interests: None declared |
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David J Brookman, Rural Locum Coonamble NSW Australia
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It is a supreme irony that in Australia we subsidise the pharmaceutical industry through the PBS (i.e. the taxpayer). This additional income is used to subvert evidence based prescribing, academic research, and promote inappropriate use of pharmaceuticals. Academic careers can be made with seeding from the pharmaceutical industry and the pressure to publish in quantity outweighs the expense and time cost of conducting well designed research. That CME has become dependent on the industry is not a move of necessity, but a calculated marketing strategy by the industry, not as a conspiracy, but as a duty to their shareholders. The solution appears simple - discount the PBS subsidy by the marketing cost for each pharmaceutical brand and direct this money to research that matters (like realistic strategies to increase indigenous health), and education that is targeted at correcting manpower deficiences, and correcting knowledge weaknesses in providers rather than building quasi academic networks promoting pap and quackery. Competing interests: None declared |
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Saliha Nazir, Specialty Registrar Year 3 Psychiatry of Learning Disability Bassetts Resource Centre, BR6 7WF
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The ethical issue about the sponsorship of medical education by pharmaceutical companies has long been a subject of debate. Ray Moynihan's well researched article succintly highlights the "fundamental incompatibility" between the two. On the other hand, Dr. Simon Hatcher, in his response has correctly pointed out that the difficulty arises with doctors and how they relate to drug companies. An article in the New York Times stated that: "In 2006 the latest year for which numbers are available , the drug industry accounted for about 30% of the American Psychiatric Association's $62.5 million in financing. About half of that money went to drug advertisements in psychiatric journals and exhibits at the annual meeting, and the other half to sponsor fellowships, conferences and industry symposiums at the annual meeting." However the worrying trend is the undisclosed amounts of money and perks given by the pharmaceutical companies to key opinion leaders which recently were the subject of Congressional investigation. If everything is above board then why the secrecy? There is no doubt that the pharmaceutical companies spend millions on research which is useful but it would be naive to think that marketing does not play any role in the selling of drugs. After all they are in the field to make money. Social concerns are not the primary reason why they are in the business. There is a disturbing undercurrent of social conditioning associated with the role of Pharmaceutical companies in the Continuing Medical Education. This needs to be identified and acted upon. The use of critical appraisal is a right step in the direction. But there is an urgent need for government legislation to regulate the interaction between the medical community and the Pharmaceutical companies. Competing interests: Brother doing an internship in a pharmaceutical company in Europe. |
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David T Reilly, retired vascular surgeon CH64 2UU
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May I make a Level 5 anecdotal addition to the debate over drug industry funding for medical education? Some years ago, when I was a fairly new consultant, I was invited to give a talk on peripheral vascular disease to some of my primary care colleagues over supper at a small hotel. About 20 of us sat down to an unmemorable buffet before I spoke, using slides in those pre Powerpoint days, and at the end I fielded a number of questions. One GP asked me what was the place for Praxilene (naftidrofuryl oxalate) in the treatment of intermittent claudication, and I responded that as far as I could see there was no evidence for any useful clinical benefit. At this, the drug rep sponsoring the meeting burst into tears, and explained to me later that she would have got the sack if her superior had been present. Until then it hadn't occurred to me that my colleagues were having their supper bought for them, and the meeting organiser hadn't thought to tell me. But if I had known, should I have kept quiet to avoid hurting the rep's feelings(and job prospects)? Competing interests: David Reilly is a retired vascular surgeon |
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David G Tucker, Holistic practioner hants SP10
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For the benefit of a paradigm shift, towards a more rational, natural, logical system of health care, let us all hope that this is so....before the hypocratic oath of 'first do no harm' , is further compromised. It is way past time that the profit motivated business of allopathic prescriptive medicine was replaced by a genuine system that is effective in reducing the incidences of all the current rapidy escallating detrimental health issues. It is only by the maverick, questioning, students of any disciplne,not blindly accepting that teacher/text book/lecturer/professor is correct, rather than perhaps, misinformed,that any supposed 'truth' is reappraised and maybe changed for the better....but be prepared to be at first ridiculed, derided and condemmed....especially if your new view of things effects someone's balance sheet! Competing interests: None declared |
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Joanna Moncrieff, Senior Lecturer University College London, WC1E 6BT, Philip Thomas, Rhodri Huws
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Moynihan describes the defeated efforts of a group of psychiatrists to free the annual Congress of the Royal Australia and New Zealand College of Psychiatrists from drug company sponsorship 1. These psychiatrists can take heart from the fact that the British Royal College of Psychiatrists conducted their 2008 Annual Meeting without reliance on any industrial sponsorship. It was a breath of fresh air not to be confronted by an array of drug company stands and representatives as you walked into the meeting. The success of the conference shows that a rigorous and stimulating academic meeting can be held without funding from the drug industry, albeit in less plush surroundings than usual. The Critical Psychiatry Network has been encouraging the Royal College to take action for several years now and we applaud the decision to run the Annual Meeting without sponsorship. The recent College policy on relations with the pharmaceutical industry also takes some important steps, such as prohibiting company sponsorship of speakers or attendees at College-run meetings and the commitment not to use commercial sponsorship for College public education campaigns 2. However, the policy misses some important opportunities. In particular it fails to recommend the freeing of continuing medical education from direct drug company influence by the use of blind Trusts and it is a shame that it does not follow the example of the Academy of American Medical Schools and recommend a comprehensive ban on the provision of gifts and free food 3. We were also disappointed that the College decided not to follow our suggestion to compile a public register of interests of their members, so that everyone could become aware of the scale of commercial income received by individual psychiatrists, including leading academic and opinion leaders. Competing interest disclosures in Journals and meetings do not require that the amount of income is declared, but this is often what is truly shocking. By abrogating responsibility for this policy to local institutions, the College failed to provide the leadership role that it is so well placed to assume. Yours, Reference List (1) Moynihan R. Is the relationsip between pharma and medical education on the rocks? BMJ 2008; 337:484-485. (2) Royal College of Psychiatrists. Good psychiatric practice. Relations with pharmaceutical and commercial organisations. 2008. Royal College of Psychiatrists. (3) Association of American Medical Colleges. Indstry Funding of Medical Education. 2008. Washington, DC, Association of American Medical Colleges. Competing interests: The authors are all members of the Critical Psychiatry Network |
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Alexander FRANKLIN, Physician Toronto, M5P 2X9
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A Tale of Two Cities. At one time the Toronto Academy of Medicine (1907) was an established institution. It had lecture rooms, the William Boyd library, the Drake Paediatric Museum, an Academic History of Medicine programme and the separate Osler Hall for large meetings. In 1984 the Academy started to fail financially and in a few years the properties were sold; the books and museum contents given away. The building is now a Baha'i Temple. At present Toronto no longer has an Academy of Medicine or any other similar Medical society. The reason for the Academy's bankruptcy: it did not occur to the fiscally naive Toronto doctors to ask International Pharm.corps for more than a $1,000 contribution, the same amount paid by Individual benefactors,(including the writer). The situation is happily and vastly different for the palatial Royal Society of Medicine at One Wimpole St. Through the fiscal smarts of thr RSM Board, the building was redesigned internally by the HERON Group, who were given an extra floor in exchange. The RSM received large donations from many Pharm. corps.,their names gracing the various magnificent lecture halls. The world famous WELLCOME Library, Museum & FREE lectures at 183 Euston rd.is an another example of medical education funded by the pharm.industry. The NOVARTIS Foundation at 41 Portland place is home to important scientific meetings. The unique Dr.F.NETTER (1906-1991),8 vol. ANATOMY ATLAS was originally commissioned by CIBA Pharm.corp. In Ontario, CME outside the teaching hospitals, depends on the generosity of pharm. companies paying for Specialists to visit the many Ontario small towns to give FREE after-work dinner-lectures. The Ontario Government does not pay for CME costs or travel expenses. As a result of distance and lack of Government funding many doctors cannot afford out-of- town CME meetings. International & Canadian pharma companies are essential to help Canadian doctors keep up-to-date. Competing interests: None declared |
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David J Reinhardt, Neuropsychologist/Psychopharmacologist Garden Grove CA 92841
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There is no question that big pharma "gifts" influence prescribing decisions. This has been shown in numerous studies. Continuing education is a requirement for MDs, Dentists, Podiatrists, Psychologists, Pharmacists, Nurses, Social Workers, Family Therapists, and nearly all licensed professionals. MDs have and continue to stand out as the highest paid of these professions. Only one of these professions has a "rich uncle" paying for their education. Please! Competing interests: None declared |
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Salique Miah, Foundation Year 2 Doctor Ashville Surgery, 171 Upper Chorlton Road, Whalley Range, Manchester, M16 9RT
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Dear Editor, The fundamental tension at the centre of the Continuing Medical Education-Pharma debate has been obscured. Business spends money in the hope and expectation that that expenditure will generate income. This is an undeniable economic and entrepreneurial fact. That pharmaceutical companies continue to spend money on doctors’ education is surely then an indication that they are successful. The debate must be re-cast into one of impartial evidence based education (and therefore prescribing) versus biased and deceptive education (and therefore harmful prescribing). Excusing the status quo by claiming that no other source of funding is available for CME is an act of dissimulation. If some health care professionals want to argue in favour of inculcating doctors into becoming unofficial employees of the pharmaceutical industry, then let them say so openly. But let’s not kid ourselves into believing that funding has no impact on independence. It is not subconscious bias or “irrational prescribing” that is the issue here, but rather the subversion if not corruption of doctors by the pharmaceutical industry. From “me too” drugs to manufactured pseudo-medical problems; the full spectrum of these tactics must be more prominently discussed in medical school. It is truly appalling that students are not even made aware of the dangers of this multi-million pound marketing industry (in which I include pharmaceutical sponsored CME), aimed squarely at them. Indeed the most insidious influence they exert is propagating the idea of altruism and partnership. Gifts, appreciation and respect make a potent combination. Students must be armed with specific ethical training to deal with this particular problem. After all, what is the point of five years of medical training, only to become a highly qualified drugs rep? Competing interests: None declared |
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