Who pays this doctor? It’s time patients knewBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3039 (Published 06 May 2014) Cite this as: BMJ 2014;348:g3039
All rapid responses
The issue behind pharmaceutical companies funding doctors' education including travel to international conferences is not new. The recent campaign to develop a register of doctors' interests should be welcomed but we must consider who should be paying for these expenses? Should it be the doctor themselves or perhaps the employer? In the UK the NHS provides very little financial support for doctors continued medical education. Although it is appropriate that the pharmaceutical industrys financial influence is limited we need to work out how to replace it.
Competing interests: No competing interests
This helpful article addresses an important point that may become even more important as more private providers compete for NHS contracts. The question is therefore wider than the relationships with pharmaceutical companies. The Association Palliative Medicine has recently produced a position statement on this which is on our website.
The register McCartney has started is very welcome, but likely only to be effective if very widely used.
Competing interests: I was one of the authors of the APM position paper on doctors' relationships with industry
WHO PAYS THIS CONGRESS? IT'S TIME PATIENTS AND DOCTORS KNEW
Paolo Vercellini, M.D.1,2
Paola Viganò, M.D.2,3
Edgardo Somigliana, M.D.2,4
1Department of Obstetrics and Gynaecology, University of Milan, Italy
2"Luigi Mangiagalli" Endometriosis Study Group
3Department of Obstetrics and Gynaecology, San Raffaele University, Milan, Italy
4Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
Paolo Vercellini, M.D.
Istituto Ostetrico e Ginecologico "Luigi Mangiagalli"
Università degli Studi di Milano
Via Commenda 12 – 20122 Milano, Italy
Tel.: +390255032917; mobile: +393382105559; e-mail: email@example.com
Margaret McCartney addresses the issue of competing interests of prescribers, and also points out that patients do not know whether their doctors are chosen key opinion leaders, paid by a drug company to increase prescribing of a drug, or whether their doctors' travels to international conferences were paid for by the drug company making the product they are being recommended.1 In fact, the information disseminated in scientific meetings regarding medications and devices, may easily undergo a bidirectional undue influence, as a result of payments to those who deliver the information and to those who receive it.2,3
As it cannot be excluded that the quality of the data presented is distorted as a result of conflicts of interest,4,5 and because key opinion leaders may influence the audience through their lectures,2 patients should know not only who pays their doctors,1,6-8 but also who pays the congresses where their doctors are persuaded to use the drugs that will be prescribed to them. Medical conferences rely heavily on industry sponsorship.4 When speakers and attendees are both paid by pharmaceutical companies, the risk of spreading biased information is worryingly increased. Therefore, not only we enthusiastically welcome the whopaysthisdoctor initiative, but also suggest that health authorities set up a public central registry of competing interests for scientific societies or individual organisers, where declarations regarding medical conferences and invited speakers can be listed.
Moreover, publication of conflicts of interest in the online and printed congress programmes should be fostered or even rendered mandatory. Through this simple measure, participants and lay people would be aware of:
1. the general conflicts of interest of the scientific societies9 or of individual organisers who arranged the meeting, independently of that particular event;
2. the direct support to the congress made by industry through "unconditional" payments to the scientific societies or individual organisers;
3. the indirect support to the conference made by industry through payments for programme slots for sponsored symposia, breakfast or luncheon lectures, satellite meetings, and exhibition space rental;
4. the number of registrations bought by individual companies in advance of the meeting;
5. the society or organisation, or individual people responsible for the financial balance of the meeting, i.e., those who gain or loose money according to the degree of success of the conference;
6. the conflicts of interest of invited speakers and the amount of money they received for delivering lectures in that particular meeting;
Congress programmes, usually stuffed with advertisements, would become more informative. In addition, the conference organisers should declare in the programme that the final conference financial statement will be published online, indicating the date of publication and the website or webpage where the statement will be available.
When invited speakers show an initial slide where conflicts of interest are listed, the audience typically has insufficient time to appreciate if and to what extent these could interfere with the content of the presentation.2 Moreover, the source and the amount of money received for that particular presentation are usually not specifically indicated. In addition, lack of peer-review renders the information delivered at invited lectures potentially unsafe, especially within the context of sponsored symposia.4
The issue of competing interests in medical science has been addressed intensively with regard to information disseminated in writing; it seems now time also for verbally disseminated information to undergo a similar process.6 At the end, patients and national health systems may pay for conceptual drawbacks and conflicts of interest associated with biased presentations at congresses also, but not exclusively, in terms of increased cost of interventions, overtreatment, and suboptimal use of limited healthcare resources. Indeed, part of the usually higher cost of new drugs compared to standard ones may be due to expenditures for sponsorship of the former molecules through medical conferences.
Without industry sponsorship, medical conferences would probably rapidly disappear.2-4 Some authors argue that this might not reveal detrimental to the scientific community, and that nowadays alternative modes for research dissemination and education are available.2,4 The problem here seems not only to avoid or limit financial support from industry whenever possible (examples exists, such as the Preventing Overdiagnosis Conferences; http://www.preventingoverdiagnosis.net), but also to make it transparent to everybody, so that anyone could put the information received into the right context. Who pays this congress? It's time patients and doctors knew.
1. McCartney M. Who pays this doctor? It's time patients knew. BMJ 2014;348:g3039.
2. Moynihan R. Key opinion leaders: independent experts or drug representatives in disguise? BMJ 2008;336:1402-1403.
3. Moynihan R. The dos and don'ts of collaborating with industry. BMJ 2012;344:e3247.
4. Ioannidis JP. Are medical conferences useful? And for whom? JAMA 2012;307(12):1257-8.
5. Spence D. End the scandal of free medical education. BMJ 2013;346:f3936.
6. Godlee F. Doctors should tell patients who is paying them and why. BMJ 2014;348:g259.
7. McCartney M, Goldacre B, Chalmers I, Reynolds C, Mendel J, Smith S, Bewley S, Gordon P, Carroll D, Dean BJ, Greenhalgh T, Heath I, McKee M, Pollock A, Gordon S. Why the GMC should set up a central registry of doctors' competing interests. BMJ 2014;348:g236.
8. Wen L. Patients can't trust doctors' advice if we hide our financial connections with drug companies. BMJ 2014;348:g167.
9. Rothman DJ, McDonald WJ, Berkowitz CD, Chimonas SC, DeAngelis CD, Hale RW, et al. Professional medical associations and their relationships with industry. A proposal for controlling conflict of interest. JAMA 2009;301:1367-1372.
Competing interests: No competing interests
The register that is proposed seems largely to be a waste of time as it is unlikely to help the patients.
Indeed, what ARE patients to do when they discover a conflict of interest. There’s not much research to provide an answer, but one experimental study found that people given such a disclosure made poorer judgments than those not given the disclosure (Cain DM, Loewenstein G, Moore DA. The dirt on coming clean: perverse effects of disclosing conflicts of interest. J Legal Studies. 2005;34:1–25).
So, trying to account for the effect of the conflict of interest is likely a waste of time. The patient could completely disregard everything the doctor says on the topic; but that won’t work unless they choose another doctor. So what we’re left with is no different from not knowing at all.
A reason disclosures are becoming more prevalent is that they offer little threat to big pharma, or they’d be trying harder to get around them.
We might be better off concentrating our efforts in eliminating the gifts and benefits which lead to the conflicts of interest, rather than being delayed in what really needs doing.
Competing interests: No competing interests
Zimny is right that there is an imbalance in the relationship between doctor and patient, which means knowledge of a doctor's financial interests is never going to be a panacea for resolving all biases and prejudices in medicine. However, a register like whopaysthisdoctor is not just for patients, but also for doctors.
As doctors we are often reliant on the views of Key Opinion Leaders for the clinical knowledge we acquire and the decision we make. Whether it is through journal articles, editorials, educational events or published guidance it is essential that we have a good understanding of whose lead we are following, and whether or not they have any affiliation with the treatment that they recommend.
It is often difficult to ascertain a doctor's interests due to inconsistencies in their declaration - particularly at conferences and educational events where the culture of declaration is not well embedded. If the GMC held a single, compulsory, publicly available list that would make such a process simple and reliable, while also making it convenient for doctors who would only make one declaration per annum rather than every time they publish.
Competing interests: I have received income from publishers including Pulse, Prescriber, and The Guardian, for writing and speaking. I played a small part in setting up the website whopaysthisdoctor.org and my full declaration can be found there.
I am pleased that Lewis and Boissaud-Cooke like the idea of whopaysthisdoctor.org. They also raise some significant points. To start with their final question about trust, I would not place much value in a trust that depends on denying patients knowledge of payments received by their doctors. If doctors feel their links with industry are appropriate, they should be willing to discuss them with patients; if they feel that patients would not trust them if they knew about these links, this is something they really need to reflect on.
Secondly, Lewis and Boissaud-Cooke's two questions about decision-making are important and do not have easy answers. It is challenging for patients to assess which treatment option is best for them and whether the recommendation of their doctor is robust. There are a range of tools which may assist patients with this: including requesting a second opinion, using decision-making aids and developing their own ability to critically assess the evidence for a given recommendation. If patients feel that a doctor's conflicts of interests are especially worrying, they may also choose to change doctors. None of this is easy, but knowledge of doctors' conflicts of interest (if any) will simply be another factor for patients - who already deal with a lot of complex information - to take into account. NHS Choices' articles for the general public already often mention the competing interests of researchers when assessing their findings; if the general public can make sense of this, they should also be able to make sense of the conflicting interests of doctors when this information is shared in an appropriate way.
I am also grateful to Zimny for his praise of whopaysthisdoctor.org and his positive attitude to addressing the information imbalance he describes. Clearly, a single website is not sufficient to deal with all aspects of this imbalance; however, it could be an invaluable mitigation measure. There is (as McCartney's column notes) better evidence that interests of the sort whopaysthisdoctor.org is asking about may affect doctors' decisions than there is about some of the other potential conflicts Zimny mentions; however, a declaration on whopaysthisdoctor.org does not stop doctors from being open and reflective in other ways as well. A declaration of interests on a website clearly does not absolve doctors of their professional responsibilities - just as my declaration of a COI here does not absolve me of my responsibility for what I write - but it could help doctors to reflect on their responsibilities and to discuss them with patients and others.
Competing interests: I played a part in setting up whopaysthisdoctor.org and have campaigned around conflicts of interest more broadly. See here for a fuller declaration of interests http://jonmendel.wordpress.com/about/
I applaud the author's intent to minimize financial conflict of interest by advocating a website where physicians can publicly declare financial conflicts of interest in the hope that patients can therefore be better informed and take this information into account regarding treatment options, etc. The author claims, rightly, that there is an information imbalance in the physician patient encounter, which ought to me mitigated.
This is laudable. Unfortunately, however, information imbalance is inherent in the work of the physician. If the patients already knew medicine presumably they wouldn't be asking for our advice. There will be many conflicts for us as physicians, not all financial. Perhaps if you're a physician your friend is a pharmaceutical CEO, and while she is not paying you, you perhaps feel differently to their/her product than you would otherwise. Should that be reported? There are many examples that we all can come up with or have experienced ourselves of similar situations where our own motivations (more often than not non-financial) may be antagonistic to what our patient wants or needs. The simple fact is that all of us are conflicted in small ways every day with many of our patients. Maybe they look different, or dress different, or aren't nice. Should these too be reported? Is money especially corrupting and therefore needs a class of its own?
Medicine is more than a job, it's a profession and a calling. We're supposed to place the patient's needs first and be their advocate; that's what we do as physicians, and that's what makes us different. We can't offload that responsibility onto the patients, with the expectation that they look up a website and make a judgement about whether or not their doctor is "really" on their side.
As physicians, just as every other human, we're conflicted, even if the conflict doesn't involve money. We're still expected to be on the patient's side, however, every time.
Competing interests: No competing interests
Thomas Lewis's response sounds excessively defensive to me.
"How can we ensure that patients have the appropriate education to interpret the information correctly and make an informed decision?"
That smacks of the sort of old-fashioned paternalism that is now out of fashion. I know GPs who welcome patients who arrive with Google printouts and want to discuss their treatments.
" how can we ensure this project is effectively implemented without risking damage to the trust integral to the doctor-patient relationship?"
That trust is betrayed if the doctor has his judgement changed because he's being paid to prescribe a product. Honesty about motives doesn't destroy trust. It promotes trust.
Competing interests: No competing interests
We really like the idea of whopaysthisdoctor.org and am fully behind the proposal to submit any conflicts of interest. We do however have one or two questions regarding how patients could use this resource effectively on a day-to-day basis.
E.g. Patient goes to Dr Pharma who prescribes a new drug due to Big Pharma influence. How would the patient realise they are not getting the ‘usual’ Evidence Based Medicine (EBM) treatment? We think many are unlikely to be experts and recognise they are not on the best EBM treatment.
So the next big question is if the patient looks up Dr Pharma's conflict of interest, and discover the links with Big Pharma, then what can/do they do?
How can we ensure that patients have the appropriate education to interpret the information correctly and make an informed decision?
Finally, how can we ensure this project is effectively implemented without risking damage to the trust integral to the doctor-patient relationship?
Competing interests: TLL is a writer and editor for iMedicalApps.com, a website dedicated to providing news on the integration of mobile technology into medical care and the reviewing of medical apps for mobile devices. He is paid for his contributions as a writer and editor. He neither consults nor receives reimbursement from app developers or creators. MBC has no competing interests.