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Views & Reviews No Holds Barred

Margaret McCartney: Forever indebted to pharma—doctors must take control of our own education

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1965 (Published 13 April 2015) Cite this as: BMJ 2015;350:h1965

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Counting other peoples sins does not make one a saint

Dear Editors

I welcome Dr Spurling into the discussion

Most readers (myself included) will agree, as Dr Spurling states, that "everyone selectively quotes research articles when they argue a position", but usually the quotations reflects what the authors found in their studies. It is therefore unusual to find any authors who tolerated their findings being reported so selectively (and with such bias) such that it does not accurately reflect the actual results of the study at all.

Dr Spurling does not appear to be bothered by such misleading reporting by various other authors and lobbyists.

To illustrate what is actually happening, let me give an example of what had happened in these reporting, removing the emotional and subjective elements out of the equation:

The authors reported that their meta-analysis of have found association of conditions related to the activity X, or no significant association. We have found no evidence of better outcome from activity X but cannot exclude the possibility that good can come out of this black activity X. Any conclusions about good or bad outcomes are speculative because none of the studies that the authors found examined clinical outcomes."

I would find it hard to accept any readers and authors to just quote "The authors reported that their meta-analysis of have found association of conditions related to the activity X" as the finding, particularly when "or no significant association" should be given the same weight as the presence of association.

This is only a few steps away from selective quoting an author who wrote "There is no association between A and B", as "There is association between A and B" and leaving out the "no"!

Dr Spurling defends his (and his co-authors') precautionary recommendation is evidence-based, and suggests that because "the pharmaceutical industry has not presented convincing research evidence that their information to doctors is beneficial", this is further proof of support.

I beg to differ.

Dr Spurling and co-authors made their recommendation in 2010, thus their burden of proof for their statement should be at the time of publication, and should not rely on future supporting evidence (or the lack of it) to support their recommendation. I would have accept it if Dr Spurling have asserted their recommendation is a "safe" measure based on rationalisation and subjective value system.

But Spurling et al actually states " In the absence of evidence of net improvement in prescribing from exposure to promotional information, we recommend that practitioners follow the precautionary principle and thus avoid exposure to information from pharmaceutical companies unless evidence of net benefit emerges.", ie there is no net evidence for (or in my view against) promotional information, I cannot see how Dr Spurling seek to misrepresent his case as evidence-based through the lack of it.

Dr Spurling suggest that I seek to be paid more, that because other professionals has continuing education without sponsorship, the public has no stomach for orthopaedic surgeons to be paid more to meet professional obligations.

I had actually wrote that

"our professional time as doctors is not "free" and if there is any suggestion that we as doctors should pay for our education with our own time and money, then perhaps we should call for better renumeration for our work when we call to remove commercial sponsorship to CME activities."

and I do feel that my surgical colleagues are unfairly singled out by Dr Spurling when my intent is clearly for the medical fraternity as a whole. As for "sponsorship-free" continuing education, depending on the country, practicing solicitors generally requires 20 hours or less Mandatory Continuing Legal Education annually of which a significant proportion can be done in-house or without specialised setup or equipment. The general cost of attaining those points is a mere fraction of that of a doctor.

If you work in Australia, it is almost certain a doctor would have to incur travelling costs in order to maintain their CME (continuing medical education), and when courses and national meetings (of Colleges and Associations) costing at least $1000 in Australia, I will not be surprised if the cost of CME for a doctor with recognised speciality (including GP) is at least $20000 annually; this of course does not include loss of income from taking time out to attend these CME. I also point out some (if not most) of these courses and meetings are already partially or indirectly sponsored so the real cost to doctors would have been even higher. And I very doubt the time spent by doctors on CME is less than 20 hours a year.

Dr Spurling states that "The onus is on those who don’t agree with the precautionary conclusion of our review to provide evidence showing the benefit of information from pharmaceutical companies.".

I suggest that he is seriously mistaken. Taking the cue from his fellow GPs in Australia (some 43,400 in 2011 Australian Bureau of Statistics), I believe the reverse is true.

Dr Spurling is a member of the group who launched No Advertising Please campaign in October 2014 the RACGP (Royal Australian College of General Practitioners) annual conference to much media support and fanfare. More than 6 months down the track, there is less than 350 signatories who pledge to not see visiting pharmaceutical representatives (drug reps) at their practice for one year; if international signatories are removed, less than 300 Australian are involved (and not all of them are GPs)

Of course Dr Spurling is welcomed to use his value-system and rationalisation process and suggest that the less than 1% written support from his GP colleague does not mean that those who did not sign the pledge are opposed to the idea, but alas I hold a very different (and commonly accepted) view: that those who did not write, did not happen.

Perhaps other readers may agree with me that the onus is on Dr Spurling to convince his immediate colleagues first, who are more likely to have drug reps going into their rooms than my surgical colleagues.

At the risk of repeating myself, I would like to stress my main reason to join this discussion, (some would say my 'bone to pick' - pun intended) was the selective quoting of findings which misleads readers about the article results.

It would now appear that both authors and readers can be guilty of this.

Beware ye of the leaven of the Pharisees

Reference
1. Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLOS Med 2010; 7: e1000352.

Competing interests: No competing interests

09 June 2015
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia