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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: (Published 13 April 2015) Cite this as: BMJ 2015;350:h1965

Rapid Response:

Being cynical about the self interest of big pharma..... and governments/ doctors do not live in a vacuum; learning about the latest fad without endorsing it

Dear Editors

I thank Dr Claudina A MICHAL-TEITELBAUM for her second response to my rapid responses.

I agree that to a casual observer, the use of the word cynicism may be a rather strong word but Dr MICHAL-TEITELBAUM may be interested to know that the word according to the Oxford Dictionaries is defined as:

Cynicism NOUN inclination to believe that people are motivated purely by self-interest; scepticism:
2.a school of ancient Greek philosophers, the Cynics.

I am unfamiliar with the state of the national healthcare in France, but having being a doctor across the millenia in Australia, I often felt certain aspects of the national healthcare scheme (known as Medicare here) are treated like political footballs by different governments of the day. I suspect many UK doctors felt the same way about the NHS.

Just like commercial companies whose primary activity is about profit generation for its shareholders, some changes enacted by various government (in UK and Australia) seemed to be more about vote-winning rather than actually addressing the problem.

This is why there is always a healthy dose of cynicism in me (with eyes rolling) whenever I find out there is an announcement of introduction or change to a Medicare program. Of course I do not take that approach when dealing with patients!

With reference to the rest of Dr MICHAL-TEITELBAUM's reply, regardless of the reasons behind Spurling et al's findings, you are absolutely correct to suggest that big pharma will manipulate information available to the doctors and the patients at large. There is also no doubt that the the driving force for any commercial company in their activities is to promote their products, be it openly or surreptitiously.

However, medical education is not simply about learning about or confirming ideas already known and taught: it is also about challenging conventional thinking and finding applicability to individual patients in front of you.

Should one rely solely on "evidence-based medicine" in the form of peer-reviewed level 1 articles and guidelines, the medical practitioner will be at least 5 years behind the times in term of awareness of medical advancements available.

That is not to say doctors should be practising at the cutting edge of modern medicine (afterall we have all seen fads come and go), but at least there is an expectation that doctors should have some familiarity with the current popular ideas and devices.

Information about these topical issues is rarely available from journal articles upon inception; most information/propaganda about new ideas/ devices are usually from individuals or companies promoting them.

To quote the late Prof T.K. Shanmugasundaram, past-president of the Indian Orthopaedic Association: 'If you want to be a cutting-edge surgeon, stay with the times. But your patient may suffer often. But if you want to be a safe surgeon, be five years behind the times'.

In my career, I have seen orthopaedic fads involving Minimally Invasive Surgery, Metal-on-metal hip arthroplasty, hip arthroscopy, Patient-specific cutting guides for knee replacement etc just to name a few; none of them is discredited but certainly initial enthusiastic fanfare associated with their widespread introduction distilled with time into well defined indications for their application. So I am well aware of the pitfalls associated with commercial-led promotion of ideas/devices.

Neither am I suggesting doctors should actively pursue benefits from commercial sponsorship or endorsement (no doubt when that happens, the professional integrity is compromised). I have no doubt about that.

However, I would advocate 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.

Competing interests: I am guilty of attending many lunches sponsored by drug companies, hospital administration, governments, my parents and lastly (and most frequently) myself

20 April 2015
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia