From the $80 hamburger to managing conflicts of interest with the pharmaceutical industryBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1939 (Published 03 May 2019) Cite this as: BMJ 2019;365:l1939
All rapid responses
I have observed the venality of some physicians for decades. Academics and practicing physicians share this trait. The psychiatrist Karl Meninnger is purported to have said, "I have treated many physicians over the years, but the one condition I never cured any of them was greed." (This is a paraphrase, as I remember it.)
It's clear that the business of the pharmaceutical industry is business. The great Canadian physician, Sir William Osler wrote, "The practice of medicine is an art not a trade, a calling not a business." There are many ways that drug companies use physicians to sell their products and Booth and Detsky discuss some of them. A book could be written on the subject.
In the USA, we have the Sunshine Law that mandates that all payments to doctors from "industry" be reported to the government by the payer. Anyone can see these at the CMS Open Payments or ProPublica's Physician Tracker websites. It's illuminating to see who is on the take and for how much. It would be great if other countries did the same.
The practice of paying residents and physicians to attend so-called CME meetings is particularly heinous and addicts many to feed at the trough. Many of my Canadian colleagues who take advantage of this perk are embarrassed to discuss it with me. Is a trip to Mexico to meet with one's handlers and drink Margaritas really worth it?
We have a long ways to go in this area. It's hard to get data from the EU and elsewhere re: how practicing physicians and academics are being co-opted by industry. It's a sensitive subject.
Bravo to Drs. Booth and Detsky for an entertaining and important personal view.
Competing interests: No competing interests
I really enjoyed this well written article by our Canadian colleagues regarding a strategy to manage conflict of interest.
I work as a heart surgeon in the UK and have been increasingly conflicted by my increasing conflicts of interest. The first time I faced a difficult decision was when I was using a technique of endoscopic vein harvesting to reduce the size of the scar of the leg wound when patients have the saphenous vein harvested for coronary artery surgery. We in Blackpool were one of the first centres to adopt this technology the UK. The company paid for us to run a yearly study day and this helped the wider dissemination of this technique safely to other centres. Of course I collected our data and submitted it to a peer reviewed journal and subsequently collaborated with other units to look at 3 year outcomes and published it. Most recently we looked at 10 year results to publish, that apart from the cosmetic improvements, there is no long term impact on life span or re-intervention rates. Over the past ten years many units have visited us (funded by industry) and started offering it to their patients and recently our data was used by NICE to recommend its wider use. I have gone on to adopt many other new technologies and have received "reasonable" fees for effort and time outside my work schedule. I have been aware of the possible effect of bias on myself and have tried to have the results reviewed by independent doctors so the results are fair to both reader and patients. If I have found a lack of benefit I have passed the data back to my industry colleagues and changed my practice, sometimes to find a long silence for a period.
The real problem with conflicts of interest in medicine is that the relationship between doctors and industry is too complex to cover accurately with one article or one response. The pursuit of improvement is intricately linked between driven individuals and corporations that are by definition not charitable agencies looking to balance books to stay in a competitive arena. We as doctors need to be involved with industry to trial out new technologies but by making others aware of our relationships, be open to scrutiny. This I believe is a better way than, to not be involved at all, because this strong approach would drive the introduction and the safe adoption of new techniques into the health costs of nationalised systems which may be more difficult to justify. Having tried to work with other players there are bigger problems than conflict of interest in academic organisations which drive policy and agenda.
I think there will never be a perfectly unbiased way of doing medicine or surgery but trying to publicise the relationships and confessing to these relationships is the first step in the right direction.
Having spent a lot of time with industry, I am aware that many of them are genuinely keen to hear honest and truthful facts from clinicians, so if the technology does not have a future, they are keen to move their money and efforts to better ideas. I do believe it needs to be a symbiotic relationship as even though it is tempting to paint the industry partners as a purely evil bunch the truth is far from that and the majority are in the business for the same reasons, as us doctors, but answer to shareholders rather than patients though sometimes they could be the same people.
I am glad that this topic is getting more light thrown upon it. I would like to warn against taking polarised views of all relationships but rather be aware that much progress depends on a healthy relationship between doctors and industry and a more appropriate approach is to try and police the individuals on both sides that deal with reassuring lies for personal gain rather than make a stance on uncomfortable truths.
Of course I may be biased so please take that on board while you decide for yourself!
Competing interests: Am or used to be a paid proctor for Edwards Lifesciences, Abbott, Cryolife and Maquet.