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Should you go to pharma sponsored educational meetings?

medical educational meetings – why the pharma fuss?

By Bradford VTS

The short answer is we don’t think you should – i.e. NO. You’ll find many medical educators who are dead against using any form of pharmaceutical sponsorship for meetings of any kind.   But back in the 70s, 80s, 90s and naughties, it was common practice.  So, why have we become so anti-pharma?   After all, don’t they produce drugs that HELP people against diseases?  Why are we so against pharma without whom some diseases bring unbearable suffering?

Let’s make a comparison to football.  Football was once a game based on the true spirit of the game – a competition between groups.   Footballers did not make such great money as they do now.    One of my patients, a famous footballer for Bradford, told me that he loved the game.   The pay was reasonable, but he had another main job too.   The spirit was all about football and celebrating the game, and they behaved professionally too.   But these days, it seems like it is a massive money-making business and some footballers do some very naughty things!   Billions are involved, and players earn a fortune – The average wage of a Premier League footballer is just over £60,000 a week, which equates to more than 3 million a year.   £60k A WEEK!!!   What about the above-average footballer – well, let’s not go there. It’s pretty shocking – all for being good at kicking a ball around compared to the skill required of a surgeon to remove a tumour and save a human life!

So, what’s this got to do with pharma?  In a similar vein, pharmaceutical companies in the 40s and 50s made an incredible contribution to the country’s health.  They discovered cures and treatments for conditions, and everything was a balance between helping people and generating some profit. But, of course, no one can deny anyone making some profit from the good they do. 

But the difference these days is the balance between those two things – doing good vs making a profit.   When profit is significantly out of kilter with doing good, the moral standard of that company progresses towards greed!   The balance has gone.   So, many pharma companies concentrate on making as much money as possible.  And the numbers involved are huge (many times over what the footballers get).  Yes, they want people to get better and help people, but the primary focus is selling the drug.   But what’s the problem with this?  After all, you might be thinking if you had a particular medical condition and there was a drug to alleviate suffering or potential suffering, then you would want it.  And kudos to the company for discovering it who should be rewarded with profit.

Research in social science demonstrates that the recipient of a gift feels a sense of obligation that is often subconscious.  Even when funding is unrestricted (i.e. course content and faculty are determined by the program director, not industry), the content favours the sponsor’s product.  Therefore, if you run a workshop with pharmaceutical sponsorship, even if you don’t mention their drug, you automatically promote it by merely talking about the disease.  The audience make their own subconscious links between the disease and the drug.  You may not realise this – whether you’re the organiser or the attendee – you are being played!

These days, the biggest problem is that pharmaceutical companies are promoting their drugs in the medical field (to us doctors) as THE SOLUTION to common conditions and pulling us away from a lifestyle approach. For example, look at the numerous drugs promoted for diabetes – and these drugs are not exactly inexpensive!!!    Look at a bit of heartburn and reflux.  First of all, the condition is now labelled as a “proper medical condition” – GORD.  This plants the seed in doctors’ and patients’ minds that “they need a pill for a proper medical ill”.  This results in the prescription of PPIs (now available over the counter) rather than making better lifestyle choices like stopping smoking, losing some weight and looking after their gut health.

And that’s how they make their money.  By selling their drug as much as possible – over any lifestyle choices.   But guess what.  They are not wholly to blame for this.    WE ARE TOO.   As physicians, we run courses and meetings and even workshops funded by these companies.   We talk about the disease or condition at length, and by doing so, we PROMOTE THE DISEASE.  And by promoting the disease, you do not have to promote the drug.  It just automatically happens as a consequence! Clever yet straightforward.

I’m a big fan of lifestyle medicine, and yet we do little to promote it.    In these educational meetings, half the time is spent on the pathophysiology of the condition and the other half on the investigations and drug management options.    If there is space given to lifestyle changes – it’s a one-liner statement!

In a consultation for heartburn (which I refuse to call GORD), we often talk at length about the condition and the medicine options to treat it. But then spend a measly 30 seconds on lifestyle measures they can take.   30 seconds of a 10-minute consultation = 5% of the consultation.  INCREDIBLE.   The same goes for musculoskeletal conditions – many will talk about the condition and the drug (an NSAID – how to take, side effect, beware of etc.…), followed by a quick “here is a leaflet on exercises”.   Same for diabetes – lots on the DISEASE, lots on the medication, and piddly amount on lifestyle.  I am glad to see it changing for diabetes, though – with these structured education programmes – but I feel we need to do more – lots more.   Many patients I have come across have said that they thought “medicine was the only option” for their diabetes, and there was nothing else.  Shocking!

So back to pharma and meetings. There’s a great article in the BMJ.  The British Medical Journal, June 4th 2021  Here are some of the points it raises:

  • Commercial medical educational meetings affect prescribing choices both overtly and subliminally.
  • The research shows that doctors cannot detect bias, no matter how clever or reflective or independent they think they are. They’re human, after all, and possess the same biases as all humans.
  • The medical world, aided by the pharmaceutical companies, are converting more and more things into diseases and expanding the market for existing diseases. This then helps “market” the new disease like GORD (formerly ‘heartburn’), resulting in an increase in PPI sales.
  • It’s common for pharma to omit or minimise product harms
  • Key opinion physician leaders sell the disease (not the drug). The drug automatically is promoted – they don’t need to do anything further.
  • “Industry-funded CME distorts doctors’ understanding of diseases and treatments and ultimately harms patients” – Professor Fugh-Berman.

So have a think for a moment and make up your independent mind about pharmaceutical sponsored meetings. It’s a shame we have to use pharmaceutical funding, isn’t it? Don’t get me wrong.  These companies have helped make significant advances in medicine.  But some, like some footballers in the analogy above, sometimes step into “naughty” territory – where greed, profit and presumed power outweigh the good.  But sometimes it is more subtle – for example, turning common non-serious medical ailments into “significant medical conditions”, which is then marketed as requiring a medical drug – their medical drug, helping to medicalise EVERYTHING!!!

Most businesses out there have a HEALTHY Continuing Professional Development budget to help their members develop!    In the UK, the medical profession doesn’t receive much funding towards CME, and that’s why many of us go for free education.   And I understand the appeal of free medical education.   But until CME gets its act together and stops using pharma, should we be paying out of our own pocket for our education?   Whether we should or shouldn’t, we all need to be aware of the creation and expansion of the market for existing diseases.  So, be mindful of attending free meetings sponsored by pharma.

What are your thoughts on this issue? What needs to change, if anything? How can we fund education if no free CPD is available?  Leave your comments below. 

SOME GREAT ARTICLES FOR FURTHER READING

Industry-funded medical education is always promotion—an essay by Adriane Fugh-Berman
BMJ 2021;373:n1273
Although awareness of individual conflicts of interest and ethical problems with physician-industry relationships has increased, few people realise just how much continuing education is used for product promotion. Many countries require doctors to complete a certain number of hours of continuing medical education (CME, known as continuing professional development in the UK) to maintain a medical license. But CME is heavily funded and influenced by drug and medical device manufacturers. And because CME is considered education rather than advertising, no country regulates it as product promotion.  Studies analysing content have shown consistent messaging in industry-funded CME that favours sponsoring companies’ drugs and disadvantages competing products.   The messages work: commercial CME affects prescribing choices. A sudden tripling in prescribing of an antipsychotic—an increase lasting at least three months—at the Minneapolis Veteran’s Affairs Medical Center was traced to a grand rounds presentation by a speaker paid by the manufacturer.  A 1992 study found that after an all-expenses-paid CME symposium held at a tropical resort, prescription rates for the CME sponsor’s drugs more than doubled!!!

Is it time to nationalise the pharmaceutical industry?
BMJ 2020;368:m769; Mariana Mazzucato, Henry Lishi Li, Ara Darzi
Drug companies fail to take account of the public interest and relentlessly focus on short term returns, say Mariana Mazzucato and Henry Lishi Li. But Ara Darzi argues that the profits drug companies make are vital for developing new medicines.

Pricing of pharmaceuticals is becoming a major challenge for health systems
BMJ 2020;368:l4627; Steven G Morgan & Suerie Moon. 
Manufacturers using their market power to maximise profits results in prices that are unjustifiable and unaffordable, argue Steven Morgan and colleagues.  Pharmaceutical innovations over the past half-century have enabled effective treatment and prevention of a wide range of illnesses. These advances were so important in modern healthcare that equitable access to them has been deemed to be a fundamental human right. Fulfilling that right creates tremendous social value but poses a significant policy challenge owing to its costs. Global expenditure on pharmaceuticals reached $1.135tn (TRILLION!!!) in 2017, up 56% from 2007.  Although demand for medicines is one of the drivers of pharmaceutical expenditure, rising prices are a primary concern for health system managers because medicines are increasingly being priced at levels that appear “unfair.” In this article, we review evidence that drug prices often exceed value for money and reasonable compensation for firms’ investment in research. We argue that pharmaceutical pricing is a growing challenge for all countries, calling into question the sustainability of the systems that are supposed to drive pharmaceutical innovation.

Exposing drug industry funding of UK patient organisations
BMJ 2019;365:l1806; Piotr Ozieranski, Emily Rickard & Shai Mulinari
Drug company payment disclosures have limited transparency, but Piotr Ozieranski and colleagues find that they are increasing in value and are targeted at select patient organisations,  From 2012 to 2016 the drug industry donated over £57m (€65m; $73m) to UK patient organisations, with the annual sum more than doubling over the period.  The funding benefited a small number of organisations and activities related to research and public involvement.  KEY MESSAGES: The industry gave priority to commercially high profile conditions.  Industry payment disclosures had limited transparency.  Patient organisations—third sector entities comprising patients, carers, or both, that provide support and advocate for people with specific conditions—are increasingly involved in policy and research.But their contributions have been questioned when they receive funding from drug companies.  With few exceptions, existing research underscores that financial ties to an industry driven by profit-risk turning patient organisations into seemingly independent “third parties” that promote novel medicines, often with problematic clinical profiles, cost, or cost effectiveness.

CCGs fail to declare pharma funding
BMJ 2018;360:j5911.   Tom Moberly
GP commissioners in England are receiving tens of thousands of pounds from drug companies without declaring the funding in their public registers, an investigation by The BMJ has found.  The BMJ worked with researchers from the University of Bath and Sweden’s Lund University to examine payments from private companies and charities to clinical commissioning groups in 2015 and 2016. Using data collected through requests made under freedom of information legislation, they found more than a thousand payments that were not included in the CCGs’ online registers …

End pharma influence on CME, says AMA journal
BMJ 2006;332:1410.  Janice Tanne
The American Medical Association’s ethics journal has suggested reducing drug companies’ influence on doctors’ prescribing habits by stopping the companies paying for continuing medical education (CME; American Medical Association Journal of Ethics 2006;46:357-436).  Such education is required in most US states and by many medical societies. The journal devoted its entire June issue to ways to reduce or manage drug company influence on doctors.  In 2004, more than $2bn (£1.1bn; €1.6bn) was spent on continuing medical education. Medical communications companies and medical schools depend heavily on drug companies to develop educational programmes, say the authors.  

Ethical Training For Medical Students Needed

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.

Is the relationship between pharma and medical education on the rocks?
BMJ 2008;337:a925.  Ray Moynihan.  
How much longer will medicine’s flagship educational events fly the colours of the drug industry?  In the heart of Manhattan Island one misty morning a few years back, I watched as hundreds of psychiatrists streamed into their flagship educational event, the annual congress. Even before arriving they were welcomed by giant advertising billboards on the streets outside, plastered with the name of a major sponsor, Pfizer, the biggest drug company in the world and the maker of Zoloft, the world’s top-selling antidepressant. Once inside, their first port of call was the huge exhibition hall, where well-dressed salespeople moved among the high tech booths and hypnotic neon, exchanging pleasantries with doctors lining up to play video games and win prizes. And then, of course, there were the sponsored educational sessions. That year—2004—psychiatrists learnt about bipolar disorder over breakfast at the Marriott Marquis Hotel, courtesy of Eli Lilly. Over lunch at the Grand Hyatt they studied maternal depression, thanks to GlaxoSmithKline, and for dinner it was generalised anxiety disorder in the grand ballroom of the Roosevelt Hotel, funded by Pfizer.   Although the educational flagships of many medical specialties proudly fly the colours of their drug company sponsors, psychiatry has long been suspected as being most entangled with industry; a suspicion that is confirmed by the world’s nascent disclosure regimes. In the small northeastern state of Vermont, where drug makers must now disclose payments to doctors, psychiatrists are the biggest recipients.  In Australia, where the courts have forced the industry to disclose the details of every sponsored event, psychiatrists are “educated” with industry’s hospitality more often than any other subspecialty.

Pharma and CME: View from the US
BMJ 2008;337:a1023.   Suzanne Fletcher
In the United States, commercial support for continuing medical education has grown steadily over the past decade. In 2006 it provided more than half, about $1.5bn (£0.75bn, €0.95bn) or 60%, of the income for educational programmes doctors must take to maintain their medical licences. Evidence shows that commercial support distorts what doctors learn.  In 2007 I chaired the Josiah Macy, Jr conference on Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning ( www.josiahmacyfoundation.org). A major recommendation emerging from the conference was that organisations providing accredited continuing education should not receive commercial support from drug or medical device companies.  The Macy report, from the conference, summarised the ethical concerns. Commercial support places doctors and nurses who teach continuing education activities in the untenable position of being paid, directly or indirectly, by the manufacturers of healthcare products about which they teach. 

Industry involvement in continuing medical education: time to say no
Can Fam Physician. 2014 Aug; 60(8): 694–696.  Sheryl Spithoff
The pharmaceutical and medical device industries fund a substantial portion of the continuing medical education (CME) of physicians in Canada. Along with this financial support come avenues for industry influence.  Continuing medical education organizers are often under overt pressure to design sessions and choose faculty to attract industry funding. Organizers might also be affected by more subtle tactics. Research in social science demonstrates that the recipient of a gift feels a sense of obligation that is often subconscious.  This might cause CME organizers to respond in predictable and accommodating ways to sponsorship from industry. The conflicts of interest CME faculty (organizers and speakers) have with industry likely also have an effect on CME content.  Whatever the mechanism, CME with industry involvement has a narrower range of topics and more drug-related content than CME without direct industry involvement. Even when funding is unrestricted (course content and faculty are determined by the program director, not industry), the content favours the sponsor’s product.  Few dispute that the bias introduced by industry involvement in CME affects physician prescribing. And, as stated by the US Senate Finance Committee in 2007, “it seems unlikely that this sophisticated industry would spend such large sums on an enterprise but for the expectation that the expenditures will be recouped by increased sales.” The real question is whether industry’s influence is harmful. Most agree that industry’s primary objective of increasing sales creates an inherent tension with the physician’s goal of getting the best medical information.

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