The new entries are Professor Simon Stewart, Head, Preventive Cardiology at the Baker IDI Heart and Diabetes Institute, and his colleague, Dr Melinda Carrington, General Manager of the Baker’s Disease Management and Preventative Programs.

They appeared in an advertorial promoting cholesterol treatment sponsored by Astra Zeneca, and published this month in Medical Observer magazine. They were quoted discussing the findings of a study of patients taking cholesterol medication that was funded by Astra Zeneca, and designed and conducted by the Baker.

The advertorial is particularly noteworthy for a few reasons:

• The close links between the Baker and pharmaceutical industry marketing are already the subject of considerable controversy, with the Medicines Australia code of conduct committee recently upholding a complaint over another campaign featuring the Baker.

• Last year in this Crikey story, the head of the NHMRC, Professor Warwick Anderson called for an end to doctors and other health professionals participating in such advertorials. Anderson was, in a former life, Deputy Director of the Baker Medical Research Institute. It may simply be a coincidence, but there do seem to be far fewer experts popping up in pharma advertising in Australian Doctor and Medical Observer since Anderson’s statement.  So the Astra Zeneca one really does stand out and is likely to be attracting quite a bit of comment in quarters concerned about conflicts of interest arising from close relationships between individuals, institutions and industry.

Meanwhile, on related topics, a campaigning US Senator is leading a charge for medical schools in the US to disclose their  policies on conflicts of interest and requirements for disclosure of financial ties between staff members and drug firms.

The British Medical Journal recently reported that Senator Chuck Grassley, an Iowa Republican who is the leading minority member on the Senate Committee on Finance, wrote to 23 medical schools that had not completed a survey by the American Medical Student Association.

The student association surveyed all 146 medical schools, of which 126 provided information about their policies. The association posted the results on its PharmFree Scorecard website and graded the schools’ policies from A to F (failing).

Senator Grassley asked the 23 schools to provide a copy of their conflict of interest policy, their communications with the NIH about conflicts of interest and research by their professors, the amount of grant funds from the NIH and other federal grants received by the institution from 2004 through 2008, and for the names of the principal investigators for each grant.

Senator Grassley’s letter, a press release, and a list of the 23 schools are here.

You have to pay for full access to the BMJ article but the abstract is freely available here.

Croakey welcomes feedback from those named on the Register, and will gladly publish their responses.

:

• What is the role of the media in Mr Ward’s death?

The 4 Corners report on the death of Mr Ward, an Aboriginal man who was incarcerated in the most inhumane of conditions, was distressing at so many levels. I mean no disrespect to the team who produced the report when saying that it was an “easy” story, in one aspect anyway.

This is because the failings that led to his death – the systematic problems as well as the failures of ordinary human decency – were so very clear-cut. There were no ambiguities or mitigating factors – just a series of stuff-ups that were at least partly reflective of pervasive racism, at both individual and institutional levels.

The program generated plenty of moral outrage – at all the institutions and individuals who contributed, in one way or another, to Mr Ward’s death.

Afterwards I wondered about the role of one of society’s most powerful institutions – the media. It seems that the bureaucrats and politicians didn’t act as they should have – despite having plenty of warnings that such a tragedy was likely -  because they were under no obvious political or public pressure to do the right thing by people like Mr Ward.

When the former Corrective Services Minister spoke of her failure to win her Cabinet colleagues’ support for improving the conditions for prisoner transport, I wondered if it might have been a different story if the WA Government had faced days of page-one headlines on the issue.

So the story I’m pitching: interview the key informants for the 4 Corners story to see if they’d ever tried to get media coverage for their concerns in the years leading up to Mr Ward’s death, and what response they’d had.  Examine the amount and type of media coverage in WA about the broader issues – prisoner transport and the care of Indigenous prisoners, in particular.

Does the so-called 4th Estate share at least some of the culpability?  We’re generally not very good at asking ourselves these questions – much easier to point the finger elsewhere.

• Documenting the Baker deal

When senior researchers and members of the NHMRC gathered in Canberra recently for a workshop on conflicts of interest, one of the hot topics for discussion was the controversy about the sponsorship deal between Sanofi-Aventis and the Baker IDI Heart and Diabetes Institute, which was found to be in breach of the Mecicines Australia code of conduct.

It got me thinking that it would be informative to rigorously investigate the views of Baker staffers about the issue, and also to document the internal processes that led to the deal. Who signed off on it? Was the Institute’s Board involved? These are all important matters, and there is some value in understanding them.  The lessons from this episode are relevant beyond the Baker’s walls.

Sounds like a case of excessive modesty – even a quick scan of the Crikey Register of Influence shows that many medicos are very willing and able when it comes to marketing. Looking at the bigger picture, there’s a strong argument that modern medicine has done such a good job of marketing itself that we as a society are now paying far more than we ought to be for many treatments and procedures whose benefits have been oversold.

But I digress. The point of this post is to alert you to an interesting story at this science blog. Someone enterprising there has done some digging post the Federal Court revelations about  industry-funding of journals.

The story begins: “Scientific publishing giant Elsevier put out a total of six publications between 2000 and 2005 that were sponsored by unnamed pharmaceutical companies and looked like peer reviewed medical journals, but did not disclose sponsorship, the company has admitted. Elsevier is conducting an “internal review” of its publishing practices after allegations came to light that the company produced a pharmaceutical company-funded publication in the early 2000s without disclosing that the “journal” was corporate sponsored”.”

It’s definitely worth reading the entire post, and there are quite a few interesting comments as well. The credibility of scientific publishing has taken a hit.

“Agreements between not for profit research institutes and the pharmaceutical industry can be fraught with conflict, even if an iron clad contract is in place to ensure the independence of the parties involved.  The recent case of Sanofi-Aventis contributing 25cents per pack of Plavix sold in Australia to the Baker Institute is an interesting case in point.  Both parties are publically adamant that the funds are entirely ‘without strings’ and this is most probably true in the legal and contractual sense.  However, it speaks volumes that the 25 cents per pack is derived from the Plavix marketing budget.

Pharmaceutical companies are past masters at managing and manipulating social obligations and reciprocity for their marketing benefit.  Gifts engender a feeling of indebtedness on the recipient and a social obligation to reciprocate in some way to the giver of the gift.  In this way, the phrase “much obliged” has become synonymous with “thank you”.  Marketing expenditure in any industry is always associated with a quid pro quo for the ‘investing’ organisation – increased sales, as Ken Harvey highlights in his response.

In the case of the Baker Institute, this arrangement provides a guaranteed income stream, so the Institute would be commercially ‘mad’ to conduct any research that could jeapordise this arrangement.  While the Institute, according to public statements, legally retains its right to research whatever it likes, conducting research that may be unpalatable to Sanofi may jeapordise renewal of this agreement or the development of future agreements (with Sanofi or other companies).  Sanofi is a large pharmaceutical company with many commercially successful drugs, so the agreement using a ‘royalty’ from Plavix could provide leverage to reduce research in other areas such as diabetes that may adversely affect other drugs in its current portfolio or development pipeline.

Accountability would also be more complex with a corporation than the more well studied individual practitioner.  A practitioner will face clients and may be asked awkward questions in a one to one situation which may reflect on the trust of a patient in their practitioner.

Corporations are faceless entities which are also charged with a different charter – looking after the corporate bottom line (and shareholders, if applicable).  Therefore there is a different sense of public accountability for their actions.

In this case, it can be argued (and probably will be) that the Baker Institute was doing the best deal it could to generate research funds to improve medical research for the greater good of society.  One wonders if the contract will be released publicly to demonstrate the transparent nature of the agreement?”

“We thank everyone for their comments. This is an innovative donation arrangement so we are not surprised at the range of responses.

Some raised concerns, some were based on misunderstanding or preconceptions and others were very supportive of the initiative.

The issues raised in the correspondence, and many more, are dealt with in detail here.

From the outset we have been determined that this should be an open and transparent arrangement, and we are comfortable that important questions of independence and influence are well covered.”

It will be interesting to see whether this response allays or inflames concerns. To my mind, it raises some questions for the Heart Foundation, given the disclosure that Prof Jennings is Chair of the Foundation’s National Cardiovascular Health Advisory Committee.

Meanwhile, here are some other comments on the deal:

Dr Stacy Carter, Senior Lecturer, Qualitative Research in Health, Centre for Values, Ethics & the Law in Medicine and the School of Public Health, University of Sydney:

The naivety – or wilful ignorance – that Melissa describes is both critical and incredible. Doctors and research institutes entering into such deals with pharmaceutical companies are like pantomime characters: the wolf is approaching, the audience is shouting ‘look behind you’, they keep eating their ice-cream.

My colleagues and I have been engaged in some qualitative research around these issues for a while. Get a group of consumers into a room and ask them about drug marketing, and they will soon begin trading stories from their own experience that demonstrate how susceptible to influence many doctors are. Consumers are also under no misapprehensions about the power of corporate profit motives.

Meanwhile, one of the most consistent patterns in research is this area is that most doctors think they (and presumably their reputations) are impervious to influence. I suspect this is the same for many medical researchers.

Consumers look for independence in their medical practitioners and in research: they want to be able to trust. But trust demands trustworthiness, and ties to industry inevitably undermine this trustworthiness. One has to wonder why some doctors and researchers refuse to look up from their ice-cream and face the wolf.

***

Michele Kosky, Health Consumers Council WA:

Some health consumers will feel a real sense of disappointment that a distinguished research institute like the Baker has to engage in this kind of fundraising venture which appears to potentially compromise the independence of the research and influence medical practitioners’ prescribing habits once again.

***

Dr Alasdair Millar, physician:

I worked at the BMRI for 6 months in the late eighties and support its work.  Your article and the one in The Australian do make it clear that the funding to the BMRI is unconditional, and if that is true it is an important fact: the BMRI can do what it likes and no doubt good research will be done with it, and that could benefit medical practice.

Any dubiousness in the arrangement is in the link with prescription volume, in other words the involvement of the BMRI in a marketing effort of a single pharmaceutical company.  The marketing aspect is doubtless the reason Sanofi did not just give a grant of $500,000 to the BMRI.

I presume that the 25c gift will be conditional on prescribing clopidogrel as Plavix, rather than Iscover or simply as clopidogrel, and that in future, when the patents for clopidogrel run out, the BMRI funding will fall unless the trade-name prescribing continues; so in the long run it will have problems.  However, by then a generation of doctors will be used to prescribing clopidogrel as Plavix and the impact of loss of patent protection to the company will be blunted.  Perhaps this is the strategic objective.

It’s also worth pointing out that the 25c per script to be paid to the BMRI will in fact be paid for by Australian taxpayers directly, because clopidogrel is subsidised by the PBS.  The cost of clopidogrel to government via the PBS is substantial and is a legitimate source of concern.

One could make the case that more public good would be gained if the company simply cut the cost of Plavix by 25c per prescription, and that given the subsidy, the Australian government might feel it should have been consulted, especially given that it probably provides substantial funds to the BMRI through the NH&MRC.

**

Dr Ian Haines, Melbourne cancer specialist:

I basically agree with Ken Harvey that the fundamental problems are:
1. The Baker Institute lending its logo to the sanofi advertisements which is indefensible and appears intended to deceive people that the Baker endorses the product Plavix.
2. Donations from Sanofi to the Baker being tied directly to scripts written.

Most health professionals would strongly endorse philanthropic donations from pharmaceutical companies to our leading research institutions which are fully transparent. However, do highly respected and prominent key opinion leaders such as Gary Jennings expect us to seriously believe that next time they are giving a major presentation to doctors, or involved in writing clinical guidelines related to these agents or reviewing journal articles that may be critical of or negative about Plavix or reviewing research grants looking at questions that may favour a rival product that they will be able to be totally disinterested and dispassionate?

If so, their behaviour would be almost unique in human history and they would be potentially reducing their own research funding.

Even if they are truly unique in human history, the perceptions of doctors at their presentations or doctors whose grants are turned down or researchers whose manuscripts are declined will still range from significant scepticism to profound cynicism to outright anger.

The only proper course of action now is for any researcher associated with the Baker to decline to do any presentation, manuscript review, review article or guideline that was in any way related to Plavix or any competitor product. There is no alternative action that would preserve the perceived credibility or integrity of the Baker in the public mind.

Alternative means of funding our major research institutes are urgently needed.
***

Dr Jon Juredini, Healthy Skepticism:

The dangerous thing about this piece of marketing is its plausibility. Most readers will see it as an act of philanthropy, albeit one carried out in a way that will enhance the image of the company. Until I read Ken Harvey’s posting, I didn’t see all the dangers.

At the same time as the Vioxx case before the Federal Court is producing an alarming string of stories about the hazards of overly close ties between doctors and pharma (as an example, see this story in the Oz and this one in The Age), Sanofi-Aventis has enticed a prominent medical research institute into a bed that is likely to prove most uncomfortable.

The 1 May issue of Australian Doctor has just landed on my desk, confirming this story in today’s Oz.

Page 13 carries a Sanofi-Aventis ad for its blood thinning medicine clopidogrel (brand name Plavix) that also boasts the logo of the Baker IDI Heart & Diabetes Institute.

Readers are told: “When you write a Plavix script, Baker IDI & Diabetes Institute benefits too. For every Plavix script dispensed through retail pharmacy in 2009, sanofi-aventis will donate 25c to support their medical research and preventative health programs.”

The deal has already raised $100,681 for the Baker, according to the advertisement.

It’s a clever campaign. While everyone loves to receive a gift, most people feel even better about giving one. Rather than wooing doctors with the usual range of prezzies – nice meals, trips to somewhere exotic, crappy pens etc – this campaign is turning them into gift-givers.

This may be clever but it’s also extremely dubious. Is it suggesting that considerations other than what is best for the patient before them might influence doctors’ prescribing choices? Perish the thought.

And here’s a few other questions:

• Will all of the Institute’s researchers be declaring this tie in their future conflict of interest statements?

• Will they declare this conflict when making any public pronouncements – in the media, in journals, at conferences, in committee meetings – about any conditions or areas of research where Sanofi-Aventis may have an interest, especially in relation to this drug?

• Will the public’s confidence in the Institute and its scientific integrity be dented?

One of the lessons to have emerged so far from the Vioxx case is the naivity – or perhaps in some cases wilful ignorance – with which many doctors have entered into relationships with pharmaceutical companies.

The companies use these relationships to their marketing advantage; while there may be some gains for the individual doctors involved in terms of access to research funding and so on, they also risk suffering damage to their reputations and perceived independence.

This may also be the lesson for the Baker; the deal may bring them in some extra dollars, but at what cost?

Dear Crikey

Many thanks for the dubious honour of being included on your register of influence.

It is an inadequate way of investigating medical corruption but it may at least start a discussion on this vital topic.

The problem is that the medical education agenda has been hijacked by vested interests, particularly the pharmaceutical industry but in other cases it may be equipment or prosthesis manufacturers.

Every doctor is the recipient of drug company sponsored hospitality. This hospitality is lavish but the educational agenda is primarily the attraction. Conferences which provide high quality education are very well attended.

The way in which this process to some extent corrupts or influences the doctors attending  is subtle but significant as the agenda tends to be focussed on areas for which drugs are effective available and profitable.

The reason for which I was named in your column was for an article about absolute risk. This is an area I have worked in for over 15 years. The result of my research was to develop a risk calculator to help doctors decide when to take drugs for cholesterol and hypertension. The main effect of utilising this tool was to reassure patients that they were actually low risk and did not therefore need to take expensive drugs.

In 2001 I undertook a study using the tool which was published in the Medical Journal of Australia. 1 of the conclusions of the study was that up to 60% of people in Australia taking cholesterol lowering drugs were in fact low risk and shouldn’t be taking them, this implied that we were inappropriately prescribing several hundred million dollars of drugs every year in Australia.

In spite of the fact that the article and the conclusions were not challenged there was no public discussion about the paper, no interest from government health officers and no invitations for me to discuss my data at meetings. Data suggesting an overuse of expensive drugs does not draw headlines in journals that are funded by drug companies or meetings subsidised by them.

The program that I developed has been downloaded for free by hundreds of doctors in Australia and overseas, but I receive no funding to continue development or research. Needless to say drug companies have no interest in supporting my program nor in inviting me to speak to their conferences as my message is clearly not to their benefit.

What is interesting is that some of my learned colleagues have co-operated with the pharmaceutical industry to produce risk calculators that present data in a way that encourages overuse of drugs. These calculators are purchased by the pharmaceutical industry and then distributed to doctors for free.

The advertorial that I was extensively quoted in was in fact stressing this message that proper risk assessment reassures the worried well that they don’t need to take medication.

For your list to take on more meaning, it would need to understand and detect a conflict of interest. As I received no income for my contribution to the article nor from selling my program (which is free) and as I receive no income from drug companies, I don’t have a conflict of interest. I do receive sponsorship for conferences and payment for speaking to other doctors but this is a tiny part of my income.

I doubt that many of the doctors quoted in your list received remuneration for their comments or endorsement.

Sometimes when I am asked to do an educational talk by a drug company, they wish to know what my thoughts are about their product or even to check the content of my talk. Colleagues have told me that they have been told they will not be invited to talk if their attitudes are not supportive of the company’s product. Clearly this is unacceptable but very difficult to detect and expose.

There are, however, areas of massive conflict of interest where doctors make decisions or recommendations that have large influence both on the practise of medicine and their incomes.

Possibly the most glaring example is in the area of interventional cardiology. Interventional cardiology includes the practise of inserting stents into blocked or narrowed coronary arteries. This practise is widespread and probably the single most expensive procedural item on the commonwealth health bill. Guidelines for deploying the procedure are written mostly by the proceduralists themselves who make in some cases over a million dollars per year from this activity.

An example will serve to illustrate the point. A personal friend recently attended a GP with a history highly suggestive of stable angina. He only had chest tightness on exertion and had not started any medication. He was referred to a leading cardiologist at one of Melbourne’s leading private hospitals. Without any discussion he had an angiogram and a stent was inserted into his coronary artery.

The cost of this procedure was $6000 for which he was not covered by insurance.

He was not told by the cardiologist that extensive randomised trials have found that stents provide no survival benefit nor do they reduce the risk of heart attacks. He was also not told that he would be obliged to take 2 antiplatelet drugs for at least 12 months which would expose him to a higher risk of bleeding, and were he to need urgent surgery for an unrelated condition he would be exposed to a very significant risk of having an acute blockage of his stent. The appropriate treatment of this patient is to have active risk factor management and aggressive cholesterol lowering.

Now this is not an isolated example, I suspect it is pretty much standard care, but of course statistics are not readily available on this form of malpractice.

Similarly, guidelines for the management of certain types of heart attacks are strongly in favour of early intervention and stenting. These guidelines are written predominantly by proceduralists and ignore recent evidence that early stenting does not reduce risk.

The same can be said for coronary bypass surgery which as an industry is largely being replaced by stenting. The only properly conducted randomised trials into bypass surgery are over 20 years old, showed only small benefit in a subgroup of patients and did not include any of the medical treatments that have dramatically changed the outcome for these patients. These procedures are very useful at reducing angina but many patients are told or believe that they are having it to reduce their risk of death or heart attack.

The history of medicine has many shining examples benefitting mankind and reducing suffering.

Parallel to this is the presence of massive profiteering from procedures which appear rational but which are later proved to be of no benefit. Examples include routine tonsillectomy, circumcision, hysterectomys, Caesarean section, radical mastectomy, and prostate cancer screening.

However in terms of cost to the community the cardiac interventional industry probably takes the cake.

At the time, I thought it a big call which wouldn’t necessarily garner widespread support. However, you can see below that much of the feedback, from various groups and individuals, is broadly supportive. I wouldn’t be surprised though if it’s also generated some behind-the-scenes muttering, given the proliferation of promotional professionals.

Professor Garry Jennings, Director, Baker IDI Heart and Diabetes Institute, agrees with Anderson:

“I agree with Professor Anderson, especially in relation to participation in commercial advertising. In our field, if something is worth saying, it is worth doing so in the thousands of peer review journals that are published each week. The public and our peers have a right to know who is behind the scenes and whether a particular view is freely expressed or bought.

That said, a blanket ban might not be so important if there was frank and open disclosure – it’s the relationship being there and NOT being disclosed that causes the greatest problems.

In this respect, participation in commercial advertising may be less problematic than the more surreptitious alliances that are sometimes present in relation to advertorials and disease awareness programs. With advertising it is for the most part clear that the health professional and the pharmaceutical company are in league, almost certainly under a commercial arrangement which is arguably no different to a respected sports star participating in fast food advertising (and probably less harmful).

Disease awareness campaigns are more complex though, and health professionals should be very careful how they are quoted in them whether or not they are being paid. There is often not a good match between disease burden and hype and although a new treatment for a disease for which there has previously been no treatment is often worth telling people about, there are enough examples where health professionals have been manipulated by companies paying for their commentary in the cause of public awareness for us all to heed Professor Anderson’s advice to take extreme care.

I have personally experienced situations when my freely expressed and well meant views were dressed up in advertorials and surrounded by material that the casual reader might reasonably assume was mine.”

***

Medicines Australia. A spokesman, speaking on behalf of chief executive, Ian Chalmers, disagrees:

“This is a matter for judgment by the individual medical practitioner involved. There is no reason why an appropriately qualified medical specialist should not be free to impart knowledge and information about the efficacy of a medicine with which he or she is familiar.”

***

Dr Chris Mitchell, president of the Royal Australian College of General Practitioners, agrees:

“The RACGP has endorsed the AMA Code of Ethics 2006 and we believe that general practice is an ethical and honest profession. As a part of this, we have agreed that RACGP members should not participate in commercial advertising or advertorials.

The RACGP has a sponsorship policy which clearly states that any sponsorship activity should be in line with the principles of the AMA Code of Ethics.

The RACGP has agreed that college members should not be involved in/ appear in advertising of commercial products where it appears the GP is endorsing that product. The RACGP believes in the primacy of the GP/ patient relationship and believes that GPs should not enter into any arrangement that would impact on this.”

***

Dr Rosanna Capolingua, president of the AMA, agrees:

“As found in the AMA’s Code of Ethics (and supported in our Position Statement on Advertising and Public Endorsement) the AMA advises doctors:

2.2.3        Do not endorse therapeutic goods in public advertising

2.2.4        Exercise caution in endorsing non-therapeutic goods in public advertising.

Further, health care professionals are currently not allowed to undertake such endorsements, as covered in the Therapeutic Goods Advertising Code 2007, as follows:
(b) Advertisements must not contain or imply endorsement by:
(i) any government agency;
(ii) hospitals and other facilities providing healthcare services;
(iii) individual or groups of healthcare professionals, other than where
the emphasis is on the availability, which may include the price of
therapeutic goods through his/her retail business; or
(iv) by individuals, who are healthcare professionals by way of their
representation in advertisements or academic qualifications, and /
or who are likely to be known as healthcare professionals by the
reasonable person.

There may be a serious perception of a conflict of interest for doctors who publicly advertise or endorse therapeutic goods – that doctors will prescribe or recommend a medication with which they are publicly associated rather than a more effective (or cost-effective) treatment. We need to ensure that patients continue to trust their doctors to prescribe or recommend treatments in the patient’s interest (and not the doctor’s perceived self-interest).”

***

Associate Professor Merrilyn Walton, University of Sydney, agrees:

“The role of pharmaceutical companies is to make a profit – their marketing is designed to sell their drugs. Health professionals are required to put the best interests of patients first. By promoting a particular drug (in the context of little knowledge about a drug and its role in improving a particular patients health care) health professional are putting the interest of the drug companies ahead of the interests of patients. The public needs to be able to trust health professionals and their judgements about the best drug for them- if they are compromised in advertising, the perception of trust is lost. If there is a payment or advantage to the health professional there is a real conflict rather than a perceived one.”

***

Michael Roff, CEO of the Australian Private Hospitals Association, has a bob each way:

“This is an important issue and we are pleased to see the NHMRC will be fostering the debate by hosting a forum next year. As I read Professor Anderson’s comments, he is saying while his personal advice is for health professionals not to participate in such campaigns, he goes on to say if they do, there should be full and open disclosure and I think that this is the real issue. Otherwise are we saying that Professor Ian Frazer should not have been involved in promoting the benefits of Gardasil, even though he openly disclosed he received a financial benefit from the commercialisation of the vaccine?

There are complex issues involved but full disclosure of interests would appear to be a reasonable course of action. I understand that in Australia, both the pharmaceutical and medical technology industries have codes of conduct that deal with the issues of disclosure. Whether or not these mechanisms are resulting in appropriate levels of disclosure or whether their scope is adequate may require further examination.

***

The Australian Healthcare & Hospitals Association also has a bob each way:

“The AHHA recognises the high level of trust consumers place in doctors and health services and therefore supports a system of full disclosure of financial arrangements between any health professionals and health service providers and the sellers of pharmaceuticals and other health care products.

It is essential that consumers can trust that advice they receive from their health care provider is unbiased by any commercial interest and based solely on the professional opinion of the provider.

A perception of bias among health care providers can be as damaging to consumers’ trust in the health system as an actual bias. Therefore, while the AHHA does not support a ban on health professionals’ involvement in advertising and promotional activities, we do support the mandatory disclosure of thus involvement to patients.”

***

Professor Peter Brooks, Executive Dean, Health Sciences, University of Queensland, agrees – because the proposal would lead to “more transparency”.

What do you think? Join the Croakey discussion…

Croakey is surveying the heads of medical research institutes and other health organisations for their views, as well as those individuals known to have an interest in such issues. We will keep updating this post so stay tuned...And please let us know what you think.

Response from Dr John Dowden, Editor, Australian Prescriber

1. Should doctors and other health professionals and professional organisations participate in advertorials sponsored by companies that are promoting products or raising awareness about diseases etc?

Advertising: ideally, no. Raising awareness: possibly.

2. If not, why not?

People generally trust health professionals, so a statement from a health professional may be readily accepted by other professionals and the public. That trust will be undermined if the professional is being paid for their comments.

3. Are there any circumstances where you would support it?

It is easier to support messages about prevention, but there can still be potential conflicts of interest if the organisation or individual giving the message will benefit from providing the service.

4. Any other issues you’d like to raise?

Clinicians who have conducted drug trials become very knowledgeable about the products used in the trials. They are important resources of information and can be expected to share their results. However, there is a risk of becoming an advocate for a particular product. Many stories of ‘breakthroughs’ seem to have an expert attached. I don’t think all of these experts realise that they have become part of a marketing campaign.

***

Response from Dr Stacy Carter, Senior Lecturer, Centre for Values, Ethics & the Law in Medicine and the School of Public Health, University of Sydney

1. Should doctors and other health professionals and professional organisations participate in advertorials sponsored by companies that are promoting products or raising awareness about diseases etc?

No

2. If not, why not?

Because it changes the incentive structure and professional identity of health professions. Corporate priorities and health professionals’ priorities should be very different. Corporations must put their shareholders first. Health professionals should put individual consumers’ (their patients’) interests first. (Of course this is an over-simplification, and of course health professionals have plenty of other competing interests, but that doesn’t diminish the very real difference). Spruiking a company or product to anyone who will listen for cash is the opposite of providing thoughtful, tailored advice in an individual patient’s best interest. Thus a doctor in an advertorial undermines not only their own trustworthiness but by implication that of their whole profession.

3. Are there any circumstances where you would support it?

No – let corporations do their own advertising.

4. Any other issues you’d like to raise?

I think the same principle applies for consumer organisations.

***

Response from Jon Wardle, School of Population Health, University of Queensland

1. Should doctors and other health professionals and professional organisations participate in advertorials sponsored by companies that are promoting products or raising awareness about diseases etc?

In instances in which they are remunerated specifically for this purpose I think that no, they should not be allowed to market specific products – even under the guise of disease awareness. This view may represent my admittedly Goughish leanings but I believe that professional involvement in company sponsorship which obviously points to specific products and excludes other options in health should only be allowed without monetary incentive. Any relationship needs to made obvious.

2. If not, why not?

There is a very real and obvious conflict of interest in selling the goodwill of these institutions and persons and any financial relationship should be disclosed in detail and made publicly accessible. In many circumstances the public has invested substantially in these groups and individuals and they share an obligation to promote the public interest.

3. Are there any circumstances where you would support it?

There may be some circumstances where it could be supported – for example a generic drug being promoted for free by individuals with no financial gain (I am thinking here of something like HIV therapy). However I feel that this should be the practitioner’s choice. If they feel passionately about the therapy they should not have to be paid to advertise it. I’m certain that this would reduce the number of people willing to put their hands up. Otherwise a disclaimer of conflict of interest – possibly similar to that seen in medical journals but with more specific details – could appear prominently in the piece. However, under no circumstances should a specific product be suggested to be superior over similar products unless supported by research.

4. Any other issues you’d like to raise?

I notice you’ve included complementary medicines in your register of influence – as you are aware this is my main area of interest. You may be interested to know that a separate category of CAM exists called ‘practitioner only products’. According to the TGA this is meant to be a professional range not accessible to the lay public but in reality it offers a loophole excludes these products from labelling laws (as they are not meant ‘for the public’ though I find they are quite easily accessible) and allow for unsubstantiated health claims to be made (again, as they are marketed towards health professionals they are thought to have the wherewithal to critically approach this information). I have found that the supplement/pharmaceutical companies are abusing this loophole to encourage off-label, adventurous or plain unproven and unlikely prescribing for their products. Given the fact that the majority of CAM CPE (about 90%) is run by these companies and that practitioners (not just CAM but pharmacists and doctors) are allowed to sell this product at the site of prescription (with recommended practitioner mark-ups of between 50-75% – as far as I am aware the only other industry that has profit margins this high is liquor in a restaurant setting) I feel that this is a massive oversight on the part of regulators. I’ve not looked into the advertising in professional CAM journals in depth but I can say that from the cursory experience I’ve had with reading them I find much of it to be often more dubious than public advertising.