Brett Forge, a physician and cardiologist from Warragul in Victoria, has sent in the
following comments regarding his inclusion on the Crikey Register of Influence:

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 attendingĀ  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.

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