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Oct 14, 2011

Conflicts of interest in health and medicine: calls for a culture change

It seems we are in the midst of a veritable outbreak of reports raising concerns about conflicts of interest in health and medicine. Guideline developers under scrutiny

It seems we are in the midst of a veritable outbreak of reports raising concerns about conflicts of interest in health and medicine.

Guideline developers under scrutiny

The BMJ has published a study investigating financial conflicts of interest among members of panels producing clinical practice guidelines in the US and Canada on screening and/or treatment for hyperlipidaemia or diabetes between 2000 and 2010.

The results are freely available but in a nutshell, 52 per cent of panel members had conflicts, of which 138 were declared and 12 were undeclared.

Panel members from government sponsored guidelines were less likely to have conflicts of interest compared with guidelines sponsored by non-government sources (15/92 (16%) v 135/196 (69%).

Many of the panel chairs had financial conflicts of interest.

The researchers concluded: Organisations that produce guidelines should minimise conflicts of interest among panel members to ensure the credibility and evidence based nature of the guidelines’ content.

Calls for cultural and legislative change

In a related editorial, Edwin Gale, emeritus professor of diabetic medicine from Southmead Hospital, Bristol, argues for a change of culture in medicine:

“It has been said that ‘it is difficult to get a man to understand something when his salary depends upon his not understanding it,’ and the medical profession has been slow to understand the importance of conflicts of interest….What is needed is a change of culture in which serving two masters becomes as socially unacceptable as smoking a cigarette…”

The BMJ editor, Dr Fiona Godlee, thought the  analogy with smoking helpful, and wrote:

“Doctors led the way in the early anti-smoking campaigns, with posters saying “Think first—most doctors don’t smoke.” Now it’s doctors who must clean up their act. How to do this? Focussing on the individual addict was only a small part of the smoking story. What really made the difference was public education, social marketing, advertising bans, and eventually (and still to be achieved in many parts of the world) bans on smoking in public places. So yes, let’s find ways to make these conflicts of interest socially and professionally unacceptable—your ideas on how to do this would be welcome.”

Perhaps there are some ideas in this BMJ article by Andrew Jack, the pharmaceuticals correspondent for the Financial Times, reviewing global moves for greater disclosure of the ties between health professionals and companies.

He reports that since 2008, Denmark has required companies to disclose to the Medicines Agency any payments they make to doctors, and even details of extensive “unpaid involvement” such as unremunerated work on advisory boards.

There have been calls for a similar approach in the Netherlands, and politicians in France recently drafted legislation that requires companies to release details of payments to doctors. In Scotland, doctors working for the health service are already required to declare any conflicts of interest with drug companies (although Jack reports that accessing and policing this information is difficult).

Jack predicts that pressure for greater disclosure seems likely to grow.

And Gary Schwitzer’s Health News Review blog summarises other COI developments in the news.

Meanwhile, in Australia…

Mark Metherell reported in the Sydney Morning Herald that the Australian Orthopaedic Association is holding its annual conference in New Zealand with high-level support from Johnson&Johnson. Or, as the headline writer put it: Surgeons happy to be supported by companies behind hip implants fiasco.

And this Sunday morning, if you tune to ABC Radio National’s Background Briefing, you will hear a former pharmaceutical industry insider speaking candidly with Ray Moynihan about how she sold medicines to Australian doctors for more than a decade.

Moynihan – these days a columnist with both the BMJ and The Medical Journal of Australia – says:

“While much is written globally about pharmaceutical marketing, this is one of the first times in Australia that a former insider has spoken so frankly and fully about the way doctors are persuaded to prescribe the latest and most expensive medicines. Her revelations come against a backdrop of the nation’s expenditure on pharmaceuticals continuing to explode – at close to 10 percent a year – now reaching almost $10 billion annually.

One of the most alarming aspects of what we will learn from this former industry insider is the way in which a network of senior influential specialists are quietly working with drug companies and being paid generous sums to help promote the latest products – without the knowledge of their patients or the public.”

Moynihan says the program explores the timely debate about the need for much greater disclosure of the details of doctor-drug company interactions, featuring speakers from the Australian Medical Association, Medicines Australia, and Healthy Scepticism.

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3 thoughts on “Conflicts of interest in health and medicine: calls for a culture change

  1. Ben Mullings

    People have been complaining about conflicts of interest in mental health advisory panels too:

    Conflicts of interest go beyond lucrative financial deals, and also extend into political power and control about who gets to speak on behalf of a given health issue and how public funding gets allocated. In the current drama unfolding around cuts to the Better Access to Mental Health Care program, we have consumers, mental health professionals, and concerned members of the public, finding it terribly hard to have their perspective heard against the loud voices of a few hand-picked experts that the government has selected to ratify their decision to cut psychological services:

    There are broader issues in all of this about tokenism in the politics of health policy, where panelists are chosen for their symbolic power, rather than on the basis of whether their position reflects the genuine needs of people in society. It’s as much about being seen to have a token spokesperson to represent a matter of public concern, as it is about the need to have well recognised public figures that will tow the party line. What we end up with is a small group of panelists, with caricatured opinions, that are skewed by vested interests and political ideology. The needs of the both the public and of health practitioners get left at the door.

  2. Mary Osborn

    Disclosures of conflicts of interest do not make a difference. Health professionals have had a co-dependent relationship with the pharmaceutical industry for a long time. As long as the decision makers in government continue to allow this dependency to continue, as long as the medical colleges continue to allow the industry to run their education and training sessions, as long as the industry is allowed to sponsor and support medical conferences, as long as pharmaceutical industry representatives are allowed to continue to influence health professionals in decision making around prescribing, as long as evidence-based institutions allow the industry to change disease thresholds, as long as journals continue the practice of ‘ghost writing’ NOTHING will ever change.

  3. ihaywood

    Conflict of interest is a much broader issue than drug/device manufacturers, they aren’t the only, or even the most powerful influence. Drug reps spruik their drug but I’ve never heard a drug rep threaten a doctor for prescribing another company’s drug or using a non-pharmacological intervention. However hospital and Government officials regularly dole out all sorts of threats ranging from censure, sacking or even imprisonment around certain prescribing decisions.