Doctors' education: the invisible influence of drug company sponsorship

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http://www.bmj.com/cgi/content/full/336/7641/416

BMJ 2008;336:416-417 (23 February), doi:10.1136/bmj.39496.430336.DB

Feature

Doctors' education: the invisible influence of drug company sponsorship

Ray Moynihan, conjoint lecturer, University of Newcastle, New South Wales, and

visiting editor, BMJ

Ray.Moynihan@...

As calls to end drug companies' direct sponsorship of doctors' education echo

round the world, an investigation in Australia reveals sponsor involvement in

the education of thousands of general practitioners, writes Ray Moynihan

We've all been there-the educational seminars, the medical symposiums, and the

scientific conferences generously sponsored by big drug companies. The visible

signs of sponsorship at these events are obvious: the smiling drug company

representatives, the colourful company logos, and the high tech stalls in the

exhibit halls. But what about inside lecture theatres, where high quality

education is delivered to doctors by respected speakers? Surely the sponsors

have no input into those sacred places of independent education?

It seems that invisible influence may be flowing through these sponsored

seminars-even those accredited by august associations-far more often than many

of us realise. In a rare look behind the scenes of sponsored medical education,

the Australian Broadcasting Corporation's Background Briefing programme

(www.abc.net.au/rn/backgroundbriefing/) will this weekend show that it is not

uncommon for drug company sponsors to suggest speakers at sessions that are

assumed by the thousands of general practitioners who attend them to be totally

independent. Drug industry representatives have confirmed that similar practices

take place in the United Kingdom, where roughly half of all education for

doctors is sponsored by drug companies.

In the case of one popular Australian provider of medical education, HealthEd,

leaked documents and emails from a range of sources show drug company sponsors

having input into the selection of some speakers at seminars held in recent

years, despite the fact that these have been aggressively sold to general

practitioners in brochures claiming that " all content is independent of industry

influence. "

Doctors in the dark about sponsorship?

In an email to the drug giant Sanofi-Aventis, HealthEd asks, " Could you please

suggest a couple of speakers for our scientific committee's approval? " The drug

company emails back: " Please find attached our suggested speakers. " One of the

speakers suggested by the drug company sponsor is subsequently accepted and

delivers a presentation at a HealthEd seminar. Doctors attending that seminar,

held at a university, were not verbally informed of the sponsor's role in

suggesting speakers.

Another set of leaked emails features communications between the same

educational provider and CSL, the company that markets the analgesic tramadol

(Tramal) in Australia. While negotiating sponsorship arrangements with the

provider, for a planned session on headache, a CSL representative writes that

the company would like HealthEd to " determine the speaker's opinion re: Tramal

as I would like to ensure he positions it appropriately. " HealthEd replies that

it " will reconfirm opinion of headache speaker re: Tramal to ensure balanced

presentation. "

In another email the drug company Organon, now part of Schering-Plough, writes

that " we would like to put forward the following two doctors for consideration "

as speakers for a seminar on women's health. The educational provider replies,

" We will do our best to accommodate your request. " The drug company's suggested

speakers are ultimately accepted, provoking this grateful response to the

educational provider: " I would like to again sincerely thank you for the

political help . . . in respect of orchestrating the favourable consideration of

the proposed topic and speaker. "

When asked about its sponsorship arrangements with HealthEd, Schering-Plough's

managing director in Australia, Shaju Backer, said that " as part of the

sponsorship, [drug] companies are allowed to suggest speakers and topics, "

which, he added, then undergo a peer review process to see which are suitable.

Schering-Plough also made public an extract from an email sent to it by

HealthEd, which stated that top level " platinum " sponsors were routinely offered

the chance to " work with us to determine a speaker and topic for the programme, "

subject to conditions that the speaker be authoritative and scientifically

balanced and that the content be evidence based. The drug company said it

sponsored such meetings to help ensure that drugs are used appropriately in

Australia. It stressed that no guarantee is given that the topics or speakers

nominated by sponsors will be chosen and that this is not a condition of

sponsorship.

Industry suggestions are " filtered "

In an extended interview about sponsorship, HealthEd convenor Ramesh Manocha

repeatedly and strenuously defended the content of his seminars as totally

independent. He said that suggestions from the industry for speakers were

" filtered " through his company's working groups or scientific committees, which

commonly include two or three doctors, including himself, and which make

decisions entirely independently of industry sponsors. " We filter the

suggestions that come from the industry, " he said.

In relation to the material in the leaked emails Dr Manocha said they dated back

to 2006 and that in all cases decisions about content were made by HealthEd and

its working groups, not the industry sponsors. He did, however, concede that

measures were not at that time tight enough in relation to the demands of

sponsors. " We have accordingly tightened up and established guidelines to

prevent them from making these kinds of demands from us. " Moreover, he said it

was " standard industry practice for sponsors to be involved " in the running of

independent educational seminars.

Reacting to specific emails, Dr Manocha said that the speaker suggested by

Sanofi-Aventis had been cross checked with independent sources before being

accepted and that in the case of the CSL request he admitted talking to the

prospective speaker about his presentation but brought no pressure to bear on

him. In the case of Organon Dr Manocha agreed that he had asked his scientific

committee to accept the speaker suggested by the drug company because he " felt

that speaker was a person who was capable of presenting on the topic without

being influenced. "

Another document that shines light on the relationships between sponsors and

educational providers is a 2008 HealthEd brochure that the educational provider

had used to seek sponsorship from drug companies. That brochure states that " at

each seminar as a platinum sponsor your company can . . . work with us to

determine a topic that is on message for your product area. " Platinum sponsors

typically pay the educational provider around $A10 000 (£4700; 6200; $9100) to

be a sponsor at a one day seminar and receive many entitlements, including

stalls in the exhibit area and free passes for their favourite general

practitioners.

When asked about the 2008 sponsorship brochure (which the BMJ obtained from a

drug company sponsor this month) Ramesh Manocha said that the brochure was no

longer used and that the wording should have been changed. He did, however, say

that for up to 25% of the sessions at his most recent seminars-specifically the

sessions relating to new products-he had sought a list of suggestions from the

sponsoring drug company for potential speakers.

Sponsors suggesting speakers is " not unusual "

The drug industry's representative body Medicines Australia has confirmed that

the practice of inviting input from sponsors into the selection of speakers is

by no means uncommon. Its chief executive, Ian Chalmers, said, " It's not unusual

in a sponsored professional event for pharmaceutical companies to be offered the

opportunity of suggesting speakers. "

In an interview with the BMJ last week the medical director of the Association

of the British Pharmaceutical Industry, Tiner, confirmed that the

practice of sponsors suggesting speakers for accredited events also occurred in

the UK, where, he said, drug companies fund roughly half of all postgraduate

education of general practitioners.

Dr Tiner said that the organisers of educational meetings might ask their drug

company sponsors, " Who would you suggest we invite to talk about this topic? "

Drug company sponsorship would then provide funding to bring speakers from

outside the local area, so by accepting the sponsors' suggestions for speakers

the educational providers " would often get access to speakers they were not able

to invite themselves, " he said.

The view from the drug industry is that allowing sponsors to suggest speakers

does not compromise the independence of medical education, as the educational

providers have ultimate control over who speaks. However, research for the

investigation in Australia reveals several examples where sponsors' suggestions

were embraced by the company providing supposedly independent education. Doctors

attending those seminars were not told of this invisible sponsor influence,

although during the period when the research was being conducted for this

investigation HealthEd made changes to its website, saying that in some cases

sponsors are offered a chance to suggest speakers, subject to a list of

conditions.1 <http://www.bmj.com/cgi/content/full/336/7641/416#REF1>

Disclosure or disentanglement?

Industry representatives in Australia and the UK strongly argue that, in the

interests of transparency, doctors attending educational sessions should be

fully and explicitly informed if sponsors have suggested speakers for

educational sessions. Dr Tiner told the BMJ that his personal view was that he

would " have absolutely no problem making it clear, if a sponsor has had input

into suggesting speakers-I would have no problem with that whatsoever. "

Such a degree of disclosure could radically change perceptions of the content of

accredited education, which many doctors believe to be independent of sponsor

influence. While welcoming the call for more transparency, Des Spence, of the

pressure group No Free Lunch, says that in practice this sort of disclosure

would not happen. Dr Spence says that in his view these sponsored events are

" marketing masquerading as education " and that " it isn't appropriate that

industry should be sponsoring education. "

The evidence, such as it is, tentatively indicates that the prescribing habits

of doctors may be affected by attending sponsored educational events, albeit

only in the short term. A survey of doctors who attended courses funded by

single drug company sponsors found that after the course " overall the sponsoring

drug company's products were favored. " 2

<http://www.bmj.com/cgi/content/full/336/7641/416#REF2> A review of the

evidence on interactions between doctors and drug companies, published in 2000,

found that drug company sponsored educational events " preferentially highlighted

the sponsor's drug(s) compared with other . . . programs. " 3

<http://www.bmj.com/cgi/content/full/336/7641/416#REF3> An earlier review of

the evidence published in 1993 suggested that " company-sponsored . . . courses

may have a commercial bias even if conducted under guidelines designed to ensure

the independence of the event. " 4

<http://www.bmj.com/cgi/content/full/336/7641/416#REF4> Although all these

findings may have limited applicability to contemporary circumstances, they

suggest that sponsorship of educational events may well result in an increase in

sales of the sponsor's products.

Harvard professor Blumenthal, an internationally recognised authority on

relationships between doctors and drug companies, says that the industry is

certainly looking for a return on its investment in medical education. " Why

would for-profit companies, in this country at least (the United States), pour

more than a billion dollars a year into continuing medical education without the

expectation of gaining anything from it? " he asks.

The obvious problem with allowing sponsors to suggest speakers is that they will

tend to select speakers who will at best, from the company's viewpoint, favour

their drug or, at least, not contradict the sponsor's marketing messages. The

problem is not that individual speakers will change their presentations

according to sponsor's wishes; the problem is that doctors attending these

sponsored sessions may not be getting the full range of views, in an educational

setting supposedly free of industry influence.

In a landmark paper in 2006 Professor Blumenthal and colleagues called on

academic medical centres in the US to end the direct drug company sponsorship of

continuing medical education events (also known as continuing professional

development). In its place they suggested the creation of some sort of blind

trust to fund education at an institution level.5

<http://www.bmj.com/cgi/content/full/336/7641/416#REF5> Others, such as

Mansfield from HealthySkepticism, a group critical of pharmaceutical marketing,

have called for medical education to be funded by the taxpayer through a system

of competitive grants.

Oversight of these educational events is currently a self-regulatory affair, and

medical associations everywhere seem uninterested, at this stage, in

guaranteeing genuine independence from industry influence. Perhaps the recent

revelations from Australia-and confirmation from the industry itself that it is

" not unusual " for sponsors to suggest speakers-will sharpen the lines of debate

about how to achieve more independent education or at least greater

transparency.

________________________________

RM thanks Carlisle and Miranda Burne for research assistance.

Competing interests: None declared.

CSL and Sanofi-Aventis declined to comment.

References

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gift? JAMA 2000;283:373-80.[Abstract/Free Full Text]

<http://www.bmj.com/cgi/ijlink?linkType=ABST & journalCode=jama & resid=283/3/373>

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<http://www.bmj.com/cgi/ijlink?linkType=ABST & journalCode=cmaj & resid=149/10/1401>

5. Brennan TA, Rothman DJ, Blank L, Blumenthal D, Chimonas SC, Cohen JJ, et al.

Health industry practices that create conflicts of interest: a policy proposal

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<http://www.bmj.com/cgi/ijlink?linkType=ABST & journalCode=jama & resid=295/4/429>