The pharmaceutical industry seeks to increase sales by influencing how doctors prescribe medications. To help achieve this goal, it sponsors the education and ongoing training of doctors.
The College of Family Physicians of Canada – the organization responsible for accrediting continuing medical education and certifying all family doctors in Canada – has expressed concern about industry’s influence over doctor education. In 2010, the College commissioned a taskforce to determine how much the sponsorship money was affecting the content of the educational programs it accredits. The College stated it did this with the intent of maintaining the “trust of its members, their patients and the Canadian public.”
According to an article in the College’s journal by Dr. Francine Lemire, chief executive officer at the College of Family Physicians of Canada, the College-appointed taskforce presented its findings and recommendations at the November 2013 board meeting, but did not make them public. Lemire also reported that at this meeting, the board asked the College to do a cost-benefit analysis of ending industry funding. Despite being asked to present this analysis at the November 2014 board meeting, the College has not yet released its findings.
In June 2015, we sent a request to Dr. Lemire to release the cost-benefit analysis on ceasing industry support. She declined our request, stating that the College was still examining the financial impact of dissociation and expressing concern that the loss of industry money would have a significant effect on College activities.
Why is pharmaceutical sponsorship a problem and what can be done about it?
All Canadians should be concerned about pharmaceutical sponsorship of physician education. Sponsorship biases the content of educational programs. In particular, it leads to a narrower range of topics. For example, industry-sponsored educational programs tend to emphasize medications and ignore other treatments, such as diet, exercise and physiotherapy. Additionally, the programs favour the pharmaceutical sponsor’s products.
This bias, in turn, has a harmful effect on physician prescribing. Studies show that physicians who interact more frequently with the pharmaceutical industry have poorer prescribing habits: they are less likely to follow independent guidelines and more likely to prescribe expensive medications.
The implications of industry influence over doctor prescribing are clear in the current opioid crisis. Purdue, a pharmaceutical company, funded tens of thousands of pain-related educational events that touted the benefits of OxyContin (a potent opioid painkiller) and downplayed its harms. As a result, sales of OxyContin and other potent opioids skyrocketed. As sales increased, so did harms from opioid use. Deaths from opioid overdoses now outnumber deaths from car accidents in Ontario.
Medical organizations need to have the courage to take a different approach. Several large American medical institutions have successfully halted all industry funding. Sloan Kettering Cancer Center reports that it was able to cut industry funding by holding conferences at the hospital instead of expensive off-site venues, using in-house faculty as presenters instead of flying in and housing outside experts, cutting back on its budget for advertising CME events in mail-outs and ads in journals, no longer providing meals at conferences, and increasing fees for those attending CME events by 10% to 20%.
Patients have the right to know about industry sponsorship of doctors’ education
The College’s worry about the financial impact of the loss of industry funds does not release it from its ethical obligation to be transparent. As members of the College of Family Physicians in Canada, we call on all final reports on pharmaceutical funding of education and the cost-benefit analysis on ending funding to be available to College members and other Canadian medical societies.
More importantly, the information should be available to the members of the public. Canadians are affected by industry influence whenever their doctor writes a prescription. Patients pay the costs when doctors prescribe a newer, more expensive medication instead of an older, equally effective medication with a well-established safety profile. Canadians have a right to know how much industry is influencing Canadian family doctors’ prescribing habits and how this influence can be stopped.
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That’s why I use Dr. Google
A must read for all physicians and members of the public is ‘Bad Pharma’ by Ben Goldacre. The book describes the infrastructure created and the systematic work of industry that is ongoing to promote its products at all cost.
The RIAT initiative, that has arisen (http://www.alltrials.net/news/riat-initiative-for-publication-of-historical-clinical-trial-findings-2/) offers real time solutions that I have adviced patients to use, when we are considering any new or old medicine for use in their healing.
The work of deconstructing this infrastructure and network of influence, will affect many, many people. Many of whom earn their livelihood or credentials through work with industry.
This work has to continue and the ongoing emergence of evidence and truths must continue to be voiced.
Commentary by Registered Nurses’ Association (RNAO):
The authors are to be congratulated on their timely warning about the perils of pharmaceutical funding of physician education. It is timely, as a national approach to drug policy is on the agenda. As the article shows, the sizable sums of money on offer from drug companies are tempting to cash-strapped health organizations, but the contributions to education are a misnomer. The intent of the funding is to market more medication, and in the end, the loser is the client and the health system. The result is a tipping of the balance towards over-medication and away from other treatments which may be safer, cheaper and more effective.
This is not just a physician issue, as the number of non-physician prescribers like nurse practitioners is increasing and RNs too are soon to be prescribers; surely the pharmaceutical companies will have their eyes on them too.
We like to think that our health professionals are immune to the effects of the marketing, but as an extensive review of the literature by Spurling et al. [Spurling, G.K., Mansfield, P.R., Montgomery, B.D., Lexchin, J. Doust, J., Othman, N. and Vitry, A.I. (2010). Information from Pharmaceutical Companies and the Quality, Quantity, and Cost of Physicians’ Prescribing: A Systematic Review. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000352.%5D shows, physician exposure to pharmaceutical company information shows associations with “higher prescribing frequency, higher costs, or lower prescribing quality.” It makes sense when one realizes that it is easier for time-constrained health practitioners to use the most available education resources.
It is an evident conflict of interest for drug companies to be offering funding for provider education. They would not spend these large sums of money if they were not reaping substantially greater amounts due to altered prescribing. Add to this the huge amount of money that goes to direct-to-consumer advertising, and you have the makings for public health disasters like the OxyContin crisis referenced in the article. Canada wisely bans direct-to-consumer advertising, but we must tighten the ban because drug companies do creatively skirt it.
Pharmaceutical companies use these various forms of marketing to augment their consistently high profit rates [Figure 20. http://www.yardeni.com/pub/sp500margin.pdf%5D. Canadians are particularly hard hit. As Health Quality Ontario concluded, the average expenditure on prescription drugs in Canada is the second highest in the OECD, after the US [Health Quality Ontario. (2015). Ministers’ Roundtable on Pan-Canadian Pharmacare: Summary Report Prepared by Health Quality Ontario. July 13]. It is no coincidence that the portion of citizens covered by a public drug insurance plan is the second lowest (again, trailed only by the US). A national universal pharmacare program with single-payer purchases would countervail the monopoly power shielded by absurdly strong patent protection. Such a program would also include a national formulary and detailed guidelines for effective prescribing that would replace the current system that is too readily gamed through marketing masquerading as education.
We offer five observations:
1. It would be in the public interest to release the cost-benefit analysis on ending drug industry financing of education programs accredited by the CFPC.
2. It is time to get the health industry off drugs: health organizations should acknowledge the inherent conflict of interest in accepting pharmaceutical industry funding, and end it.
3. Governments should fund health care at levels that health-care organizations have less temptation to take drug money.
4. The federal government should tighten the ban on direct-to-consumer advertising of prescription drugs and resist any attempts to weaken it.
5. A national universal pharmacare program with a national formulary and guidelines for effective prescribing would solve the drug education funding problem, and in the process it would be cheaper, cover all Canadians, and yield better health outcomes. A ban on user fees would guarantee access and support prescription compliance by clients.
Transparency is not enough. There should be a firewall between Pharma and how physicians care for patients. The loss of industry money would have a significant effect on College activities for the betterment of patients and public at large. The article highlights the Rx Opioid crisis resulting from Pharma influence. Unfortunately due to continued misinformation and pharma power the opioid crisis has yet to be resolved and should serve as a testament to the many challenges of trying to right the wrongs. A survey of physicians indicated the majority felt they could not be influenced but their colleagues could. Although we can say that physicians are well educated professionals we must not forget human nature’s implicit bias. For this reason the system must support an ethical and socially responsible approach. “One of the first duties of the physician is to educate the masses not to take medicine” Sir William Osler. Money may be the economic driving force but it is also a destructive force.
Cree Prophecy (First Nation):
We cannot wait until the last tree has been cut down
The last river is poisoned
The last fish caught
And discover we cannot eat money
As a member of the pub;lic and a consumer of healthcare services, I agree completely with the authors that we have the right to know the extent to which our physicians are influenced by pharmaceutical funding of CPD. I think that the Sloan Kettering Cancer Centre model should be examined as an alternative.
In regard to Pain Research, I would point out that pain researchers receive less than 1% of available grant funding in Canada. Unrestricted educational grants have been an important source of funds for researchers, who otherwise would have no opportunity to carry on such research. All the Canadian Medical Faculties monitor funding so unless sponsorship is by an unrestricted educational grant, then it is unlikely to be accepted for peer review. What was done in the past, to promote opioid prescriptions, was reprehensible. However, Canada has many talented researchers carrying out pain research. I think we need to be reluctant to discount research that was supported by an unrestricted educational grant. However, it is always important to be critical and examine for sources of bias. Ultimately, we need more dollars for pain research.
%featured%I am startled that the CFPC appears to view this as a purely utilitarian issue, the outcome of which is dependent mainly on (a narrowly framed) cost-benefit analysis%featured%. A large body of research has quantified the adverse effects (some subtle, some heavy-handed) of pharma cash on educational integrity, research bias, and physician practice. Pharma quite understandably views educational funding as an investment in its world-view that will yield excellent returns down the road. Why end the practice? “Because it’s 2015.”
I question the CFPC leadership [including the Board] for not publishing the report upon its approval by the Board. One could assume that that some pressure was exerted that resulted in the publication delay.
The attached link to a newly published BBC article does a good job explaining how “companies with vested interests spread ignorance and obfuscate knowledge.” Marketers and lobbyists (often one and the same) are smooth operators.
http://www.bbc.com/future/story/20160105-the-man-who-studies-the-spread-of-ignorance
If one has any doubt as to the true mission of pharmaceutical companies, one only need look at the goals for recruiting ‘good influencers.’
http://www.healthcaresuccess.com/pharmaceuticals
In my personal experience, I have encountered physicians who truly care about the patients they serve, physicians who provide indifferent care, and physicians who care most about the money. Patients are merely the means to an end. When quality healthcare and patient safety are not priorities, physicians can be easily influenced.
Pro Publica is an excellent resource.
http://www.propublica.org/series/dollars-for-docs
Psychiatrist Daniel Carlat talks about his personal experience as a Pharma ‘dupe’: https://www.youtube.com/watch?v=XOCM88LzCOY
http://carlatpsychiatry.blogspot.ca/2015/07/hospitality-and-pharma-relationship-on.html
Researcher Alan Cassels, drug policy researcher affiliated with the School of Health Information Sciences at the University of Victoria:
http://www.alancassels.com/
http://focusonline.ca/?q=node/516,
http://umanitoba.ca/outreach/evidencenetwork/alan-cassels.
In closing, I leave you with a Disney clip from The Jungle Book. It underscores the need to vigilant in healthcare. We need to ferret out who is trustworthy and who is not.
https://www.youtube.com/watch?v=Nh5kxentrY0
%featured%Although the Canadian Family Physician displays more ads than other general medical journals, these notices with questionable value save subscribers less than $70 per year (or less than $6 per issue). I look forward the College’s cost-benefit analysis being made publicly available.%featured%
Our study of journal ads was published by PLOS ONE:
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0084790