Exposure to industry promotional activity can lead to doctors recommending worse treatments for patients

This is my BMJ Rapid Response, of the 6th January 2018 
to Mike Thompson, CEO of the ABPI.
[Association of the British Pharmaceutical Industry]

I share Mike Thompson’s disappointment in some aspects of Tom Moberly’s article ‘The pharma deals that CCGs fail to declare’, in particular in the title which I suggest would have been better written as “Competing interests that CCGs fail to declare”. I also share the concern about the article’s inclusion of the “pharmaceutical Gift Cycle” for the very reasons that Mike Thompson outlines.

Mr Thompson encourages that “a discussion [is] to be had” and I offer comments in that spirit.

I am not sure that it is helpful to refer to this article in terms of “fake news”. This term has gained a platform largely through the rhetoric of Donald Trump and reduces complex arguments to the dichotomous “right” or “wrong”. Such binary positioning risks hampering the very “discussion” that complex considerations necessarily require.

It is vital to note that all of the “initiatives” that Mr Thompson outlines, in terms of transparency between industry and healthcare, including the ABPI’s “Disclosure UK” are based on guidance. Yet we know from Scotland, that when the public are consulted, the majority are of the view that all declarations should be mandatory.

Mr Thompson states that “any concerns about the conduct of a pharmaceutical company should be brought to the attention of the Prescription Medicines Code of Practice Authority.” I can only offer my experience here which is that this is a most difficult thing to do, for a number of reasons. For the last decade I have been raising awareness of the lack of transparency relating to competing financial interests in the “education” of UK Psychiatrists. As a result my career has at times been vulnerable and relationships with valued colleagues have been affected. It is virtually standard, that in asking about transparency of competing interests, any request is perceived as lacking due “deference”. This in itself seems to demonstrate cognitive dissonance that medical professionals are uniquely able to separate cognition from outside influences.

As Mr Thompson points out, this article gives evidence that three quarters of funding received from the pharmaceutical industry was for education and training events. This is a finding that matches the evidence established in NHS Scotland. In my local hospital, for example, it is routine for Continuing Medical Education (CME) to be sponsored by the pharmaceutical industry and at least two NHS Boards in Scotland have had no budget whatsoever for supporting Continuing Medical Education and so have relied entirely on the commercial sector for this support. It remains routine, in my experience, for there to be invited lecturers (key opinion leaders) who are paid significant honorariums. Yet most doctors have little or no awareness of the scale of potential financial conflicts of interest for those providing their “education”.

Continuing Medical Education is necessary for GMC Revalidation. All UK doctors must follow this requirement, but if in good faith UK doctors are not aware of the potential scale of competing financial interests, it seems that there is little chance for patients to have any awareness of outside factors that may influence prescribing, surgical procedures, or indeed any intervention.

I would strongly suggest that the cherished ideal “fully informed consent” is being denied as a consequence. The recent Mesh scandal may be one of the most striking examples of this and of the harm that resulted.

To conclude it is not accurate to state, as Mr Thompson does, that the UK has “strictly regulated support for continuing professional development”. Current systems are based entirely upon guidance rather than regulation. It is encouraging then that Mr Thompson confirms that “we believe that strictly regulated scientific dialogue is a critical responsibility we have.” I am hopeful that this means that the ABPI will support the introduction of Sunshine legislation to the UK as soon as possible.

I do hope that Mr Thompson does not think this is an attempt to “marshal arguments” simply to support some sort of “philosophical” position (although I am of view that considerations of philosophical medical ethics are essential to Good Medical Practice). Mr Thompson will be aware that there is longstanding evidence that exposure to industry promotional activity can lead to doctors recommending worse treatments for patients.

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