In a recent post I outlined [the generally hidden] commercial influences of ‘key opinion leaders’ in British Psychiatry.
My research into what is publicly available on competing financial interests in key opinion leaders has left me wondering how much of what we term Evidence Based Medicine (EBM) might actually be considered as Industry Biased Medicine? A decade ago, Ray Moynihan was asking the same question and shared in the BMJ his examination of the “role of influential experts paid by industry to help educate the profession and the public”:
Ten years on and this issue continues to merit open discussion particularly in a time where there is a shared ambition for what is now often termed “Realistic Medicine”. One of the key aspirations of Realistic Medicine is “fully informed consent”: however without full, open, easily accessible, public transparency of competing financial interests involved in medical education and research, such fully informed consent cannot be assured.
One of my interests is in medical ethics. I have been an advocate and campaigner for greater transparency in science for much of my career. Long before any other, the sociologist Robert K. Merton argued that science needs to be “disinterested”.
Any intervention studied by medical science (whether it be a pharmacological intervention, a surgical intervention, a psychological intervention, a social intervention, or any other form of intervention including placebo) has the potential for positive outcomes, negative outcomes and a range of outcomes in between. Careful consideration also has to be given to the time period involved in any scientific study as interventions may well have more than just short term effects.
I took a petition to the Scottish Parliament that asked the Scottish Government to consider introducing a Sunshine Act. As part of the gathering of evidence for this petition the Scottish public were consulted and the majority conclusion was that it should be mandatory for all competing financial declarations to be openly declared in a single, searchable database. Two years on from this consultation and Scotland has no such system.
This therefore leaves governance to a range of Royal Colleges and Learned Societies and Associations. This piecemeal, uncoordinated system has facilitated a situation where commercial interests can be hidden. Whilst the General Medical Council (GMC) guidance on transparency is clear, to my knowledge, no medical professional has ever been investigated for not following this guidance in relationship to payments from industry (the one GMC case mentioned here, January 2014, related to non-declaration of private practice income).
[the "Disclosure UK" database is not helpful as any healthcare professional can opt out and it does not necessarily include all academic disciplines]
I give this summary as a backdrop to my interest in transparency. I am not “anti-medication”, I fully support scientific innovation, and I understand that there is a wider range of competing interests than just financial (such as career progression, awards, prestige etc). What is clear is that evidence has repeatedly found that financial competing interests can lead to doctors recommending worse treatments for patients. In April 2015 I expressed this concern to the then President of the Royal College of Psychiatrists, Professor Sir Simon Wessely:
“One outstanding issue is the culture within healthcare (psychiatry is certainly not alone in this) that somehow discounts the evidence that involvement with the pharmaceutical industry influences practice. This happens to be covered in this week’s BMJ: Forever indebted to pharma—doctors must take control of our own education.”
In my correspondence of 2015 with the Royal College of Psychiatrists I suggested that they should carefully consider following the template and database of “Who pays this doctor“. However, the system subsequently put in place by my College included few of the features of this template.
In the UK, the pharmaceutical industry spends over £40 million a year on doctors and academics who market and promote their products. Often these are the same doctors and academics (‘key opinion leaders’) who appear elsewhere as part of “approved Continuing Medical Education”.
In December 2016 the outgoing CEO of the Royal College of Psychiatrists, Vanessa Cameron, stated in the Psychiatric Bulletin:
The current CEO of Royal College of Psychiatrists, Paul Rees, stated (8 June 2018): “Our policies and procedures around declarations of interest are already sufficiently robust”.
However it is the case that the Royal College of Psychiatrists still has no single, searchable register that records all payments to its members. It is therefore impossible to determine the scale of any potential payments that have been made to “educators” on prescribing of psychiatric medications in the UK.
The current President of the Royal College of Psychiatrists, Professor Wendy Burn said on social media (29 July 2018): “In the UK at least there is a lot less Pharma sponsorship than there was 20 years ago. Partly because most of the drugs we use are out of patent and partly because the climate has changed. No more than 5% of College income can be from sponsorship”. However, it is the case that the RCPsych International Congress is a significant revenue opportunity for the College and that this has involvement of ‘key opinion leaders’.
My posts on transparency predominantly explore UK psychiatry – as this is the specialty within which I work. I have no wish to single out the Royal College of Psychiatrists of which I have been a member for 25 years. Indeed, it is my view, and that of some others, that all the Royal Colleges and Learned Societies and Associations have dismally failed to ensure full transparency of competing financial interests. It is my worry that this approach is a major obstacle in the way of achieving Realistic Medicine. It also leaves the medical profession, and medical science, open to ongoing scrutiny of its professionalism and integrity.
Declarations of interest: I was one of those involved in setting up Who pays this doctor? I was one of those who signed a formal complaint to the Royal College of Psychiatrists and then to the Secretary of State for Health.