I am a rational being. Mostly. I am rational in all sorts of situations. Although when good dark chocolate is around, I am more of an instinctive creature. I am also a bloke. This means I am not hopelessly beholden to the lures of shopping, right? That’s a woman thing, right? Wrong. That’s just a cliché. I’m just a sucker for different stuff. I am not a sucker for shoes. Unless they are in an adventure shop. Then I am hopelessly enslaved by the promise that I could be hardcore action guy (insert bionic man nanananana sound right here), if only I had more thermals. You know, the 200 weight ones. Merino wool of course.
The thing is, I’m a sucker like pretty much everyone else. I’m susceptible to marketing. I’m also a doctor. That’s the point where my pathetic inability to resist the tricks of the advertisers becomes more than just an issue that requires negotiation with my bank account. That’s the point where it becomes an issue for everyone I look after.
Why mention this? Well, you probably missed this, but right now, I can continue to toil away in Australia and accept the bounty of pharmaceutical companies, and not tell anyone about it. A bill was knocked back in the last week that proposed the there should be legislated restrictions on the way medical practitioners and drug companies interact (you can see some more here). A variety of reasons to knock it back were given, but the end result is we’re left with the self-regulation model, and that’s a model which is emplyed very successfully by some, but leaves plenty of room for companies to significantly influence the information reaching practitioners.
Medical practitioners have to keep up to date with education. Drug companies know this. They also know doctors are time poor so they spend serious money on reaching them. They start young too. The first attendees at the drug company lunch are always the med students (easy to spot, up the back, next to the pastry table and stocking up on carbs to avoid having to buy dinner). It doesn’t take a genius to figure that they aren’t paying doctors to talk at conferences, shouting them dinner, flying them to big meetings or dropping off samples because they’re on a mission to spread more love than Barrie White after his drink has been spiked with Spanish Fly. (If you’re under any illusion as to how much goes on, read this excellent discussion from The Global Mail).
The weirdest part of it is that doctors recognise that they are suckers for it, and distrust those in the pay of these companies. Here’s just one trial that covers this fact very clearly. In this study, as soon as industry funding was mentioned, the quality of the research was immediately marked down. It’s a classic case of “I’d be above influence, but those guys who published this research have less independent thought than a muppet” for some, although there are many who recognise the potential to be influenced by distorted research and carefully scren what they read in that light.
Open disclosure in all areas of medicine and research is something anyone who is ever going to be a patient should be arguing for (oh, right, that’s all of us). It’s well proven that medicos are more likely to prescribe stuff from companies they have a relationship with, and this potentially distorts the practice of evidence-based medicine. Evidence-based medicine already has significant threats because it’s based on about half of what’s really out there. Best estimates suggest that around half of clinical trials conducted never get reported. What does tend to get published is the stuff that looks good. The worst case scenario would be that the same amount of evidence that is out there supporting current treatments is sitting in the shelf of the filing cabinet that won’t unlock, and it’s more likely to be the stuff that says it’s all bunkum.
Now, it’s not actually as bad as that “the cup is half full, but it’s full of blood!” scenario. Better yet, there’s movement on this to support individuals who have been arguing for better disclosure of research results. Numerous campaigns have sprung up around the world both to limit pharmaceutical company influence and, more importantly, to work on full disclosure of all research. The most prominent of these is over at www.alltrials.net, driven by Dr Ben Goldacre and actually getting lots of support. Having posted before on open access publishing you could probably guess that I’ve signed their petition because open access to look at the literature is fairly useless if all the literature is just selling a good news story. We can’t afford for research to be condemned to report only the sort of fluff that would be placed after the weather report on the nightly news, much as I like a surfing squirrel.
For fields of research to progress it’s really vital that we know all the results good and bad, sexy and ugly, epic win or epic fail. We need the “Journal of Stuff That Totally Didn’t Work Out Due to Bad Luck or That I Am Rubbish”. Given how much is learnt from the study or experiment that doesn’t work out, how does it make sense to skew our publishing to the things that did work? The initiatives mentioned above and moves to ask authors to submit their raw data for open scrutiny, or provide more on their methodology and statistics might actually start letting clinicians see the all of the evidence on a topic and form a more balanced and informed opinion.
As for the free lunch, it’s only a matter of time before disclosure becomes part of the deal for everyone, and not just up to the individual doctor to make a decision on. The US Physician Payment Sunshine Act requires reporting of all payments or similar transactions to individual doctors and teaching hospitals that exceed US$100 in a year. The Dutch are also reporting arrangements where the doctor exceeds 500 Euros per year. While Australia might be the Dad who figures 1999 was the year they were the coolest version of their self they will ever be in their life and dresses accordingly forever, I doubt it. Disclosure requirements seem likely to be on the way, which seems pretty fair to patients and doesn’t impose anything onerous on the many doctors, including most of the ones I know, who already avoid manufacturers like the plague.
Then we could all feel better that everyone knew what was going on, and I could get back to buying those action pants that the ad tells me will be just what I need for the trip to the park with the kids.
PS In the spirit of the open disclosure I believe in, I do not accept products from company reps, nor do we allow those reps into the Department I work in unless we are required to examine specific items of equipment. I have never been paid for an appearance (ha!), nor have I ever had any costs relating to any educational meeting or conference reimbursed. I did have a few sandwiches when I was a student, but it was Newcastle, and I was a student, and those sandwiches represented high culture.