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CORRESPONDENCE: A. Bush, Dept of Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Fax: 44 2073518763. E-mail: a.bush{at}rbh.nthames.nhs.uk
There is an old proverb that goes: "He who sups with the devil should use a long spoon." This seems to apply to the increasingly uneasy relationship between physicians and the pharmaceutical industry, with the perception that some spoons have become short to nonexistent, as some people have perhaps allowed professional boundaries to become blurred. Some recent activities of big pharma companies have been troubling. There have been well-publicised scandals about the suppression of data unfavourable to a novel medication or, at least, of extreme economy with the truth. There have also been concerns that meta-analyses commissioned by the industry usually come up with answers favourable to the industry 1. A welcome attempt at openness on the part of the medical profession is the increasing publication of conflict of interest statements, so that the reader or listener can determine whether there is likely to be any bias. The philosophy is that everything should be declared and that the target audience, not the author, should determine what is relevant, and this is right. But although this is a step in the right direction, it does not go nearly far enough. The statement "I have received US$5,000 from Company X as lecture fees" could mean, "I have been paid expenses to lecture at a meeting which is compiled completely independently from industry" but also, "I have spoken at a satellite symposium from slides completely provided by the company, uncritically purveying what the company has instructed me to say". The implications of these two interpretations of the same (truthful) conflict of interest statement are very different.
Pharma companies may sponsor symposia that are part of an academic meeting (for example, the American Thoracic Society (ATS) Congress, the European Respiratory Society Congress) or those that are independent, stand-alone ventures. In many cases, the quality is excellent, the speakers are independent and of a high standard, and the audience is given access to high-quality continuing medical education (CME) that they would otherwise not have received. Sadly, though, this is not always the case.
I suggest this as a result of recent attendance at an international meeting where a far less satisfactory scenario played out, and where, damagingly, there were a large number of delegates from the developing world, to whom the virtues of very expensive new medications with doubtful benefit but high cost were being oversold. The superb presentations in the main meeting, about how to deliver care at low cost to the needy, were counterbalanced by presentations on medications which are, in world terms, expensive luxuries at best and, at worst, offer no real additional benefits over those of standard therapies. These symposia were advertised in the programme of the main meeting but had no input from the congress programme committee. It is time this situation ceased. Indeed, the ATS has led the way by assuming control over satellite symposia that are advertised in the main programme of their annual Congress, and have been rewarded by some companies withdrawing funding because they no longer wish to take part in the evening programme. So much for any desire for truth and objectivity by at least some parts of big pharma!
It would be naïve to imagine that a complete divorce of pharma and the medical profession is likely, desirable though that may seem to some and despite the fact that this has been achieved with the tobacco industry. In fact, some companies have provided much-needed support for CME, in an ethical way and making no attempt to influence content, in a manner that is helpful and wholly admirable. Indeed, the increasing requirement for CME, pushed on the profession by the regulatory authorities, is not matched by funding to meet the requirements, and without external funding these requirements will not be met. However, I suggest that there needs to be much tougher regulation of sponsored meetings, and I propose the following for debate. In this context, I define a pharma-sponsored meeting as one which is totally funded and the programme controlled by a pharmaceutical company, and exclude the case of companies exhibiting on stands at professional meetings.
1) All pharma-sponsored meetings must satisfy the criteria of at least one professional body for CME credits; these bodies need to ensure that credits are not given out uncritically.
2) All pharma-sponsored meetings must be scrutinised in detail by at least one independent professional, perhaps nominated by the relevant professional society, who has the absolute right to change any topic or speaker on the programme. Furthermore, the entire budget of the meeting is to be scrutinised.
3) This aforementioned scrutiniser should be completely independent of the industry; any fee in recompense for time spent must be paid to a research fund or charity, not to the individual in question.
4) Every speaker must prepare their slides independently of the sponsoring company and submit them for peer review to the independent scrutiniser, who has the absolute right to mandate changes.
5) The meeting will be attended by the independent scrutiniser, who will submit a report to the relevant professional body. It may be appropriate for the scrutiniser to chair or co-chair the meeting, to ensure that there are no last-minute changes. The scrutiniser should have the opportunity to give a short assessment at the end of the meeting, if necessary.
6) Speaker fees and travel expenses must be capped; for example, only coach class travel should be used, and payment for preparation and speaking at an hourly rate should be commensurate with what professional bodies recommend as appropriate for compiling other professional reports.
7) A strict per capita financial limit should be placed on entertaining the audience or gifts supplied to them.
8) There should be severe financial and other penalties for companies and speakers who attempt to subvert this process.
I suggest that these proposals, or something based on them, should be made mandatory. Those in industry whose ethical principles are high would have nothing to fear from them. They would not preclude a particular product being discussed but would ensure that a proper context is given and that only claims that are supported by high-quality evidence are made. In fact, they would protect the industry, by ensuring that companies are associated with a high-quality educational or scientific output. The profession would also be protected, the public reassured and the quality of medical meetings would be enhanced.
Statement of interest
A statement of interest for A. Bush can be found at www.erj.ersjournals.com/misc/statements.shtml
FOOTNOTES
The content of this editorial reflects the opinion of the author and is not representative of the viewpoint of the ERS.
REFERENCES
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