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Healthy Skepticism Library item: 15699

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

 

Publication type: news

Doctors and Drugs
SBS Insight 2009 May 26
http://news.sbs.com.au/insight/episode/index/id/67#transcript


Full text:

Have you ever wondered how your doctor decides which drug to prescribe? Where do doctors get their information about drugs? A court case against the maker of the anti-arthritis drug Vioxx is revealing some of the tactics’ used to market the drug, it’s alleged the company budgeted up to 6 million dollars in just one year for free samples of Vioxx for doctors, talked about neutralising or discrediting doctors who didn’t support Vioxx and created a new medical journal which appeared to be independent but favoured the company’s products. Vioxx was withdrawn from sale in 2004 after concerns that it increased the risk of heart attacks.

JENNY BROCKIE: That got Insight wondering about the broader relationship between drug companies and doctors and what it means for you, the patient. That’s what we’re talking about and you can join in via our twitter feed. Good to have you here tonight. Joann, I am going to start with you, your a GP in inner Sydney. How many drug reps would visit you in an average week?

DR JOANN GOODIER, GP: I would probably have about 15 would come and visit, but I wouldn’t see 15, I would probably see about three a week.

JENNY BROCKIE: How do you decide who to see?

DR JOANN GOODIER: I usually see reps who are promoting a product that is new in its class as well as somebody I have not seen previously or an area that I don’t know very much about.

JENNY BROCKIE: Renata you’re a GP too, how often would drug reps visit your practice?

DR RENATA CHAPMANKONARASKA, GP: Twice a week.

JENNY BROCKIE: What do they give you – what sort of things do they leave behind?

DR RENATA CHAPMANKONARASKA: They usually bring something to eat, because that’s the time of lunch. So they bring some sandwiches.

JENNY BROCKIE: They bring sandwiches?

DR RENATA CHAPMANKONARASKA: Yes. Sometimes they do. Not always, but often. And they bring obviously some material advertisements and samples.

JENNY BROCKIE: Joann, you agreed so show us some of the things that you have received from drug reps. Let’s have a look.

DR JOANN GOODIER’S DESK TOYS STORY:

DR JOANN GOODIER: Some of the things they give us in regard to promoting their drugs are actually incredibly useful to show our patients. This is actually an educational thing that I can use in regard to obesity – which is one of our main issues at the moment.

This is actually a cup that was given to me by one of the pharmaceutical companies and yes, it shows very easily what is considered a safe amount of alcohol for a patient to drink. Now, I don’t see that as advertising to the patient. I see that as an educational tool.

Then here is a selection of pens that we get and they only have the actual brand names and most of the patients wouldn’t have a clue what the brand names of these drugs are. This is definitely one of the products that are commented on by my patients when they come in, they see it as being quite a lot of fun, and then they suddenly see that it’s actually got the brand name of a product inside of it.

What I’m saying is yes, it is branding, but it’s actually the fluid that makes it so eye catching. Moving on from other things on the desk – we’ve got a tongue depressor. This is branded, this is non-branded. What I will often do is open it up. It goes into the mouth so that you can have a look at the patient’s tonsils. This is a good example of a book that is available -it’s all about cholesterol – that allows the patient to actually look at it at their leisure. This is actually a new contraceptive aid, it is the new contraceptive ring for young women and older women.
That is so useful to be able to show the patient what it is.

JENNY BROCKIE: Joann, do those things put the company names front and centre in your mind or in the patients’ mind, do you think they have an influence at all?

DR JOANN GOODIER: Often I don’t remember who the company is and I don’t think that is a problem, unless I need to find out so I can get information about the product and I will either speak to the medical information department of the drug company, so I don’t have a problem with it as long as it’s balanced. What I’m being given is reliable information and that’s where I think it is up to the doctor to be able to assess what’s reliable and what isn’t.

JENNY BROCKIE: Could you be influenced do you think?

DR JOANN GOODIER: Everybody can be influenced by advertising and I think we are wrong to think that advertising doesn’t exist in every single facet of our lives.

JENNY BROCKIE: Now, I noticed a model in your surgery – you brought some of the things along – this is a shoulder?

DR JOANN GOODIER: Yes that is a shoulder.

JENNY BROCKIE: And it’s got the Vioxx brand name on it.

DR JOANN GOODIER: Yes it does.

JENNY BROCKIE: Now given that Vioxx has been withdrawn from the market, have you thought about binning that and not having it on display?

DR JOANN GOODIER: No, because this is really useful. What I could do is cover that up. That would be, I accept that can be appropriate, however, this is a really useful thing to be able to show the patient what is going on with the shoulder.

JENNY BROCKIE: And you haven’t felt the need to cover up the name at all?

DR JOANN GOODIER: I don’t have it sitting on my desk all the time. So no, I haven’t as yet.

JENNY BROCKIE: Okay. And how heavily did that company market, because we have heard a lot about the marketing techniques of this company, and there’s a court case running at the moment in relation to that drug. How much did the marketing affect you, how much was it marketed to you?

DR JOANN GOODIER: It was marketed in the sense that it was in the press a lot, the reps were coming to see you a lot, you were offered objects like this, so in that regard, it was marketed more than other drugs. It depends on how often people come to see you, and often what’s happening is that the drug can actually be marketed by more than one pharmaceutical company. They actually will use their own team of representatives plus they may have another team of representatives. So that means that there is a double group that is coming to talk to you about the same drug.

JENNY BROCKIE: Martin, you’re a professor of cancer medicine. You brought in a sign that you have on your desk. What does it say and why do you have it?

DR MARTIN TATTERSALL, UNIVERSITY OF SYDNEY: It is a sign relating to my disclosure of interests that might influence my prescribing and treatment of cancer patients. I have a heading that says, “Pharmaceutical Companies” I specifically say I have received no honorary or financial support for more than ten years from pharmaceutical companies.

JENNY BROCKIE: Can you hold it up and show us?

DR MARTIN TATTERSALL: Yes – sure.

JENNY BROCKIE: So that sits on your desk or you have it by your desk so people can read it?

DR MARTIN TATTERSALL: It’s has been sitting on your desk?

JENNY BROCKIE: Ineke, you’re a final year medical student, you spend time in hospitals and general practices. What sort of things do you get offered as a student?

INEKE WEVER, MEDICAL STUDENT: We pick up mostly what gets offered to doctors as a kind of by-pass. Students will walk past a lecture with a pharmaceutical food being put on offer, sandwiches, but also the pens and note pads and students will never say no to a free pen or note pad.

JENNY BROCKIE: Or a free sandwich I imagine?

INEKE WEVER: Exactly. So you pick up that stuff t here and also in a general practice, if your GP – that is your supervisor is getting visits from pharmaceutical reps and your sitting in with them, then you get exposed to that marketing as well.

JENNY BROCKIE: Bill, you’re with Pfizer, one of the big pharmaceutical companies. Why do you spend so much money on this stuff?

DR BILL KETELBEY, PFIZER AUSRTALIA: It’s important to understand these items are of minimal value. They’re not hugely expensive. Yes, they have been used in the past, but in fact I think what we’ve appreciated as an industry and as a society is that they become a bit of a lightning rod for detractors for the industry and fundamentally they’re beginning to detract and negate the professional interaction that we’re trying to have with doctors. So ….. We’re actually doing away with them, they will be taken off the market as of the beginning of next year. We put a submission to the code review that is on going, the Medicines Australia code review and recommended that they actually be taken off the market and my understanding is this is actually going to happen.

JENNY BROCKIE: I want to stick with this for a moment, we will get on to things like sponsorship and education and so on later on, but before we do, Jon, you’re running a campaign around the relationship between doctors and pharmaceutical companies – drug companies. Why, what are you worried about?

DR JON JUREIDINI, HEALTHY SKEPTICISM: What we’re worried about is the well being of patients. The pharmaceutical industry has a responsibility to make a profit, some bad things have been made by pharmaceutical companies but setting that aside you can’t question their need to turn a profit for shareholders and part of that involves marketing. We doctors have a different responsibility we have a responsibility to our patients. While we might benefit personally from our interaction with the pharmaceutical industry, we have to set that aside in favour of what’s in the best interests of patients and I think what concerns me is that our colleges and other learned bodies within medicine, academic institutions are not sufficiently rigorous in protecting individual doctors from the temptation that comes with the possibility of working with the pharmaceutical industry.

JENNY BROCKIE: David you’re a cardiologist, do gifts and visits from drug companies influence you, what do you think about what John is saying?

PROFESSOR DAVID COLQUHOUN, UNIVERSITY OF QUEENSLAND: I’d like to know in what way influence me. I actually don’t like the desk toys, I prefer to have some paintings around my room and other things, the only thing that patients can see is fish oil, which I have an obsession about. In the interests of patients and I give them the diet commandments etc. That influence, I don’t like the pens, I like my own pen, just quietly.

JENNY BROCKIE: What sort of things would you accept – what have you accepted?

PROFESSOR DAVID COLQUHOUN: Like, I’ve accepted many years ago, a nice little picture of the hard arteries, I took the logo off, it just left that there. In the past I have accepted a pen, a plastic pen worth about a dollar. And yes, sponsorship to present American heart meetings, ticket over there.

JENNY BROCKIE: A ticket away, which we will talk about later. That is much bigger than a pen.

PROFESSOR DAVID COLQUHOUN: I don’t like the desk toys. If I want something I will have it. I accept articles, published in the New England Journal, if you have up dated articles I may have missed, that’s about it.

JENNY BROCKIE: Paul, I’d like to talk to you, you wrote the ethical guidelines on how specialists should interact with drug companies. Does this sort of thing matter from your perspective?

PROFESSOR PAUL KOMESAROFF, ROYAL A’ASIAN COLLEGE OF PHYSICIANS: It matters a great deal and I disagree with a couple of the last points. There is a mountain of evidence that shows that advertising works and the answer to your question to Pfizer, why this advertising is undertaken is that it sells drugs. And even though when you ask physicians or any kind of practitioner whether they’re influenced, they will say no. We know that there’s a lot of evidence to show that is just not the case. Any kind of advertising, whether it’s items of small value or substantial gifts like overseas travel, has an effect on the prescribing habits of clinicians and it contaminates the relationships between doctors and their patients.

JENNY BROCKIE: David?

PROFESSOR DAVID COLQUHOUN: Yeah, there’s a lot of words there and words have weapons. Changes behaviour- one of the greatest problems we have in cardiology, in the American Heart Association – Heart Foundation, is to get doctors to follow the guidelines. Get that cholesterol down – take the fish oil – take the aspirin, one of the problems is it’s very hard to get doctors to get with the guidelines. If doctors prescribe more cholesterol lowering medications – fantastic – that’s what we want. There’s where we can co-operate together. If they do change, fantastic, that’s what we want, good rational prescribing, not inappropriate – I don’t know of doctors given the wrong drugs.

JENNY BROCKIE: Okay, we’re not talking about rational prescribing in that sense, what we’re talking about is the relationship between drug companies and doctors. I would like to ask you, you represent drug companies and your members have a code of conduct for those drug companies. You’re now planning to ban some gifts that we heard Bill talking about. Why and where do you draw the line, what’s acceptable and what isn’t?

WILL DELAAT, MEDICINES AUSTRALIA: We do have a very comprehensive code of conduct, 200 pages the last edition. We are currently in the process and I’ve been chairing the panel that is reviewing the code for the next three years and we have invited submissions from a number of stakeholders and we have heard that there’s a perception or concern that patients are being exposed to advertising of prescription medicines. So we have decided in our next edition of the code we will actually restrict those items of brand name reminders.

JENNY BROCKIE: What sort of things, Will, where do you draw the line?

WILL DELAAT: We will draw the line at things which can leak outside the surgery and into the general public, so if they are pens, tissue boxes, coffee mugs, we think it is highly appropriate with change in community sentiment to actually restrict those to those items as we have seen earlier that are purely for use within the surgery.

JENNY BROCKIE: So just those things, what about things like models and stethoscopes and things like that?

WILL DELAAT: Well, they can only be used in the surgery, they can not leak outside.

JENNY BROCKIE: Patients see those things in the surgery, so what’s the difference?

WILL DELAAT: We believe it is important that the doctor has at their disposal those things that they can use effectively – as we’ve heard before -to elaborate to their patients the conditions that they have, but we don’t think it is appropriate in this day and age to have those things going outside into people’s homes, into the local newsagents or taxis, in terms of pens and other things which often leak outside the practice.

JENNY BROCKIE: Okay Joann, doctors are regularly given drug samples too and you agreed to show us some of those, let’s have a look at that.

DR JOANN GOODIER’S DRUG SAMPLES STORY:

DR JOANN GOODIER: This is a good example of what sort of samples and the number that a small general practice actually receives. There are only four of us in our practice. We have the opportunity to receive a lot more. On occasions I will actually ring the pharmaceutical company myself and say I would like some samples, I’m looking to start a patient on them. They are usually very helpful.

JENNY BROCKIE: Joann, it must be easier to start someone on a drug you have a sample of, but I wonder also whether it predisposes you and the patient to use that drug, whether that’s how it actually works having the free sample.

DR JOANN GOODIER: Well, for me, I don’t agree with that. The advantage of the free sample for me, is it keeps the cost down to the patient if they don’t end up being able to stay on the drug and medicines are expensive now for patients even with the support that is given by the government, also we are really concerned about adverse events. If you start a patient on a drug, you will know relatively quickly if they can tolerate that medication. That’s where I see the use of samples.

JENNY BROCKIE: But do the samples give that drug a head start in a sense?

DR JOANN GOODIER: No, no. Not for me.

JENNY BROCKIE: Okay Jon, what about the argument the patient benefits here, they get to try out an expensive drug they may not otherwise get an opportunity to have?

DR JON JUREIDINI: The most common outcome of that is that they keep on that expensive drug. The idea of adverse events is a really important. Pharmacists are trained to monitor the prescribing of medication to make sure it’s being prescribed safely and appropriately, that there are no cross effects with other drugs that the medicines are not out of date. All of those things are missing when we doctors give out samples.

JENNY BROCKIE: You don’t agree with samples at all?

DR JON JUREIDINI: Absolutely not and the argument that it helps out people who can’t afford medication is evidence to the contrary, most samples go to those who can best afford medication and many of them end up going to the doctors’ own families.

JENNY BROCKIE: We have some patients here who go to the doctor and may want to comment. Chantel, what do you think listening to all this?

CHANTEL CHADWICK: Actually I’m an asthmatic and I got a puffer prescribed or given to me by the doctor, it had 28 free samples, in the puffer, and I’m still on the puffer to this day.

JENNY BROCKIE: What do you think of what you have heard so far, do you think there are issues or don’t you care?

CHANTEL CHADWICK: I do care, I go to the doctor a fair bit. But at the same time if the medicine does work, then I’m happy to take that.

JENNY BROCKIE: Anyone else, Want to comment Allan, what do you think?

ALLEN JONES: I am living with prostate cancer, so I’m having a few problems. My neurologist handed me a script for Viagra, and I thought this is going to cost me about 100 dollars. My GP – when I told him said “Great Allan, I have a sample of this for you.” And he gave it to me – I was able to try it – I discovered it didn’t work. So I went back and then we went a different direction. If I hadn’t had that free sample, I would have gone out, bought a box. Yada yada ….

JENNY BROCKIE: Anyone else want to comment on this, what do you think, yes?

PROFESSOR PAUL KOMESAROFF: Here too, you have to look at the evidence, I respect the fact there are sometimes benefits and it is sometimes convenient for general practitioners. But the evidence about free samples is they don’t go to indigent patients on the whole, they always favour expensive new medications about which much less is known with respect to adverse effects and interactions with other drugs and they by-pass the extra supervision.

JENNY BROCKIE: Rob, I’d like to bring you in here, you’re a specialist at Royal Prince Alfred hospital in Sydney, and you chair the ethics committee. How often do drug reps visit your hospital and how do you deal with it at the hospital?

DR ROB LOBLAY, ROYAL PRINCE ALFRED HOSPITAL: Well, the drug people at the hospital all the time in association with the monitoring of clinical trials that is separate from reps who are involved in marketing. But they’re there every day, visiting different parts of the hospital.

JENNY BROCKIE: Can they talk to anyone at any time if they want to?

DR ROB LOBLAY: We do have a hospital policy, that junior doctors shouldn’t be seeing reps on their own, they should always be with a more senior experienced colleague, who can put the information into perspective and make sure that it’s accurate and be able to answer the questions from the junior doctors.

JENNY BROCKIE: Bill, last year Pfizer was fined the maximum $200,000 by your own industry body which is represented here. After at least one of your reps told doctors that a competitor drug was dangerous and may be withdrawn, that was the concern. This was described as extremely misleading in the decision and other reps were found to have acted inappropriately too. Does the marketing of drugs sit comfortably with providing the doctors the proper information – is there an inherent conflict in that?

DR BILL KETELBEY: No, not at all. What is clear is that we are the developers, the discoverers, the makers of these products. It is important that we use that information to pass it on to doctors to make sure they are as informed as we are about the products

JENNY BROCKIE: But there was clearly a problem about the way people were being informed here?

DR BILL KETELBEY: And what happened in this case was an unfortunate inappropriate sharing of information between drug reps that allowed unapproved information to be passed on. Clearly there was a breakdown in systems and once we became aware of it, obviously through the case, we intervened and have cleaned up our processes and procedures. I think what is fundamental to this though is while there was a fine imposed way more significant to us was the impact on our reputation as a professional organisation that really stands by and advocates the Medicines Australia code.

JENNY BROCKIE: Well you were forced to send corrective letters to all GPs and pharmacists in NSW and Queensland as a result of that incident?

DR BILL KETELBEY: Yes. It was important that we corrected any potential misinformation that been passed on. As I say, it was unapproved information, shouldn’t have been passed on, we recognised that, but I think what it points to that the Medicines Australia code works, it has teeth, when breaches are uncovered it certainly sanctions appropriately.

JENNY BROCKIE: Gordon Renouf, you, Choice surveyed GPs about visits from drug reps, what did you find in the survey?

GORDON RENOUF, CHOICE: The survey, which was a representative sample of Australian GPs and found the average number of visits from reps was 7 per week, about the level that doctors here are saying, some though a third had more than ten per week and others more than 20 per week. The issue for me is not so much the small gifts and so forth, it’s the fact that there’s a lot of drug reps going to doctors, they become one of their most important sources of information. Consumers will be better served when doctors have more access to objective information and the best possible access to clinically valid information and we think there should be a lot more independent provision of that sort of information for doctors.

JENNY BROCKIE: Garry Jennings, your from Baker IDI, which is a diabetes and heart research institution. You recently formed a partnership with a big drug company around a particular drug. Tell us how that worked and why you did it?

PROFESSOR GARRY JENNINGS, BAKER IDI HEART AND DIABETES INSTITUTE: Well we’re a medical research institute so therefore we have to have relationships with the pharmaceutical industry. They’re the only groups that can actually get a discovery which is a new treatment out into the market into every pharmacy in the world and doing some good. In this case, what we saw was really an opportunity for some cause related marketing, something that has been around for a long time, but not previously related to prescription drugs. The important thing about it is, it’s a donation, it was untied in terms of the way we can use that money, it will be used for public interest research, not related to the interest of the company. It is from a marketing budget and we would see it as a better use of as far as the community is concerned of that marketing budget…

JENNY BROCKIE: Now what was going to happen was that 25 cents from each packet of a particular anti-clotting drug was going to go to that research, is that right, from each …?

PROFESSOR GARRY JENNINGS: That was certainly in the beginning the way it was going to work, I think it’s now becoming just a straight donation.

JENNY BROCKIE: Now let’s have a look at the way the company publicised that deal. The ad was shown in the medical press, it’s a long ad down the side of a page, this is the top of it, then it goes to a second section there, then the third section. Ken Harvey, you complained about this association, this idea, why did you complain about it?

PROFESSOR KEN HARVEY, LA TROBE UNIVERSITY: It’s unethical to tie the donation of money to an institute, to the specific prescribing of a drug, that is against the code of conduct of Medicines Australia and it was found to be, but more importantly it actually ends up disadvantaging patients because this drug at the moment is under patent, at the moment, as I say, the government will pay the costs, except for patient co-payment, but in a year or two it will come off patent. When it does come off patent, generic companies can come in and much more cost effectively to produce the same alternatives. The problem with this deal is that doctors will keep on prescribing the more expensive brand name and patients will be disadvantaged.

JENNY BROCKIE: Your response, Gary?

PROFESSOR GARRY JENNINGS: I think that is hypothetical. Our arrangements for a year and I understand the drug doesn’t come off for a few years, it can only be prescribed under authority – that is – with permission from the PBS. It can only be prescribed under very restricted guidelines, so I don’t see much opportunity for the number of prescriptions to be influenced by this arrangement, nor do I see the generic argument as being relevant when it’s a few years off in the future.

JENNY BROCKIE: Will Delaat, you represent the drug industry and last week you fined Sanofi-aventis – who I should mention we did invite onto the show tonight and they declined to come on – you fined that company $25,000 over this arrangement, from inside the drug industry, what was the concern about it?

WILL DELAAT: Well, it’s difficult for me to comment precisely on what the code of conduct committee, how they viewed this particular complaint, because that is totally separate to the board of medicines Australia we have a separate code of conduct committee made up of independent physicians, representatives of the Medical Society, the government.

JENNY BROCKIE: But you must have a view about it, a $25,000 fine?

WILL DELAAT: We haven’t had the full details of their deliberations, so I suppose if they have deemed it to be inappropriate, that’s obviously the result of the independent review committee. But we still are waiting to see exactly the details of those deliberations.

JENNY BROCKIE: Ken, a huge amount of medical research is funded by drug companies – we know that, that’s part of the way the world works. What’s the difference? At least this is out in the open, at least it’s transparent?

PROFESSOR KEN HARVEY: I have absolutely no problems with drug companies being philanthropic to the Baker institute or others, that’s wonderful and it is an important corporate responsibility to fund that research. But to tie donations to doctors prescribing a specific drug is not appropriate. As I say, it came from their marketing budget, quite rightly because the aim of a marketing budget is to get brand names prescribing in perpetuity, to get the brand name into a doctor’s head, so that even when a drug goes off patent the doctor keeps on writing the more expensive drug, and that is the problem.

JENNY BROCKIE: Garry, that is what’s happened now, you have the donation now, instead of it operating this way, was it a mistake in hindsight to do that, what you did originally?

PROFESSOR GARRY JENNINGS: Well I think the issues with Medicines Australia has been to do with the advertisement, not with the arrangement, that I don’t think anyone is disputing. Like any other industry, this particular industry is able to make philanthropic donations to good causes. Was it a mistake? Well yes, I guess in the sense we have to do it a different way and I understand that probably this is a true test of whether it was a donation or not, the fact it’s going ahead.

WILL DELAAT: I just want to comment on what Ken said about the prescriptions for the drug post the patent expiry – in the way things operate in Australia is the pharmacist gets incentivised by the government, a dollar fifty for every time they convert the original brand when it goes off patents to the generic, so I don’t see how they can possibly be keeping the patients on that branded product after the patent expires.

JENNY BROCKIE: Quick comment from you Ken and then I want to move on.

PROFESSOR KEN HARVEY: 44% of drugs prescribed are branded expensive drugs despite the fact that there are generics available … Patients have got to plead, this is after generic substitution, it is not working, though the government is certainly trying to make it work.

JENNY BROCKIE: Okay, let’s move on – I want to talk about educational events, because last year Australian pharmaceutical companies ran I think 33,000 of them, they cost $62 million. More than half of that money was spent on hospitality, things like flights, meals, hotels, presumably for doctors, or at least a lot for doctors why is the industry spending that kind of money, Will, on educational events?

WILL DELAAT: There are a couple of important points to make here. One is that the makers and discoverers of the medicines are the ones that have all the information and it is only reasonable that they want to educate doctors about how to use those medicines in the context of the disease. So a number of educational events are conducted and hence the figures that you just quoted and they are bona fide educational events, the hospitality is purely secondary to the education that takes place. There are tremendous amounts of very good education that takes place across the whole of Australia today on weekends and evening meetings. Doctors won’t give up their evenings or weekends just to go for a meal, they only do it because they are getting value out of it. You have to put these issues in perspective, we talked about representatives before, that is only one element. There is a whole lot of very good education that takes place for the medical profession that is provided by the pharmaceutical industry.

JENNY BROCKIE: Okay Joann, you’re nodding your head?

DR JOANN GOODIER: I really think that’s true. We need it. We need to be able to find a way to work together and really openly. There is a balance. They have the information.

JENNY BROCKIE: Jon?

DR JON JUREIDINI: It’s absolutely clear that the imperative for most education that’s sponsored by the pharmaceutical industry is marketing not education. There’s absolutely no reason why we as a medical profession need to have any education provided by the pharmaceutical industry. The data that we need in order to be educated is freely available in the public domain. We have to accept as doctors that we don’t have a right to be given very comfortable circumstances in which to have our education that other professions don’t take for granted.

JENNY BROCKIE: Bill, can I get your reaction to this, how much would Pfizer spend on this sort of thing every year?

DR BILL KETELBEY: Well, the information is in that report as for the whole of the industry. Pfizer spends $6 million last year on education, 3,000 events, 100,000 doctors were educated. I think the comments that have come from the audience reflect the need. Ultimately that is what it is, there is a need there, we are satisfying a need. It’s not just the industry doing the education, colleges are doing it, divisions of GPs are doing it, the MPS is doing it, we are part of the education continuum. But what is fundamental is in any market research we do, it’s clear that GPs value what we are doing and in fact in very recent market research the commentary has been that they believe their patient care would have been substantially diminished had it not been for the education that we were providing.

JENNY BROCKIE: What’s in that for you, for Pfizer?

DR BILL KETELBEY: We are able to promote our products at the same time as educating doctors, fundamentally.

JENNY BROCKIE: Jon, if doctors are getting useful information and they are getting education and drug companies are prepared to pay, what’s the problem?

DR JON JUREIDINI: The problem is that the evidence shows that the information that is given at drug company sponsored educational events is not balanced – it favours the products that are being sold by the pharmaceutical companies.

JENNY BROCKIE: Ian Arthur, you’re a NSW GP, you said you rarely attend these educational events. Why?

DR IAN ARTHUR, GP: I think often they’re not a very good educative value, particularly the evening ones, you turn up there, wait for people, have a few drinks, have something to eat the guy gets up to speak, often pretty much promotes his product, and then people go home, you’re tired. So I actually stopped going to those. The information things I go to are weekend ones or whole day and in that situation you are really just getting a little bit of lunch, maybe morning, afternoon tea, no alcohol and you will get a range of speakers and cover a topic in depth.

JENNY BROCKIE: David, you wanted to say something about this, you’re quite involved in all of this.

PROFESSOR DAVID COLQUHOUN: And also teaching medical students for nothing for the last 20 years as well because the government doesn’t subsidise it. For the last 20 years because of my passion of lipid and diet and heart disease. A lot of committees – like the weekend things you’re talking about, independent committee -I spoke at a Pfizer one, the difficult things, how we manage them or natural therapies and heart disease. No-one had any control over what I was talking about, it was enjoyable.

JENNY BROCKIE: Were you paid by Pfizer?

PROFESSOR DAVID COLQUHOUN: Yes I was, but I was paid about a third of what I would do during the week ordinary working and I came economy class just like today with SBS and the food was better, so the lavish dinners just doesn’t happen any more. And in terms of consultant fees the government pay me a lot, three times as much of consulting for the government.

GORDON RENOUF: And the lavish dinners don’t happened because people were upset about them and called for change, and more change is required. In our survey, 3 per cent of GPs, not specialists, were invited to go overseas for their training, last year- just one year, 3% of GPs we surveyed. If you’re in a unique speciality, you may need to go overseas for adequate training but I can’t see how that level of overseas travel for GPs is warranted.

JENNY BROCKIE: Bill, do you want to comment on that?

DR BILL KETELBEY: Well I can’t comment on that particular circumstance.

JENNY BROCKIE: On overseas trips in general, a reaction to why you need to go over seas to get the training rather than have it locally?

DR BILL KETELBEY: There are overseas meeting, substantial huge big overseas meetings, where clearly the information is of a global nature and it is absolutely appropriate that specialists in those particular areas do attend those meetings and we on occasion absolutely do sponsor specialists to attend these meetings and pay for them.

JENNY BROCKIE: Rob?

DR ROB LOBLAY: I think the crucial thing that hasn’t really come out is that it’s all about who picks the topic, and who picks the speaker and the content. If the speaker, the content and the topic are chosen by the doctors, and the sponsorship is from the industry, there’s usually not a problem…. It is the sessions where the industry picks the speakers and the topics which are of most concern.

JENNY BROCKIE: Matthew, you’re a respiratory specialist. I wonder where you draw the line on all of this?

DR MATTHEW PETERS, RESPIRATORY PHYSICIAN: Well, I draw the line at only the vain and ignorant are, believe that they’re uninfluenced, sitting next to Gordon and one of the things one must be careful about is one presenting drug or non-drug solutions to the same problem. So I do and I have been involved in advisory boards and I think they formulate good policy and provide good imput as long as they’re appropriately constituted.

JENNY BROCKIE: Do you get paid for that?

DR MATTHEW PETERS: Yes, and that pay would be somewhat less than I ordinarily earn to get in my normal job where I have to take a day off to do these things if it’s a full day. In terms of educational sessions for GPs I never give a pre-scripted preparation. I have my own standard, my own slides, my own presentation. That’s the practice that I follow. I think that actually has credibility with GPs. And these days GPs are actually, interesting to see what the industry say, but my perception is GPs are asking for some speaker or others and will turn up for some and will not turn up.

JENNY BROCKIE: Will, I would like to ask you a question, until a year ago you ran the company that made Vioxx. In court we’ve heard how far that company considered going to sell Vioxx. We heard a lot of evidence about marketing and so on, things like a plan to fly in a Vioxx-friendly expert to an educational event who would quote, “drop a few concerns about competitors drugs”, the publishing of this journal and so on. Do you think doing those things is okay in terms of these conferences and these events?

WILL DELAAT: Look, it would be very inappropriate for me to talk about the actual Vioxx situation because it’s before the courts as you rightly said before. The point I really want to make in answer to your question is that, that particular company that was behind Voxx, Merk, I worked for almost 20 years and I know the values of that company in putting patients and patient outcomes first. I think it’s only fair to say that the company acted responsibly at all time, I. I know personally despite the fact my involvement with the company for those many years, is I can lie straight in bed at night because I know the company acted responsibly.

JENNY BROCKIE: So you think that sort of marketing is all right, you think the idea of planning to fly in a Vioxx-friendly expert for a conference who will drop a few concerns about a competitor’s drug is all right?

WILL DELAAT: Look, if we’re talking big picture here, not specifics about those particular examples, we’re talking about the hypothetical, companies will bring experts in from countries like the US where the research has been undertaken for the medicine, where sometimes the medicine has been on the market a lot longer than it’s been here in Australia and experts will come in and talk to their colleagues in Australia, that is common practice across the industry.

JENNY BROCKIE: Ken, very quickly, I want to ask you a question too, what would happen if all these conferences disappeared? Where would doctors get their ongoing education?

PROFESSOR KEN HARVEY: As John said, there’s a lot of independent resources, and in particular in Australia we have the national prescribing service which is funded by government to give independent information to doctors and GPs and indeed I give lectures for the national prescribing service in third rate motels as some of my colleagues say, without $200 a head dinners but they’re valued. We believe that we give good independent information. We promote generic drugs where it’s appropriate and non-drug solutions as well.

JENNY BROCKIE: Some twitterers are saying they would like disclosure on some of these issues and others are saying they think it is important that doctors do have a relationship with pharmaceutical companies as developers of new drugs. Paul, I wanted to ask you a question about your organisation’s UK counterpart on this question of disclosure, because it’s recommended that doctors in training be weaned off drug company education. I’m using quotes here, within five years. And that all gifts to doctors including food and travel should end. Would you be recommending that here?

PROFESSOR PAUL KOMESAROFF: The Royal Australasian College of Physicians makes broad recommendations to doctors but doesn’t tell them what to do. Our role is to provide the evidence and the arguments to empower people to decide for themselves. It is our view that that is the way things should go. We recognise that it is important to have this conversation within the community and that there needs to be a process of cultural change. We think that process has occurred or is occurring and that doctors are becoming increasingly aware of the risks of accepting gifts of going to events that are called educational events but are really promotional events under a different guise and we also accept that people recognise the risks associated with exposing students to pharmaceutical promotion.

JENNY BROCKIE: Some members of the public keen to have a say.

MEDICAL STUDENT: Yes, as a medical student, we’re taught extensively how to find our own evidence-based research into what we should do in practice. And I think as John said drug company-sponsored education is biased and there are ways to find out unbiased sources of formation, the National Prescriber Service.

JENNY BROCKIE: Well, Janette is here from the National Prescribing Service and it might be a good opportunity to give her a say about what service you provide that is separate from all this?

JANETTE RANDALL, NATIONAL PRESCRIBING SERVICE: Well we’re an independent organisation Jenny, funded by government and it is our role to provide a very independent and balance voice in all of this. And I agree with what you said, there is a real tension between promotion and education and I think that is a very fine line to walk. So we accept that drug companies will promote their products and that GPs can find that information quite helpful, but we also see that there is a very large need for an independent voice in all of this.

JENNY BROCKIE: Gentleman up the back and then David I will come to you.

JOHN FLORIO: Just recently I was working on a cruise ship as a massage therapist. There were 50 chemists that came onto the ship, there was no education, there was nothing like that, but they were all on there, partying, having a good time, $10,000 a head, this cruise was.

JENNY BROCKIE: They may have been on holiday?

JOHN FLORIO: No, they weren’t on holiday, there was 50 of them on there for a promotion because they got the top sales in their chemist.

JENNY BROCKIE: So it was a sales celebration.

PROFESSOR DAVID COLQUHOUN: There’s an insult to the integrity the doctors are the specialists giving the talks, to say I’m influenced because Pfizer put on a thing… That I won’t talk about diet and heart disease, we had the heart foundation 50 year anniversary in Brisbane last week, a fantastic time, where are all the people here? Could have gone, fantastic, it was partly supported by the pharmaceutical industry, as well as registration and… Give the money to the heart foundation, totally independent, who we had talking etc, etc.

JENNY BROCKIE: How would you react David to the idea of being weaned off this drug company money and these events?

PROFESSOR DAVID COLQUHOUN: I was weaned off the breast when I was a kid, so this weaned off, what do you mean by weaning off?

JENNY BROCKIE: It’s a term I have in quotes, I think it was used in the UK actually.

PROFESSOR DAVID COLQUHOUN: Will the government come in? They are not supporting undergraduate education at all, post graduate education, who is going to do it

JENNY BROCKIE: Bill?

DR BILL KETELBEY: To follow on from that exact point, I think that is fundamental that the significant amount of money that is put into education, medical education as we’ve seen from the code, who is going to fund it? If it doesn’t come from the industry, where is that funding going to come from?

JENNY BROCKIE: Gordon?

GORDON RENOUF: Well the bottom line is the consumer welfare depends on getting good medical outcomes which depends on the best possible evidence available to doctors, we agree on that much. The question is how to fund that. We believe that the national prescribing service is a great model, it should be more significantly funded so it can get to more doctors, currently you get about 80 full time equivalent staff, about 3,000 drug reps. So there are ways to fund the MPS more. If we save on irrational use of medicines, if we help the drug companies reduce their marketing budget so they still make as much money, we’d all be better off.

JENNY BROCKIE: Ian?

DR IAN ARTHUR: There are really good learning opportunities on line now, run by the college of GPs, really good things through the university of Queensland, about 6 or 7 of those, and you can spend 6 hours, you go through a whole learning programme, it’s interactive, it doesn’t cost anything, you can do the learning on your own, it’s very good quality.

JENNY BROCKIE: Will, what do you think of this?

WILL DELAAT: Well, look, this comes back to the whole concept of the education that’s provided. In some way it seems to be inherent in the conversation that it’s tainted in some way. This is bona fide genuine education that doctors want. Doctors see value in it, they turn up to the meetings so far as representatives are concerned, there’s about 90% of GPs very happy to see reps get that kind of input into their knowledge about new medicines. I think it is a bit of a storm in a tea cup essentially.

JENNY BROCKIE: Lady here wanted to say something, yes?

MEDICAL STUDENT: Surely even if you say that it’s independent information, there’s still a drug company name attached and you’re engendering a feeling of good will and then there’s some sort of obligation to repay that. Not explicitly, but implicitly, in that you get this feeling that you’ve had something.

JENNY BROCKIE: Are you a medical student by the way?

MEDICAL STUDENT: Yes.

WILL DELAAT: Let’s be realistic… the pharmaceutical companies are fiercely competitive. They are commercial operations. They return a profit to their shareholders there no question about that. The issue we are talking about here is do they put patient outcomes first. I can tell you from all my years of experience, they do, they will go out of business very fast if they weren’t concerned of patient outcomes.

JENNY BROCKIE: Ken, what do you say to that?

PROFESSOR KEN HARVEY: Vioxx.

WILL DELAAT: Vioxx what?

PROFESSOR KEN HARVEY: Come on, you suppressed information about side effects, you tried to neutralised critics that tried to put that alternate information. The whole issue about Vioxx, it’s not the only one, is one about industry trying to control information, trying to suppress honest information

JENNY BROCKIE: We will have to tread carefully, because this case is being heard, even though it’s a civil court, it is being heard at the moment. The point you’re making is that there have been incident where you think that is under challenge.

PROFESSOR KEN HARVEY: I have students who have tape recorded drug rep consultations with GPs, we’ve published the results, the information that drug reps say is overtly positive the side effects and down sides of drugs are camouflaged and not talked about and it is biased information.

JENNY BROCKIE: Martin, you recently surveyed patients to see how aware they are of interaction between drug companies and doctors. What did you find in the survey you did?

PROFESSOR MARTIN TATTERSALL: We found almost complete ignorance of what was going on, although it may be theoretically out in the open, patients did not know about whether their doctors or the doctors they saw had any interactions with the pharmaceutical industry. They indicated they wanted to know and they said that if they knew they would be better able to evaluate the information they’d been given.

JENNY BROCKIE: Do patients care? Those of you who are here, I don’t want the medical students to comment, I would like to hear the patients comment, yes gentleman up here?

PHARMACIST: I’m a pharmacist, working both in the industry and in community pharmacy, and I find it very difficult to counsel a patient for 15 minutes trying to tell them that both your Amoxil and your Amoxocyllin and your Cylomox are the same, now why is it on the script, written as Amoxcyllin not brand medicine.

JENNY BROCKIE: And the lady over there wants to have a say too?

WOMAN: I’m a locally patient.

JENNY BROCKIE: A lowly patient?

WOMAN: A lowly patient, I understand the importance of the pharmaceutical companies but I would like my medicine prescribed because it’s good and not because it’s a free sample, not because they had interaction with a pharmaceutical company. I would like my GP to do investigation of their own.

JENNY BROCKIE: Bill, Pfizer in America recently announced that it would start publishing consulting and speaking fees that it paid to doctors and is thinking of revealing benefits worth more than $500 a year to individual doctors, including meals, I know you want to say something. Is Pfizer here likely to follow suit with something like that?

DR BILL KETELBEY: Well let me pick up first of all on some of the comments that have already been made, inherent in a lot of comments is the issue about transparency, the transparency of what the pharmaceutical industry is doing. I would say to you, that the pharmaceutical industry amongst all industries must be one of the most transparent there is. Pfizer publicises its full research pipeline on a public website, all clinical trials we understand are publicised on a website.

JENNY BROCKIE: This is specifically about publicising the money payed to doctors.

DR BILL KETELBEY: There is inherent in this a transparent ethic that we are trying to get across at Pfizer and I know the industry is as well. So all payments, donations, are all publicised on a website or grants or fellow ships.

JENNY BROCKIE: But to individual doctors?

DR BILL KETELBEY: And in America there is now a new initiative that is being put in place where actually doctors are going to be put on a public website, they’re going to be named on a public website for those that have received greater than 500 dollars a year.

JENNY BROCKIE: That’s my question, would you consider something like that here?

DR BILL KETELBEY: We think it is an interesting initiative. It is going to start next year. We’ve made no local decision on it. Clearly we need to take into account local needs and requirements. It is appealing, we like the idea. We have to review i

JENNY BROCKIE: David, how would you feel about that, having your association… The payments… Publicised?

PROFESSOR DAVID COLQUHOUN: I went to an Omega3 meeting, gave up work, to go to what’s really a charity. I wrote to Crieky dot com I was paid just economy air fare – just like SBS, I didn’t get lunch…

JENNY BROCKIE: Let’s get serious here. How would you feel about full disclosure of all the payments you receive?

PROFESSOR DAVID COLQUHOUN: No problems. We have the politicians in Queensland, like front page of The Australian today, I think everybody, why single out doctors when in fact I’m quite happy, I’m paid when I’m consulting with the drug companies about a third of what I would doing ordinary work.

DR IAN ARTHUR: I think there is a really important thing here that you’re missing, that is that most of the costs of medicines is paid for by the government, not paid for by the patient, so when we generate extra costs as doctors it’s generating it for the taxpayer if we’re spending a lot of money on drugs when there are cheaper options then that’s fewer patients having hip replacements, people waiting longer. So I think that we’re in a unique position as doctors we’re responsible as private people for generating a lot of public expense and it’s hidden.

JENNY BROCKIE: A quick comment from you Jon?

DR JON JUREIDINI: I want to comment on transparency issue because the reason why we know things that we know about drug companies’ behaviour is not primarily through transparency but through legal action that’s been taken that’s made things public that were meant to be private. Much of registration of failed trials on the Internet and in publication as a result of court orders or agreements made between litigators and the pharmaceutical industry. Much of this is about damage control not about a real wish for transparency

JENNY BROCKIE: Quick wrap up?

WILL DELAAT: We have to remember we have a pharmaceutical benefits scheme in Australia where all the checks and balances are in place, because when drugs are on the market, they’re put there because they’re cost effective. So it won’t cost any less when a drug company doesn’t provide the education. The cost of the drug is what it is.

JENNY BROCKIE: We will have to wrap up. Joann we started with you and I want to finish with you. Given patients are interested in knowing these things, how do you think this can all best be dealt with as a GP?

DR JOANN GOODIER: I think we’re moving forward, I really do and this is a great forum for it. Transparency will become the norm, it will happen, in every way, and I think we will learn to work together in a much better way.

JENNY BROCKIE: We did invite the AMA and the college of GPs to join us tonight, they declined.

 

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As an advertising man, I can assure you that advertising which does not work does not continue to run. If experience did not show beyond doubt that the great majority of doctors are splendidly responsive to current [prescription drug] advertising, new techniques would be devised in short order. And if, indeed, candor, accuracy, scientific completeness, and a permanent ban on cartoons came to be essential for the successful promotion of [prescription] drugs, advertising would have no choice but to comply.
- Pierre R. Garai (advertising executive) 1963