Is it time for a closer watch on the relationship between doctors and pharmaceutical industry? Dr Muiris Houston, Medical Correspondent reports
The latest edition of the Medical Council "Guide to Ethical Conduct and Behaviour", - which tells doctors how to behave professionally - contained a number of surprises.
The insertion of a key paragraph has been interpreted as a sign that the outgoing Medical Council had become concerned by the activities of doctors and pharmaceutical and medical manufacturing industries in the area of sponsorship. Indeed at the launch of the guidelines the Council President, Professor Gerard Bury, described the relationship as "cosy".
A section of the guide stated: "non-promotional educational grants represent the only accepted mechanism for financial support by the pharmaceutical and medical manufacturing industries to individual doctors".
The Irish Times last week reported that Beaumount hospital had issued a draft document to its consultants on this issue. "In regard to sponsorship for attendance at meetings (with drug company representatives), a log of all meetings attended will be maintained, together with details of sponsorship received," it said.
It may come as a shock to people to learn that between 80 and 90 per cent of postgraduate medical education in the Republic is sponsored by the pharmaceutical industry. Between 1996 and 2001 the Post Graduate Medical and Dental Board, a statutory body charged with postgraduate education, paid out €7.8 million to professional bodies. This represents just €1.3 million annually. In 2003 the PGMDB spent €833,876 on continuing medical education for general practitioners.
The bulk of pharmaceutical company largesse involves the sponsorship of clinical meetings, medical association AGMs and conferences at which research is presented, all extremely appropriate activities without which doctors could not keep up with the latest advances in medicine.
However, alarm has been expressed that some pharmaceutical company money is channelled into activities peripheral to education. While many would not quibble with an eminent foreign speaker having his flights and accommodation paid for, the same cannot be said of other aspects of sponsorship.
Is it appropriate that doctors are themselves put up overnight in plush hotels as part of attending a meeting? And what of the regular practice of paying the travel expenses of hospital consultants (and some junior doctors) attending conferences abroad?
Every doctor, this writer included, has benefited from the support of the pharmaceutical industry. Whether it is free pens, free mugs with promotional logos, golf balls or umbrellas, we have all been regular recipients of minor gifts. They are distributed by the representatives who call to surgeries and clinics and are available at promotional stands at medical conferences.
Section 14.1 of the Irish Pharmaceutical Healthcare Association (IPHA) code of conduct says: "a person promoting a medical product must not supply or promise to health professionals, gifts, pecuniary advantages or benefits in kind unless they are inexpensive and relevant to the practice of medicine".
The question that arises from any sponsorship, no matter how small, is how much does it influence the prescribing of the doctor who receives it?
This very question was the subject of an entire theme issue of the British Medical Journal, published last May. An editorial titled: "No more free lunches", said "our central argument is that doctors, drug companies and most importantly patients would all benefit from greater distance between doctors and drug companies".
It went on "Doctors and drug companies must work together, but doctors do not need to be banqueted, transported in luxury, put up in the best hotels and educated by drug companies. The result is bias in the decisions made about patient care".
Strong stuff and one that raised the hackles of the industry and of many doctors. The Irish Times contacted a half a dozen doctors in preparing this article. Most felt that their prescribing was not influenced by pharmaceutical company hospitality. Just one expressed distaste for the dependence of the profession on the industry for its educational needs. However, all acknowledged that, to an outside person, the relationship might appear overly cosy and suspect.
What about the industry itself? Steve Ross, general manager of Glaxo Smith Kline (GSK) Pharmaceuticals (Ireland) says doctors simply do not have the resources to travel to international meetings. Referring to the new Medical Council guidelines, he said, "the industry welcomes this. Both doctors and the industry need to take care. If our relationship is perceived as too cosy, then that calls into question both sides".
Describing the Republic as being four to five years behind the US on this issue, he said GSK had introduced a strengthened ethical code on January 1st this year. "We have gone further than the IPHA code so we do not get involved with bringing a group of 20 doctors to Mount Juliet to play golf," says Ross.
What is the situation in the US? About three years ago, the issue of pharmaceutical company relationships with individual doctors became a national one. Both media attention and subsequent government action brought about a change in practices. Golf with customers was banned and it was acknowledged that because doctors are prescribing for a third party (patients) the normal rules that might apply to other industries were not appropriate.
In Europe, both the UK and Scandinavia have demanded higher levels of appropriate links between the industry and doctors. Other countries have voluntary codes of practice similar to here. But there is no single pan-European approach to promotional activity by the pharmaceutical industry.
According to Andrew Witty, president of pharmaceuticals for Europe with GSK, in some European countries governments contribute nothing to medical education.
"The industry would prefer if governments took more interest in educating doctors about new drugs and new medical procedures," he says.
Drug companies also sponsor patient advocacy groups. Again there has been some controversy about this. According to Dr Harmon Eyre, medical director of the American Cancer Society (ACS), there have been occasions when the industry has crossed the line by linking support to advocacy groups in return for backing specific products. "But generally if resources for advocacy are available, they should be shared for the common good by means of unrestricted educational grants."
Here the Irish Cancer Society accepts funding from the pharmaceutical industry to send expert staff to international conferences where data on recent advances in treatment is presented.
The entire issue of pharmaceutical sponsorship needs debate in this country.
If nothing else the recent Medical Council guideline has helped to initiate this. As Mr Michael Dempsey, president of the IPHA says: "I am happy with what the Medical Council has done. We hope to discuss this with them and to move the issue forward."