BMJ  2008;336 (21 June), doi:10.1136/bmj.a413

Editor's Choice

Key opinion leaders, your time is up

We’re lucky in medicine to have an unending supply of mysteries to ponder. Some of these—like why vitamin A supplementation benefits some children while harming others—are amenable to scientific research (doi: 10.1136/bmj.39575.486609.80;doi: 10.1136/bmj.39542.509444.AE). But there are mysteries of a different sort, ones that are in our power as a profession to resolve. Why, for example, is it considered normal for medical leaders to accept personal payment for promoting a company’s drug or device?

This week Ray Moynihan asks whether paid "key opinion leaders" can be independent or are just drug representatives in disguise (doi: 10.1136/bmj.39575.675787.651). His interview with former sales representative Kimberly Elliott suggests the latter. We know from independent studies that paid opinion leaders can increase use of a target drug or device. Even if we didn’t know this, we would have to assume it from industry’s continued funding of "KOLs." Speakers who don’t make enough impact on drug sales are dropped, says Elliott.

Perhaps most troubling is the way industry grooms potential opinion leaders. Quoting from the magazine Pharmaceutical Marketing, Moynihan says that industry staff are told to find doctors who will endorse their products "who may be further down the influence ladder," and then help "raise their profile, and so develop them into opinion leaders."

Of course industry is doing nothing illegal, and it employs many fine people motivated more by improving health care than making a profit. In this week’s Head to Head, Charlie Buckwell argues that industry has an ethical obligation to work with influential health professionals so that each side understands the other’s thinking (doi: 10.1136/bmj.39541.702870.59). The fact that these interactions can affect clinical practice is not necessarily bad, he says, since this can help doctors appreciate the benefits of some drugs.

But is this the best way to inform doctors? What of evidence based medicine, which asks us to use information that has been gathered systematically and evaluated objectively? Moynihan also spoke to Richard Tiner of the Association of the British Pharmaceutical Industry, who said that key opinion leaders are "free to speak about other medicines" and their presentations are "often quite balanced." Surely doctors should be setting their sights higher than this?

Buckwell argues for tighter rules and role definitions, and there are signs that things are improving. It’s now rare in the best forums that speakers fail to start with a slide declaring their conflicts of interest. But how often do these declarations tell the full story? Have you ever heard speakers say that they were paid an honorarium and travel expenses and that the sponsor prepared their slides?

Such transparency is crucial if we are to understand the full extent of the influences we are under. But can we look ahead to something even better, to an era of truly independent medical leadership? Giovanni Fava thinks we can and should (doi: 10.1136/bmj.39541.731493.59). He envisages "a reservoir of truly independent experts" and calls for an end to "business disguised as science." Medicine sorely needs leaders, but not if a they’ve been bought.

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