bmj.com Rapid Responses for Abbasi and Smith, 326 (7400) 1155-1156

Rapid Responses to:

EDITORIALS:
Kamran Abbasi and Richard Smith
No more free lunches
BMJ 2003; 326: 1155-1156 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

what is the alternative: Abdullah Shehab (30 May 2003)

Saying no to free lunch: not easy as it seems: G.N. Malavige (30 May 2003)

the effect of seeing drug reps & influencing subsequent prescribing: Bernard Choi (30 May 2003)

Why we need a charter: Dr Graeme T.R. Spencer (30 May 2003)

'But it's only a free pen...': Lucy-Jane Davis (30 May 2003)

Physicians' links with pharmaceutical companies...: David N. Andrews (30 May 2003)

Doctors as the middlemen: Pitt O Lim (30 May 2003)

No More Free Lunches: John P Chapman (30 May 2003)

Horses for Courses: Medwyn Williams (30 May 2003)

This is just the beginning!: Wiel M Maessen (30 May 2003)

I have sinned, and yet....: stephen f hayes (30 May 2003)

Free Pizza - goes a long way: Andrew Robinson, Canada (30 May 2003)

Drug dependent health care is fundamentally wrong: Antony E Green, Anne Foxley (30 May 2003)

Drug Lunchesh: elias E Anikwe (30 May 2003)

Not just drugs...: Rachel Myr (30 May 2003)

The entanglement is greater than we think: Philipp A Conradi, Loy Yap. Jacqueline Hughes (30 May 2003)

Editors'bias: Olav Meirik (30 May 2003)

How apposite - No Free Lunch: Anne Foxley, Antony Green (1 June 2003)

Enough already: Simon Wessely (1 June 2003)

'Mea Culpa' : By Dr Joseph Obi: Joseph .C. Obi (1 June 2003)

Why are we afraid?: sudhir kaligotla (1 June 2003)

What's wrong with a free lunch: Simon A. Kaye (1 June 2003)

Why do we like the freebies?: Susan J MacCallum (1 June 2003)

People in Glass Houses...: James Hickman (1 June 2003)

Not Holier than Thou: Adam Moliver (1 June 2003)

No Free Lunch: Sarah E Gull (1 June 2003)

BMJ heal thyself...: Richard T Halvorsen (1 June 2003)

Sponsors or Spivs ?: Bernard C BOYD (1 June 2003)

an australian viewpoint: ian c arthur (1 June 2003)

Re: This is just the beginning!: Antony E Green (1 June 2003)

Noble as it sounds, journals in West Africa cut off drug companies to their peril: Joseph Ana, LU2 7AE. (1 June 2003)

Relationship between the Drug Industry and Doctors: Umesh PRABHU (1 June 2003)

Free Lunch learning is better than lunch free learning!: Sidha Sambandan (1 June 2003)

Science and Money Changers: David Elpern (1 June 2003)

Spouse Scorn: Des Spence (1 June 2003)

A hungry student's view: Ruth H Armstrong (1 June 2003)

The bonfire of vanities: John Hopkins (1 June 2003)

Responses to Abbasi/Smith article: Dr Deepak Malhotra (1 June 2003)

Yes Its Possible!: Mohan Devegowda (1 June 2003)

Re: Re: This is just the beginning!: Wiel M Maessen (1 June 2003)

NO MORE FREE LUNCHES: Nigel Puttick (2 June 2003)

gullible greedy pigs: paul kerr (2 June 2003)

The Cloak of Service: Nasir R. Awan (2 June 2003)

Big pharm owns worldwide cessation policy: John R. Polito (2 June 2003)

Time to own up: Colin Fitzpatrick (2 June 2003)

Re: Enough already - Critical Psychiatry Network campaign: Duncan Double (2 June 2003)

Subliminal messages: Jeremy J Black (2 June 2003)

Doctors and the Drug Industry: Jeff D. Chapman (2 June 2003)

People in glass houses should be careful about stones: Andrew J Ashworth (2 June 2003)

Re: Relationship between the Drug Industry and Doctors: Rita Pal (2 June 2003)

Understand the business economic model and recognze the inevitable: Robert A Knuppel (2 June 2003)

Naivete: Martin D Talbot (2 June 2003)

Free journals or free conferences: David A Sulch (2 June 2003)

Medical Model: Gerard D Finnegan (2 June 2003)

More freedom: dr nayyar yaqoob (3 June 2003)

Who pays for lunch is not important when you are out with your real friends: michael a james (3 June 2003)

The Parasites Who Take a Free Ride on Our Taxes!: Carol A Teasdale (3 June 2003)

Conflict of interest: "Alzheimer disease seems to suffer more than most in this respect": Alexei R. Koudinov (4 June 2003)

Free Lunch is never a free Lunch: Mohammed Mujtaba Ahmed (4 June 2003)

Free lunches - ok if they are a la carte: Angus M Ross (4 June 2003)

Ethics Committees are part of the problem, not the solution.: Linnie Price (4 June 2003)

..on a positive note..: Radhika R Hariharan (4 June 2003)

The hosts who never get a 'thank you'.: Gurli Bagnall (4 June 2003)

I ask why and how: Francesco Carelli (4 June 2003)

Evidence based sponsorship: Frank O Wells (4 June 2003)

In Who�s Interest?: June C Nicholls (4 June 2003)

Well Done BMJ and about time.: Dr. Terry D. Lynch (4 June 2003)

Nurses will be their next target: Liz Darlington (5 June 2003)

Entanglement with government and pharmaceutical companies.: Peter L Jenkins (5 June 2003)

A paper in search of emotional intelligence?: Marios Adamou, Marios Adamou, Anthony S. Hale. (5 June 2003)

Do I smell sour grapes?: David M Lewis (5 June 2003)

The medical profession is losing our trust.: James J. Ebersold (5 June 2003)

Reform must also include:: June Brown (5 June 2003)

Mental Health Crisis: Adrienne G. Shoemaker (5 June 2003)

The real costs of free lunches: Catherine E Richards (5 June 2003)

No free lunches - no loss: Peter C Arnold (5 June 2003)

Solution: increase professional income by free market means: Richard G Fiddian-Green (5 June 2003)

Journals should avoid drug advertisments completely.: Frances E Fermer (5 June 2003)

Conflict of Interest: June C Nicholls (5 June 2003)

Free lunches exist - and the NHS needs them: Philip Rutledge, Simon Maxwell (5 June 2003)

No more free lunches: Peter D O Davies (5 June 2003)

Medicine As Big Business: Stephen S. Engleman (5 June 2003)

Hippocratic Oath Revision: Fredrick E. Keller (6 June 2003)

Stop Bribing Doctors: Trish A. James (6 June 2003)

Doctors can stop the inappropriate relationship NOW: Debbie A Lawlor (6 June 2003)

Follow the money trail: Jacob W. Dijkstra (6 June 2003)

Reform overdue!: Arnie Welber (6 June 2003)

Actually in re: prescription freebies to doctors: Donna M Birkholz (6 June 2003)

The Problem is world wide: Ange Kenos (7 June 2003)

'Symptomatic relief medicine' is bad medicine: June C Nicholls (7 June 2003)

How to dance with porcupines: Steven Rudolphy (7 June 2003)

Current attitudes are unacceptable: Zvonko Rumboldt, Vedran Carevic (11 June 2003)

One other point: James D Curran (11 June 2003)

a cynic's riposte for the holy joes: john i hickey (11 June 2003)

Medical Education needs drug sponsorship: Liz Spencer (16 June 2003)

A former drug rep's opinion.: Michael Wood (17 June 2003)

The grip of the market: K. S. Madhavan (25 June 2003)

NO FREE LUNCH: Mike L (25 June 2003)

Independent evidence-based information to promote rational pharmacotherapy.: Nina H. Bjarnason, and Jens P. Kampmann (27 June 2003)

Cancer treatment and unholy connections: Patricia A. Wootan, 12401 (11 July 2003)

Doctors and Drug Companies: Moses Abe (12 March 2004)

what is the harm with it?: anshul avijit (25 May 2004)

Bullying of the companies: Carlos Cuello (26 May 2004)

NO FREE LUNCHES !! WHY NOT ?: S GADA (17 June 2004)

Declaration of Competing Interest: forced confession?: Anton E Joseph (17 August 2004)

Re: A hungry student's view: Wendy Lydall (11 April 2006)

what is the alternative 30 May 2003

Abdullah Shehab,
Lecturer in Medicine
University Of birmingham
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Re: what is the alternative

This business of pharmaceutical companies play a great role in influencing doctors patient management lacking evidence.
Almost all medical conferences and meeting are sponsored by these companies and imagine stopping the sponsorship. Also obviously the senior doctors are the one with great reward from these visits on the hand juniors will be satisfied with cold lunch. anyway the issue is more complex than simply medical students to be asked to take a revised Hippocratic oath that forbids the accepting of money, gifts, or hospitality in my opinion. There should be an alternative or if not then I believe in old saying �if you can't beat them, join them�.
Competing interests: None declared

Saying no to free lunch: not easy as it seems 30 May 2003

G.N. Malavige,
Lecturer in Microbiology
Department of Microbiology, University of Sri Jayawardanapura
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Re: Saying no to free lunch: not easy as it seems

It is certainly true that drug companies influence doctors prescribing habits. This may in turn lead to doctors prescribing expensive and often unnecessary drugs of the drug companies whom "buy them pizzas". This is more of a problem in developing countries than developed countries where doctors are paid less and expected to do more which often leads to dissatisfaction with work and frustration. The doctors may never be able to afford to participate in international conferences or hold workshops or seminars without the sponsorship from drug companies.
While there may be codes of practice regarding the relationships between doctors and drug companies in developed countries, such codes or governing bodies to look into patients rights do not exist in developing countries. The majority of the population in developing countries is poor and do not question or suspect the prescribing behavior of doctors, which puts them at a greater risk of exploitation. Moreover, since most doctors practice evidence based medicine, this evidence should be not be influenced by pharmaceutical companies.
It is evident that pharmaceutical sponsorship is vital for continuing medical education and other professional activities. So far "codes of practice" and educating doctors regarding the ethical issues involved with "free lunches" has not had any impact on the behavior of the medical profession nor the pharmaceutical companies. Therefore, taking audits of prescriptions of doctors and critically analyzing them may have a greater impact. For instance, most hospitals have audits regarding transfusion of blood products, which limits unnecessary transfusion and proper usage. Similarly, prescriptions could be examined randomly and good prescription guidelines issued for those who prescribe drugs unnecessarily. The measures American universities have taken could also be very effective as it is always easier to stop a bad practice before it occurs than after it occurs.
Reference:
1. Abbasi K, Smith R. No more free lunches. BMJ 2003; 326: 1155-1156
Competing interests: None declared

the effect of seeing drug reps & influencing subsequent prescribing 30 May 2003

Bernard Choi,
general practitioner
RG6 7HG
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Re: the effect of seeing drug reps & influencing subsequent prescribing

seeing drug reps undoubtedly influences prescribing - subconsciously, if not consciously. If it didn't, drug companies wouldn't spend millions of �/$ & time allowing their reps to see drs! drug companies are not charities, when their jobs & bonuses depend on their profit & share price!
Competing interests: None declared

Why we need a charter 30 May 2003

Dr Graeme T.R. Spencer,
GP
Earnswood Medical Centre, 92 Victoria St, Crewe, Chesire, CW1 2JL
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Re: Why we need a charter

I've always remembered reading about how nofreelunch.com started after a New York doctor realised that patients thought he was paid by the pharmaceutical industry because he walked around his psychiatric department with a Prozac logo on his briefcase .....
Competing interests: None declared

'But it's only a free pen...' 30 May 2003

Lucy-Jane Davis,
Medical Student
Peninsula Medical School
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Re: 'But it's only a free pen...'

Having worked within the pharmaceutical industry; then moved into research; and now studying as a (slightly mature) medical student, I am delighted to have read this article.
I worked as a medical editor/writer within the pharma industry - I was an elusive 'ghost writer'. I left the lucrative option of a career in this field because I realised that my desire to make people 'better' - to act for the patient - couldn't always be realistically sustained in that environment.
Pharma companies shouldn't be villainised, as they do exactly what 'it says on the tin' - they make money. And to do this they spend money (and lots of it) on seducing the people who they want to prescribe their drugs. It's just advertising and PR - and we don't complain when supermarkets do these things. However, there is a more complex, ethical argument which comes into play with the care of patients (and the costs associated with this).
I made a tough decision when I decided to start again as a medical student. Further to this was a promise to myself to try to avoid the free lunches, post-it notes and mugs provided to suggestively sell products to me and my patients. I know it's going to be difficult - and I know that I will sometimes give in to a sandwich. Sometimes the implications of the situation are hard to see when it's 'only a free pen'.
However, it is only by opening up the debate and being explicit about the links between the pharma industry and doctors that we can maybe move the focus from spending money on selling to spending more money on R&D, distribution to a wider patient group, and reducing the economic costs of drugs for our patients.
Competing interests: None declared

Physicians' links with pharmaceutical companies... 30 May 2003

David N. Andrews,
postgraduate student & psychologist
Kotka, Finland
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Re: Physicians' links with pharmaceutical companies...

Although I am United Kingdom citizen, I have been living in Finland for five years now. In that time I have been able to see some astounding prescibing practice. A client of mine was diagnosed with and autistic spectrum condition, and was placed on a high dosage of neuroleptic medication, despite the fact that such medications are contraindication in autistic conditions.
In Finland, there is a large input from the pharmaceutical companies into the training of physicians, and much of this comes from incentives rather than from direct sponsorship of training programs (or so it appears, from the news bulletins I saw when I first moved here).
Many Finnish medcial graduates end up doing research for the companies, and they become - effectively - pushers for those companies' products. Another client of mine was diagnosed with Attention Deficit Hyperactivity Disorder, and refused to use the Ritalin that the psychiatrist had prescribed, and the same psychiatrist reversed a previously given diagnosis of an autistic spectrum condition as aresult of the fall-out. It is known that Ritalin use in children diagnosed with ADHD is being called into question, for many reasons (side effects and lack of long-term benefit at reasonable dosages being two of these), and it is certainly a very questionable practice to prescribe this medication for an adult.
In my opinion, there is not a great deal of safeguard over the links between physicians and the pharmaceutical companies (certainly in Finland, but also I suspect in the UK). For that reason I voted YES to all questions in the poll.
David N. Andrews psychologist Kotka Finland
Competing interests: None declared

Doctors as the middlemen 30 May 2003

Pitt O Lim,
BHF Lecturer in Cardiology
Wales Heart Research Institute, Heath Park, Cardiff CF14 4XN.
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Re: Doctors as the middlemen

The problems highlighted by the editorial regarding the unhealthy interaction between drug companies and doctors are probably much more prevalent in Cardiovascular Medicine than in any other branches of medicine. This is unsurprising since heart disease is the major cause of death in industrialised nations. In response to this, perhaps a resurgence of a past phenomenon, more efforts are being put into prevention, or if you would like, �pre-emptive intervention� to reduce the statistical risk of suffering a cardiac outcome in the future, via multiple risk factors modification. There is a huge market in this epidemiologically-led "statistical medicine" hence drug companies which have a share in this market grow to be quite influential. Often than not, most drug company sponsored trials attempt to widen the indications of their drugs. Personally, I felt that it is quite unsatisfactory to "treat" the assumed underlying disease process (often asymptomatic) without having means of assessing drug response apart from simply telling individual patients that if they take a given drug, their risk of suffering an event is reduced by say 30% over 5 years. In a sense taking a preventative drug is not unlike taking out a life insurance policy. The emphasis is on relative rather than absolute risk reduction. Using the same logic, one could increase the chances of winning the lottery by 100% by buying 2 rather than 1 lottery tickets. There is obviously a divergence of interests between the drug companies and the doctors with regard to drug prescribing. The drug companies would like the doctors to treat the "average" patients to maximise drug usage, whereas ideally the doctors should treat patients on an individual basis. There is clearly a need to do more research that allows doctors to predict drug response. In other words, it is wasteful and makes no sense to treat 1000 "average" individuals to benefit one. We should be looking for ways to identify that one patient, who is the drug responder, and not to subject the 999 other patients to treatment unless they too benefit as measured by some reliable tests, which would allow one to continue or stop treatment confidently. It is time to shift the emphasis from treating the statistical risk to treating the disease. This would reduce somewhat the unduly influence of drug companies in their ability to shape prescribing on creative presentation of drug company sponsored trials that hides data that conform to the law of diminishing return.
Competing interests: None declared

No More Free Lunches 30 May 2003

John P Chapman,
Burnt-out Principal in General Practice
519 Jockey Rd B 73 5DF
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Re: No More Free Lunches

What a wonderful editorial; so good for the image of a profession already in distress. I look forwards to seeing the BMJ free of advertising by the pharmaceutical industry and I shall take you seriously when it happens, otherwise I shall consider your points mischievious and hypocritical.
Competing interests: I am a GP who would not get lunch if I could't justify the time spent getting yo the Postgrad department as educational

Horses for Courses 30 May 2003

Medwyn Williams,
GP & Medical Director PCO
Anglesey. LL77 7PT
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Re: Horses for Courses

Whilst totally agreeing with the basic premise that doctors should tread carefully when dealing with pharmaceutical companies, is it not rather fanciful and patronising for the editor to preach on ethics when the BMJ is so heavily subsidised by pharmaceutical company revenue.
Indeed, it was not possibly to open this week's BMJ without first removing a drug company sleeve. I totally concur with the sentiments put forward in the first letter on page 1211 in this week's journal about the need for "serious" medical journals to carefully select their drug advertisements.
Maybe it is time for the whole profession to put its house in order?
Competing interests: None declared

This is just the beginning! 30 May 2003

Wiel M Maessen,
Board member of Forces International
Netherlands
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Re: This is just the beginning!

Tomorrow is World No-Tobacco Day. It is organized by WHO's Tobacco Free Initiative and a result of the work of the FCTC[1].
We have evidence that the FCTC meeting of 1999 in Berlin was sponsored for over 70% by the manufacturers of NRT products[2], the ones who are benefiting of World No-Tobacco Day and smokers demonisation.
So, even at the high level of the WHO, it seems that 'some' conflicting interests exist!
It is about time someone starts a study on the narrow financial ties between the medical organisations (worldwide) and the pharmaceutical industry. And how they do influence the policies of nations?
What is the medical profession for? For health care or for its own care?
P.S. Do the Nays mean: we want to keep big bucks and an ever-growing social/political control? It's a pity that the profession of the one who fills in the poll is not asked for. Could give us some interesting viewpoints...
P.S.2 The REALLY incredible thing is that more than half the people voting voted NO to most of the questions! What would the poll results have looked like if it said "tobacco companies" instead??? This poll shows the grave of independent medical profession and practice. The Big Pharma Empire over Medicine. Thus Politics.....
---
[1] www.fctc.org
[2] www.forces-nl.org/WHO
Competing interests: None declared

I have sinned, and yet.... 30 May 2003

stephen f hayes,
hospital practitioner, dermatology
Isle of Wight, England
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Re: I have sinned, and yet....

This theme issue raises points which are already being commented on in national broadcast and printed media before a day is out. It is disturbing if true that research is selectively suppressed by drug companies and this debate must run its course with no holds barred.
However, as has been observed, the Soviet Union when private industry was supressed produced no new drugs of worth. I saw a patient who was prescribed phenylbutazone and amidopyrine, cheap and very nasty drugs both banned in the UK, for a soft tissue injury sustained at the Moscow Olympics. Perhaps there is a happy medium between the profit motive and benefits to patients, and an uneasy balance needs to be struck between the horrors of private profit red in tooth and claw and the dead hand of central state control.
I have been on 3 overseas trips funded by drug companies. In each case I believe I was asked because I was a GP clinical assistant, so a doctor whose prescribing habits might influence colleagues. Knowing this, I accepted the invitations because I felt like it.
On 2 of the trips, arranged by the same company, there was a good quantity of high quality education with nationally significant speakers on relevant subjects, which I thought improved my practice and professional self esteem. I valued networking with colleagues from around the country both in workshops and at table. I was grateful and would accept a similar offer from this company again.
The third trip, the most luxurious, distant and expensive, had an minimal educational content which it turned out was almost wholly promotional. The accomodation and entertainment were sensational and I couln't have afforded them myself ordinarily. I subsequently felt ashamed for going on this particular freebie, but reflected that as a loyal and productive key operative in a big organisation, it would have been nice if "the company" took me and colleagues out for a nice weekend with a combination of team building, training, networking and "thank you" good times, just now and then. My brother in law who sells mobile telephony gets this sort of perk from his company.
The organisation I work for, the NHS, didn't send me a card or a bottle of wine after I was viciously assaulted by a violent patient, but did threaten to sack me when I attempted (unnsuccessfully) to resist his re-allocation to my list 3 years later. So is it surprising if people like me take goodies from a third party when they are offered, knowing the money is ultimately being squeezed out of the tight fisted NHS?
I have also taken money from pharma companies to pay for education I organised. There was some promotional activity, but also good education which wouldn't have happened without the funding. And good products which won't happen without the profits.
Competing interests: have taken trips and money for education

Free Pizza - goes a long way 30 May 2003

Andrew Robinson,
Medical Resident
Vancouver,
Canada
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Re: Free Pizza - goes a long way

1. Residents are often targeted by pharmaceutical companies with 'free pizza' etc for noontime rounds. When we accept these gifts, we are called drug company schills by some of our colleagues.
The fact is, residents work unreasonably long hours in many situations, and are dispersed throughout the hospital. The idea that someone has prepared a lunch for us is great. It beats waiting 15 minutes in line at the cafeteria to get bad food and then end up 15 minutes late at our educational session. It beats making a lunch at home, and then leaving it in the fridge in another part of the hospital, (which inevitably where many of the superbugs in hospitals originate - the residents fridge), and then not being able to get it.
The fact is, no free lunch for residents often equals no lunch at all.
2. While we may not think we are being influenced by sponsorship - "That lunch was sponsored by the makers of Vasotec, and I only prescribe Altace - how can you say I was influenced." The fact is that we are. Even if it means something as simple as being less likely to criticize the pharmaceutical industry for something like inaction on HIV in Africa etc.
3. While the Evidence-Based Medicine crowd may initially have thought that EBM would lead to more cost-effective medicine, the fact is that the rigorous research that is demanded now for a therapy is so expensive that it can only be done by industry. A great example of this is in the Mediterranean Diet trials (ie the Lyon, and the Indo- mediterranean diet). These trials are imperfect trials, and have been assailed by some because of some methodologic flaws. The fact is that these trials could only be as rigorous as a 'CURE' trial, a 'HOPE' trial, a 'MIRACL' trial etc. if they had the billions of dollars of big-pharma behind them. Today's young Evidence-Based Doctors, (such as myself) constantly ask the question 'Where is the Evidence?' when dealing with lifestyle/diet/exercise - all non-pharma interventions - this is why Salmon Oil capsules are prescribed, but not many people tell their patients to 'Eat more Salmon' ......
4. While it may be that people who attend more pharmaceutical dinners etc. also prescribe more drugs, is this a cause and effect relationship? IE, if you are forced to attend less dinners will your prescribing habits change significantly? Maybe those who spend more time at drug dinners also spend less time per patient (which is known to be associated with increased prescribing of medications). Maybe those who attend drug dinners are already more favourable to the industry, and would prescribe regardless?
Competing interests: None declared

Drug dependent health care is fundamentally wrong 30 May 2003

Antony E Green,
Nutrition
Peterborough PE1 5HY,
Anne Foxley
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Re: Drug dependent health care is fundamentally wrong

We would like to see an end to the pivotal assumption that the only possible solution to health problems is that which is supplied by drugs.
This assumption is fundamentally flawed and can never work.
The body is affected by everything that goes into it and consequently has to attempt to deal with all-comers. Dis-ease comes about when the body is failing to adequately handle something, be it bacterial, viral or food. Drugs at best (and worst) attempt to handle a specific aspect of a symptom or symptoms, but they also have a very strong tendency to take over body or organ functions - this is WRONG!
The only thing that is capable of putting the body right is the body itself. The best thing that drugs can do for the body is to provide an environment in which the body can heal itself - nothing more is necessary - but this is not the object of the makers of drugs.
Not one drug has ever been invented that actually CURES anything! It never will be invented, because the perfect drug is designed to create a patient dependency - this is how pharmaceticals make their money. They will never make the money they seek by finding cures that end such a dependency.
Cures are available but there is no money involved for the industry giants because they do not involve drugs and so they are not interested.
Food is the answer, not drugs. A proper understanding of nutrition is absolutely essential - something that 99% of doctors do not have - to be able to see how diseases start and how to properly treat them. We have had considerable success long after doctors have given up with "incurable" patients simply because we address the cause and not the symptom.
Wake up to reality - drugs are not the answer, but as long as doctors are feted and subsidised by drugs manufacturers you cannot possibly end the culture that has more people ill now than ever before.
You will have ever increasing waiting lists of chronically ill people as long as the current regime persists. Yet the answer is available now - if you want to see it. Until that day arrives 99% of doctors and scientists are blind by choice.
Competing interests: None declared

Drug Lunchesh 30 May 2003

elias E Anikwe,
staff psychiatrist
walsall, WS2
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Re: Drug Lunchesh

There is nothing in this publication that is new or alarming. The nature of medicines is such that whether we like it or not, we will always rely on drugs produced by pharmaceuticals. I am quite comfortable getting these free gifts because they are not compelled to offer them at all whereas we cannot escape from prescribing. There is the new-found desire to criticise, and this is one of them. The assumption that patient care suffers is also simplistic because patients are attending clinics and demanding latest treatments that they read about on the web. I do not think viagra was marketed by corrupt doctors stuffed on free pizzas! I'd rather accept their bribes than let it swell their already fat accounts!
Competing interests: None declared

Not just drugs... 30 May 2003

Rachel Myr,
staff midwife
S�rlandet Sykehus Kristiansand, NO-4626
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Re: Not just drugs...

Thanks again to the BMJ for bringing up the issue of mutual back- scratching to sell drugs. It is not just drugs being marketed aggressively to health services providers; medical equipment is also "presented" with studies whose impartiality is at best open to question. At worst, the so-called research is blatant PR hype. The relationship of industry to research is not often discussed; my field has the dubious honor of using a technology, electronic fetal monitoring, which entered our repertoire without clear evidence of its efficacy and its safety, and which in the subsequent decades has failed to fulfil its much touted 'promise' of better outcomes. The machines we are now putting in place to 'upgrade' this technology have not been in widespread use anywhere, and the research supporting their efficacy seems all to have been done by persons associated with the manufacturer. The user's manual contains an impressive list of source literature, but not one citation in the text showing which source any claim is based on. To the uninitiated it looks scientific enough, but that impression quickly gives way to disgust and indignation in the critical practitioner. For at least one of the more bombastic claims in the manual, a quick check of the Cochrane Library shows no grounds for such sweeping conclusions whatsoever.
Artificial breastmilk substitutes are another group of products for which the relationship between industry and health service providers does not always tolerate the light of day, though this problem seems to be worst on the other side of the Atlantic, where women have samples foisted upon them as they leave maternity wards, because the hospital has promised the manufacturer that these 'gifts' will be distributed, in return for getting discounted prices on the product for in-hospital use.
It has always struck me as pathetic that we can be had for the cost of a few self-adhesive memo notepads, polyester visor caps, ballpoint pens, or a pizza. While I am the last to say midwives are overpaid, we do make enough to keep ourselves in both writing implements and food. .
For me as a public employee and professional health care worker, it is important that I not only be independent of industry influence, I must be clearly seen to be independent as well. This means, for example, bringing my own food when attending a 'seminar' put on by a manufacturer who provides refreshments as an enticement to come listen to their drivel. I say drivel because if it were truly worthwhile information, they shouldn't need to lure us in with secondary rewards.
The bottom line is if these silly tricks didn't work, the drug and medical equipment and baby milk companies wouldn't resort to them. How gullible do they have reason to think we are?
Competing interests: None declared

The entanglement is greater than we think 30 May 2003

Philipp A Conradi,
GP
Maypole Health Centre 10 Sladepool Farm Road Kings Heath, Birmingham B 14 5 DJ,
Loy Yap. Jacqueline Hughes
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Re: The entanglement is greater than we think

Thank you very much for your balanced article, neither doctors on a whole nor the pharmacutical industry are the only villains in this entanglement. Politics and the media also take part in this process of interconnecting self- interests. The logical chain starts with an industry sponsored trial whose favourite results get heavily advertised and will feature in the medicine and science sections of national broadsheets and tabloids. Opinion leaders will promote the drug in question and highlight the need to use it. Politics with its inherent trait towards short term gains finally set the rules to use those drugs via guidelines and targets.
Curently we see a huge push towards unilateral cardiovascular preventive medicine. There are several new cholesterol lowering drugs in testing and ready to come on the market. Based on recently published trials ( 1,2 )are many calls to lower the target cholesterol level and to widen the indication for using cholesterol lowering drugs in additional patient groups.A critical analysis of these trials doesn't necessarily support the widespread use of statins outside secondary prevention. The Heart Protection Study ( 1 ) reports on a highly selected patient group. The relative risk reductions are impressive though the absolute numbers are small.The same applies to the PROSPER ( 2 ) trial, the authors enrolled just 25 % of the originally referred patients. Most of the results are statistically insignificant or inflated by using composite end points..
Disentangling industry and medicine ( and media and politics too), is a win win situation. It will save money and stop the creation of false hopes, it brings an end to political prescribing and will increase mutual respect.
1
Competing interests: I went to evening meetings sponsored by different pharmaceutical firms

Editors'bias 30 May 2003

Olav Meirik,
Senior reserach associate
Instituto Chileno de Medicina Reproductiva, Santiago, Chile
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Re: Editors'bias

I agree with the views expressed by Abbasi and Smith in their commentary about bias and studies sponsored by drug companies. However, Abbasi and Smith themselves appear to have a bias when they refer to the systematic review by Lexchin et al.(1) as being done �by North American researchers� instead of �by researchers in the Americas�. One of the four authors of the paper is affiliated with the University of Campinas in Brazil. Biases are problematic, sometimes they are unconscious, be it they are related to drugs and profits or to developed and developing regions of the world.
1. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003;326:1167-1170.
Competing interests: Residency in Latin America

How apposite - No Free Lunch 1 June 2003

Anne Foxley,
Private Nutrition Specialist
Peterborough,
Antony Green
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Re: How apposite - No Free Lunch

How often is the answer stated in the question? <center>THE ONLY FREE LUNCH IS THE CHEESE IN A MOUSETRAP!</center>
 This could not be more appropriate. The cause of 95% of illness is food - or the bodies inability to deal with that with which it is presented several times a day, either through ignorance of need or increased-sensitivity. Drugs are not the answer, proper understanding of nutritional needs and careful consideration of allergic reactions would provide the answers in the vast majority of cases of illness. How much information do doctors recieve in their six years or so of training? A single morning or afternoon! The single biggest factor in illness is relegated to the least important because it has been deemed irrelevant by a megalithic industry that thrives on ignorance. Doctors are not trained in nutrition and the CAUSES of illness. They are trained in diagnosis and drug therapy because that is where the money is. The system is inherently corrupt and protects and preserves itself with tremendous alacrity - something that should be admired for the way it treats itself, but not for the way that it treats those it claims to be treating. 90% of those that go through the system complain that the system fails them comprehensively, but as there is no alternative (on a large scale) to the drug culture they have no option but to return again and again to drink from the poisoned chalice. Have I got a competing interest? Only in that we teach people how to get better for themselves - unlike the ingrained belief that "you get ill, you go to the doctor and he gives you a pill that fixes you" - this totally ignores the responsibility that people have to themselves in causing and treating their own illness. Doctors don't cure people, bodies cure themselves if they are given the right food and environment. Outside of killing bacteria, trauma and crisis managment there is nothing that can be done with drugs to cure people. So let's have a more open minded approach to the whole problem and begin teaching doctors about the real nature of illness instead of teaching them about drugs. I doubt that this will even get published on your website because it will make far too many people uncomfortable - how many people out there are prepared to consider that their training and profession is largely a front end for exploitation of the very people that have to trust it.
Competing interests: None declared

Enough already 1 June 2003

Simon Wessely,
Professor of Epidemiological and Liaison Psychiatry
GKT School of Medicine
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Re: Enough already

What a sad and dispiriting issue of the BMJ this week (May 31st 2003). Acres of newsprint, numerous articles in various shapes and forms, and to tell us what? Pharmaceutical companies manufacture drugs, and, amazingly enough, also promote them. And who do they promote them to � the people who prescribe their products � namely doctors. Astonishing. And sometimes doctors, who represent humanity in all its shapes and forms, succumb to these blandishments. What a surprise.
So it seems that the pharmaceutical industry systematically promote and protect their interests. Given their scale, and contribution to the national economy (which probably does more good to health, incidentally, than the products they promote) this is hardly surprising, but is it unique?
I have in my career to date received 53 research grants. My Dean hopes that I will receive many more. These have come from 20 sources, mainly research councils, government departments and medical charities, with only one from a pharmaceutical company � grant number 12 out of 53. I have, however, like all academics, had dealings with industry at many levels over the years, just as I have had dealing with people who support research from a variety of different institutions and constituencies. And all of them have agendas and special interests. Few can be said to be funding research purely out of a disinterested pursuit of the truth, science for science�s sake. Those who spend our money � be it raised by taxation or from charitable donations, are as aware of their constituencies as any one else. Indeed, many have rather more powerful agendas than even pharmaceutical companies � some subtle, some not subtle at all.
And I have succumbed to these pressures myself? But of course. Grow up. When one approaches a funding body, even the saintly MRC or Wellcome, let alone the single issue charities or government, one knows what is flavour of the month, the current political concern, the bee in the bonnet of the Chief Executive, the particular piece of political correctness needed to achieve success this year, and the roads down which one should not travel. As every academic who has ever had a grant rejected (and is there another other academic?) will tell you, good science is the ticket of entry, but doesn�t guarantee the prize.
And what about the blandishments from industry? Have they perverted my clinical practice over the years? A meticulous search of the wreck that is my desk reveals nine pens, including, miraculously, a Parker pen long thought lost, two of which have clear company logos on them. As an academic I travel a lot � I attend academic meetings, usually overseas, at least once a month (personal communication from my wife, made between gritted teeth). I think that means over 200. I am certain than on at least four occasions I have been sponsored by industry � Pfizer, Lilley and two others that I can�t remember, since you ask - possibly slightly more. I am not sure. I can remember the cities (Copenhagen twice, Vienna once and somewhere else), but not always the company. Has that made be into a drug company lackey, slavisly promoting their products? Who can say, but I doubt it.
It is time we all grew up. Everyone has conflicts. Everyone has agendas. Everything affects patient care. Our own personal prejudices, likes and dislikes, the time pressure we are under, the number of patients left to see, family and cultural backgrounds, the influence of our teachers for good or ill, how tired or jaded we are, the volume of paperwork we still have to complete, fear of litigation, the list is endless � there is very little in our lives that does not affect how we manage patients. A few pens, a sponsored sandwich lunch for our weekly research meeting, and even a trip to another forgetable conference, probably are rather low in the list of things that affect our decision making.
And what is the proposed solution for this latest non problem? If USCF is to get its way, and we are to believe Ray Moynihan, it is an almost unbelievable Orwellian world of supervision, prohibitions and restrictions. I have declared above that I have received one grant out of 53 from industry. According to the proposals this means that I am to be banned from having anything to do with medical education � �planning, manager, teacher or author�, even if I willingly declare my tainted past. Well, at least I will have more time to do my research. But will I? Apparently not. I can�t quite grasp what the �rebuttable presumption� mentioned in the article, but the sub clause that �researchers with conflicts of interest cannot do research using human subjects� seems to imply that even that is denied me. Even if I escape that, my professional organisation is being urged to �probibit researchers with conflict of interests conducting research�. So that�s out then. Teaching, research, all gone. Oddily enough, nowhere does it say that I can�t see patients � yet isn�t �protecting patients� from wrong doers like myself the point of the entire ludicrous exercise?
That is sinister enough, indeed, so much so one wonders fleetingly if this is meant as a reductio ad absurbam argument intended to self destruct. But there is another unwelcome sub text to the theme of the entire issue. It is easy to point out the agendas of industry. Indeed, anyone who did not realise this is, in my opinion, too na�ve to practice medicine seriously. And one can point out similar agendas, hidden or not, conscious or unconcious, in most of the insitutions that we come into contact professionally � Royal Colleges, medical journalists, the BMA, government, quangos, even, God forbid, medical journals. Sensible reasonable people know this, and act and interpret accordingly. But what is the result of this constant stream of articles that bring to our attention what we already knew? It is a gradual erosion of something far more important � that of trust. Eventually we will trust no one and nothing. We will take nothing at face value, and see conspiracy and plot behind every official or institutional action, prisoners of our own paranoia. As Oonora O Neil demonstrated in last year�s seminal Reith lectures, it is this erosion of trust in our institutions, public and private, that may ultimately be more corrosive to the public good and well being than a few more company pens.
Professor Simon Wessely Conflicts of Interest scattered throughout the text.
Competing interests: scattered throughout the text

'Mea Culpa' : By Dr Joseph Obi 1 June 2003

Joseph .C. Obi,
Chief Consultant
WellnessClinics.co.uk
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Re: 'Mea Culpa' : By Dr Joseph Obi

As this will be my very last BMJ article 'out of contract' ; I might as well 'come clean'...and 'shame the devil'.
During my very many years as a struggling 'barefoot physician', I guiltily (but addictively) enjoyed as many free lunches as the twinkling little stars in the sky.
I also made it an unflinchingly professional 'point of absolutely dignified duty' to 'hippocratically reach out' for as many 'freebie' stethoscopes, drug samples ,desk lamps, pen torches, overalls, sphygmomanometers, note pads tourniquets , mini-encyclopaediae and CDRoms ,as my ageing little ward coat could tastefully contain ; without suspiciously setting off the various in-hospital security sensors and alarms.
But please note that (although I frequently 'grabbed at' as much 'loose gear' as I could), I regally held my head up high...and never ever accepted any 'tatty stuff' which would put my noble profession into abjectly pitiful disrepute.
However...to be pontifically candid...when push eventually came to shove; I always relied on EBM (and the BNF) to make highly defensible clinical choices which were 'in my wee little judgement'... the very very best at the time for my cherubic and loveable patients.
Perhaps if the Pharmaceutical Industry actually conducted a bit more qualitative research into the 'real-world' prescribing practices of their 'clinical luncheon guests', then perhaps they may be pleasantly surprised to find it more fiscally feasible to replace all the 'caviar ,venison and cognac'...with plain old 'beans on toast'.
Dominus Vobiscum...
Competing interests: Dr Joseph Chikelue Obi MBBS MD MPH DSc FRIPH has impeccably enjoyed quite a great amount of 'edible and non-edible pharmaceutical freebies', in his highly controversial career.

Why are we afraid? 1 June 2003

sudhir kaligotla,
SPR liaison psychiatry
North manchester general hospital
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Re: Why are we afraid?

This issue of the BMj has obviuosly raised a lot of interest amongst the medical profession.
I must confess, I have used drug company money to organise several educational meetings.I have always tried my best to keep the meetings/conferences unbiased and free from the influence of the industry.
On the other hand I have attended several meetings which have been purely promotional .Iam not afraid to use my common sense and my training to be able to differentiate the evidence .
Unless we can listen to what the drug companies have to say to us how can we make our choices .I feel it is important we listen to all views and sometimes if there is a lunch thrown in ,its our choice whether we take it or not.
Competing interests: None declared

What's wrong with a free lunch 1 June 2003

Simon A. Kaye,
GP principal
Green Close Surgery, LA6 2BS
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Re: What's wrong with a free lunch

Yes there is something wrong with our unhealthy relationship with drug companies - how did it come about - years of chronic underfunding of medical education and the erosion of a doctor's relative position with other professions.
As soon as dear old Ken and Mrs T started trying to run our National Health SERVICE as a business the rot really set in - business thrives on kick backs , corporate hospitality and patronage.
How do we get out of the situation? - proper funding - of our profession in general and medical post-graduate education and research in particular.It remains to be seen whether the new GP contract will really adddress some of these issues.
We need to decide as a nation what kind of Health Service we want - for now I'll keep my nose in the trough and eat the slops thrown my way - but I may be forced to decide on a quick escape to the abattoir!
Competing interests: None declared

Why do we like the freebies? 1 June 2003

Susan J MacCallum,
Staff specialist haematologist
Sydney NSW 2030 AUSTRALIA
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Re: Why do we like the freebies?

From a haematologist's perspective, I can't deny that development of new medications has revolutionised cancer therapy, and benefited many patients. It would be foolish to demonise drug companies out of hand. What is fascinating , however, is the way in which highly educated medical professionals have fallen so heavily for the company-provided trinkets, trips and entertainment. It would seem that something is lacking in our professional lives - perhaps the often onerous nature of work, together with remuneration well below that of our business counterparts, ongoing anxieties with medical negligance litigation, and the decline in the esteem in which doctors are held in the community. Drug companies are able to make doctors feel special and well looked after, which is something Area Health Services, HMOs NHS etc do not.It is not our interests to have insight into the relationship, which is essentially a business one. We should realise that we are vulnerable and should recognise that dinners etc are provided, not because we are lovely hardworking people (although that may be true) but on a strictly "cash for comment" basis
Competing interests: Addicted to post-its

People in Glass Houses... 1 June 2003

James Hickman,
GP Principal
The Health Centre, North Curry, Taunton, TA3 6HY
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Re: People in Glass Houses...

Dear Editor,
Regarding your front cover of the issue 31 May 2003. May I refer you to the back cover and inside pages 1, 3, 5, 7, 9, 10, 18, 19, 20, 31, 32, 43, 44, 80 and 90.
Yours faithfully
James Hickman
Competing interests: None declared

Not Holier than Thou 1 June 2003

Adam Moliver,
Consultant Psychiatrist
Charlton Lane Centre Cheltenham GL53 9DZ
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Re: Not Holier than Thou

Of course I am influenced by reps. The industry would not employ them otherwise. Are doctors different from other people? Why should we miss out in, a capitalist-individualist society on the perks that other professionals get? If a stockbroker gets a "free " lunch why not a doctor?
Doe it matter which SSRI I prescribe ? I very much doubt it.Given the way companies use the licensing system (depression with panic, without panic with anxiety without OCD etc)I am not convinced that one is better than the others so Ill use the one that gives the best dinner.
Medicine may be moving from a Hippocratic profession( I never took the oath by the way) to a technical activity. Freebies are part of that
Competing interests: Been to drug comopany meetings and lunches SHares held in industry

No Free Lunch 1 June 2003

Sarah E Gull,
Consultant gynaecologist
West Suffolk Hospital Bury St Edmunds
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Re: No Free Lunch

One of the constraints created by the system of drug company sponsored lunches is that of restricted access. At our hospital these lunches are freely available to doctors, but not to other members of staff. Not suprisingly this creates barriers towards interprofessional learning and resentment from other disciplines. No educational programme can flourish under such biased conditions.
Competing interests: None declared

BMJ heal thyself... 1 June 2003

Richard T Halvorsen,
General Practitioner
WC1N 3NA
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Re: BMJ heal thyself...

How aptly symptomatic of the illness, that the very edition of the BMJ containing the editor's wise words calling for "greater distance between doctors and drug companies" should contain an advertisement placed by SKB seeking "a commercially astute physician...[whose] role will include strategic input into how we can build closer partnerships with key influencers including PCOs and Prescribing Advisors, consultants and other clinicians."
Competing interests: None declared

Sponsors or Spivs ? 1 June 2003

Bernard C BOYD,
none
1 Robinson Circular, Arima, TRINIIDAD
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Re: Sponsors or Spivs ?

The email feeding frenzy on the Editorial by Abassi and Smith reminds me somewhat of some colleagues at the "dinner meetings" held two or three times weekly. Curiously, most of them are not young practitoners looking for a free meal, and they generally form the core audience at every meeting. Every drug (oops!- pharmaceutical) company is in heavy competition for the ears (and stomachs) of the doctors, and every medical rep tries to outmanoevre her colleague with presentations of statistics and "references" in very, very fine print. A closer look at the latter will show dates as far back as 1979 in an obscure journal!
I suspect that my prescribing may be influenced by these charming ladies (99% are both), all university graduates, who talk with absolute conviction about their product - until they switch companies and after their month of through indoctrination return with an amazingly revised view of both products.
I have been spomsored (in part) by a pharmaceutical company to attend a conference abroad in which they would have had no interest, except that they may be conviced that I might just be a little more inclined to remember their product. Attending sponsored meetings can be a humbug, especially when they insist on "giving a short presentation" before the actual speaker. Equally annoying, and less forgivable is the practice of the consultant who virtually promotes the drug clearly being peddled.
So, how do I attend these sponsored meetings. First, I look at the name of the speaker (usually a local specialist), then I scan the subject. Both must satisfy my interest. Many have neither the ability nor the experience, and the subject has often been beaten to a pulp over the months. Finally, I love presenting some awkward questions which I have seen raised through an internet search. If the speaker cannot respond, he or she goes some points down. ButI still get invited.
Being an age when snacks or small meals at night are more acceptable, the dinners are not an overwheming attraction. Pens are really my thing, and I now have a collection (I keep every one) which will be the envy of my colleagues. And I may use them as research material when presenting my paper on Medicine, Medical Reps and Morality and my book on The Principles and Practice of Sponsored Prescribing!! Perhaps I may even get joint sponsorship by several companies.
Competing interests: none

an australian viewpoint 1 June 2003

ian c arthur,
private general practice
14 toormina road, toormina , 2452 australia
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Re: an australian viewpoint

Congratulations on a very lucid summary of the dangers and costs or doctor-pharmaceutical company entanglement. I have contacted my mid north coast division of general practice with a view to ending all drug company sponsorship of meals and educational seminars sponsored by the division. A copy forwarded under separate e mail.
Competing interests: None declared

Re: This is just the beginning! 1 June 2003

Antony E Green,
Nutrition
Peterborough PE1 5HY
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Re: Re: This is just the beginning!

Surely the whole point of this is not whether somebody sponsors an event or an individual but whether the interests of those seeking influence are genuinely for the patient and improving patient health or care.
In the comments by Wiel Maessen he appears to be missing the point that the WHO is trying to improve the collective health by raising the smoking issue and encouraging people to stop smoking. Should they only do this by sending out leaflets with no information on how to achieve this goal because it could be seen as promoting products? This type of event is inevitably going to cost somebody something and in fairness those who will benefit from the exposure are right to be making a contribution to that cost.
On a personal note I don't believe that some of the non-smoking drugs should even be allowed to be marketed because they are more insidious than the product it is trying to supplant - you all know which I am referring to - so why prescribe them?
Everyone is in business to make money - if you don't then you don't eat, but the way you make money is of paramount importance. If it is dependant on bribery to induce others to adopt practices or products that do not place the patient as the top priority then it is exceptionally hypocritical for doctors or practitioners to use them.
What seems to have gone out of the window is personal responsibility. Far too many "professionals" fail to consider this when they regularly prescribe something that they know doesn't work or work as well as another product on the grounds that they have been "bought", even on a temporary basis, by the manuacturer.
The first thing that a responsible practitioner should ask is "Is this the best thing that I can do for my patient?" If the answer is "no" and proceeds anyway then personal responsibility has no part in this and the practitioner should find another job.
Competing interests: None declared

Noble as it sounds, journals in West Africa cut off drug companies to their peril 1 June 2003

Joseph Ana,
managing editor, BMJ West Africa
UK office, 65 warden hill road, Luton.,
LU2 7AE.
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Re: Noble as it sounds, journals in West Africa cut off drug companies to their peril

Kamran and Richard raise very major ethical issues in their editorial. However no where else is the widening gap between The north and The south more glaring than in healthcare delivery, training and health information disemmination. In the North, USA, Western Europe and Japan, drug companies fall over themselves to spend their trillions on doctors and other health professionals including all the trappings listed in this editorial. On the other hand, in the south, we toil and sweat to get noticed by drug companies. As a result, All of Africa, most of Asia and Eastern Europe, where resources available for health care and health professionals are meagre and inconsistent, our colleagues will heed Kamran and Richard's advice at their peril.
In the face of abject poverty, in most cases health professionals and policy makers, even though aware of the double edged sword nature of the hand-outs from drug companies, cannot do otherwise because to break the link will lead to no patient care in many cases. Will Governments ( national and international), global monetary institutions and rich western countries plug the gap if drug company largese are declined?. For a start, locally published journals, and locally conducted research will disappear without drug company support. The subscription base is lamentable because the profesionals are poorly paid, and national organisations of doctors and others are too poor to consider free distribution of journals.
It is probably true that doctors prescribe more after seeing drug reps., but I doubt that this applies to the majority. If one takes on example, there are several classes of anti hypertensive drugs and in each class there are many different items. All the manufacturers promote their drugs by soliciting doctors as prescribers. I believe that most doctors by and large stick to the few anti hypertensive drugs that they are familiar with, knowing their mode of action, side effects and dosages.
It really does not matter how many free lunches they eat they are likely to stick to what they know- a case of better the devil you know --. It is not believable that most doctors change their preferred drug after every free lunch, because to start with, the patients will not take it if there are too frequent changes of medication. We already have enough problems trying to convince patients ( and rightly so)about the occasional cost-driven changes.
In places like West Africa we do not yet have the luxury of drug company over indulgence. Infact can somebody tell us how to change their bad habit?. How to make them support local health initiatives, programmes and publications.
Competing interests: � Joseph Ana is managing editor BMj West Africa edition which like most otherjournals seeks and get adverts from drug companies with mixed results.

Relationship between the Drug Industry and Doctors 1 June 2003

Umesh PRABHU,
Consultant Paediatrician
Fairfield Hospital, Bury BL97TA
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Re: Relationship between the Drug Industry and Doctors

Of course strictly speaking there should not be any association between doctos and drug industry. However how many doctors can afford to go abroad and stay in a 5 star hotel with the salary they get from our NHS?
How many meetings NHS can afford without sponsorship from the drug company?
Out of 7 meetings I have attended in the last 6 months, only two were not sponsored by the drug company. Both of them were costly, organised by private firms and the fees per day was �280. Other 5 meetings were either free or my Trust paid only �70 per day. Calculate this across the country for 100,000 doctors (registered with GMC), approximately �100 to 200 million pound extra per year. In a cash restricted NHS can we even imagine this? Most Trusts have restricted the amount doctors can spend on CME per year to �750 to �1000 per year. This includes course fees, travelling and accommodation.
I have following suggestions
1. Overseas trip abroad should not be sponsored by the drug company. 2. Doctors eating out for social purpose should not be sponsored by the drug company. This must be a desciplinary offence. 3. There must be clearly defined and resoanable expenditure paid by the drug company in any sponsored meeting. Who ever organises the meeting should declare it. 4. Any doctor who works in the NHS and gives lecutre in a drug company sponsored meeting should declare it in his apprasial folder. 5. Presribing practice of such a doctor should be compared with the national guidleines. 6. Funding for personal development should be increased.
Yours sincerely
Dr. P Umesh Prabhu
Competing interests: I do give lectures in company sponsored meetings

Free Lunch learning is better than lunch free learning! 1 June 2003

Sidha Sambandan,
General Practitioner
Yare Valley Medical Practice; 202 Thorpe Road, Norwich NR1 1TJ
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Re: Free Lunch learning is better than lunch free learning!

The degree of influence of drug industry depends to a great extent on the individual targetted. When will the BMJ "disentangle" from the Drug Industry? How much was gained from the Drug adverts on this issue? (16 FULL PAGES! excluding BMA News and Classfied Ads supplement + wrappers). Strangely, it has dropped to 16 from the 26 full pages of Drug Adverts in the BMJ of 25th of January! This is despite charging over �300 to the subscribers. I shudder to think what would become of the educational courses of very high standard that are often entirely sponsored by the Drug Industry. Majority of the doctors are not seduced by the marketing. My observation is that the Pharmacists in Primary Care Organisations and Nurses are far more influenced by the drug industry over the last six years. I wonder what research evidence we have for this. Over the last few years the industry has been marketing directly to the public via the internet, and media. Some academic posts too are being sponsored by the Drug Industry. Do we have to throw away the baby with the bath water? What is needed is "Mindful practice" by critically appraising the so called "Evidence Based Medicine" in the light and context of our professional practice. This requires an insight and awareness of the hidden agendas of the person or organisation trying to influence us, by listening to what is being said, but paying attention to what is not being said!
Competing interests: None declared

Science and Money Changers 1 June 2003

David Elpern,
Solo Practitioner
Williamstown, MA 01267, USA
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Re: Science and Money Changers

Sir Thomas Browne's bon mot would be a good introduction to this special edition of the BMJ: "No one should approach the temple of science with the soul of a money changer."
As a medical practitioner in "The States" perhaps I have been more corrupted than my colleagues in the U.K. The situation here is bleak. The pharmaceutical companies court us, the medical schools and the public (the latter with direct to consumer advertising). This is a triple threat. Visit our journals for a picture of glossy ad hell. The cynical reality is that it doesn't matter what the ads say. The idea is to get the name of the drug imprinted in the mind of the busy doctor with the prescription pad. Then, when faced with a patient with, say acne, who needs a topical retinoid Drug "X" will be prescribed over Drugs "Y" and "Z". It doesn't matter what the ad says. It is name recognition that matters when a harried physician writes a script.
Each new regulation from government or the AMA to limit the contamination of the soul of the practitioner is met with a novel innovation on the part of the drug companies to circumvent it. Now they call us "consultants" when they want to pay us to hear about a new expensive product. We are easy (often eager) prey.
In the U.S. our specialty journals have an equal number of glossy drug adverts to pages of text. I do not see the print BMJ so wonder to what extent you are dependent on drug advertisements.
In one of the responses Dr. J. Chapman writes: "I look forwards to seeing the BMJ free of advertising by the pharmaceutical industry and I shall take you seriously when it happens, otherwise I shall consider your points mischievious and hypocritical."
Dr. Chapman has a valid point - I think the Editors should respond. However, it is clear that the BMJ editors have more freedom than those of the major North American journals. The latter would not dare to print such an issue. They would have to give equal time to self-serving commentaries by industry spokespersons.
The rub is that there are fantastic drugs; drugs which help many of us to live better and longer lives. But, many of these are drugs for the rich and drugs for the insured.
I suppose coming back to Sir Thomas Browne occasionally will be therapeutic. Today, as in the past, our medical schools, professional societies, and major journals are run by the money changers. Most practitioners are willing accomplices. Those few outliers are viewed as unimportant Luddites by organized medicine and industry. Their voices are silenced.
Competing interests: Infected with the virus as are _all_ physicians

Spouse Scorn 1 June 2003

Des Spence,
GP
Maryhill Health Centre, Glasgow G20 9DR
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Re: Spouse Scorn

The pharmaceutical industry became an issue for me when I become a local clinical governance lead. I found myself being invited to meetings aboard, offered chairmanships fees, offered lectureship fees and endless invitations for lunches and dinner. I was flattered and felt this was recognition I deserved. One night ,however, my wife pointed quite rightly that I was still the snivelling oaf she met at medical school and that I must never loose sight of this!
I realised that I was just being used and manipulated by Big Pharma and that medicine wasn�t about me but the patients. I visited �nofreelunch.com� and took the pledge. I earnestly followed the my commitments under the pledge. I organised a local meeting and invited all GPs in Glasgow to attend. I presented a revised version of the PowerPoint presentation from the nofreelunch website to include a UK perspective. This attracted about 15 GP and medical students. The Glasgow Herald , however, were interested and ran number of stories. I made a number of public statements based on research about the pharmaceutical industries and the interaction with doctors.
Following one article the APBI sent a information pack and covering letter about the role of the ABPI and they also enclosed a copy of the newspaper article. I felt faintly threaten by this as the Pharmaceutical Industry are renown for their litigation. I decided to phone the ABPI to express my concern over why the �information pack� had been sent. They were unable to answer this but asked my to refer to the code.
I read the ABPI code of practice. The ABPI code ,however, borne no reflection to what I had experienced as a doctor. If doctors read this you will understand that this code is broken everyday, everywhere and in ever setting. This involves free trips to international conferences (Junkets in all but name), paying for nights out, unlimited alcohol, sponsorship of Christmas parties, and soft �consultancies� . In the hospital sector consultants often get �looked after�. Doctor and pharmaceutical representatives know that these practices go on constantly.
So why does no-one complain ? Well frankly this would be seen as ratting on Father Christmas. Doctors see this as �harmless�, �the only perk that we get� and �does not effect� their clinical practice. This is why nobody ever complains to APBI and why there is this wall of silence.
We spend five billions pounds a year on medicines in the UK the same sum to run of whole of primary care. Medicines and medicalisation of human condition have caused great harm in many aspects of society . We desperately need regulation of the pharmaceutical industry because contrary to their PR departments spin their core work is profit. We need mandatory code of practice for doctors which involves a declaration of interests/contacts with pharmaceutical industry. The problem is that money talks and no government is willing the tackle �Big Pharma�.
Remember that thanks to the pharmaceutical industry you have more chance of developing hypertension these days than dying!
Take the Pledge at nofreelunch.org
Competing interests: None declared

A hungry student's view 1 June 2003

Ruth H Armstrong,
medical student
University of Glasgow, home postcode G3 6HW
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Re: A hungry student's view

As a strapped-for-cash medical student, it can often be hard to resist the temptation of drug company goodies, including free lunches. After watching the recently aired "Dying for Drugs" documentary on Channel 4, I was appalled, but sadly not surprised, by the underhand, unethical pratices of these companies. I have decided therefore to boycott drug lunches and freebies, and to make my feelings known by signing any attendance sheets to the effect that I refuse to be bribed by pharmaceutical companies, when the money spent providing me with a bacon and brie sandwich and pen could be better spent promoting and implementing an ethical drug pricing policy for developing nations. I would urge other medical students and doctors to think about doing the same.
Competing interests: None declared

The bonfire of vanities 1 June 2003

John Hopkins,
GP
Stoctkon TS17 6EY
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Re: The bonfire of vanities

Dear Dr Smith,
Your inference that my colleagues and I would sell our souls for the sake of a plastic pen and a slap up lunch at Pizza Hut is, frankly, a bit wide of the mark.
There are two main criteria that apply to any prescription. The first is that it should stand a reasonable chance of working. Otherwise the patient will come back, possibly several times. The second is that it should be cost effective. Otherwise the local prescribing managers will come down like a ton of bricks.
Compared to these irresistible forces, the offer of a cucumber and tuna sandwich will have little impact.
Commenting on your editorial the other day, the Times compared Richard Smith to Savonarola, a fifteenth century monk who condemned moral corruption in Florence. For his troubles, he was burned at the stake. Not a fate that even his sternest critics should wish on Dr Smith.
Yours sincerely,
John Hopkins
Competing interests: I rarely speak to drug reps

Responses to Abbasi/Smith article 1 June 2003

Dr Deepak Malhotra,
Consultant, Aviation Medicine
Sydney, Australia
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Re: Responses to Abbasi/Smith article

It is amazing that the only ones to protest against the article are Psychiatrists. Well, well you would expect that. After having declared that every feeling humans have is a result of depression they have done an admirable job in promoting anti-depressants. I am just waiting for the day when Psychiatrists will recommend that we mix anti-depressants in the town water supply.
Competing interests: None declared

Yes Its Possible! 1 June 2003

Mohan Devegowda,
GP
mohans clinic 613 2nd main first stage indiranagar bangalore560038
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Re: Yes Its Possible!

Sir,
One day it will happen that most of the doctors refuse free lunches and freebies. The day all of us look and analyse our conscious probably we will achieve. But at the moment the person who doesnot accept and patronise the drug industry is a fool and a loser [materialistically]. Doctors have gone to the extent of opening their consulting chambers with the financial help of pharmaceutical company. I strongly believe people should pay for learning instead depend on free lunches during CMEs. The day is not far people will realise this.
Competing interests: None declared

Re: Re: This is just the beginning! 1 June 2003

Wiel M Maessen,
Board member of Forces International
Netherlands
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Re: Re: Re: This is just the beginning!

Mr. Antony E Green says:
"In the comments by Wiel Maessen he appears to be missing the point that the WHO is trying to improve the collective health by raising the smoking issue and encouraging people to stop smoking."
Is the WHO's real objective to care "genuinely for the patient and improving patient health or care"? Or is it mainly a political organisation that first looks where its money comes from and then determines its main objectives? [1]
If the WHO really cared it would care about the millions of *real* deaths caused by famine and disease in the underdeveloped countries and not fighting 'virtual' deaths that are computed by computer models like SAMMEC.
But it looks like the political analysis on WHO's behaviour explains much more about the choices they make.
The most important sponsor of the WHO is the US. Smoker demonisation started first there. Why? Maybe because the pharmaceutical industry is a better sponsor of the US government and political parties as the tobacco industry? Pharmaceutical companies donated about 3 times the amount of money to US political parties in 2002 compared to the tobacco industry.[2]
All other major sponsors are western countries. Doesn't it sound logical that an organisation like the WHO fights its sponsors' 'problems' first?
So it's not only the direct funding of the WHO by pharmaceutical multinationals that dictates their choices but also the American government receiving ample funds by that same industry.
WHO's choices are not determined by *real* needs but by political interests....
Orwell's Big Brother has gotten a face and it is obviously the Big Pharma's one.
-----
[1] http://forces-nl.org/download/whowhat.pdf
[2] http://www.opensecrets.org/industries/contrib.asp?Ind=A02 and http://www.opensecrets.org/industries/contrib.asp?ind=H04
Competing interests: None declared

NO MORE FREE LUNCHES 2 June 2003

Nigel Puttick,
Consultant Anaesthetist
James Cook University Hospital TS4 3BW
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Re: NO MORE FREE LUNCHES

Editor � In your themed issue, while referring to drug companies, you omit to mention the potential influence of manufacturers of medical equipment, implants and other disposables. In my role as consultant anaesthetist with responsibility for equipment I often meet with representatives from these companies. As I am clinically very busy and rarely have time for lunch I am usually unable to take advantage of any such offer, and I decline any hospitality while a purchase is being negotiated. The relationship is often the opposite of your suggestion: I regularly welcome representatives in order to discuss their products and to show them something of our clinical practice, in recognition of the need for a dialogue with industry to ensure our needs are provided for.
However your leading article �No more Free Lunches� asks the very pertinent question �how did we reach the point where doctors expect their information, research, education, professional organisations, and attendance at conferences to be underwritten by (drug) companies?� � well, at least in respect of attendance at conferences I am sure many others will confirm my personal experience. The only way I have been able to attend major international conferences has been through industry sponsorship. For example, I attended the World Congress of Anaesthetists in Montreal in June 2000 at the expense of an equipment manufacturer, who paid my (economy) airfare and modest hotel bill, and a pharmaceutical company who paid my registration fee. My NHS employer is only willing to contribute a flat rate of �600 towards any overseas conference, which is almost always insufficient for the purpose, indeed this amount is less than the cost of most two-day meetings in the UK. I would point out that my Trust is among the more generous in terms of study leave funding. So I would suggest that at least part of the answer to the question you posed is that the NHS woefully undervalues the attendance of its senior clinical experts at reputable international conferences. Most colleagues in other specialties can confirm that the only way to attend key meetings in other countries is to accept industry hospitality. In other developed nations, for example Australia and New Zealand, paid attendance at one international meeting per year is included in specialists� contracts; it is high time the NHS did the same.
Nigel Puttick FRCA
Competing interests: � None declared

gullible greedy pigs 2 June 2003

paul kerr,
gp principal
frew terace surgery, irvine, ka12 9dy
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Re: gullible greedy pigs

Insulting, patronising, anecdotal and ironic: four words I would use to describe the doctor/drug company entanglement issue of 31 may 2003. The cover of this conspiracy theorising BMJ pictures doctors [mostly thick GPs, we assume] as fat pigs, drug reps as snakes and patients as impoverished, unimportant, rodent-like party voyeurs. Good bit of satire and pretty insulting. Maybe the BMJ will come to the same sticky end as other punchy satirical mags.
It is patronising because it presumes that we thick GPs are so gullible that we do not know that we are being sold products when we see reps. Get real. I know, you know, we all know that that is what drug reps do. Watkins and his co-researchers show us a lot of cross-sectional data of rep-seeing GP attitudes and behaviour. As they say, the plethora of data does not show causality. Fine. But to come out with a biased, unsubstantiated clanger such as �For some general practitioners, the frequency of contact must be greater than their need to know about new drugs� is just anecdotal rubbish. I assume that this preconceived idea was the reason why the authors carried out the study in the first place. In any case, given the enormous number of products out there, it would [anecdotally] take a lifetime of posh lunches to know everything about all drugs � new or old.
But the biggest gripe I have with the BMJ in this issue is the double standards shown by the BMJ editorial team in their editorial on the subject. As they say in the �competing interests� epilogue, the BMJ has a considerable income from the pharmaceutical industry. Bit ironic, in my opinion. My advice for the editorial team would be to ban all drug company adverts in their journal before hectoring to the masses. Do as I do, not as I say.
If a rep wants to see me in my free time to discuss a product, I do not think it unreasonable to expect a nice lunch or a good dinner. I will eat and, hopefully, enjoy the meal and I will not feel guilty about it. I will not feel obliged to prescribe because, for me, the meal is the price to talk to me, not to bribe me. Only joking, I am a thick, shallow, gullible, conspiratorial greedy pig.
1. Watkins C, Moore L, Harvey I, Carthy P, Robinson E, Brawn R Characteristics of general practitioners who frequently see drug industry representatives: national cross sectional survey. BMJ2003;326:1178-9
2. Abbasi K, Smith R No more free lunches BMJ2003;326:1155-6
Competing interests: � None declared

The Cloak of Service 2 June 2003

Nasir R. Awan,
Assistant Professor of Neurosurgery
Lahore Medical & Dental College, Canal Bank North, Tulspura, Lahore, Pakistan
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Re: The Cloak of Service

No matter what we may think but as clinicians, we remain vulnerable to the newer and innovaive marketing tricks of the pharmaceutical industry. It is unimaginable the ways it can, does and, I'm afraid, will continue to influence us.
Till not very long ago, I used to take pride in refusing lunch and dinner offers by pharma companies. Instead, I would ask them for literature documenting their efficacy etc. That lead to some sharp medical reps identifying my weakness and hunger for the printed word. Realization slowly dawned on me when I started receiving books and photocopied journals. Instead of being fed pizza, I was being fed books!
I then came up with a good alternative. Like some colleagues of mine, I started asking for bulk samples for the non-affording patients (who frequent all hospitals in the developing countries like Pakistan). The thought that I was playing a Robin Hood of sorts was a very satisfying for my conscience. Whatever I got out of these rich companies, I was using for the poor. Imagine my surprise and shame when a colleague pointed out that I had been routinely using one specific brand of a drug only because it had been bulk sampled in my ward!
I wonder if we can ever get out of this tangle and escape their influence. If not, then does it really matter if this manipulative sway is used for a little benefit of the poor?
Competing interests: None declared

Big pharm owns worldwide cessation policy 2 June 2003

John R. Polito,
Founder, WhyQuit.com
WhyQuit.com, 709 Black Oak Blvd., Summerville, SC 29483
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Re: Big pharm owns worldwide cessation policy

Why just the physician's free lunch? The pharmaceutical industry now owns worldwide cessation policy � at every level - and is making a "killing" selling OTC NRT products generating a 93% midyear relapse rate and using physicians to help.[1] Do you think my summary is how they'll market the lozenge, gum and patch to physicians over lunch? Not on your life! In fact, I had a brief online exchange with the study's industry "consultants" who admitted that OTC NRT isn't half as effective as the local neighborhood quit smoking program, but then go to great lengths making childish math and cost arguments as to why a 93% relapse rate is preferable to vastly superior interventions.[2]
Forget doctors and journals, the pharmaceutical industry owns a controlling interest in the cessation education presentations of most major health non-profits, which today are little more than pharmacy storefronts. And, whether just lazy or hoping for a cozy job later, senior government health bureaucrats allowed pharmaceutical interests to actually write U.S. cessation policy.[3] In doing so they have damaged and destroyed the efficacy of countless short-term (2 to 4 week) community abrupt cessation programs around the world. Imagine alcoholics wearing IV bags full of alcohol during AA meetings. NRT and gradual weaning have transformed once serious programs into bad jokes.
[1] Hughes JR, Shiffman S, et. al., A meta-analysis of the efficacy of over-the-counter nicotine replacement, Tobacco Control. 2003 Mar;12(1):21-7. http://tc.bmjjournals.com/cgi/content/full/12/1/21?ijkey=5.ko5/Oz4yutI
[2] Tobacco Control eLetters, Shiffman, S, et. al. OTC NRT 93% Midyear Relapse Rate, 10 Mar 2003 - http://tc.bmjjournals.com/cgi/eletters/12/1/21#89
[3] U.S. Clinical Practice Guideline (June 2000 USDHHS), Appendix C, Financial Disclosures for Panel Members, Consultants, and Senior Project Staff - http://whyquit.com/whyquit/A_GuidelinePanelDisclosure.html
Competing interests: Abrupt nicotine cessation programs director

Time to own up 2 June 2003

Colin Fitzpatrick,
Medical Adviser
Eastern Health and Social Services Board, Linenhall Street, Belfast, BT2 8BS
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Re: Time to own up

I found this theme edition very encouraging. For years I have been amazed by the naivety of my colleagues as they accept yet another free lunch / pen / foreign trip. They fail to recognise the sophistication of pharmaceutical marketing and excuse their behaviour on various grounds.
One favourite is �It doesn�t influence me�. If this were true, they would find that the reps would lose interest in them and move on to another colleague who is more easily influenced.
Another excuse is that the NHS could not afford to fund postgraduate education without sponsorship. It must be remembered that the money that provides sponsorship started in the NHS coffers. It was paid to the companies in exchange for expensive drugs and a small proportion is being reinvested. If we got some discounts on drugs, perhaps we could afford to provide education. In any case, colleagues who provide courses that do not ultimately result in increased drug sales will inevitably find sponsorship hard to obtain.
Many doctors do not realise that this behaviour is not the norm in modern society. I have a number of non-medical friends who work in various organisations within the public and private sector. They are generally not permitted to accept significant hospitality from those who sell products to their organisation and are horrified at the willingness of doctors to see sales reps and accept lavish hospitality.
There are a number of possible answers to the problem of inappropriate drug company sponsorship and promotion. I suggest that a code of openness and disclosure would be a good start. Every healthcare organisation � hospital trust, GP practice, etc � should develop a code of conduct. This should include the introduction of a register of interests listing all hospitality, sponsorship and significant gifts (over �5). The code and the register should be available to patients and the public. Doctors who do not abuse their position should have nothing to fear from this. Our MPs already have to adhere to such a code and it seems to work for them.
Annual appraisal also provides an opportunity for the doctor to reflect on the appropriateness of his/her relationship with the pharmaceutical industry. If the doctor lists gifts, hospitality and sponsorship under the probity heading of the appraisal form, the annual appraisal can include a discussion on how this has influenced practice and whether they need to change their behaviour in the future.
Competing interests: I am responsible for provision of advice and support on prescribing to the 400+ GPs in the Eastern Area of Northern Ireland. I do not accept drug company sponsorship or gifts.

Re: Enough already - Critical Psychiatry Network campaign 2 June 2003

Duncan Double,
Consultant Psychiatrist
Norfolk mental Health Care NHS Trust, Norwich NR6 5BE
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Re: Re: Enough already - Critical Psychiatry Network campaign

Simon Wessely may think that the relationship between the pharmaceutical industry and the medical profession does not matter.¹ This might be alright if all doctors took as refreshingly sceptical a view of medical practice as he does. He has agreed to chair a debate at the Critical Psychiatry Network conference on "Antidepressants are no better than placebos" (for details see www.criticalpsychiatry.co.uk/AnnualConference2003.htm). However juvenile he may regard the staging of such a debate, he at least seems to recognise the importance of the academic argument about the effectiveness of antidepressants. There is a genuine issue about bias in clinical trials of antidepressants, as further demonstrated by another article in this theme edition of the BMJ.²

The Critical Psychiatry Network does think that psychiatrists should declare their interests in drug companies.³ It also thinks that all organisations and conferences addressing psychiatric issues should provide full public disclosure of the amount of funding they receive from the psychiatric drug industry. A resolution to this effect was passed by the World Federation for Mental Health at its Membership Assembly, which was held at the Vancouver Conference and Exhibition Centre on 25 July 2001.⁴ The Critical Psychiatry Network is not receiving any sponsorship from the drug industry for its annual conference. It is dependent on subscriptions from delegates. The day's conference and debate are open to the public and there is a printable booking form at http://www.critpsynet.freeuk.com/form.htm.

Wessely S. Enough already. bmj.com/cgi/eletters/326/7400/1155#32821 1 June 2003 [Full text]

Melander H, Ahlqvist-Rastad J, Meijer G, Beermann B. Evidence b(i)ased medicine�selective reporting from studies sponsored by pharmaceutical industry: review of studies in new applications. BMJ 2003;326: 1171-3 (31 May) [Abstract/Free Full Text]

Thomas P & Bracken P. Time for openness on antidepressants. Guardian, Monday March 4, 2002 [Full text]

World Federation for Mental Health. Resolutions at the Membership Assembly. [Full text]

Competing interests: Founding member of Critical Psychiatry Network I have always kidded myself that any money I have taken from drug companies has been to reduce their profit.

Subliminal messages 2 June 2003

Jeremy J Black,
GP Principal
Llandaff North, Cardiff CF14 2FD
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Re: Subliminal messages

My local University Teaching Hospital has recently sold its soul for art. The previously featureless side of a multi-story building (overlooking one of the busiest roads in the city) has been adorned with a giant daffodil, one hundred feet high. Pretty it may be, but in the bottom left corner of this giant wall-hanging is the all too obvious Pfizer logo.
It has been suggested that the erectness and immunity to wilting of this reproductive growth might refer to a specific product of the sponsor?
Competing interests: I have attended Industry sponsored educational meetings and have a "freebie" stapler on my desk (albeit with the sponsors named neatly covered with masking tape). I also work as a Medical Advisor for the LHB.

Doctors and the Drug Industry 2 June 2003

Jeff D. Chapman,
No Affiliation
None, Boston, MA 01284
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Re: Doctors and the Drug Industry

In their editorial Abbasi and Smith point out the tangled web of interests in drug development: journals, drug companies, the clinical trials industry, universities, and politicians. The ethical and sociological problems however, are no different than in any other industry -- without independent oversight any industry tends to eventually shortchange their customers to the benefit of their owners, vendors, and employees, and the pharmaceutical industry is no different. Here in the States the FDA has compromised its independence by deriving a major portion of its budget from the funds provided by the pharmaceutical companies to review new drug applications. American citizens are unwilling however to fund FDA drug oversight directly from their own taxes, so until another interested party oversees the pipeline entryway we will continue to see pharmaceutical development driven by what can best be marketed rather than what is most cost-effective and health-promoting.
Is there another qualified chaperone though besides governments? The editors hint at an answer when they notice "Doctors have become dependent on the industry in a way that undermines their independence and ability to do their best by patients." So there is indeed a possible solution: groups of doctors (such as the American Medical Association) should sponsor their own independent trials of medicines. Until doctors themselves take responsibility for the quality of the medicines they prescribe, they have little right to complain.
Competing interests: None declared

People in glass houses should be careful about stones 2 June 2003

Andrew J Ashworth,
GP
Bonhard House, Bo'ness, EH51 9RR
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Re: People in glass houses should be careful about stones

Should doctors seek to extract the Drug Industry�s corneal speck of dust without first having addressed our own ophthalmic motes? While, in ivory tower never-never land the only largesse shown to doctors is by the drug companies, we must also acknowledge that the subjection of our professional position in all therapeutic areas to managers (on whose reports salaries and even revalidation depend) with different ethical codes and objectives is achieved by inducing dependence on the organization rather than inspiring professional duty.
In spite of rigorous testing of drugs before companies permit them to come to market, organizations place addition hurdles in their way in the form of various committees and local protocols. While these organisational obstacles claim the moral high ground of promoting rational prescribing and �evidenced based medicine�, it is salutary to consider the difficulty that Lister might have had in promoting the use of carbolic soap in the modern NHS! We might perhaps review the propriety (or at least the accountability) of doctors taking part in activities designed to control costs in preference to increasing quality.
Resistance to he introduction of High Dose Buprenorphine for treatment of opiate addiction in Scotland is illustrative. There is good evidence that the drug is effective and, with an acknowledged mortality associated with the current drug of choice, Methadone: the drug company in question might have expected a ready market without depending on �free lunches�. Despite the reasonable assumption that Scottish Patients might have benefited in a similar way over a similar period to Swedish Patients (1), State supplied healthcare has until now virtually prevented the introduction of this drug to NHS patients, using informal and formal committees where declaration of conflict of interest is not required. During the same period, Naltrexone (whose prescription is not without adverse consequences (2)) has reached the pharmacy counter with remarkable alacrity. Naltrexone (which is the maintenance drug of choice following privately funded treatment for addiction) works out at a similar daily cost to Methadone while, at least initially, Buprenorphine is more expensive. It is not clear whether the resistance to Buprenorphine is based on cost to the organization or other undeclared factors but, despite �Free pens and Pizzas�, Scottish patients are denied a treatment that is available to their English counterparts by a layer of committees that can prevent (though they cannot facilitate) access to effective drugs.
A few doctors may be significantly �dependent on the drug industry in a way that undermines their independence and ability to do their best by patients�: a much larger number comply with the (sometimes unreasonable) constraints of managers who control benefits that have much more influence than a few free lunches. We should seek to disentangle ourselves from all vested interests, save those of our patients. Perhaps a start would be for the GMC to provide the facility for all doctors on the medical register to declare all interests (including salaries and prestigious positions) and the bodies having influence over those interests. For the time being, a medical profession that lives in glass houses (albeit with opaque windows) should be careful about throwing stones.
1 Kakko J. Svanborg KD. Kreek MJ. Heilig M. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial.[comment]. [Clinical Trial. Journal Article. Randomized Controlled Trial] Lancet. 361(9358):662-8, 2003 Feb 22. Held at BMA Library UI: 12606177
2 Colin A Graham, Gordon W McNaughton, Alastair J Ireland, Kerry Cassells, David Mountain, Gil Blackwood, A J Ashworth, A Kidd, and John Strang. Take home naloxone for opiate addicts BMJ 2001; 323: 934
Competing interests: � I sometimes take lunch with drug representatives: on the last occasion the menu was baked potato & cheese with sparkling water � I paid �8.40 for both parties. I have been taken to dinner by a company seeking to use a sedation technique to convert opiate addicts to Naltrexone: I had a further meeting at which I provided lunch. I have not taken up the offer of involvement. I have invented a method of preventing Buprenorphine diversion to the black market: I have made no profit from this invention. I have discovered a rapid detoxification technique using Buprenorphine and Naltrexone: since the technique uses Buprenorphine (which is effectively banned in Scotland), I may only provide this to patients in the private sector and intend to do so.

Re: Relationship between the Drug Industry and Doctors 2 June 2003

Rita Pal,
Editor NHS Exposed www.nhs-exposed.com
XXXXXXXXXXXXXXXX
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Re: Re: Relationship between the Drug Industry and Doctors

While Dr Prabhu has some interesting points, I wondered whether he would consider these answers to his suggestions.
1. Overseas trip abroad should not be sponsored by the drug company.
If the conference is sponsored by a drug company, there is clearly no reason why they should not pay for doctors to attend. It is a simple practicality.
2. Doctors eating out for social purpose should not be sponsored by the drug company. This must be a desciplinary offence.
"Disciplinary offence". For a person who is so senior, you have some strange ideas about what constitutes a disciplinary offence. All my colleagues are busy doctors and have limited time to attend 7 meetings a year. We do all enjoy the education provided in a relaxed atmosphere were we can talk shop and the drug rep can educate us. I am sure you will appreciate that education is excellent for doctors. I learn most of my pharmacology from Drug reps at dinners. In addition, after 82 hours and lack of food from the NHS, drug reps come as a welcome perk.
Education in drug pharmacology enables me to compare and contrast medications to be prescribed. Sure you cannot consider an opportunity for education - a disciplinary offence.
I think people forget that the best education is done in a relaxed atmosphere, with ample food, friends and discussion. Drug companies are educational to all doctors. I think this point has been missed.
3. There must be clearly defined and resoanable expenditure paid by the drug company in any sponsored meeting. Who ever organises the meeting should declare it.
"Reasonable expenditure" has a definition in business. Drug companies are all businesses and their balance sheet will certainly will not allow over generosity in finances. I would have thought you would be aware of the first rule of accounts and business :) which is "thou shall spend the least amount of capital to obtain the most gains"
4. Any doctor who works in the NHS and gives lecutre in a drug company sponsored meeting should declare it in his apprasial folder.
Appraisal folder? Would this be so that doctors who support other drug companies can have access to it during revalidation. Judgemental decisions from the powers that be is always worrying. Are we going to start operating a Big Brother like approach eg Dr Richard Smith gave a lecture and Pfizer provided the sandwiches - lets place a big cross next to his name! The suggestion you make is a breach of human rights for any doctor who should have the freedom of choice - to lecture anywhere he wishes without judgemental interference from those who are supposedly politically correct.
5. Presribing practice of such a doctor should be compared with the national guidleines.
National Guidelines? I am sure you learned many years ago that human beings are genetically different. Each person is an individual. Drug therapy should be catered to the patient seen and treated eg someone may be allergic to Aspirin and the doctor may need to prescribe Clopidogrel. National Guidelines are merely suggestions for management. Doctors treat the patient and tailor treatment to the symptoms and history. Individual treatment is important as you well know. Comparing prescribing habits for doctors to national guidelines would provide a inaccuate statistical analysis due to a simple point - most doctors, GPs etc treat the patient with drugs applicable to their condition and state no matter what the national guidelines stipulate. You cannot suggest that doctors freedom to prescribe should be interferred in this way.
6. Funding for personal development should be increased
Interesting point. Ofcourse it depends on what your definition of personal development is.
For the record, none of my colleagues or myself are swayed by drug companies. We all prescribe for the patient in front of us. We all use drug companies as an adjunct to our education. I find drug reps very useful in finding me papers, answering my questions etc.
We were taught to treat the patient not obey drug companies. I believe most doctors are of this quality. I therefore feel that restrictions by monitoring their method of practising suggested by Dr Prabhu is counterproductive and a breach of human rights for many honest and hard working doctors. Doctors are free spirits by nature. Each of us have our own ideas about management. Doctors should be given the freedom to develop management strategies without being dictated to by the powers that be. There is also nothing wrong in drug companies providing the education that is not in the British National Formulary.
Kind Regards
Dr Rita Pal
Editor
www.nhs-exposed.com NHS Exposed
The Truth Behind the White Coat
Competing interests: � None declared

Understand the business economic model and recognze the inevitable 2 June 2003

Robert A Knuppel,
Professor
Women's Integrated NetworkLLC, 600 Mamaaroneck Road, Harrison, NY, 10528
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Re: Understand the business economic model and recognze the inevitable

The responses so far to this article are varied, worthwhile, and truly demonstrate the chaos of the middleman in a multitrillion business.
As I finalize my MBA thesis my thoughts continue to hopefully raise my colleagues sensitivities to system management with the recognition they are not autonomous and lost the marketing battle to the pharmaceutical industry years ago.
Change is difficult. We need to recognize that the best model for delivery of medication for the " worried well" (which constitutes the vast majority of medications prescribed) is not using a labor intensive service such as a visit to a very well trained and intentioned professional. You will not be prescribing these drugs in the future. Most of these medications have equal effectiveness so the formulary, pharmaceutical benefit manager, and the nurse practioner and pharmacist will be the "prescriber", lowering the cost of distribution. I believe 1/3 of all marketing costs in 2002 were directed at the consumer with less attention paid to the physician.
Why were we not this vocal about potential conflicts ten years ago? The model has now shifted and we will need to look for alternative funding for publications, continuing medical education,and our societies annual functions. Sinners need not repent...it is too late. Figure out how to alter the system and create a positive effect from this chaos.
Competing interests: � lecturer and recipient of pharmaceutical grants

Naivete 2 June 2003

Martin D Talbot,
Consultant Physician and Director of Undergraduate Medical Education
Sheffield Teaching Hospitals NHS Trust, Sheffield, UK, S10 2JF
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Re: Naivete

Well said BMJ and Lucy-Jane Davis. I for one cannot believe the naivete of colleagues who say that their dealings with the drug houses do not effect their professional behaviour. Do they really, really belive that the drug industry is that stupid? They should ask themselves, for example, why it is that the industry spends three times as much on marketing (including involvement with doctors) than research.
Competing interests: None declared

Free journals or free conferences 2 June 2003

David A Sulch,
Consultant Physician
Queen Elizabeth Hospital, Woolwich SE18 4QH
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Re: Free journals or free conferences

Dear Sir,
I find your arguments re pharmaceutical sponsorship bafflingly hypocritical, confronted as I was by numerous drug company advertisements throughout this week's BMJ. Sure, we'd all like to receive free journals rather than paying for them. In what way is that more morally justifiable than receiveing free pens or diaries?
I am a consultant geriatrician, who does acute general medicine, is the lead stroke clinician and the lead for a stream of Reforming Emergency Care at our Trust. The cost of attending one conference (the European Stroke Conference, where I presented research results) exceeds the 'average' study leave allocation from our Trust for a whole year. How am I supposed to attend all the other relevant conferences to maintain my CME unless I either a) pay for it myself or b) receive sponsorship to help me to do so? And no, still won't prescribe clopidogrel in acute stroke until I see clear evidence to suggest that I should. I think most doctors have a degree of independent thinking.
Yours faithfully,
Dr David Sulch
Competing interests: I have received funds from Sanofi-Synthelabo towards the cost of attending an overseas conference

Medical Model 2 June 2003

Gerard D Finnegan,
Project Manager
BT48 6HW
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Re: Medical Model

We read with interest the BMJ article on the relationship between large drug companies and health care professionals. It is a complete disgrace the linkage that currently exists in the health care environment and from which patients and carers are beginning to challenge the professionalism of certain health care professionals due to the perfidious activities of pharmaceutical companies. In their quest to perserve their obscene profit margins they are willing to go to the extreme lengths of manipulating and indeed undermining the role of health care professionals.
We require a completely new approach by health care professionals to instil confidence within society in relation to the medical model approach to mental health and health in general.
Competing interests: � None declared

More freedom 3 June 2003

dr nayyar yaqoob,
assistant prof of medicine
pakistan
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Re: More freedom

i would propose that there should be an independent body providing funds for research and monitoring the conflict of interests and this body can be funded by the drug companies instead of financing individuals & showering gifts
Competing interests: � None declared

Who pays for lunch is not important when you are out with your real friends 3 June 2003

michael a james,
consultant cardiologist
taunton & somerset nhs trust, musgrove park, taunton, somerset, ta1 5da
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Re: Who pays for lunch is not important when you are out with your real friends

Doctors and drug companies are naturally and necessarily closely linked. We share many common goals and objectives (but also some that are different). Furthermore, a large proportion of the staff of drug companies are the very same doctors and research scientists that we trained with. Most importantly neither Doctors nor drug companies can exist without the other and it is therefore essential that we have a close collaboration and understanding. This close collaboration has been essential for the progress of medicine and by definition has thus been to the immense benefit of patients. As your article points out all significant advances in drugs (and technology)over the past 60 years have been developed by drug companies. Without these advances medicine would be virtually powerless, (and largely pointless).
Naturally, any organisation which operates within a free market must also be concerned with its own survival and profitability. However, this is not fundamentally "evil",indeed we are extolled the virtues of the free market on a daily basis. If only the health service operated in a free market it would be much more efficient and effective we are told. Well you can't have it both ways if the free market is good for the goose....
Corporate hospitality is not something invented by the drugs industry, it exists wherever the free market exists and yet the rest of the free world seems to survive the pernicious influence of these seductive temptresses. The reason is because the hospitality is also part of the free market and is by definition freely available. We are not trapped like moths in the bright glare of this hospitality because there is equally as much hospitality available from the next company and the next. Indeed when hospitality is so freely available why would anyone want to restrict their options to one particular provider? Thus there is no logic behind the "corruption" concept. However, what the drugs industry has done is to imaginitevely use this hospitality in an immensely constructive and helpful way, a way that benefits doctors and patients (indeed it would not be too much to say mankind). I know of no other agency that would have been prepared to fund the enormous progress of the past 60 years, and take on the additional responsibilty of educating the health providers. Certainly we have repeatedly been shown that governments are not prepared to do it (most are pretty ruluctant to even fund the delivery of health care - the fruits of this research!). Whilst charities simply do not have enough funds to take over the whole responsibility of research and development. I am not suggesting that these companies do this out of a spirit of generosity, but it is the very fact that they have a vested interest that makes them willing to take it on.
Those bodies that undertake research have a necessary duty to disseminate the results of that research, who else could do it? Inventions can only be explained by those that understand them. However, it is equally true that the enthusiastic but partial originator may not be able (or willing) to see the flaws. It is the duty of the educated audience to sift and digest the information, sometimes to accept, sometimes to reject and sometimes to refine. It matters not who funds this process it only matters that it happens at all and the audience maintains its impartiality. The competitive free market ensures that even if some individuals are tempted to lose sight of their impartiality they will always be counterbalanced by someone else with a different axe to grind, the free market ensures that we are flooded with different view points and fosters healthy debate and cotroversy. I believe that it would actually be detrimental if the task of educating health providers was put solely into the hands of a single agency, who would control the way opinion was driven then?
The ideal system might be one where generous philanthropists fund all research, but shall we come back down to the real world. The ideal practical solution is one where drug companies fund research (yes, because they have a vested interest and therefore a motivation) but the possible excesses of the drug companies are kept in check by collaboration with independent doctors, hospitals and departments - and surprise surprise that is what we have. This is because everything in the world develops by evolution and evolution as we know may not produce the best result, but it produces the result that works and is suited to that particular environment. It would not be unreasonable to ask for increased monitoring of the health of this symbiotic system but to prevent it would be to strangle the lifeblood of research and indeed education itself.
Competing interests: None declared

The Parasites Who Take a Free Ride on Our Taxes! 3 June 2003

Carol A Teasdale,
N/A
N/A
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Re: The Parasites Who Take a Free Ride on Our Taxes!

If pharmaceutical companies were charged a fair sized research tax on their sales by the government, the money could be pooled and distributed by an independent trust fund. Researchers, universities and students could then apply for the funding for original ideas and it would remove any blockages to cures. People could also contribute through fundraising to student education, confident that it would be untainted by external influences.
Companies could then register an interest in producing any new drugs after trials, and their applications could be considered in light of the true benefits to society. This means that researchers work would come under close objective scrutiny by the pharmaceutical companies who will want to buy an effective product. Researchers might also be driven by the needs of the community with a particular health need, rather than false promises designed to play with the stock markets. Compared to a system that encourages stretched truths on new drugs and puts pressure on researchers to be bias, there would be so much more freedom for innovation to flourish.
Of course, the company would still have to sell the product they produce, but at least doctors could have more confidence in their ability to do their job long before the company sales man knocks.
Essentially the industry should not be dictating the market, patient's needs should. It should not be having a free ride off the NHS and its clients, it should pay all the way. The pharmaceutical industry is the parasite on the back of the NHS and it has grown up with it, becoming inseparable in so many doctor's working lives and the minds of MPs.
Anyone taking a good look at the NHS might consider why it isn't giving people the essentials it was designed for all those years ago. Why do we have people who cannot afford dental treatment or eye tests, but can get expensive new drugs and treatments which could have been insured for?
A reminder to medical students who don't believe that they could ever be influenced by companies at an early stage. Banks and building societies spend millions of pounds attracting younger people to bank with them, even at the risk of huge debts being ran up. Lifelong loyalty can be brought with vouchers and gifts and all the efforts are well rewarded in time.
I feel strong about the issue of patient betrayal because one of the greatest sales cons must have been for synthetic thyroxin, which I take. They managed to sell it without the research to prove that it was as effective as a natural medicine people were already using. Today the product loyalty has been blindly carried on to the next generation of doctors. This shameful loyalty was purchased with so little, not even a decent research study. It proves to be an excellent demonstration of the long term power of product loyalty, as many GP's today won't prescribe the older alternative, even chosing to dismiss it all together. Instead of an empowering choice of medicines we have ended up with one. How is this health 'care'?
Competing interests: None declared

Conflict of interest: "Alzheimer disease seems to suffer more than most in this respect" 4 June 2003

Alexei R. Koudinov,
neuroscientist and editor
Rus Acad Med Sciences, Moscow, Russia; Neurobiol Lipids, PO Box 1665 Rehovot 76100, Israel
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Re: Conflict of interest: "Alzheimer disease seems to suffer more than most in this respect"

Inform a Colleague
Editor,
I appreciate all readers' responses associated with the major Editorial by Abbasi and Smith (p. 1155) in this week's BMJ theme issue on the relationship between doctors and the drug industry.
I have my response (May 31, 2003) published in association with another key Education and Debate article by Smith ("Medical journals and pharmaceutical companies: uneasy bedfellows", p. 1202).
I would like to alert readers of my discussion contribution that is on the subject of the conflict of interest in the field of Alzheimer's disease, that journal Nature Medicine (Vol. 5, 713) found "to suffer more than most in this respect", and that "judging by recent events, this reputation seems justified." The links to the bibliography describing those events are provided in my May 31, 2003 BMJ letter .

Sincerely,
Alexei Koudinov, MD, PhD
neuroscientist and editor
http://anzwers.org/free/neurology
http://neurobiologyoflipids.org

Competing interests: None declared

Free Lunch is never a free Lunch 4 June 2003

Mohammed Mujtaba Ahmed,
Prescribing Pharmacist
Doncaster West PCT Doncaster DN4 8QN
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Re: Free Lunch is never a free Lunch

I, in my role, as prescribing pharamcist, end up seeing a rep with my general practitioners and yes it always ends in the medical rep trying to convince me more of their product than the GP's.
Medical reps, although doing their job (that's what they are paid for) will try to influence which ever way they can. These following examples are not anecdotal, , we can find them everywhere in every PCT, hospital and every day there are discussions among people like me and GP's, consultants, hospital departments etc.
I recently met the rep promoting Symbicort and he tells me. "Mohammed good news I have left your area and now promote the drug to dispensing doctors". My answer was this still would not change my advice regarding symbicort that it was not an appropriate combination and should not be used 1st line. His reply "Mohammed dispensing docotors are not interested in evidence they want a good deal on price". Your evidence goes out of the window.
I have some GP's who will not see any reps at all, others will see and greatly influenced. Some see with the motive to grab freebies. What I can't understand is that we all health professionals either with salaried job or self employed status. So why is it difficult to feed ourself? or run our business without the input from pharmaceutical industry.
We have seen repeatedly pharmaceutical companies mislead health professional and yes none of us have that extra time to go through the literature every time a meta-analysis is published or double blind trials are published. They do not present full information (celebrex (6 months data instead of 12 months data) and Istin (All Hats off to Istin).
In United Kingdom we have Regional and district medicines information centres in every hospital. Why not utilise their skills. National Prescribing Centre and Drug and Therapeutic Bulletins do a wonderful job in presenting the evidence. Is it so difficult to follow them instead of seeing a rep.
Those who have spare time! and see rep in their own time why not read? or surf the medical internet sites like www.druginfozone.nhs.uk.
This debate will go on and on. There are people who will justify seeing a rep and others against. It comes down to your own ethics. I have a GP who justifies using ACE 2 antagonist first line in essential hypertension. On the other hand I have a GP who sees a rep every day but is only influenced 20%. It is easy to see who is influenced more readily. Just look at their prescribing of black triangle drugs.
I was so against Crestor (new antihyperlipidaemic) that rep had to offer me a trip to Isle of New Jersey. Ofcourse I refused.
I know this will bring further uproars from my medical colleagues but why not leave prescribing to prescribing pharmacists? Medical practitioners should diagnose and ask prescribing pharamcists to prescribe by class e.g. PPI, NSAID, ACEI, BBlocker etc and then based on most cost effective evidence use the drug.
I personally do clinics and yes I do prescribe (my GP's still has to sign the prescription and ok it). Good communication and sound clinical knowledge has led to confidence in each other and improvement in patient care. After all that is what we all are trying to do.
Mohammed Ahmed
prescribing pharmacist
Doncaster West
Competing interests: � None declared

Free lunches - ok if they are a la carte 4 June 2003

Angus M Ross,
GP registrar
Masham, North Yorkshire, HG4 4DZ
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Re: Free lunches - ok if they are a la carte

Sir,
I fear that, yet again, we have shot ourselves in the foot by devoting an entire issue of the BMJ to such a negative portrayal of the relationship between the medical profession and the pharmaceutical industry.
The timing was particularly unfortunate given the uncertainty surrounding both Consultant and GP contracts. We live in an imperfect world and despite often dubious ethics, drug companies are a fabulous resource, providing funding for books and equipment as well as sponsoring trips to conferences. Funding that is often impossible to obtain from post-graduate departments. As individuals, we should still have the freedom to assess every 'free lunch' and decide for ourselves if it is ethically compromising or not. Breaking ties with the industry will not help our profession or our patients.
Yours faithfully,
Competing interests: � None declared

Ethics Committees are part of the problem, not the solution. 4 June 2003

Linnie Price,
Research Co-ordinator
Research and Development Support Unit, Peninsula Medical School, Torbay Hospital, TQ2 7AA
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Re: Ethics Committees are part of the problem, not the solution.

Dear Sir
Your hope that Research Ethics Committees (RECs) have a role to play in �ensuring that new scientific trials are scientifically justifiable� must be faint indeed.(i) RECs are not remitted to undertake scientific review of protocols, as clearly stated in the Governance Arrangements for NHS Research Ethics Committees (GAfREC). �It is not the task of an REC (sic) to undertake additional scientific review, nor is it constituted to do so�. (ii)
Furthermore RECs and their members are as entangled with drug companies as the rest of the medical profession, and their members just as likely have financial and other conflicts of interest.
Of particular concern is lack of transparency within the ethical review system. RECs operate in secrecy, explicitly in deference to the pharmaceutical industry�s requirement that �commercial confidentiality� be protected. Committee minutes are confidential, and members� competing interests, if declared, are not required to be included in annual reports, the sole means by which RECs are publicly accountable. (Indeed, no MREC annual report has yet been published, even though MRECs have been in operation for nearly six years). The prevalence of conflict of interest within committees, and whether and how bias is prevented is therefore unknown and unknowable, and the commercial needs of the pharmaceutical industry take precedence over those of democratic accountability within the UK ethical review system.
Given the failure of the RECs to put their own house in order in relation to conflict of interest, it is over-optimistic to hope they have a part to play in policing the pharmaceutical industry, whose interests their procedures are largely designed to serve.
i Abbasi K and Smith R. No more free lunches. BMJ 2003; 326, 1155-56
ii Department of Health. Governance arrangements for NHS Research Ethics Committees. http://www.corec.org.uk/Interim.htm
Competing interests: None declared

..on a positive note.. 4 June 2003

Radhika R Hariharan,
Asst Professor
Baylor college of Medicine, Houston Texas USA
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Re: ..on a positive note..

Having worked in a system that did not allow "free lunches" or even the occasional medical representative visit onsite, I felt seriously deprived of information on the newer and emerging medications on the market. The educational role of these informal physician-industry contacts should be recognized. Moreover, most physicians, at least in the US, have formulary restrictions that significantly reduce bias in prescribing.
Competing interests: None declared

The hosts who never get a 'thank you'. 4 June 2003

Gurli Bagnall,
Patients' Rights Campaigner
Independent
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Re: The hosts who never get a 'thank you'.

M.A. James, consultant cardiologist, like most others who submitted a rapid response, missed the point. There is no such thing as a free lunch. Someone pays for it and in this case, the �someones� have no choice in the matter.
Whether through direct payment or subsidies from taxation, dinners, pens, weekends in luxury resorts etc. are added to the cost of medication and it is the patient who picks up the tab every time. They are the hosts who never get thanked.
It has been argued that �freebies� makes no difference to patient care; that doctors are not influenced; that they make up their own minds about what to prescribe and how much. The medical �error� statistics say otherwise. Whether through inappropriate prescribing or misdiagnoses by the �opinion� pushers who protect manufacturers of disease causing chemicals, the statistics tell a very different story.
Calling the burgeoning numbers who are protesting in the press and on the internet as activists does not change the fact that the medical profession is the author of that particular situation. The enthusiastic response entitled �Enough Already� is a case in point. This piece offers an explanation as to why ME, GWS, MCS and other such conditions are labeled as hysteria, malingering, or hypochondria. Dress it up or dress it down, people are being hurt and even killed by those �harmless� freebies.
Competing interests: None declared

I ask why and how 4 June 2003

Francesco Carelli,
GP- EURACT Council National Representative
20123 - Milan - Italy
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Re: I ask why and how

I ask how it'd be possible to organise a scientific meeting on research or on teaching methodology without a sponsorship by a drug company.
I ask why a GP could not be allowed to be sponsored to participate at a Congress when he/she is going as a researcher, or presenting a paper, a poster, as lecturer, as active real participant.
I ask how a GP, being representative for his/her Country, could afford every time all expenses to participate actively working in International Workshop and Meetings.
I ask why some specialist doctors are sponsored to go everywhere, without being researchers, without presenting accepted papers, without being able to speak in the Congress' official language.
I ask why some doctors are prevented from participating in meetings interesting for their daily practice and style of work, because of costs and " politically correct " competing interests, while others are not prevented from "eating" not "science" but "tourism" in the most beautiful areas of the world.
I ask to think about how to change all this
Competing interests: � None declared

Evidence based sponsorship 4 June 2003

Frank O Wells,
Chairman, Marix Drug Development Ltd
Llantrisant, CF72 8UX
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Re: Evidence based sponsorship

As a former member of BMA Council as well as the previous Medical Director of the ABPI, I find the tone of the current edition of the BMJ bitter, but I am not surprised. Indeed, nothing changes. Most people do not want to listen to a reasoned argument from reasonable people from within the industry, as is reflected by this edition and by the balance of rapid responses already received.
My reason for responding now is to relate something referred to in the press release issued by the ABPI at the time of publication of this edition but which has not seemingly been taken up. This was the comparative study which I conducted, together with Professor Stuart Murray, on the effectiveness (or otherwise) of postgraduate meetings for general practitioners in a British region which were either sponsored by a pharmaceutical company or not so sponsored. All the postgraduate meetings approved by the Postgraduate Education Department for the region over a 3- month period were assessed by representatives from a panel of assessors appointed equally by either the Postgraduate Department or the ABPI who attended every one of these meetings for the purpose.
Questionnaires were given to the attendees at each meeting asking for their comments on the educational content of the meeting, the suitability of the venue and the extent of promotional activity (if any). The assessors expressed their own opinion as well and a follow-up was conducted one month later to assess the retention of information by those who had attended. Suffice it to say that the end assessment of this exercise showed that the quality of education was at the very least equal, whether the meeting was sponsored or not.
Sadly, permission to publish the full results (which were actiually in favour of the commercially sponsored meetings, some of which contained no promotional material at all) was refused by the Postgraduate Department, but a summary is in the public domain. It can be read in the Journal of Pharmaceutical Medicine 1995; 5: 177-179. I commend this sole item of published evidence based effective pharmaceutical sponsorship to the debate on this issue.
Yours sincerely,
Dr Frank Wells
Competing interests: � (Retired) former medical director of the UK trade association for the pharma industry (ABPI)

In Who�s Interest? 4 June 2003

June C Nicholls,
None
Parent
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Re: In Who�s Interest?

A noble and honourable profession, where only the academic elite is invited to embark but yet it appears that sometimes, the most basic of logic and commonsense eludes its exclusive members.
For those that see �no wrong� in current cosy relationship between Big Pharma and the medical profession, I have one question: would they also like to see the same in the wider realms of commerce where conflict of interest is never regulated?
Somehow, I don�t think so.
The issue is not simply one of a few pens, a free pizza lunch, and we all know it. It is about the efficacy of independence. In what, as some would ask � in the way research are conducted, results presented and published, (drugs) prescribed and ultimately, but more importantly, the way governmental policies are swayed, shaped and adopted.
Not true? In my humble opinion: (well � that�s not really important � but I�d like to give a clue; Toxic fumes including carbon monoxide poisoning. Never heard of it?)
Then again, sometimes it takes a personal tragedy to �see the light� � the warning light � as did a leading Professor of Environmental Toxicology, an expert in chemical and biological warfare at the University of Leeds, UK, when he made a thorough study of the evidence and became �convinced� with a problem with the so-called �safe-drug�, after the death of his wife.
Quoting the professor from an article: �I was in pieces at the time but I just forced myself to look into this. I just thought maybe there is something in it, so I started searching for evidence on the suicide risk related to Prozac and it just came tumbling out. It was just devastating finding this.�
In reply, the company statement reads: �There is no credible evidence that establishes a causal link between Prozac and violent and suicidal behaviour.�
�No credible evidence that establishes a causal link� is that salt to many wounded hearts.
The ethos of the profession is all about the duty of care to people you serve. Therefore which side of the fence you belong to in this argument, remember this: Judas never enjoyed the spoils of his betrayal.
Competing interests: � None declared

Well Done BMJ and about time. 4 June 2003

Dr. Terry D. Lynch,
Psychotherapist and GP
Limerick, Ireland.
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Re: Well Done BMJ and about time.

Well done for highlighting this enormously important issue. As a GP for 20 years, I have for over ten years been very uncomfortable regarding the excessively close alliance between the medical profession and the pharmaceutical industry. In the interest of the public we serve, it simply HAS to change. This relationship has become so cosy that many doctors fail to see the conflict of interest which exists between both groups. So cosy is the relationship that many doctors have lost their sense of discernment regarding the relationship, seeing little need to seriously question it.
This relationship has ensured that issues which favour the pharmaceutical industry get considerable medical media coverage, while issues which do not enhance the pharmaceutical industry recieve less priority in the medical media and medical education. It is my view that this relationship leads to censorship regarding what doctors are educated about. It has to stop. It is insidious, pervasive, and fundamentally unethical in my view.
Dr. Terry Lynch,
Family Doctor and Psychotherapist
MB. BCh. BAO. DCH, DFP, DObst., MRCGP, MICGP
MA in Humanistic and Integrative Psychotherapy
Author of �Beyond Prozac: Healing Mental Suffering Without Drugs� (Marino, Ireland, April 2001)
Competing interests: � None declared

Nurses will be their next target 5 June 2003

Liz Darlington,
Nurse Practitioner
Timperley Primary Care WA15 6PH
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Re: Nurses will be their next target

Having recently moved from secondary care where I felt reasonably well protected from reps I am utterly amazed at the fiscal pharmaceutical environment that prevails in primary care and the volume of invites to 'educational meetings' with free lunches, trips to TV shows etc that have been put my way.Supplementary nurse prescribing is about to take off in the UK very soon and as such nurses prescribing POM's for chronic disease are going to be easy targets too. What is even more worrying is the plans of the DOH to have pharmacists as prescribers, the majority of which are self employed business men and women, making direct profit out of what and how much they dispense. If thats not a conflict of interests then what is !!!.Surely it has to limited to hospital pharmacists who are NHS employees with not ulterior motives.For similar reasons should we have dispensing GP's??
Competing interests: None declared

Entanglement with government and pharmaceutical companies. 5 June 2003

Peter L Jenkins,
Consultant Psychiatrist
Independent Practice
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Re: Entanglement with government and pharmaceutical companies.

Isn't it about time for a full issue upon the abuse of the DOH's quasi monopoloy and employment power in twisting our professional agenda?
The fight to prescribe drugs, when they were new, such as selective serotonin reuptake inhibitors, viagra, clozapine and donezapril when clinically indicated due to opposition from self opinionated doctors confused into believing they should protect the public purse has caused far more problems for my patients than a few free lunches. Drug companies are an easy target, far more complex is addressing the stigma and socio- political discrimination which patients in general, and mental patients in particular, experience from society, their elected politicians and members of our profession colluding with these reactionary forces.
Paying doctors properly would disincentivise free lunches, sponsored eductation and "unaffordable holidays". Many members of our profession should reflect that a sandwich at one's desk is no more holy than a decent lunch and that comfort, time and luxury are useful in ameliorating stress in a profession whose members both need and deserve such amelioration.
Finally that sponsored research shows positive outcomes suggests that selection of studies occurs and that studies likely to be negative are excluded from funding, i.e. good commercial judgement, not machiavellian manipulation.
Competing interests: � None declared

A paper in search of emotional intelligence? 5 June 2003

Marios Adamou,
Specialist Registrar/Honorary Lecturer
St Martins Hospital, Canterbury, Kent, Ct1 1AZ,
Marios Adamou, Anthony S. Hale.
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Re: A paper in search of emotional intelligence?

The editorial by Abbasi and Smith[1] is emotive. With the use of words such as banqueted, riddled and machinations the authors evoke emotions to support their argument. Why though choose the emotive and not the analytical path in their argumentation? Clearly if put under scrutiny arguments can be debated and readers can reach their own conclusions. Do the authors honestly believed their readers could not reach their own conclusions or is the premise of their argument so weak is difficult to present differently?
The paper re-brands doctors as na�ve corrupt and unable to make informed decisions. In the past, the societal branding of the doctor was of an esteemed, honest, reliable and hard working individual. This branding was not a product of marketing but the result of the vocation, commitment and lifestyle choice of thousands of doctors. The benefit from the re-branding of doctors by the authors as na�ve and corrupt individuals particularly in a time of low morale in the Health Service[2], is questionable, although clearly in tune with a doctor-busting zeitgeist.
In addition this paper openly accuses companies for bending rules. Some may find this defamatory.
In our opinion, if the authors wanted to make the argument that the relationship between the Medical Profession and the Industry needs to be redefined, shouldn�t begin by stirring up emotions and labeling the members of the Society the Journal Represents. There must be other ways.
1. Abbasi, K. and R. Smith, No more free lunches. BMJ, 2003. 326(7400): p. 1155-1156. 2. Kmietowicz, Z., Quarter of GPs want to quit, BMA survey shows. BMJ, 2001. 323(7318): p. 887-.
Competing interests: � M. Adamou is a co-investigator to pharmaceutical companies producing or developing neurotropics. A.S. Hale is an investigator and advisor to pharmaceutical companies producing or developing neurotropics.

Do I smell sour grapes? 5 June 2003

David M Lewis,
General Practitioner
The Tudor Surgery, 139 Bushey Mill Lane, Watford, Herts, WD24 7PH
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Re: Do I smell sour grapes?

You are correct in identifying the close relationship between the drug industry and medicine. However, there is so much good that can come from judicious use (exploitation?) of the industry's largesse, which by the way seems to be diminishing with the contraction of the economy.
The small organisations with which I am involved could not continue to arrange professional meetings without sponsorship. May be if the organisation is not self-funding it should not exist at all, but that is a moot point.
How can you square the lavish sponsorship/donations from industry to the medical royal colleges' headquarters with the denouncement of the cosy relationship with industry?
I smell sour grapes from a (socialist) lobby group.
The issue is not the cosy relationship between doctor and drug rep(s). The issue is proper training in the necessary negotiating skills and professional attitudes that allows mature appraisal of the advertising influences that Big Pharma (and Medical Devices Companies) focus onto a naive profession. Here is a real application of EBM skills that deserves greater emphasis.
Competing interests: Organise professional meetings sponsored by drug companies. Have received sponsorship for attending/speaking at local/national/international meetings

The medical profession is losing our trust. 5 June 2003

James J. Ebersold,
Non-Medical
EMC Corp, East Greenbush, NY 12061
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Re: The medical profession is losing our trust.

I am not in the medical profession; rather I am a consumer of medical care. The influence of the drug companies is undeniable through various physician perks as well as (at least in the U.S.) the drug advertising on television. The doctor is influenced with the drug company junkets, the patient is influenced with advertising to get the latest drugs, and then the physician is pressured/influenced to prescribe something that may not really be needed. Why would the drug companies advertise and wine and dine if it didn't work. They certainly are entitled to make a profit but the whole interaction of patient, doctor, and drug company is tainted and all have some blame. Is a wonder that medical cost keep spiraling up. The drug companies do anything they can delay to the market a generic drug. They try to convince us that latest drug is better than the last one they tried to convince us was great. Is Clarinex really any better at indoor allergies than Claritin? They want me to believe it - but I don't.
I don't have a lot of confidence drugs are as well tested as they should be and are prescribed only when medically required. I feel the primary motivation of the drug companies is profit not the curing of disease. No doubt they produce some amazing drugs but primary goal should be what is best for the patient. The whole drug establishment would like to supress or ignore the value of nutrition or medicine on the progression or prevention of disease - after all you can't patent a vitamin or broccoli.
In summary there is plenty of blame to go around. The drug company should not be trying to influence patients to take a particular drug especially when most people would not really understand the drug and how it works. The drug companies should not be subtly buying off doctors. The physician and medical profession should be the unbiased gatekeepers that can objectively evaluate drug therapies and any other potential therapies for maximum patient benefit.
Competing interests: None declared

Reform must also include: 5 June 2003

June Brown,
None
Sugar Land, TX, USA 77479
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Re: Reform must also include:

In addition to the relationships of doctors to their pharmaceutical reps and drug companies, the relationships of these same doctors to their HMOs and insurance companies must be considered for reform. Too many people fail to get the treatment they need because of the dictates of these last two mentioned entities. And too many people are opting to forgo medical treatment all together because they, one, no longer have faith in the medical industry to have their best interests at heart, and/or, two, they cannot afford treatment at all, with or without their insurance.
Competing interests: None declared

Mental Health Crisis 5 June 2003

Adrienne G. Shoemaker,
Certified Health Consultant
Santa Rosa, CA 95401
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Re: Mental Health Crisis

I agree that the doctor/drug company relationship needs changing. I would like to stress that people with mental health issues and poverty can not afford the drugs that help them maintain functional lives. It is the fact that mental health drugs are increasingly expensive and people on disability and public aid programs can not afford them. The doctor's office (samples) is often the only place where they have a port in the storm of their often difficult and complicated lives. The doctor/mental health is a life-saver and the only hope as a liaison between this population and an outside world that does not understand mental health issues. This is a growing crisis, in which people get lost through the cracks, and needs to be addressed. If nothing else, a review of drug prices, mental health drugs in particular, is in order. The prohibitive prices are impairing the quality of life for single mothers and often grandparents that are raising their grandchildren.
I am all for change in the other areas that you address on this survey. Please realize that some drugs are necessary for daily life for those that are bipolar. They are discriminated against in so many ways, not the least of which is the media's role in dramatizing their lives as psychotic episodes. Also please do not lump all doctors into one category, there are some that do a lot of good and are quietly altruistic on a daily basis. The good ones have not all "left the building" so to speak. Leave mental health drugs out of this - or help reduce the prohibitive costs. Canadian pharmacies are now being regulated as many were forced to order prescriptions over the internet at a reduced cost and that door may be closing completely. It is imperative that this situation is looked at more closely. Best of Health - mental and otherwise, Adrienne G. Shoemaker
Competing interests: � None declared

The real costs of free lunches 5 June 2003

Catherine E Richards,
Community Nutritionist
Kelowna, British Columbia
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Re: The real costs of free lunches

Pharma companies don't really pay a cent for all the freebies they give out. Indirectly we are all paying for our own free lunches.
Pharma companies must make enough profit to pay for the goodies that they give to us. They make enough profit for these freebies by selling their drugs at higher prices. They sell drugs to people. Most people have insurance plans or work benefits or government subsidies that help to cover their drug expenses. Insurance companies, benefit plans, and governments get their money from all us us through our premiums, our taxes, etc.
I don't mind buying my drugs at prices that will get free pizza for residents, or coffee and sandwiches for inservices, but I sure as heck resent paying for frivolous promotional trips complete with massages and tours. I question the virtual pharmacies that can be found in many doctors' home bathroom cabinets, stocked amply with samples intended for their patients. The more we accept from Pharma companies, the more drug costs will rise, and the more we all pay.
Everything in life is a cost/benefit issue. This ratio is not always reflected in dollars and cents. The questions we must always keep at the top of our thoughts are: #1 When I suggest this drug or holistic or whatever treatment, is my reasoning justified and unbiased?; #2 Is my quality of care for my clients/patients improving?; #3 Is society as a whole going to benefit from my actions?; and #4 Do the answers to the first 3 questions fit with my personal sense of ethics?
While I encourage putting a charter in place, I wonder how successful it will be. Infant formula companies have proven just how fatally a firm guideline on sales techniques can fail when the bottom line is a dollar sign.
The root of the problem is in a lack of understanding and of adherence to ethics and societal values -- the lack of understanding can largely be fixed at the student level.
Physician, heal thyself, let the Pharmas follow your lead. I'll start by buying my own hockey tickets next season.
Competing interests: I date a Pharma manager and share his season tickets to our local hockey games.

No free lunches - no loss 5 June 2003

Peter C Arnold,
former GP
Sydney, Australia
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Re: No free lunches - no loss

Soon after starting practice, I ceased seeing representatives and asked my staff to discard all advertising mail. This released many hours monthly for consultations.
As a reader of generalist journals, I do not believe that I was missing out on relevant information. I saw no need to be the first to prescribe a new medication, and cautioned patients about side-effects which come to light only after a medication has been marketed for some years.
Avoiding pharmaceutical companies in my practice was no loss, but I see problems for medical journals trying to break even financially without their advertising. Dispensing with pharmaceutical advertisements could raise our BMA/BMJ subscriptions and/or force authors to contribute to the costs of publication. A tough call for a journal as profitable as the BMJ!
Competing interests: None declared

Solution: increase professional income by free market means 5 June 2003

Richard G Fiddian-Green,
None
None
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Re: Solution: increase professional income by free market means

What an indictment of socialised medicine. No wonder the standard of care in the NHS has fallen so far behind that in the better centers in the US.
No attending(consultant) I knew in the US had the time to be bought by pharmaceutical companies. Drug reps know that good attendings cannot be bought and concentrate their marketing on the residents who write most of the orders. That does not influence the quality of care and the administrators make sure that the system is not abused.
From what I have seen in Europe the majority of doctors are so impoverished relative to those in the US that they are far more happy to receive and even to ask reps for support for computers, travel etc. Drug reps know that and exploit their impoverished states. Hence the need for regulation.
The NHS has bred mediocrity. If all NHS patients had private insurance and could choose their GPs and go directly to a specialist of their choosing if they preferred the situation would change rapidly. The schizophrenic behaviour required to run a private practice and meet NHS commitments would disappear. The standard of care would rise rapidly. Many jobs might be lost but many more higher paying ones would be created especially if people were able to purchase supplementary insurance to meet their personal preferences.
Is it not time the UK bit the bullet? If some doctors preferred to work in an established NHS hospital let them, but let the patients decide if they want to go to those hospitals. Let the hospitals increase their income, pay their staff more and improve their facilities and services in accordance with free market forces.
Forget about petty conflicts of interest and let the outcomes data, those who have generated it, and patient satisfaction speak for themselves.
Competing interests: None declared

Journals should avoid drug advertisments completely. 5 June 2003

Frances E Fermer,
General Practitioner
The Surgery ,1A Welbeck Road ,Bolsover,Chesterfield ,Derbyshire,S44 6DF
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Re: Journals should avoid drug advertisments completely.

I appreciate your efforts to highlight the problems of a too close relationship between doctors and drug companies (BMJ no 7400). I for one would be delighted to see you go further and remove all pharmaceutical advertising from the BMJ.
BMJ 7400 itself had 15 pages of pharmaceutical company advertising. Removing this would have the additional enviromental benefit of reducing the journal by at least 3 double A4 sheets.
I would be interested to know the amount of the production cost of each BMJ which is paid for by pharmaceutical sponsorship. Even if losing this cost us for example an extra 30p per copy this would only be around �15 per annum more on our subscription.
The results of the straw poll for this issue suggest that this move could be greeted favourably by the majority of your readers.
Competing interests: � None declared

Conflict of Interest 5 June 2003

June C Nicholls,
Parent
None
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Re: Conflict of Interest

In this debate, it has highlighted the very problem, over a period of time that has undermined the very virtues on which great institutions were built upon, self-interest.
We are all guilty but it is only the extent of our drive for self- preservation and the extent to which we are prepared to break moral codes, circumvent rules and regulations and even break laws, when it becomes an issue.
Here, this debate has opened up the Pandora�s Box. Now that the horse has bolted, in my humble opinion, the time is right for each and everyone of us -- professionals, institutions or otherwise -- to take a step back for an objective view (Not subjective as seen with so many of the responses so far!) in dealing with this very important issue of, conflict of interest.
Any conflict of interest starts of small and almost irrelevant. The fact is, each �pebble� that makes the first ripple, will eventually fan out, with implications that are wider and further reaching than any �soul� could possibly anticipate or even prepare for.
And that is the crux, I believe, the very heart of this debate.
An act can be one of action, inaction and even omission. The medical profession in all its glory, is here to serve. It owes a duty of care to the people and therefore, the onus is on members within the profession � sworn by oath to uphold its underpinning principle � to serve, not to ones own self-interest, but to the millions upon millions who have entrusted their lives in your hands.
Research and peer reviewed papers are viewed and accepted as almost �gospel truth� by Powers who have often vested interest in securing certain results. Albeit, furthering commercial interest or applying the basis of public health policies, the undisputed fact is, that the medical profession is the one profession that hold all the sway in the matter. Ultimately, the one and universal question asked by everyone from industry to the consumer is, is it safe?
And that question is answered the world over, by non other than members of the noble profession, THE MEDICAL PROFESSION.
A privileged endowed and one that can and MUST never be abused, if you do not ultimately want, �blood on your hands�.
Competing interests: None declared

Free lunches exist - and the NHS needs them 5 June 2003

Philip Rutledge,
Director of Medicines Management
University of Edinburgh EH4 2XU,
Simon Maxwell
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Re: Free lunches exist - and the NHS needs them

Editor - We agree that doctors� dependence on industry funding undermines their independence and ability to do their best for patients.1 There has been little UK research into the extent of doctors involvement with the industry. Our recent study of 487 doctors (289 hospital based doctors and 198 general practitioners) in Edinburgh showed significant reliance on industry funding to support continuing medical education.2 The industry funded approximately half of the doctors (hospital doctors 52% and GPs 41%) to attend meetings and conferences. A minority of doctors (46%) thought that this relationship created a conflict of interest although the majority (86%) believed that it did not create a bias in their own drug selection confirming the widespread (but misplaced) confidence amongst doctors that their professional integrity is immune to financial seduction.
A further problem identified by our study was that up to 20% of doctors self-funded their attendance at educational meetings. We estimate that NHS resources accounted for at most one third of the total cost. However desirable, the conclusion must be that the �disentanglement� you propose will come at great cost. This is recognised by some Trusts that actively encourage consultants and SpRs to arrange industry sponsorship for travel to national and international conferences to spare the educational budget.
For those interested in disseminating truly independent and unbiased evidence about new therapies the future looks bleak although we would like to suggest two easy steps in the right direction. Firstly, doctors who appear at educational meetings as opinion leaders, as well as those involved in medicines management, should be required to register their interests in the public domain and thus allow their peers and the public to review potential sources of bias. Secondly, large NHS organisations should create a �blind trust� that allows them to continue their altruistic support of medical education without creating conflicts of interest for individual doctors.
Dr Philip Rutledge
Director of Medicines Management, University of Edinburgh
Dr Simon Maxwell
Chair, Drug &Therapeutics Committee, Lothian University Hospitals NHS Trust
Ref
1 Abbasi K, Smith R. No more free lunches. BMJ 2003;326:1155-6
2 Rutledge P, Crookes D, McKinstry B, Maxwell S. Do doctors rely on pharmaceutical industry funding to attend conferences and do they perceive that this creates a bias in their drug selection? Pharmacoepidemiology and Drug Safety 2003; in press
Competing interests: none declared
Competing interests: � None declared

No more free lunches 5 June 2003

Peter D O Davies,
Consultant Physician
Cardiothoracic Centre, Thomas drive, Liverpool, L14 3PE
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Re: No more free lunches

Sir, There are two more subtle but probably more important ways in which Big Pharma influences medicine than the ways you describe: first, it can, over years, alter the critical mass of medical academia and secondly influence what we learn about disease.
In my own specialty of Respiratory Medicine we have over fifty clinical academic depatments researching airways obstruction but none researching tuberculosis (TB). The last such department was killed off in 1989 when the then incumbent retired.
In order to be considered for a chair an impressive list of publications will be required. If the applicant has an interest in a pharmaceutically rewarding disease, he/she will have been able to obtain research monies relatively easily and built up the necessary CV. With no pharmaceutical input the CV is llikely to be comparatively thin. Thus over a couple of decades the critical academic mass of a major specialty has become unbalanced with a huge bias towards the dieases of the rich who can afford the newly developed drugs at the expense of the poor who cannot.1
Secondly the immnense funding by Big Pharma for post graduate education has distorted our knowledge. 2 Two of the TB outbreaks of 2001 were caused by the index cases being misdiagnosed as asthma. Every General Practitioner and Respiratory Consultant in the country will have been asked to attend many Post Graduate meetings sponsored by drug companies producing asthma drugs where they will have been told that cough is a symptom of asthma. None will have ever been to a TB drug sponsored meeting where they would be told that cough is a symptom of TB.
I fear that if drug companies pull out of funding most of clinical medical academia and post graduate education would collapse. But in the long run that may be better for patients.
Refs.
1. Davies PDO. The Challenge of tuberculosis. J Roy Soc Med 2003;96:262- 265.
2.Davies P. Industry funding in medical education [letter]. Lancet 2002;359:1949-50.
3. Leese J. tuberculosis - a 19th century disease in the 21st century. CMO's Update, 31 october 2001, p.4.
Competing interests: � None declared

Medicine As Big Business 5 June 2003

Stephen S. Engleman,
Registered Professional Nurse
Special Children's Center, Ithaca, NY, USA 14850
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Re: Medicine As Big Business

There has been a significant change in the practice of medicine in the last decades. A study done at UCLA in the early 90's confirmed that the primary reason their medical students were going into the field was high financial remuneration. The second most popular reason cited was prestige and down the list at number three was to help people. That is probably the most telling research and explanation for the changes in medicine in recent years.
Gone are the bedside visit [at least in the USA], and the close personal relationship between doctor and patient. This has been replaced by the assembly line style of office visit and where one-size-fits-all treatments have become the norm and which includes generalized medication prescriptions and dosage. By the way, it was Hippocrates many centuries ago, who cautioned physicians to 'know thy patient' and 'to do no harm' - two injunctions that seems to be ignored today.
A recent study showed 49,000 to 98,000 people a year die in US hospitals from iatrogenic causes. Yet recently doctors in several states and large cities protested, not over the deteriorating health care provided here [with higher costs and increasing uninsured] but because their malpractice insurance is rising. Given the above figures it is not surprising that insurance costs are rising but instead of cleaning up the profession, they demand less accountability.
On the other side, doctors are delivering a poorer product for spiraling cost. They are rarely aware of, nor do they have the time to read about or communicate to patients the barest of information, including of course information about the drugs so routinely yet often mistakenly prescribed to patients. I can cite numerous first hand examples just from my own life, those of relatives and from 23 year practice. I know that most any other nurse could easily do the same.
Rarely do doctors know the dangerous side effects or drug interactions of the medicines they prescribe or generously give as free samples. As a result they come to rely very heavily on the drug company representatives for information. These are the same people providing perks [bribes] such as gifts and free meals [which by the way is given to other prescribers - I have personally been to one for Nurse Practitioners yet not Registered Nurses who are unable to prescribe by law]. Is there any question that the information is biased? Does anyone imagine these reps pushing the drugs of another company that might be better suited to a patient or perhaps a generic counterpart that is cheaper?
Only persons outside the medical professions would not understand the need for immediate change in the delivery of medicine. Yet doctors themselves have been unwilling, except in rare instances, to change the way medicine is delivered. Only one portion of the problem is reflected in the area of medication but with the burgeoning use of drugs, a most critical area to address immediately.
Competing interests: None declared

Hippocratic Oath Revision 6 June 2003

Fredrick E. Keller,
none
retired
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Re: Hippocratic Oath Revision

Some form of pledge, amendment, or charter commitment embodying the principles suggested by this survey would be an excellent addition or modification of the Hippocratic oat
Competing interests: None declared

Stop Bribing Doctors 6 June 2003

Trish A. James,
Registered Nurse, Medical Case Manager
48105
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Re: Stop Bribing Doctors

I am a Registered Nurse, and a medical case manager for a large insurance company. I have seen good doctors take the bribe from pharmaceutical companies in many forms, from the acceptance of exotic trips, golf outings, ski weekends, to the brainwashing of false beliefs about drugs. The University of Michigan Hosptial in Ann Arbor, Michigan, USA, has just this year recognized there is a potential conflict of interest problem in giving doctors samples of drugs, and no longer allows this practice. According to a new hospital policy, the doctors can no longer give patients free samples of drugs; this is both good and bad.
Good from the perspective that physicians have less potential to be swayed by the huge pharmaceutical companies, but bad for the poor patients who don't have medical insurance coverage and could use a break on drug costs.
I have actually seen hospital doctors brainwashed by drug companies on the uses of Tylenol. On an inpatient rehab unit (not the University of Michigan), where many of the patients had musculoskeletal injuries, Tylenol was ordered for pain relief on a very frequent basis. This was not the first drug of choice, as confirmed by other doctors on the ball, who felt NSAID's (non-steroidal antiinflammatories) would be in order. Competing interests: � None declared

Doctors can stop the inappropriate relationship NOW 6 June 2003

Debbie A Lawlor,
Lecturer Epidemiology
Department of Social Medicine, University of Bristol, BS8 2PR
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Re: Doctors can stop the inappropriate relationship NOW

There is no need or excuse for any doctors to receive any kind of 'gift' from a drug company rep. It is amazing that the responses to the BMJ survey suggest that a large majority of doctors would favour severing ties with the pharmaceutical industry (unless there is extreme sampling bias) yet most doctors continue regularly receiving drug company gifts. I am often viewed as odd amongst my colleagues because I have never taken any kind of 'gift' from a drug company in 16 years of clinical and academic practice. Doctors are extremely priviledged and extremely well paid there is simply no excuse for accepting pens (they only cost 20p), lunches, conference, travel costs or any other gifts. If the doctors completing this survey really believed in their responses they could stop the rot now ... it doesn't take any effort to say 'I don't see drug reps or accept drug company sponsorship' and refuse the offers. Debbie Lawlor
Competing interests: None declared

Follow the money trail 6 June 2003

Jacob W. Dijkstra,
Staff physician
Cleveland Clinic, Cleveland, Ohio 44195, USA
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Re: Follow the money trail

Throughout my career I have found only one reason why pharmaceutical companies would spend one penny on doctors, and that is to get them to prescribe their products. This has a corruptible effect on many physicians, for which there is absolutely no rationalisation under whatever guise. Patients have a fundamental right to know why their physicians are prescribing a particular drug. Coercion by the pharmaceutical industry, even if apparently insignificant, has no place in this decision making.
Competing interests: � None declared

Reform overdue! 6 June 2003

Arnie Welber,
HHI
US Postal Service 33172
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Re: Reform overdue!

It is quite clear we still have a so called 'Medical Mafia' and 'Pharmacutical Cartel' in USA. Simply needed is major stable reform.
Competing interests: � None declared

Actually in re: prescription freebies to doctors 6 June 2003

Donna M Birkholz,
University Extension Educator
Sheridan WY 82801
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Re: Actually in re: prescription freebies to doctors

Although I know that the free samples drug companies give doctors are an incentive for the doctors to subscribe, and patients to request, those prescriptions ....
I also know several doctors who save those free samples up and give them out to patients who would otherwise not be able to afford the medication bills.
And when my husband was searching for an effective allergy medication, his doctor gave him samples of all the free allergy meds which applied ot his condition, and instructions on how to 'test' them to see which would be most effective - much cheaper and more effective than having us go through multiple prescriptions for the drugs before we found the 'right' one.
So there's a great deal of ambivilance on my part in re: the question of restricting the 'freebies.' I can see positive impacts as well as the obvious negative ones. My larger concern becomes the situations where the doctors rely exclusively on the drug reps for information .... And of course the overall cost of drugs, which is augmented by the 'services' drug companies provide doctors in hopes of luring them into long-term lucrative relationships with the companies.
Competing interests: None declared

The Problem is world wide 7 June 2003

Ange Kenos,
Australia
3042
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Re: The Problem is world wide

Dear Sirs
The problem of the closeness of medical practitioners and the pharmaceutical indutry is world wide.
In Australia it is not unknown to see doctors receive gifts from medical supplies to furniture, computers and even holidays.
While the intention of most doctors would be honourable, it is the minority who act otherwise and the intentions of the pharmaceutical industry that harm the profession.
There is NO finer calling than medicine, and to allow doctors to be tarnished by an industry that cares more for profit than anything else is to return to the darg ages where carpenter like tools were used by surgeons.
A T Kenos Australia
Competing interests: None declared

'Symptomatic relief medicine' is bad medicine 7 June 2003

June C Nicholls,
None
Parent
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Re: 'Symptomatic relief medicine' is bad medicine

There is a lot of truth to be said about the 'subtle ways' in which Big Pharma has influenced the way medicine has evolved over the last few decades. A marked and distinct "shift" in the way medicine is practiced, from one of preventative to symptomatic relief, where today it appears all that matters, is which category of drugs is appropriate to treat any one so-called "disease" and any research conducted is all about potential therapeutic targets.
Medicine has in fact been so compartmentalised and fragmented into "neat little packages" to a point where the human body is no longer viewed as an integrated piece of creation. A perception that cannot be further away from reality but one that is, and has been, created out of a drug dependency culture.
All those wonderful drugs and yet our surgeries (hospitals) are 'bursting at its seams'. The numbers of cancer patients are increasing, asthma, obesity, childhood diseases that were once rare like autism, is on the increase, and so is every other so-called disease or syndrome as more and more are coined each day, each beautifully presented with an exhaustive list of clinical symptoms.
The marked shift in emphasis in medicine cannot be better illustrated, in my humble view, than that from the perspective of those that have been chemically injured. Where persons have been exposed, for example, to a cocktail of noxious chemicals at sublethal levels, and where carbon monoxide, a potent chemical asphyxiant is involved, there is little doubt that wide spread 'damage' is to be expected as hypoxia (anoxia and ischemia) affects each and every single cell in that body.
The damage caused is 'subtle' initially, as the body mal-functions as it heads down the cascade, leading to dysfunctional systems and finally, ends up with end organ damage. Modern medicine is at a point, where it is uninterested - has no answers to offer - until end organ damage is reached. By then, the initial major assault on the body is disregarded as 'too remote from the causation' and neuro-degenerative conditions continue to be conveniently deemed 'without etiology'.
Times are changing, as Free Radical and Inflammation research cannot continue without looking further back into the potential underlining causes. Until then, it is business as usual.
Competing interests: None declared

How to dance with porcupines 7 June 2003

Steven Rudolphy,
Principal
Mt Sheridan Medical Practice, Cairns, Qld,Australia
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Re: How to dance with porcupines

I am nice to drug reps.
I accept shareholders of large multinational companies would not spend money on doctors if this was not profitable i.e. make us prescribe more of their drugs. We should be aware of this.
Should I stop accepting gifts?
Should I stop watching the US Tennis Open where there was a huge advert for Vioxx on centre court last year?
Compare reps with political lobbyists hired hands who wine dine, politicians take them to meetings at sporting events, fly them to exotic locations on fact finding tours. The corporate lunches, the political fundraising dinners.....we are not alone on the dancefloor at the porcipine ball.
Let's put those lobbyists under the same scrutiny. Have you ever met an evidence based politician?
In the last 2 weeks I have used drug sponsorship to train 15 nurses as asthma educators (they cannot prescribe)and flown to Sydney to give a generic talk on paediatric asthma.
Just occasionally this job should be fun. If the tax payers keep the medical profession sane by funding a few dinners via the cost of drugs through taxes - this is money well spent.
I will still be nice to drug reps after reading the BMJ, hopefully a rep will bring me a latte for morning tea on Monday.
How do you dance with porcupines ? - Carefully! Hold them close and look them square in the eye.
Competing interests: � SR has attended numerous meals, conferences, had travel and hotel accomodation provided by drug companies and is currently using a drug sponsored mouse pad.

Current attitudes are unacceptable 11 June 2003

Zvonko Rumboldt,
University of Split School of Medicine
21000 Split, Croatia,
Vedran Carevic
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Re: Current attitudes are unacceptable

In response to the editorial by Abbasi and Smith we report quite recent data from our country. We have conducted a survey among medical students that participated in a course of Medical Ethics, and doctors from the Department of Internal Medicine, University Hospital Split, Croatia. Among other questions there were those about relations between pharmaceutical marketing and medical doctors (table 1).

Observed answer frequencies were significantly different from the expected ones (table 2). Respondents considered that medical doctors are scientists, professionals and humanists: the proportion of 'unacceptable� answers (among students 2/3, among doctors 1/3) is therefore surprising. The education in ethical issues requires implementation during the whole curriculum, as a form of continuous medical education, since the current attitudes leave much to be desired.

Table 1. Examples and answers in our survey (percent of votes)

EXAMPLES

non-ethical &
non acceptable
(%)

in ethical terms
barely acceptable
(%)

ethically
doubtful
(%)

ethically
acceptable
(%)

definitely
ethical
(%)

students

doctors

students

doctors

students

doctors

students

doctors

students

doctors

1. Week-end presentation of a new drug in a foreign country

12.5

10

0

40

37.5

40

31.25

10

18.75

0

2. Dinner with presentation of brand products

6.25

20

12.5

10

43.75

30

25

40

12.5

0

3. Gift of a pharmaceutical company to be used for teaching

6.25

0

6.25

0

18.75

0

50

80

18.75

20

4. Advertising of products on a professional meeting

13.33

10

20

0

33.33

30

26.67

50

6.25

10

Table 2. Discordance of students' and doctors' answers in relation to the 'optimal' answer (consensus position of teaching staff; p<0.01)

examples

discordance (%)

students

doctors

1.

100

60

2.

93,75

80

3.

81,25

80

4.

73,33

50

�

References:

1. Abbasi K, Smith R. No more free lunches. BMJ 2003;326:1155-6.

One other point 11 June 2003

James D Curran,
GP
Glasgow G41 3LQ
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Re: One other point

This is an interesting edtion of the BMJ, slighty sabotaged by the cover illustration. One point worth making, if no one already has is that pharmaceutical influence also extends to other heath care workers, and this should be looked at as well. For instance there is obvious pharmaceutical interest in practice nurses who have responsibility for chronic disease management in general practice, with a view to influencing choice of medication for such disorders.
In hospitals, operating theatre nurses, for example, are often sponsored for trips to educational meetings or simply taken out for meals by equipment manufacturers, again with a view to influencing purchase and choice of theatre equipment.
I think therefore, doctors should be aware of this, to make sure that it does not influence their practice (and also to remember that we are not the only ones who can get tangled with the drug companies).
Competing interests: None declared

a cynic's riposte for the holy joes 11 June 2003

john i hickey,
GP principal, Port Talbot
SA13. 3YE
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Re: a cynic's riposte for the holy joes

....yeah, sure we shouldn't take bribes from drug reps. Reading this article made me weary and depressed. So now we are expected to be saints, and can be persecuted if we aren't. In an otherwise barren arid landscape of escalating patient demand, unattainable targets imposed by Tammany Hall politicians and self-appointed gurus, and pious platitudes from the Royal Colleges, very often contact with a local drug rep. is one of the few bright social spots in an otherwise isolated GP's day. Of course, this is the "soft sell", but it is insulting to think we don't have the intelligence or independence to say "no". If this form of contact with the pharmaceutical industry were to be banned, it is certain that the industry would find other, perhaps less overt means of influencing prescribing - how about taking all the self-righteous DoH Whitehall Mandarins off an a team-building exercise in the Seychelles?
Competing interests: None declared

Medical Education needs drug sponsorship 16 June 2003

Liz Spencer,
Consultant Anaesthetist & Clinical Tutor
Gloucestershire Royal Hospital GL1 3NN
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Re: Medical Education needs drug sponsorship

EDITOR � Your recent editorial raises our awareness on the moral need to disentangle doctors from the pharmaceutical industry especially in light of evidence that doctors are influenced by �gifts�. I am a Hospital Clinical Tutor running an Education Centre and would like to point out how dependent medical education is upon drug companies in the UK. Many postgraduate medical centres in the UK have recently metamorphosed into Multidisciplinary Education Centres expected to open our doors not only to all medical staff but also to all healthcare professionals with no extra budget. Education and training is becoming increasingly more important due to a host of internal and external pressures beyond our control eg. NICE guidelines, CNST, Comprehensive Critical Care, Clinical Governance & adverse clinical incident reporting. At the same time the Workforce Development Confederations are attempting to resolve the long standing inequity of funding across the professions and across the primary/secondary interface and have recently reduced our Trust�s CPD allocation.
In order for our Education Centre to develop and deliver a professional service for all healthcare professionals we rely heavily on income generation both from course fees and from our friends in the drug industry � about 25% of our budget comes from sponsorship! Although this relationship needs regular review the drug companies consider it an important part of their job to become involved in the education and training of both nurses and doctors and welcome the opportunity to sponsor an event. We arrange the sponsorship in-house which has several advantages � there is often more than one company, the sponsorship has no say in choosing content or speakers and they have no input into the presentation or content of the meeting. This �firewall� protects the doctors from undue influence.
Postgraduate Centres have never received a budget for teaching equipment, stationary, building maintenance etc. and the money received from sponsorship is used to keep the Centres going as well as employ staff such as receptionists and course administrators. We can then afford to organise events for other healthcare professionals who receive less money for their on-going professional development. Without this extra income we could not develop as a multiprofessional Education centre and follow the current (and correct) tendency for healthcare professionals to learn together.
Sponsoring education through the Education Centres is relatively unbiased and is certainly preferable to the individual drug sponsored �dinner�. However we cannot afford to adopt the moral high ground and distance ourselves too much from the drug companies or the delivery of education in UK hospitals would deteriorate and patients WOULD suffer.
Competing interests: None declared

A former drug rep's opinion. 17 June 2003

Michael Wood,
Journalist
Sydney, NSW 2135.
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Re: A former drug rep's opinion.

I am surprised that many GPs believe visits from drug reps have little or no effect on their prescribing. When I worked as a medical representative in Yorkshire I saw a clear effect of my visits on the prescribing by GPs of the asthma inhalers I was promoting. Pharmacists in the villages I visited would also report initiation or increases in prescribing of the products following my visits. Pharmaceutical companies keep detailed sales figures by locality and have a good idea of who is prescribing what. Ask IMS Market Research. GPs are assigned a rank on the basis of their prescribing, with reps given a quota of "high" prescribers and "innovative" prescribers to see in a particular day. Interestingly, I was discouraged from visiting GPs who saw too many reps, as they were regarded as a waste of time: They only earned me one point towards my quota because they were regarded as poor quality and fickle prescribers.
In contrast drug companies are very creative in finding ways to see high prescribers who will not see reps, using social and educational events to make contact. GPs might also be interested in the amount of personal information that drug reps collect and keep on the doctors they visit.
It's no coincidence when the drug rep casually asks about your family, favourite sport or hobby, or remembers your birthday. It's all stored on the Palm Pilots.
Pharmaceutical companies reap substantial financial rewards from their products, and with so much at stake understandably leave little to chance.
Competing interests: � None declared

The grip of the market 25 June 2003

K. S. Madhavan,
Senior Registrar
Radiation Oncology Department,St Lukes Hospital,Highfield Road,Rathgar Dublin 6
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Re: The grip of the market

Dear Editor
Your theme issue on the drug industry and the �embrace of avarice and excess� must serve as a mirror to see ourselves in.
The relationship between the pharmaceutical industry and the medical profession is a natural one .As natural as that between the arms industry and armies the world over. It can be one of constructive co-operation and the health benefits are for all to see. But it can be, as several robust studies and investigations have shown, dishonourable and damaging.
So why do we indulge in such messy liaisons, full of biros, M&S sandwiches, business class travel and lavish conference holidays? There are the obvious reasons -pleasant sales persons, a sponsored break from the drudgery of work and well, why not? The bigger factor is the global and unflinching faith in the free market. Any debate on this influence of marketing on decision-making and health outcome is considered too old style and doctrinaire to be worthwhile. The rather subdued response to your editorial 1and the issue in general from hospital practioners is a testimony to what they think of it all. A waste of time. This mind set is increasingly pervasive with students, junior doctors indoctrinated into the free lunch way of life. The market has us all in its grip. The medical profession, it appears will only see and believes what it chooses to.
Apart from the problem of potential influence in prescription, of the devil quoting the scriptures to suit its purpose, there is the issue of priority setting.
Decisions in cancer care, for example, are in the main, grounded in evidence where it exists. Despite the army of reps set out to preach their respective gospels, the existence of guidelines, protocols and consensus statements make it difficult to influence the influential. There are problems even here. So often the press will have stories of another cure for cancer. The Health service is time and again accused of not providing a �life saving drug� .The industry thrives on this publicity. Denying drug treatment is a charge hard to bear, even for the rather stoic NHS.But while there have been advances in cancer chemotherapy, the publicity and promotion is often out of proportion to its real benefit. Surrogates of outcome such as response rates, which even non-purists amongst us would consider inadequate, may be quoted in an effort to create a niche for a drug. The distortion of the agenda goes beyond this. Radiotherapy, an important single modality of cancer treatment is considered just another tool2. In comparison to other European and North American countries where high quality radiation research and technology based studies are encouraged, there are few departments in the UK that are able to retain a commitment to this area of work. This is probably at least in part to the lack of backing from an ambitious industry and the marketing that goes with it. Achievements in radiotherapy, equivalent and often more significant, hardly ever receive the fuss and attention that goes with a drug.3
Disentanglement is the key.The University of California in San Francisco (UCSF) and the American Medical Student Association need to be commended for their work..
It is crucial that that the U.K. moves in that direction starting with the creation of blind trusts for education.. Apart from decanting the influence of the brand, access to funds would be certainly fairer than it is now. All health professionals, not just doctors, can than have access to grants without having to court salesmen.
We are easily reassured by our own integrity. And I�m sure few of us doubt the honour of our colleagues within the health system. But that is hardly enough. Our increasing knowledge from this world of competition demands that local codes and national ones such as those of the Association of the British Pharmaceutical Industry (ABPI) are constantly scrutinised. The industry-health service relationship needs re-configuring. The medical profession so often challenges politicians on issues of conflict of interest. The existing environment makes our position duplicitous and untenable.
Ref
1.Abbasi K,Smith R.No more free lunches bmj 2003;326:1155-6
2.Burnet et al Improving cancer outcomes through radiotherapy BMJ 2000;320 198-199 3.Saunders M et al Continuous hyperfractionated accelerated radiotherapy(CHART) versus conventional radiotherapy in non small-cell lung cancer:a randomised multi-centre trial.Lancet 1997;350:161-165
Competing interests: � Free lunches.

NO FREE LUNCH 25 June 2003

Mike L,
Driver
Take-Out-Taxi
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Re: NO FREE LUNCH

I work at a local restaurant delivery service. Our day business consist of about 90% of doctors offices getting free food from drug reps. From what I have experienced it's not even the drug rep who places the order. It's the doctors office. In fact I think the doctor office's are the one's who are sucking the marrow from the everyday person who has to pay the price for prescription drugs, and the drug companies are letting them do it. As if they don't get paid enough already...
Example: I made a delivery to a doctor's office that only had five employees yet they ordered enough food for each employee to eat three meals. How can you justify that? Talk about milking the cow to death... After reading a lot of articles about the free lunch policy of these companies I feel that I must add my two cents worth.
Many people say that these free lunches don't affect the overall cost of prescription drug costs. I would have to disagree. The delivery company I work for makes approximately 20 deliveries everyday, 5 days a week. The average cost of one delivery ranges from $200-$500.
Now let's see... 20 deliveries a day times a mean average of $250 equals about $5,000 a day. Take this figure and multiply it by 5 days a week... That's $25,000 a week and $100,000 a month. Wow! That's roughly 1.2 million dollars a year being spent on free lunch for doctors offices within our delivery company alone.
If you take that figure and multiply it by 60,000 drug reps, well I won't get my calculator out or anything but it's roughly 7 billion dollars a year. How can you say that it doesn't impact the market cost of drugs?
Granted I liked getting those $25 gratuities plus the $20 add-on tips but that doesn't make it right so I quit my job and became an advocate for the reform of drug rep perks. I think it is good that legislators are trying to restrict this area of the drug field.
Not to wreck my own career or yours but I would love to see the bottom drop out of the perks business... I think it would have a definate impact on the cost of prescription drugs. Doctor education is not even close to a good excuse for this practice
Competing interests: None declared

Independent evidence-based information to promote rational pharmacotherapy. 27 June 2003

Nina H. Bjarnason,
Senior Medical Officer
Institute for Rational Pharmacotherapy, Danish Medicines Agency, DK-2300 S,
and Jens P. Kampmann
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Re: Independent evidence-based information to promote rational pharmacotherapy.

Thank you for your theme issue (1) on potential unhealthy alliances between prescribers and the pharmaceutical industry.
Providing independent drug information using scientific principles may counteract detrimental results of such alliances. This is one of the purposes behind the establishment of Institute for Rational Pharmacotherapy (IRF) in 1999 as a department under the Danish Medicines Agency.
Our definition of rational pharmacotherapy signifies the treatment that has:
- The largest effect
- The least serious adverse effects
- The fewest number of adverse effects
- The lowest possible expenses
IRF publishes a monthly medical journal (in Danish) and arranges postgraduate training for G.P.s in relevant pharmacotherapeutic areas (i.e. antibiotics, type II diabetes, psychopharmacology, cardiovascular pharmacology, and rational treatment of obstructive lung diseases, gynaecological endocrinology and analgesics). In addition, IRF arranges public meetings on rational pharmacotherapy. In 2002, the title of this meeting was "Perspectives and Achievements with Rational Pharmacotherapy"; a conference organised under the Danish presidency of the European Union.
On the Internet (2) IRF publishes reviews that critically evaluate newly authorised medicinal products relevant to a large population. These reviews are given in both Danish and English. IRF also prepares pharmacotherapeutic guidelines for selected areas in co-operation with scientific societies. Examples are guidelines for the treatment of obstructive lung disease, for the use of TNF-alpha inhibitors in rheumatic diseases and for the prevention of malaria. Moreover, IRF provides survey statistics on the consumption of selected medicinal products in Denmark, sponsors independent research and participates actively in the discussion on rational pharmacotherapy in highly ranked international, peer-reviewed media (3,4).
Based on suggestion by IRF, governmental medical representatives are appointed locally in each county. These employees, who are typically pharmacists or part-time G.P.s, monitors the use of drugs in Denmark and advises G.P.s on their specific pattern in order to optimise prescription patterns. It is also possible for the G.P.s to study their personal prescription-pattern in relation to the use in the county as a whole and in Denmark (5).
Thus, IRF aims to improve rational prescribing. Institutes such as IRF and NICE may not only reduce the possible deleterious influence of industry-driven marketing activities upon prescription, but can also be an asset to the drug companies with the best products. We welcome a debate on the possibility to initiate comparable initiatives in other countries.

References
1. Time to untangle doctors from drug companies. BMJ 2003; 326: 1155-1222
2. www.irf.dk
3. Thirstrup S, Kampmann JP. Adjustment of Europe��s drug regulation to public-health needs. Lancet 2001; 358: 1734.
4. Bjarnason NH, Kampmann JP. Selection bias introduced by the informed consent process. Lancet 2003; 361: 1990.
5. www.ordiprax.dk
Competing interests: � None declared

Cancer treatment and unholy connections 11 July 2003

Patricia A. Wootan,
Administrative Ass to an Arts Community
home,
12401
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Re: Cancer treatment and unholy connections

A young friend of mine has Leukemia. AML which is more serious and harder to cure. He takes many of the same drugs my grandson took for his cancer, Burkitts's Lymphoma, 16 years ago. He has the same side effects- maybe worse because of the protocol he is on.
Where did all the money go for research on Cancer/Leukemia? Not much has changed and I believe that the connections with organizations like The National Cancer Institute and the big gun hospitals (Sloan Kettering) and research institutes and that is doctors ultimately are responsible for the lack of progress. The drug companies benefit from this circle of people who control research and development. I do not say that individual doctors are not compassionate and concerned but as long as "money" is involved and these diseases are like an industry how much control do they have.
I wrote a paper in college many years ago and what has changed? Yes some cancers are more curable, yes detection is better but children are still suffering and I see these childhood fatal diseases still hold families in their grip.
Competing interests: My husband is a doctor.

Doctors and Drug Companies 12 March 2004

Moses Abe,
Clinical Reseach Fellow , Galway Fertility Unit
University College Hospital Galway Ireland
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Re: Doctors and Drug Companies

The relationship between Doctors and drug companies needs to be strengthened but better regulated, and not severed as some are suggesting. In an ideal world, Doctors should not have to rely on sponsorship by these companies. In reality and as well in practice health care and medical research is grossly underfunded by the government at all levels! We must promote healthy competition amongst pharmaceutical companies in order to ensure high standards and timely solutions to medical counundrums. Doctors will continue work with one another to minimise bias arising from any such relationship above.We shall continue to practice within the framework of medical ethics to improve the nations health without compromising on public trust.
Competing interests: None declared

what is the harm with it? 25 May 2004

anshul avijit,
intern in s.c.b medical college &hospital
cuttack,753007
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Re: what is the harm with it?

although it seems to be an intricate problem but what is the harm in accepting free lunches unless one is too greedy about them?why should it be impossible to maintain one's ethics even if one accepts some kind of favor from a pharma company?one needn't overprescribe to show favor to a company while one can very legitimately prescribe those drugs to a needy patient.undue emphasis on a single product is a reprehensible act and should be discouraged.accepting gifts from pharma cos. while making it clear to them that no special favor will be bestowed to them shouldn't pose to be a moral problem
Competing interests: None declared

Bullying of the companies 26 May 2004

Carlos Cuello,
Paediatrics
Av. Morones Prieto 3000 pte 64710 Monterrey, Mexico
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Re: Bullying of the companies

Dear Sir & colleagues:
I am not against drug companies and a flashlight pen that once in a while they can give me as a gift; I am against the novel model of blackmail that has currently taken place. One of these models is a kind of a �friend�s club� from a milk-formula company from the USA; this exclusive membership is only for �high ranking doctors� (they rank them) with a lot of private practice. And maybe has its advantages, like free all-inclusive trips to the best paediatric meetings around the world. Perhaps this is not unethical at all� but what I do consider unethical is the bullying and blackmail (literally) from the drug representatives if the �member� decides to recommend another milk formula for his patients... at that moment, they discharge the member and retrieve all the help and support that was once �awarded�. This, of course, has several implications, like the wrath of the ex-member and the sad and unethical behaviour of �applicants� to the club who are yearning for the free trips and other gifts (I have to admit, they are good at it). Nobody, in an economic interest, can dictate a treatment or recommendation to a patient from a doctor. For me, this is degrading the image of our profession. Sadly, but true, the unethical behaviour of some drug companies exists around the world.
Competing interests: I am not in one of these clubs, an I truly hope never will.

NO FREE LUNCHES !! WHY NOT ? 17 June 2004

S GADA,
GP - salaried
COVENTRY. CV1
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Re: NO FREE LUNCHES !! WHY NOT ?

I feel that trying to distance drug companies from doctors is as hard as teaching an old dog new trick.
I do appreciated that we need to be aware of the implications of being influenced by drug companies. But, just imagine how boring medical life will be without any drug company influence in present medical profession.
1. Medical journals will be very boring with no pictures in them (pictures of adverts). Printed on cheapest possible paper. ( so very few people who are addicted to reading journal will only read them ).
2. Subscription prices of these medical journals will definitely go up as they won�t get funding from pharmaceutical companies. ( so very few of us can read them )
3. The number of journals which are being published might come down. (As they wont get money from authors for publishing their articles )
4. There will be hardly any lunch OR dinner meetings. ( because hospitals will not fund them, neither regional PCTs will fund them. Which will affect social interaction among doctors, who meet at these meetings, they might get depressed! )
5. As the number of educational meetings will reduce, doctors will struggle to find required PGEA /CME points / hours for their appraisals / PDP /assessment.
6. As there will be no free lunches, doctors might end up becoming underweight after eating hospital canteen food OR might need to leave hospital for lunch, so fewer hours for patient care.
7. As there will be very few speakers / professors / consultants who teach / speak at meetings for charity. It will curtail down drastically the culture of educational teaching. ( seriously risking CPD / updating with latest medicines in market )
8. If drug companies are not funding any new research, than there will be very few new studies which will be published. (DOH might need to seriously consider increasing funding for medical research /audit and for CME, which eventually might increase the tax everybody pays!! � like you and me ( so govt might have more say in research if not drug companies and funding might vary on ruling party in power!)
9. Studies which will be done will be small due to funding problem. ( so might end up in prescribing some medicines which are less effective ! ?ethical )
10. If there are no drug representatives, than GP�s might end up in seeing only those who are sick. They will be denied to refresh their mood OR a small break of seeing some smiling faces in between their surgery. (this might contribute to increasing stress in GP�s )
11. As there will be no free lunches and no free pens, than doctors monthly budget will increase for spending on lunches and stationery items required for doing NHS job.
12. GP�s who participate in drug trials in surgeries (some consultants in hospitals), their annual budget will be hit if the distance between doctors and drug companies.
13. If holiday conferences sponsored by drug companies are stopped, means, physicians may not get their deserved break, from nerve racking NHS work. ( might increase stress / depression / early retirement ! )
These are only 13(lucky) reasons (there are some more) for why we should not distance ourselves from drug companies. Until and unless we are aware that pharmaceutical companies are not saints OR doing charity work, they are there to push their product. Than it is up to us to decide which anti-depressant and which analgesic to prescribe.
Competing interests: Have attended scores of drug company sponsored lunch and dinner meetings.

Declaration of Competing Interest: forced confession? 17 August 2004

Anton E Joseph,
Consultant Radiologist
Mayday University Hospital, London Road, Croydon
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Re: Declaration of Competing Interest: forced confession?

I have been unsuccessful in tracing back to the time when the decision was made to extract the information on the declaration of competing interest, conflicting interest or by whatever other name one calls it. I have intended raising this issue for some time but was at a loss to find a suitable peg to hang it on.
Having very recently installed broad band technology, one of the luxuries I decided to treat myself to was to browse throught the BMJ site. I thus stumbled on theme issues and ended up with this editorial, and that was the moment of inspiration to express my concern about declaration of competing interests.
Clearly there is no room for debate on the requirement to declare interests, but what is debatable, is the requirement to have to admit to competing interest every time one has to declare an interest. There seems to be a need to plead guilty without a trial, or if you like to sign a forced confession. Although there would be many an occasion when the submission could be influenced by one's own interests, commercial or otherwise, it should not be assumed that any personal interest is necessarily a competing interest.
It may well be that this subject has been debated in the past, before the editorial decision was taken, but some preliminary inquiries indicate that there may be room for reopening the debate on the subject of competing interest.
May I therefore suggest a more open expression of interest and that competing interest be relabelled just declaration of interest, or relevant interests. This would continue to provide all the protection afforded by the requirement to declare one's interests while leaving the readers, who are perfectly capable of making up their own minds, to draw their own conclusions.
Any other competing or conflicting thoughts?
Competing interests: None declared

Re: A hungry student's view 11 April 2006

Wendy Lydall,
author
Emerald, Australia, 3782
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Re: Re: A hungry student's view

It saddens me that a person with the ethics and compassion of "hungry student" has been programmed into thinking that what developing nations need is cheaper, safer drugs. The most clever thing that the drug companies have done is to make the people who want to be healers believe that drugs are what healing is all about.
There are small clinics in South Africa and Mozambique that are successfully converting HIV+ patients to HIV-, and TB and bilharzia are very successfully treated by what has become known as "alternative" medicine. The suppression of herbal and homoeopathic medicine began in 1911. Before that homoeopathic medicine was regarded as "orthodox" in North America. The financial arrangements that nowadays exist between doctors and drug companies are just a symptom of a much bigger problem in world health.
Competing interests: I am an author who promotes non pharmaceutical types of medication.