By Martin Tattersall, Professor of Cancer Medicine, University of Sydney.
The recent launch of the No Advertising Please campaign has focused on the frequent visits to general practitioners of drug company representatives and evidence that doctors receiving information from pharmaceutical companies including from drug representative visits is associated with increased prescriptions of promoted drugs, decreased quality of prescribing and increased costs.
The Consumer Health Forum of Australia has welcomed the campaign and commented ‘it can only boost the level of trust patients place in the doctors to see a NAP poster in their waiting rooms’.
The effects of drug company representative visits on oncologist prescribing has not been studied nor is it known how many oncologists choose not to see drug company representatives. It is likely that all oncologists receive advertising in the mail from drug sponsors about new oncology products or newly approved indications.
In 2005, it was reported that 41% of medical specialists in Australia ‘had engaged in industry-sponsored research’ (1), but no more recent studies of oncologist participation in industry sponsored research has been reported.
We reported the views of patients attending general practice about doctors’ interaction with the pharmaceutical industry and their wishes for disclosure of this information (2). 76% of surveyed patients were not aware of any competing interests that their doctor may have with drug companies and 49% reported the doctors are not unduly influenced ‘despite receiving benefits or perks’.
However 78% of surveyed patients reported that knowing my doctors competing interests will ‘ help me to make better informed decisions for myself when considering my treatment options’. 78% of surveyed patients would like their doctor to make the relevant disclosure of interest verbally during the course of the consultation, and 67% would like the disclosure ‘clearly displayed on the wall of the consulting room’. Finally, 80% of surveyed patients ‘will have more confidence in their doctor’s decisions with full disclosure compared with non-disclosure”. Patients were not offered the disclosure option of inclusion on a publicly accessible web site.
Australia has been slow to embrace the transparency movement by promoting disclosure of doctor/researcher/medical educator industry associations in spite of evidence of an association between medical trainees’ interactions with pharmaceutical promotion and their preferences in use of prescription medicines. Austad et al (3) surveyed a nationally representative sample of first and fourth year medical students and third-year residents asking how often they used different educational resources to learn about prescription drugs. Among fourth-year students and residents, a series of multiple-choice knowledge questions were included about appropriate first-line therapies for clinical scenarios involving patients with diabetes, hyperlipidaemia, hypertension and insomnia. Evidence-based answers followed established clinical guidelines while marketed drug answers favoured brand name over generic alternatives.
Survey answers were used to build an ” industry relations index” assessing each respondent’s level of acceptance of pharmaceutical promotion. More than 1600 medical students (49% response rate) and 735 residents (42.9 response rate) reported common use of unfiltered sources of drug information such as Google (74%) and Wikipedia (45%). They found that 48% to 90% of fourth-year students and residents accurately identified evidence-based prescribing choices. Higher industry relations index was associated with 15% lower odds of selecting an evidence-based prescribing choice. There was also a significant association between the industry relations index and greater odds of choosing to prescribe brand-name drugs. The authors concluded that policies intended to insulate trainees from pharmaceutical marketing may promote better educational outcomes.
These findings underpin the NAP perspective that prescribers need evidence, not marketing.
It is not known how oncologists in Australia obtain evidence to inform their use of prescription medicines.
The TGA approved product information (PI) is a valid source of information current at the time of registration. Updates may lag behind research reported in abstracts of international meetings. Guidelines endorsed by regional, national and international bodies are useful, particularly if they are regularly updated. The Cochrane Collaboration publications are highly valued and reports of the National Institute of Clinical Excellence (NICE) are also used. An underused source of information about currently accruing clinical trials in Australia is the consumer friendly cancer clinical trials website (www.AustralianCancertrials.gov.au). The site details phase 1, 2 and 3 clinical trials active in different cancer centres in Australia, and also presents information about completed trials.
On October 17 2014, the ACCC, Australia’s competition watchdog, demanded drug companies publicly name any doctor who accepts consultancies or speaker fees or free travel and accommodation. The ACCC has made the demand as a condition of it formally endorsing the Medicines Australia draft code of conduct which governs the activities of the big Pharma companies in their dealings with doctors. There is currently no requirement in the draft code for the doctors to be named when accepting fees for speaking at educational events, sitting on advisory boards, from market research or accepting sponsorship to attend conferences and other events. ACCC is requiring changes to the code that will mean that all relevant transfers made by pharmaceutical member companies to individual health care professionals are reported.
Australian Doctor has been told that the commission will not demand doctors be named if they accept hospitality, for example during education events, which will be capped under the code at a value of $120. These recent developments will likely lead to a publicly accessible website which records pharmaceutical industry payments to doctors.
The University of Sydney–Sydney Medical School appointed an outside interests committee 3 years ago which requested all medical school employees annually disclose confidentially their outside interests to the committee that, together with the employee’s supervisor, would determine whether the outside interests constituted a conflict-of-interest and if so how best this might be managed. 90% of eligible medical school employees have made annual disclosures and about 30% of them were found to have a conflict of interest. The information is confidential and not accessible by staff within the University or outside. Presumably the ACCC website will be searchable by employees of scientists, researchers, academic clinicians and by medical educators, as well as by patients and referring doctors.
These developments and the No Advertising Please campaign will lead to greater public awareness of the extent of industry support of medical research and medical education and the potential consequences. The ease of online access to up to date high-quality evidence to inform doctors prescribing habits will hopefully be improved which may enhance the quality of prescribing by general practitioners and medical specialists. Educators of medical students and resident–registrars will likely be required to declare their outside interests which will be accessible to students and possibly to the public.
I believe it is regrettable that the medical profession has not been more proactive in considering how to publicly disclose outside interests, and that the ACCC has used its fiscal stick to influence industry to publicise doctor’s names who have accepted consultancy or speaker fees, or free travel and accommodation.
Professor Martin Tattersall is Professor of Cancer Medicine at the University of Sydney and a member of the No Advertising Please campaign team. For more information on the campaign, visit: www.noadvertisingplease.org.
1. Henry DA et al. Medical Specialists and pharmaceutical industry-sponsored research; a survey of the Australian experience. MJA 2005, 182: 557-60.
2. Tattersall MHN, Dimoska A, Gan K. Patients expect transparency in doctors’ relationships with the pharmaceutical industry. MJA 2009; 190: 65-68.
3. Austad KE et al. Association of marketing interactions with medical trainees’ knowledge about evidence-based prescribing: Results from a National Survey. JAMA Intern Med 2014; 174: 1283-1289.