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Ideas and Opinions |

Rethinking the Use of Physicians as Hired Expert LecturersRethinking the Use of Physicians as Hired Expert Lecturers

Jerry Avorn, MD
[+] Article and Author Information

From Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0847.

Requests for Single Reprints: Jerry Avorn, MD, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120; e-mail, avorn@post.harvard.edu.

Author Contributions: Conception and design: J. Avorn.

Analysis and interpretation of the data: J. Avorn.

Drafting of the article: J. Avorn.

Final approval of the article: J. Avorn.

Collection and assembly of data: J. Avorn.


Ann Intern Med. 2014;161(5):363-364. doi:10.7326/M14-0847
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GlaxoSmithKline recently announced that it will no longer hire physicians to lecture prescribers about its products. This commentary discusses possible motivators behind this decision and why physicians should welcome it.

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Rethinking the Use of Physicians as Hired Expert Lecturers
Posted on September 1, 2014
Emilio Gonzalez, M.D.
The University of Texas Medical Branch (utmb Health)
Conflict of Interest: None Declared
I think the title of this piece should have been "Rethinking the Use of Pharma-sponsored Physicians as Hired Expert Lecturers". Otherwise, the title is entirely misleading. I strongly believe there is a great clinical benefit in listening to physicians who are indeed medical experts in their fields both in medical education for trainees as well as in improving the quality of care provided by practicing physicians.
A lost opportunity
Posted on September 3, 2014
Abrar Khan
Banner Health
Conflict of Interest: None Declared
As far I can remember, great ideas didn't come pre-printed in journals or text books. They come from free minds speaking freely about a subject or an issue while sipping a cup of coffee, sharing a meal or a drink. It sounds very demeaning that respected well paid physicians will change their practicing behavior, and put aside their patient care for just a meal. It’s not relevant who pays for a dinner and who sponsors it. What’s more important is that it’s an effort to get few physicians start taking about patient care in the context of a new therapy that might help their patients. Thanks to the bureaucracy of few, now a lost opportunity……
Professionalism
Posted on September 3, 2014
Marc S. Frager MD
East Coast Medical Associates
Conflict of Interest: None Declared
Dr. Avorn tells us that "professionalism means taking responsibility for one's lifetime learning," yet the ABIM believes a physician has to meet their criteria for lifetime learning to demonstrate professionalism. Perhaps the ABIM is minimizing the potential for physician self-education and self-motivated displays of professionalism by urging their expensive and contentious MOC program on us.
Comment on Rethinking the Use of Physicians as Hired Expert Lecturers
Posted on September 9, 2014
Marc B. Garnick MD1, Wendy Balter2
1. Gorman Brothers Clinical Professor of Medicine Harvard Medical School and Beth Israel Deaconess Medical Center Boston, MA 2. President, Phase Five Communications, Inc., New York, NY
Conflict of Interest: Marc B. Garnick has no conflicts of interest; Wendy Balter is President of Phase Five Communications, a medical education company.
Responding to Dr. Avorn’s opinion piece (1), we find lamentable GlaxoSmithKline’s (GSK) retreat from support of physician lecture programs at a time when the introduction of novel pharmaceuticals with complex mechanisms of action and clinicians’ desire for education have never been greater.

In 2013, the US Food and Drug Administration (FDA) approved 27 new drugs, many of them completely novel. Commercially-supported physician lectures answer an urgent need for high-quality information about new drugs from experienced peers. The content of these programs is rigorous and satisfies the FDA’s stringent requirements for accuracy, objectivity, fair balance, and reliance on well-controlled studies. Commercial interests are fully disclosed, and layers of oversight—from corporate integrity agreements, compliance with the U.S. Department of Health & Human Services Office of Inspector General guidelines (2), and adherence to the PhRMA Code on Interactions with Healthcare Professionals (3)—protect prescribers and patients from unsupported claims that could lead to inappropriate use.

In contrast, non-commercially-sponsored lecturers, including academicians and other key opinion leaders, typically have accountability only to themselves and their institutions. These speakers may lack legal compulsion to disclose conflicts of interest, and may be motivated by drug costs, politics, desire for peer admiration, or fear of change. Little prevents them from advocating uses unproven to meet FDA standards of safety and efficacy.

Absence of commercial sponsorship does not ensure freedom from bias, nor does commercial support necessarily compromise objectivity. Medical, legal, engineering, and accountancy journals, for example, have long enjoyed subsidy provided by their advertising pages while trusting their readership to discern information from promotion.

In a recent independent survey of 500 clinicians, more than 90% responded that they found information provided by sponsored speakers to be timely, useful, and reliable; 94% agreed that these programs improved their care for patients (4). Clinicians also demonstrate that they value commercially-sponsored speaker programs for the information provided, not “complimentary meals.” According to Manhattan Research, 71% of physicians participated in online medical conferences last year (5).

High-quality medical education programs require substantial expertise, time, and other resources to produce. Further declines in commercial support for them would seriously compromise physician knowledge and. ultimately, patient care. The authors hope that other pharmaceutical manufacturers do not follow GSK’s lead, and that GSK rethinks this unfortunate decision.

References
1. Avorn J. Rethinking the use of physicians as hired expert lecturers. Ann Intern Med. 2014;161:363–364.
2. U.S. Department of Health & Human Services. Office of Inspector General. OIG Compliance Program Guidance for Pharmaceutical Manufacturers. May 2003. https://oig.hhs.gov/authorities/docs/03/050503FRCPGPharmac.pdf. Accessed September 3, 2014.
3. Pharmaceutical Research and Manufacturers of America. Code on Interactions with Healthcare Professionals. July 2008. http://www.phrma.org/sites/default/files/pdf/phrma_marketing_code_2008.pdf. Accessed September 4, 2014.
4. KRC Research. Survey of Physicians About Pharmaceutical and Biotech Research Company Activities and Information. March 2011. http://www.phrma.org/sites/default/files/pdf/krcsurveyofphysicians_1.pdf. Accessed September 4, 2014.
5. Manhattan Research. Taking the Pulse® U.S. 2013. New York, NY: Manhattan Research, 2013. Available at ehealthcaresolutions.com/summit/presentations/mressi_2013.pptx.
Accessed September 5, 2014.
Prescribers as Promotors
Posted on September 15, 2014
Kaenat Mulla, Adebusola Shonubi, Dev Katarey
St. Georges University
Conflict of Interest: None Declared
We read with interest the recent article by Dr. Jerry Avorn (1). GlaxoSmithKline (GSK) is an internationally renowned pharmaceutical agency and we believe their recent decision to discontinue hiring physicians as expert lecturers is not without significant consequences.
Within the article it is presumed that physicians’ desire to lecture is due to the monetary reward. However, a study conducted amongst senior Norwegian medical students stated that only 17.5% had a positive attitude towards pharmaceutical industries and the majority said they would decline monetary gifts (2). This study demonstrates that the new generation of physicians are not as influenced by a drug company’s monetary offers. Therefore, GSK’s plan to stop hiring physicians as expert lecturers could mean the future physicians who truly had a desire to educate could potentially miss out on opportunities to teach and share their knowledge. This can be combated by GSK assessing physicians teaching content beforehand.
In the article it is mentioned that an excellent alternative to educate doctors about evidence-based prescribing, free of commercial influences, was by “academic detailing”. (3) The fact that countries such as the USA have started to implement such methods means that it opens up new pathways for physicians to learn and at the same time not be influenced by drug companies, but rather the evidence behind drugs. However, evidence–based prescribing should not take away the knowledge or skills taught by expert lecturers.
One argument in the article was the “physicians’ performance of paid speaking engagement seems to be diminishing”. (1) If we were to compare this to teaching in medical and pharmacy schools, then the majority of lecturers are actually physicians. A study conducted amongst pharmacy students in Saudi Arabia concluded that 53.7% students preferred direct type of lecturing and their aid for revision were handouts made by the lecturers (4). Secondly, postgraduates who have had training and feedback from physicians in terms of their practical skills do better in OSCE’s (5). This shows that the performance is not diminishing but that practicing physicians are used to be being taught by colleagues and subsequently have trust in information provided by them.
As physicians will be the front-line prescribers it is logical that they would educate their peers. It is a shame that GSK are no longer using such a good resource as we believe that physicians provide pharmaceutical knowledge in a more clinically oriented way.
References:
1. J. Avorn. (2014). Rethinking the use of physician as hired expert lecturers. Ann Intern Med. 2014 Sep 2;161(5):363-4. doi: 10.7326/M14-0847.
2. Lea D, Spigset O, Slordal L. Eur J Clin Pharmacol. 2010 Jul;66(7):727-33. doi: 10.1007/s00228-010-0805-6.
3. Thomson O’Brien MA et al. Educational outreach visitis: effects on professional practice and healthcare outcomes. Cochrance database syst. Review. 2000: CD000409
4. Yousif MA et al. Saudi Pharm J. 2014 Sep;22(4):309-14. doi: 10.1016/j.jsps.2013.06.005.
5. Stojan JN. Med Teach. 2014 Aug 26:1-8. Medical school handoff education improves postgraduate trainee performance and confidence.

Authors:
Kaenat Mulla, Adebusola Shonubi and Dev Kata
Rethinking "Rethinking the Use of Physicians as Hired Expert Lecturers"
Posted on October 28, 2014
Michael S Sherman, MD
Martin Health Systems, Palm City, FL
Conflict of Interest: None Declared
Current dogma from our thought-leaders requires "evidence." Experience, judgment, integrating patient (with or without a concerned family present) expectations, cultural and educational differences between patients, insurance/financial/local resources differences and the in varying percentage (but always hidden) malpractice considerations which are all present in every patient interaction do not conveniently fall into this depressingly "modern" worldview.

But they are all there.

That's not the least why the idealized view from Academia in fact needs tempering for real world practicing physicians - though virtually never does this perspective appear in our leading journals. Which prompts this response to Dr Avorn's "Ideas and Opinions." It was not coincidental that the same issue of Annals contained a thorough review of available evidence concerning "Screening for Asymptomatic Carotid Artery Stenosis," which in essence concluded there are no studies employing widely held current medical practices - "including newer (anti hypertensive) classes, such as ACE-inhibitors" - all eleven of which are long available generically!

Clearly we will always need more than evidence to guide us in our many daily decisions and actions. Interactions with colleagues, however rare the opportunities in this era of hospitalists and purely office-based (confined) medicine, are helpful and relevant. One such increasingly rare venue for collegial interaction is lectures sponsored by pharmaceutical companies.

What norms are stated or implied by opinions exemplified by Dr Avorn's "Ideas and opinions?"

1. We (physicians) appear to have a lot to learn from ethical trailblazers like "lawyers, engineers and accountants," who, to quote, "do not expect that all (sic!) of their continuing education requirements will be met by free lunches, often brought to their places of work or top-tier restaurants, complete with complimentary meals. Nor ... multiday courses for continuing education credit offered at minimal cost."

But there are no CME offered at lunch (ever) or virtually any dinner. Most lunchtime interactions with pharmaceutical representatives take place in a rush chomping on rubber chicken or a sandwich. Reps are painfully careful to stay within FDA-approved labeling and gladly furnish reprints or help with subject searches. Most physicians have long since stopped attending evening lectures, because our non-physician spouses are not permitted to attend, and we have far too little time to spend with said spouses.

Unlike physicians, lawyers charge by the minute. One of my patients, a retired trial lawyer (from Boston!) actually said to me: "You know what mistake you doctors made? You agreed to charge by a level of service instead of time, like we lawyers. We charge what we think our opinion is worth and the marketplace either agrees or we starve!"

"Relative value...?" I'm not aware of any similar global agreement on the worth of one's services among our lawyers, engineers or accountants.

2. Physicians' vulnerability to outside influences seems extraordinary. We apparently risk changing our patients' therapies for a sandwich, a pen (previously) or a dinner with a speaker. Despite the glaring difference in education, we apparently are no match for the intellect and/or beguiling smiles of drug reps.

3. Off-label use of FDA-approved drugs can't possibly reflect an understanding of pharmacology or pathophysiology by licensed medical professionals (most Board-certified) required to annually maintain state-approved CME. Off-label use of drugs in places other than multi-center sites of randomized cross-over double-blind studies can mean "ineffective, unsafe or both" outcomes.

4. Knowing or working together with a local specialist speaking as an "expert" precludes personal accountability long after the talk is over.

My evident cynicism is inspired by the attitude - a recurrent theme for at least the last three decades- that physicians at once exceed all other professions in moral sanctity but at the same time are incapable of critical thought, interaction with base capitalism or that we easily relinquish our Oath to do no harm to the next blonde drug rep, flashy sales aid or "free lunch."

We are better than that.

President Eisenhower warned of a Military-Industrial-Complex threatening our way of life. What other major profession constantly pursues deeper understanding and new ideas, but has a comparable government/insurance/political opposition to paying the cost of progress? Accountants need new software annually to keep pace with the thousands of new laws passed - they pass these costs on to anyone using their services. Engineers are praised for using new structural materials or technology. Our automobiles are now moving entertainment centers and offices - fight that trend and your car won't sell!

Yet we need Prior Authorizations or outright cannot Rx new medications when "comparable" 15 to 30 year old generic precursors exist, or at the least our patients must "fail" one of these potentially less safe or efficacious drugs! Government guidelines - which growingly determine insurance benefit coverage - argue more for cost containment based on antiquated "evidence." Witness (same Annals issue) the near afterthought/parenthetical critique/disclaimer from the USPTF regarding the latest "Clinical Guideline" for screening for ACAS, immediately following their statement that "with moderate certainty...the harms of screening for Asymptomatic CAS outweigh the benefits:"

"How does Evidence fit with Biological Understanding? The medical treatment groups in the RCT's were poorly defined and probably did not include the intensive blood pressure and lipid control that is currently standard practice for the prevention of cardiovascular disease...!"

Our thought leaders extol Guidelines, while our patients are computer-savvy and ask for tests and more ways to avoid getting sick. They want the better outcomes often associated with medical progress, not population-biased , politically-motivated, cost-driven Guidelines pronounced by purists who seem anti-progress. Witness "evidence" recommending initiating screening mammography at age 50 - no one believes that!

I need some free rubber chicken just to calm down from all this....!
Author's Response
Posted on November 20, 2014
Jerry Avorn, MD
Harvard Medical School
Conflict of Interest: None Declared
Garnick and Balter argue that we should be grateful that drug companies hire physicians to teach the rest of us about the many new drugs that are introduced annually. But the purpose of such talks, often arranged through a company’s marketing department, is primarily to increase product sales rather than present a comprehensive view. It is implausible to expect these presentations to emphasize that a generic medication may be as effective as the sponsor’s more expensive product, or have a longer safety track record. (1) Concerning guidelines, several major investigations and over $15 billion in settlements have documented widespread violations of these rules as companies promoted uses of their drugs that were poorly justified and/or dangerous (2). The unpublished industry survey they cite found that fully 75% of doctors said they get informed about prescribing choices through non-CME¬ company-sponsored programs featuring hired physician-speakers – not a statistic about which we should feel proud. (3)
Of course, we academic physicians also have biases and conflicts, but claiming that the information provided by non-industry-paid doctors is inherently less reliable than that provided by company spokespeople is simply implausible. A recent survey of 2,336 medical students and residents found that those who relied more on company-sponsored information were significantly less likely to provide evidence-based answers to prescribing questions, and significantly more likely to recommend branded vs. generic products. (4) Non-industry-supported sources of information are a better way to meet the profession’s growing need to assimilate data on the comparative effectiveness of medications. (5)
Mulla et al worry that a reduction in pharmaceutical payments to physicians will reduce their involvement in teaching. Fortunately, the involvement of clinicians in educating our peers and students is a well-established tradition in medicine that will continue even if drug manufacturers don’t pay us to do so.
Khan is concerned that Glaxo’s plan to withdraw funding for sponsored lectures will mean that physicians will no longer be able to meet together to discuss new drugs that may benefit their patients. Of course we will; we’ll just have to pay for our own food.
As a nation, we have accepted the false economy that it is a bargain to accept “free” medical education from drugmakers about their products. Such bargains can only exacerbate our costliest-in-the-world per capita drug spend. With growing concern about providing safe, effective, and affordable drug regimens, this is a good time to re-think who should be defining our understanding of the medications we prescribe.

Jerry Avorn, M.D.
Harvard Medical School


References
(1) Avorn J. Healing the overwhelmed physician. The New York Times [op-ed], June 11, 2013.
(2) http://en.wikipedia.org/wiki/List_of_largest_pharmaceutical_settlements
(3) KRC Research. Survey of Physicians About Pharmaceutical and Biotech Research Company Activities and Information. March 2011, p. 16. http://www.phrma.org/sites/default/files/pdf/krcsurveyofphysicians_1.pdf
(4) Austad KE, Avorn J, Franklin JM, Campbell EG, Kesselheim AS. Association of marketing interactions with medical trainees' knowledge about evidence-based prescribing: results from a national survey. JAMA Intern Med. 2014; 174:1283-90.
(5) Fischer MA, Avorn J. Academic detailing can play a key role in assessing and implementing comparative effectiveness research findings. Health Aff (Millwood). 2012;31:2206-12.
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