Healthy Skepticism International News
January 2009
International Society of Drug Bulletins General Assembly
1-4 December 2008
Matagalpa, Nicaragua
Summary prepared by David Menkes representing Healthy Skepticism
Background
Healthy Skeptics are well aware of the bias that typically pervades drug information provided or sponsored by the pharmaceutical industry, and thus the enduring need for accessible, up-to-date, quality information free from such bias. Various national and regional bodies around the world aim to address this need; ISDB exists to “encourage and assist the development of independent drug bulletins in all countries and to facilitate co-operation amongst them” (see www.isdbweb.org). In addition to various working parties and regional meetings, General Assemblies occur every three years and offer exceptional opportunities for networking and collaboration with colleagues from around the world. The Nicaragua meeting in December 2008 attracted 60 delegates from 28 countries, including many in the developing world.
Programme
Three and a half days sounds like a lot, but in fact the programme was full and parallel sessions were required each day to accommodate the myriad of topics relevant to ISDB’s mission. Audience participation in the sessions varied considerably; in some cases inadequate chairing meant that there was no time for needed discussion. Most sessions I attended were both interesting and well presented. Highlights included:
• Roll call and presentation of new ISDB members from across the globe (including Spain, Cuba, Moldova, Armenia, Costa Rica, Peru, Colombia…)
• Challenges facing members. These are diverse but often include financial constraints, responsible in part for attrition of some member bulletins. Facing enormous challenges did not seem to daunt participants, and there were inspiring addresses by luminaries such as Gianni Tognoni (Italy) and Ciprian Jauca (Canada) who combined astute political strategy with state-of-the-art clinical science.
• Feedback from ‘breakout sessions’ was often useful and subject to lively discussion, for example on the priorities for ISDB in the coming years.
• A particularly useful session on CME, its hijack by vested interests, and strategies to counter this. Zahed Masud (Bangladesh) pointed out the salience of matching Pharma’s active distribution of information and also the pervasive social and ‘friendship’ effects of rep contacts. Benoit Marchand (Nicaragua) described development and use of an online tool for GPs to measure their knowledge and practice in therapeutics, with embedded links to ISDB, Cochrane and other educational resources.
Drug Promotion
Barbara Mintzes (Canada) and I co-presented a well-attended and lively session on drug promotion. As this topic is particularly relevant to HS’s aims, I will give some detail here and will share PowerPoint slides on request. [These available from .(JavaScript must be enabled to view this email address) - Ed.]
1. Promotion introduced as concept, seen to vary in usefulness depending on what is promoted, and by whom (commercial, government, NGO, lobbies, etc.)
2. Assessment of promotional material requires that we consider motive; who stands to gain?
3. Case-by-case we need to consider: are competing interests evident? suspected? declared? Note practices of medical journals since BMJ began requiring disclosure around 20 years ago.
a. Disclosure is complex. Need to consider how relevant/complete/appropriate/detailed
b. Lawyers understand better than doctors that competing interests are ubiquitous, a fact of life, and disclosure essential (but not necessarily sufficient: note potential perverse effects of disclosure, as described in Cain et al, J Legal Studies 2005; 34(1)1-25)
4. Common distortions
a. selective reporting of clinical trial results
b. use of surrogate endpoints (note Staffan Svensson’s HS correspondence on this topic during 2008 and recent HAI meeting poster – available at www.pharm.nu/hs/poster_surrvar_HAI_0811.pdf)
c. exaggerated benefits and minimised drawbacks of promoted products
d. adjustment of promotional content presented in various settings, in order to, inter alia, exploit regulatory differences between countries (this was the topic of another of S Svensson’s HAI posters – www.pharm.nu/hai/poster_database_HAI_0811.pdf)
5. Sources of information: HS (esp. AdWatch), HAI, ISDB.
6. Teaching on promotion should consider not just knowledge but also skills and attitudes.
a. aim to decrease overconfidence (just enough, not too much, as low confidence also problematic)
b. avoid alienating students, colleagues (reactance)
c. include experiential learning (but beware of generating over-skepticism)
7. Encourage student and clinician use of independent drug bulletins wherever possible
Having established the importance of teaching/training in the area, Barbara Mintzes then presented results of the WHO-HAI Curriculum Development Project on Drug Promotion (slides available on request). Essentials include:
1. Survey of educators conducted in 2005 (response rate = 46%; n=228; 137 medical, 91 pharmacy, from 64 countries).
a. education on promotion included to some extent in curriculum (72% of respondents)
b. modest time allocated (of respondents, 37% medical and 20% pharmacy courses allocated a half day or less)
c. problems included: opposition from other faculty; lack of perceived relevance; few courses evaluated
2. Essential contents proposed for teaching on promotion – to be launched in May 2009 at the World Health Assembly
3. Pilot testing, evaluation of new course organized by Dee Mangin and Les Toop (New Zealand)
Conclusion
I found the General Assembly to be vibrant, well organized, and with a diversity of engaging and committed colleagues from around the world. I was made very welcome and felt privileged to represent HS at this meeting. As ISDB’s aims appear entirely consonant with ours, I think there may be merit in HS having a more formal role in ISDB by progressing to full membership. Such a move would require careful discussion, as it would have both structural and financial implications for HS, and will also likely require negotiation with the ISDB Committee.
David Menkes
Hamilton, New Zealand
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