Healthy Skepticism Library item: 12987

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Publication type: news

Moynihan R.
Paying the medical piper
ABC Background Briefing 2008 Feb 24
http://www.abc.net.au/rn/backgroundbriefing/stories/2008/2166307.htm#transcript

Full text:

Transcript

This transcript was typed from a recording of the program. The ABC cannot guarantee its complete accuracy because of the possibility of mishearing and occasional difficulty in identifying speakers.

THEME

Ray Moynihan: Hello, and welcome to Background Briefing. I’m Ray Moynihan.

And today, some unsettling questions about the hidden influence of drug companies over your doctor’s education.

To work as a fully-registered GP under Medicare, you have to undertake continuing medical education, to refresh your skills and keep up with the latest research.

A common way to do that is by attending short seminars, which have to be accredited by the doctor’s association, the Royal Australian College of General Practitioners.

That GPs College says the education at these seminars must be independent, but today we’ll hear a lot of that education is sponsored directly by drug companies, who in some cases have paid for the right to have an input into how that education is run. And those sponsorship arrangements are sending shockwaves around the medical community.

Associate Professor John Eden, from the Royal Hospital for Women.

John Eden: This is the first time I’ve seen this, Ray. Are you going to take it away – that’s quite a distraction because I’ve never seen it before.

Ray Moynihan: You’ve never seen the Healthed Sponsorship Prospectus.

John Eden: This document you’re showing me, I’ve never seen, no.

Ray Moynihan: Are you aware of the sorts of entitlements that Healthed routinely offers to top level sponsors?

John Eden: No.

Ray Moynihan: Are you concerned that sponsors are being offered the chance to have a suggestion of a speaker, or other influence over topics?

John Eden: That’s putting it mildly. Yes, I am very concerned.

Ray Moynihan: Today, Background Briefing will ask how much GP education is truly independent, and we’ll reveal a disturbing level of complacency in the medical establishment about the role of drug companies in your GP’s education.

One of the most popular providers of that education is a company called Healthed, which advertises its seminars to doctors as being totally independent from sponsor influence.

Healthed’s convenor is Dr Ramesh Manocha.

Ramesh Manocha: The reason why our seminars are very popular, is because they feel that the information they are getting is independent, and if they didn’t think it was independent, they didn’t get that impression, they wouldn’t come back.

Ray Moynihan: Were GPs attending those seminars told that sponsors had an entitlement to suggest speakers?

Ramesh Manocha: No, but they were told that the topics were sponsored.

Ray Moynihan: Why weren’t they told that the sponsors had an influence, had the ability to suggest speakers? Do you think that would have been good thing to have told them?

Ramesh Manocha: Well, in hindsight, possibly, yes.

Ray Moynihan: That’s Dr Ramesh Manocha, the Director of Healthed, which he says educates more than 2000 Australian GPs every year.

We’ll be hearing more from him soon. But first, let’s visit one of his seminars, which are usually held at leading hospitals or universities.

APPLAUSE

Gary Eggar: It’s a bit like this, you know, working with obesity. A lot of people think that they know all about it, particularly media commentators, and it doesn’t always happen that way …

Ray Moynihan: This seminar took place in a lecture theatre at the University of New South Wales about 18 months ago, and one of the afternoon sessions was about obesity.

More than 100 GPs listened to a panel discussion, featuring Gary Eggar, and a Sydney doctor called Brian Sproule, who discussed different aspects of how to treat obesity.

Brian Sproule: I’ve had a lot of experience with Duromine; you get very used to it, a tablet, and Duromine has got a very good track record.

Ray Moynihan: As the session developed, Dr Sproule made several enthusiastic references to a weight loss drug called Duromine, whose generic name is phentamine.

Brian Sproule: … but I’ve never had a problem with getting people off the Duromine. I think a lot of this is related to the fact people link up Duromine with amphetamine …

Ray Moynihan: While the weight loss drug was mentioned more than half a dozen times, what was not mentioned to the doctors present, was the fact that the company marketing duromene called 3M, as part of its sponsorship package, had paid for the right to suggest speakers for the session.

Brian Sproule: So you’ve to try and prevent the weight gain, and I don’t mind my patients taking a drug like phentamine or Duromine, on an ad hoc basis, just maybe they’ve been out over the Christmas season, they’ve put on a couple of kilos, if they want to take a few phenamine, or whatever …

Ray Moynihan: Dr Sproule told Background Briefing how he ended up speaking at the Healthed seminar.

Brian Sproule: Well a representative, a medical representative for a drug company associated with obesity, came in and said would I like to be a co-presenter with Professor Gary Eggar, he’s a Professor, I’m a GP.

Ray Moynihan: So it was the drug company who invited you to speak?

Brian Sproule: Yes.

Ray Moynihan: Did you have any media training supplied by that drug company?

Brian Sproule: I suggested to them actually, I said I’m really a little bit uneasy about this presentation of the lecture’, and they said, ‘Don’t worry, we can fix this; there’s a guy who’s very good at advising about this’, and this guy bobbed up in the surgery, and he said, ‘How are you going to stand?’ and I stood up, with my hands in my pockets, and he said, ‘No, don’t do that.’

Ray Moynihan: So this is the drug company providing some sort of training for you?

Brian Sproule: Well not so much training, just pretty obvious tips.

Ray Moynihan: Presentation skills.

Brian Sproule: Presentation skills, which I was actually very grateful for.

Ray Moynihan: Correct me if I’m wrong, I’ve listened to your talk, it seemed to me you gave a fairly good hearing to Duromine, is that fair?

Brian Sproule: That’s very fair indeed, I always give it a good hearing, whether you’re listening to me, or whether I’m talking to a patient.

Ray Moynihan: Would that be why the sponsor suggested you as a speaker?

Brian Sproule: I’ve got no idea, I didn’t really ask them.

Ray Moynihan: That was Dr Brian Sproule, one of the speakers at an independent educational seminar, revealing that he was invited to speak, and even trained in presentation skills, courtesy of the drug company sponsoring the session.

The other speaker at the session was Professor Gary Eggar, a popular educator and strong advocate of lifestyle solutions to obesity.

Gary Eggar: I didn’t know that I was suggested by that drug company. I was approached by the company that organised the symposium. I wasn’t approached by 3M at all, I wasn’t asked to talk about anything specifically in relation to 3M’s product, and they only have one product in this area.

Ray Moynihan: We have a situation here where the drug company sponsor was suggesting speakers for this session. Does that sound like an independent session?

Gary Eggar: No, it’s not independent, but these things are never independent, particularly when they’re sponsored by pharmaceutical manufacturers. It’s a bit of a Catch-22 for speakers such as myself, because if there weren’t external sponsors, then there’d be nobody to sponsor these types of workshops, and the sorts of things that I do, as I say, which are non-medical, wouldn’t get sponsored, and for that reason there wouldn’t be postgraduate medical education in this area.

Ray Moynihan: Both Gary Eggar and Brian Sproule say their presentations were not influenced at all by the sponsor, but the fact remains that doctors listening to these speakers would have no way of knowing they’d been suggested by the session sponsors.

And just to check those facts, we put some questions to Dr Manocha.

Was it the case that 3M, the company marketing Duromine, suggested speakers for the session on obesity, including Gary Eggar and Brian Sproule?

Ramesh Manocha: Yes.

Ray Moynihan: Was that fact revealed to the GPs there?

Ramesh Manocha: I felt first of all that it was implicit in the fact that the company sponsoring the talk –

Ray Moynihan: I’m asking you directly, were the GPs told that 3M was sponsoring the session and had suggested the speakers? Were they told that?

Ramesh Manocha: No.

Ray Moynihan: A former employee of Healthed, Annie Shaw, last year sent a detailed complaint about Healthed to several key institutions, including the Royal Australian College of General Practitioners.

Shaw worked at Healthed on sponsorship arrangements with drug companies for several years before falling out with Dr Manocha last year.

Annie Shaw: He started with pharmaceutical companies to basically determine what the message the pharmaceutical companies wanted to give to the doctor. And at the same time, every content was advertised that it was independent.

Ray Moynihan: when you look at the pamphlets you cannot see that individual sponsors have sponsored individual sessions. How do you know that a company was able to sponsor an individual session?

Annie Shaw: The reason, because I have been involved in putting the program together with Dr Manocha. A lot of the time he cc’s his emails to me, and what the deal were and how everything was done.

Ray Moynihan: Since leaving Healthed Annie Shaw has set up in competition against Dr Manocha, running educational seminars, at locations including Lindeman Island. She and Dr Manocha are involved in an extended legal dispute.

Despite this, and whatever her motives may be, Background Briefing has corroborated the major claim that in some cases sponsors were paying for the opportunity to suggest speakers at seminars, which were then sold to GPs as independent.

Annie Shaw: The GP is that I have spoken to and the GPs who come to this conference, they think that they are attending a totally independent conference.

Ray Moynihan: A collection of internal emails reveals a pattern of drug company input into the way education has been provided at seminars across Australia, attended by literally thousands of GPs.

They provide a rare look behind the scenes into how sponsorship can really work, and what the pharmaceutical industry can get, on occasions, for its millions of dollars of investment in doctors’ post-graduate education.

The emails from 2006 show companies suggesting topics and speakers, and on at least one occasion even requesting to see those speakers’ presentations before they are delivered.

In the weeks before Brian Sproule spoke about obesity, someone from his office is in direct email communication within the drug company, which has invited him to speak. The practice manager sends an email in which we learn that the drug company is planning to play a role in putting together Dr Brian Sproule’s presentation.

Here’s a reading from that email:

Reader: I’ll be acting as practice manager for Dr Sproule during his annual holidays. He asked me to contact you regarding the Healthed meeting on July 29 … I understand you will attend to slides, powerpoint presentation etc.

Ray Moynihan: The drug company emails back:

Reader: Hi Greg, I’m still awaiting Dr Sproule’s notes, to write up the presentation. Do you suggest I send him an email?

Ray Moynihan: That email is from someone marketing Duromine, the drug Dr Sproule spoke so enthusiastically about. While he concedes the company may have helped with preparation of power point slides, he says his presentation wasn’t influenced in any way. Ironically he says he’s been concerned for a long time about the pharmaceutical industry’s influence in medicine.

A month after that last email, in the lead-up to the session on obesity, Dr Manocha, the head of Healthed writes to the same drug company, describing the forthcoming lecture as a way of helping –

Reader: – to promote both awareness and education about obesity and the place of Duromine about this. Don’t hesitate to call me should you be interested or have any questions.

Kind regard,

Dr Ramesh Manocha

Ray Moynihan: Another set of emails from the drug company CSL concerns negotiations with Healthed over its sponsorship of several sessions.

The drug company wants to clarify how a speaker at one of the sessions will refer to its product, a drug called Tramal being marketed for the treatment of pain.

Reader: Hello Ramesh. Thanks for giving me your time today. I’ll confirm that I will commit to Tramal sponsoring 4 seminars at a price of $18,000 in total, based on platinum sponsorship …

I am happy for the Sydney meeting to include a session on headache/migraine. Please determine the speaker’s opinion re: Tramal as I would like to ensure he positions it appropriately.

Ray Moynihan: So just to be clear here, a drug company sponsor of a seminar that’s supposed to be independent, is asking the educational provider to check what a speaker might say about that company’s product. And the response from Dr Manocha?

Reader: Will reconfirm opinion of headache speaker regarding Tramal to ensure balanced presentation.

Ray Moynihan: The same emails show that company is contacting another speaker directly and that they’re helping foot the bill for the speaker’s appearance, by paying the costs of his travel and accommodation.

The drug company emails Healthed informing them that they have contacted the speaker, in order –

Reader: – to determine his interest and availability in speaking at the Melbourne, Brisbane and Adelaide on ‘acute pain management – the evidence grows. Healthed to pay his honorarium, CSL to pick up the tab for airfares and accommodation. I’m excited about this initiative and look forward to working with you on it.’

Ray Moynihan: Dr Manocha replies that while he’s happy to accept the suggested speaker and pay the honorarium, he just wants to clarify a couple of points.

Reader: 1. On reflection it would probably be best if I contacted the speaker, just to maintain the separation between industry and programming.

2. Healthed will cover the standard honorarium for speakers which is $400. If he requests more, then we will have to discuss the possibility of CSL covering the difference.

We look forward to working with you, too.

Ray Moynihan: Both CSL and 3M declined to be interviewed for this program.

In an extended interview with Background Briefing Dr Manocha, the Convenor of Healthed, said topics for his seminars came from surveys of GPs, but while sponsors can make suggestions for speakers, they’re only accepted if deemed suitable by an independent scientific panel.

Ramesh Manocha: Most of these emails that you’ve shown me, and there’s only 2 or 3, relate to seminars that were run almost two years ago. And as I said before, we have first of all ceased operating those seminars where we associated with sponsors that want us to influence the content in that way. Secondly, we came to recognise that this was an expectation from some sponsors but not others. And so we put into place specific guidelines and stricter and more stringent guidelines to prevent that. And importantly, this was part of a learning curve that we have been through for the last number of years, and you’ve chosen examples at the front end of that learning curve where our measures have not been tight enough and where we have accordingly tightened up and established specific guidelines and managed the expectations of the pharmaceutical companies and sponsors to reduce, or not to reduce, but prevent them from making these kinds of demands from us.

Ray Moynihan: Background Briefing has obtained a copy of Healthed’s most recent sponsorship prospectus, the brochure which outlines the various deals for sponsors. The platinum package, Healthed’s most expensive, clearly states that drug companies can nominate speakers and help determine topics that are, to quote the prospectus, on message for the sponsor’s products.

So with the prospectus in hand, this is the question I asked Dr Manocha.

Do you currently offer sponsors the chance to work with you to determine a topic that is on message for their product?

Ramesh Manocha: No.

Ray Moynihan: Your sponsorship document as I understand it, does offer that to platinum sponsors.

Ramesh Manocha: It did, and the document is no longer used.

Ray Moynihan: I’m looking at a sponsorship prospectus that says 2008 – Sponsorship prospectus, produced by Healthed, sent to us by a drug company. I can show you a copy if you like. It says that you offer sponsors the chance to work with them to determine a topic that’s on message for your product area. Could you take a look at that, or just confirm it is the document –

Ramesh Manocha: No, I don’t – if you’ve got something that’s got 2008 on it, then you’re correct, and basically my understanding was that we worked to remove that wording after 2006 and you’re right, that wording shouldn’t be there.

Ray Moynihan: A little later in the interview, Dr Manocha again stresses he doesn’t succumb to drug company attempts to influence his seminars, saying he filters all suggestions through his scientific committees, according to guidelines of the College, the RACGP.

Ramesh Manocha: We have become increasingly aware that we must take more stringent and specific steps to reduce the demands, reduce the pressure that sponsors place on us as expressed in these very old emails, and –

Ray Moynihan: But the prospectus we just talked about was from 2008.

Ramesh Manocha: And that prospectus clear indicates that the sponsor can make suggestions will be specifically filtered by the stringent demands set out by for example, the RACGP.

Ray Moynihan: The document says the sponsor can work with you to determine a topic that is on message for your product area.

Ramesh Manocha: They can work with us insofar as making suggestions for speakers for example, and then we filter those suggestions very stringently.

Ray Moynihan: The way those suggestions get filtered is through what’s called a Working Group, or sometimes an organising or scientific committee, which has the final say in who the speakers are, and what their topics will be.

According to Dr Manocha, when suggestions for speakers do come from sponsors, his committees or working groups, consider whether the suggested speakers or authorities are their field, and capable of delivering presentations which are evidence-based and scientifically balanced.

Ramesh Manocha: Within those considerations the pharmaceutical company can make any suggestion it likes.

Ray Moynihan: And it’s just a coincidence that some of the speakers that the drug company suggest, the Working Group and Healthed accepts? The sponsorship dollars have no influence?

Ramesh Manocha: I don’t believe so.

Ray Moynihan: Background Briefing has obtained correspondence between a drug company called Organon and Healthed in the lead-up to a seminar on women’s health at the Royal Women’s Hospital in Melbourne. Organon is now part of Schering-Plough, and in a candid statement to Background Briefing, it said that it sponsors events to help ensure the quality use of medicine, and as part of its $40,000 sponsorship packages with Healthed, it was entitled to suggest speakers and topics.

Emails between the drug company and Healthed reveal how these sorts of transactions work in practice.

Reader: Dear Dr Manocha, Following our telephone conversation late last year, and our proposed inclusion of a presentation, we would like to put forward the following doctors for consideration.

Ray Moynihan: Dr Manocha replies:

Reader: We will do our best to accommodate your request. As a national sponsor we are particularly grateful for your support and we hope we can continue to work together in a similar fashion in future seminars.

Ray Moynihan: Dr Manocha goes on to say its suggested speaker has been accepted by the committee, but only after a bit of work from him.

Reader: I have lobbied the committee and the committee has agreed, after a bit of pressure from me.

Ray Moynihan: The drug company’s sales manager is pleased with the outcome, and sends back this ‘thank you’ to Dr Manocha.

Reader: Hi, Dr Manocha, This is really great news for Organon and we greatly appreciate the political help and support you extended us … in respect of orchestrating the favourable consideration of the proposed topic and speaker.

Ray Moynihan: Background Briefing wanted to know from Dr Manocha what he meant when he said he’d lobbied the Melbourne scientific committee.

Ramesh Manocha: I presented to the committee the option of that particular speaker, and I felt that that speaker was a person who was capable of presenting on the topic without being influenced, and in fact I remember speaking with that particular speaker and specifically indicating to her that her topic was sponsored in that case, and she was not to influence the content of her talk as a result of that sponsorship.

Ray Moynihan: Did the committee at the hospital in Melbourne know that the drug company sponsor had suggested the speaker?

Ramesh Manocha: I’m not sure about that, what year was that? What year does this email relate to?

Ray Moynihan: 2006. Should they have been aware of that?

Ramesh Manocha: They should have been. If I say if they were aware of that, if I hadn’t made them aware of that, I should have.

Ray Moynihan: Again this year, Healthed is organising a popular seminar on women’s health at the Melbourne Royal Women’s Hospital. The hospital declined requests for an interview to ask about what they knew of Healthed’s arrangements with sponsors, but did send a written statement about Healthed’s sponsorship brochure.

Reader: We are very concerned that the Healthed sponsorship prospectus appears to proffer or infer a level of sponsor influence over conference program content including the capacity to nominate speakers.

Ray Moynihan: The Royal Women’s in Melbourne went on to say that Healthed had reassured them that sponsorship was only sought for these seminars, after the speakers and topics had been locked in by the Scientific Committee.

Yet Healthed’s own website seems to contradict this process, by stating that sponsors may wish to nominate a speaker to present on a certain topic, subject to approval by the Scientific Committee.

And it’s not just Melbourne Royal Women’s Hospital that has been partnering with Healthed in its popular GP seminars, in recent years they’ve joined forces with some big institutions across Australia, including the Royal Hospital for Women in Sydney and Family Planning Associations.

Last September Healthed ran a women’s health update for GPs in the west; the conference flyer states that the organising committee includes medical educator of Family Planning in Western Australian, Dr Alison Creagh. And Dr Manocha confirmed Family Planning were on the committee.

So Background Briefing put a call through to Dr Creagh’s home in Perth and asked her if she had been on that committee?

Alison Creagh: No, I wasn’t. All our role was in fact to assist with the chairing for the day.

Ray Moynihan: Dr Manocha has told me that Family Planning WA was part of the organising committee and that that committee helped select speakers for the seminar, is that correct?

Alison Creagh: No, it certainly isn’t. None of us at FPWA were involved in selecting the speakers or in fact having anything to do with the organising. We only were involved on the day, as I said.

Ray Moynihan: According to the Healthed sponsorship brochure, if sponsors pay extra, if they pay at the top level, they’re entitled to suggest a speaker; were you aware of that?

Alison Creagh: I certainly wasn’t, and I find that quite shocking as a matter of fact.

Ray Moynihan: And why are you shocked by those sponsorship arrangements?

Alison Creagh: I guess I believed that the greater the distance between sponsors and the content of educational programs is, well, the greater the distance, the better.

Ray Moynihan: Well Dr Manocha says that that distance is brought about by these organising committees that family planning was part of.

Alison Creagh: Oh dear. Certainly if we had knowledge of that I’m not sure that we would have been involved in fact.

Ray Moynihan: What Alison Creagh has just said means that Dr Manocha was in fact the only person on that organising committee. He now says the situation in Perth was an exception to his normal procedures, and Family Planning were not involved in developing the educational program.

In Sydney last week, Healthed ran a big GP education day in collaboration with the Royal Hospital for Women.

Associate Professor, John Eden, who’s based at the hospital, and not part of Healthed, is also on the scientific committee that chooses speakers for that seminar. He told Background Briefing that sponsors have no influence at all, and topics come from surveys of GPs who attend.

John Eden: We don’t give industry, well I don’t, I can only speak for myself, I don’t give industry a chance to suggest topics or anything like that. Now they may come to us, as you say, and make a suggestion, but my principal goal as the organiser of the meeting that I organise, is in fact you go to the doctors and ask them what they want.

Ray Moynihan: The fact that drug companies are paying tens of thousands of dollars for your meeting, and suggesting speakers, you’re saying that doesn’t have any bearing on the decisions that you make?

John Eden: For me personally, it doesn’t.

Ray Moynihan: At this point in the interview Background Briefing asked John Eden whether he was aware of the Healthed sponsorship prospectus.

John Eden: No, I’m not aware of that documents, no, but thank you for making me aware of it.

Ray Moynihan: Would you like us to show you the document?

John Eden: I’d like to see that, sure, can you get someone to bring one in now?

Ray Moynihan: I think they might.

Here’s an excerpt from the sponsorship brochure Background Briefing showed John Eden.

Reader: As a platinum sponsor your company work with us to determine a topic that is on message for your product area.

John Eden: This is the first time I’ve seen this, Ray. Sorry, I’m just reading this, can I take it away? It’s quite a distraction because I’ve never seen it before.

Ray Moynihan: You’ve never seen the Healthed sponsorship prospectus?

John Eden: This document you’re showing me I’ve never seen, no. Sorry, I’ll put it down now, Ray, ask your question.

Ray Moynihan: Are you aware of the sorts of entitlements that Healthed routinely offers to top level sponsors?

John Eden: No.

Ray Moynihan: So you’ve been putting your name to this seminar without knowing the negotiations that go on with sponsors?

John Eden: Well I guess part of the thing is, not just, my meeting is just one meeting in the whole series of these things, I gather, but you’re right, I’m not aware.

Ray Moynihan: Are you concerned that sponsors are being offered the chance to have a suggestion of a speaker or other influence over topics?

John Eden: That’s putting it mildly, yes, I am very concerned.

Ray Moynihan: So you’ve had no sense that sponsors have been suggesting potential speakers?

John Eden: Not as direct as what you’ve just shown me, no. I’m a little shocked, I’m a little stunned, to be perfectly honest.

Ray Moynihan: What if this is widespread across the medical education industry? As our research is suggesting.

John Eden: I would personally find it very disturbing.

Ray Moynihan: Research for this program suggests this practice of top-level sponsors being entitled to suggest speakers is in fact widespread, though many individual sessions, including at Healthed events, are not sponsored at all. Moreover Dr Manocha himself says that sponsor involvement is standard industry practice, and he asserts that for up to 25% of the sessions at his current seminars, sponsors were able to suggest speakers.

Another big provider of education also has many sessions which are directly sponsored, and Background Briefing understands in some cases drug company sponsors can suggest speakers there too, though the convenor of that company declined an interview request.

Medicines Australia is the group that represents the pharmaceutical industry, and its Chief Executive is Ian Chalmers.

Ian Chalmers: It is not unusual in a sponsored professional event for pharmaceutical companies to be offered the opportunity of suggesting speakers. What’s important is that any speaker that participates in such an event must be credible. The scientific community would not in sustaining the credibility of the event, allow a speaker who was not able to speak in a manner which would sustain the credibility of the training.

Ray Moynihan: So the tens of thousands of dollars that are being paid by sponsors to the organisers of these events, does that count for anything when those people are considering what speakers to put on?

Ian Chalmers: Well a company may have an opportunity to suggest a speaker but organisers of the event are under no obligation to accept any particular speaker.

Ray Moynihan: So in your view that would ensure independence?

Ian Chalmers: Well independence comes from the rigor of the scientific committee that, from the rigor imposed by the scientific committee that approves the program.

Ray Moynihan: In the case of Healthed, the organising committee, or working group that approves the program is not always told of the sponsor’s involvement in choosing the speaker, and in at least one case, as we heard in Perth, the organising committee consists of just one person, Dr Manocha himself.

So who then will ensure that your doctor’s education is not influenced by sponsors?

The organisation responsible for regulating the continuing medical education of GPs is the Royal Australian College of General Practitioners.

The College accredits the providers of that education, like Healthed, and their guidelines demand that programs be independent from industry sponsors.

College representative, Dr Peter Maguire, would not comment on Healthed specifically, but answers questions generally about the need for independence.

Peter Maguire: We don’t want to see commercial or sponsored influence on any of the educational events which we accredit.

Ray Moynihan: So if there are companies advertising courses as independent, while at the same time allowing sponsors to suggest speakers, that’s a situation that you would take action over?

Peter Maguire: We take action wherever our criteria are not followed.

Ray Moynihan: Well that’s what I’m trying to get to: your criteria are that things are independent. I’m not sure whether you agree with the fact that suggesting speaker is independent or not independent, that’s what I’m trying to get to.

Peter Maguire: Sure, I understand. I mean it’s not really independent on face value, because often if the sponsor is a commercial entity and they want someone to speak, one assumes that they have a message that they want to come across, which clearly is not independent.

Ray Moynihan: College guidelines are supposed to ensure independence from sponsors, and indeed, the overwhelming impression of GPs attending Healthed seminars is that they are just that.

Dr Janice Kreltszheim.

Dr Dr Janice Kreltszheim: I attended this event because I felt that it was more independent than many others that are offered to us.

Ray Moynihan: Dr Maqsood Hassan.

Maqsood Hassan: I think it is mostly independent and that it’s not biased.

Ray Moynihan: Dr Camilla Andrews.

Camilla Andrews: I thought that the program was quite independent of the sponsors.

Ray Moynihan: If the GPs attending these courses think that they’re independent, how much should they be told of sponsors’ involvement?

The industry body, Medicines Australia’s Ian Chalmers.

Ian Chalmers: I think the most important issue about transparency here is that the attendees at a particular event have a reasonable expectation, indeed perhaps a right, to be aware of the nature of sponsorship that’s provided by a pharmaceutical company, and we would expect that would be good professional practice.

Ray Moynihan: So what you’re suggesting is that if sponsors do have input into speaker selection or topic determination, then that should be disclosed routinely at these educational events?

Ian Chalmers: I think that would be good professional practice.

Ray Moynihan: And if that’s not the case, would you as a representative of industry and the sponsors here, like to see that information disclosed?

Ian Chalmers: I think disclosure of sponsor influence is good professional practice.

Ray Moynihan: While flyers advertising these meetings prominently feature the logos of public hospitals and other institutions, they have no drug company logos and no mentions of sponsors names.

We asked Dr Manocha why this might be the case.

Ramesh Manocha: Because we felt that no specific reason, actually.

Ray Moynihan: Isn’t it in order to make it look as if it’s independent?

Ramesh Manocha: I don’t believe so, I think it is a small flyer, the flyers that we use are packed with information.

Ray Moynihan: The flyers are there to attract people to your seminars, and they all state that all content is independent, and yet there’s no mention of the sponsors, there’s no mention of the sponsors’ entitlement to suggest speakers. Is there a sense in which these are misleading?

Ramesh Manocha: I don’t believe so, because the flyer will attract the GP or the participant to attend the seminar, it’s very clearly indicated there that it’s very obvious that the seminar is sponsored,

Ray Moynihan: Once the GP arrives at the seminar it’s obvious.

Ramesh Manocha: Yes, correct.

Ray Moynihan: So the flyers are giving the look and feel of independence with no mention of sponsors.

Ramesh Manocha: Yes, if you – to us that didn’t represent a major issue, however we are more than happy to address that concern.

Ray Moynihan: While Dr Manocha may feel that omitting sponsors’ names from advertising material is not a major issue, it’s in fact a direct breach of the current college guidelines on medical education, says the College’s Dr Peter Maguire.

David Millikan: If we became aware of that, we would address it with the educational provider and point out to them that that is a breach of their contractual agreement with the College to be an accredited provider.

Ray Moynihan: Despite the College’s tough words, the fact remains that large amounts of GP education are sponsored directly by the world’s biggest pharmaceutical companies.

No-one is arguing that drug companies directly tell speakers what to say, the problem of influence on education is far more subtle, according to Dr Peter Mansfield from the advocacy group, Healthy Scepticism.

Peter Mansfield: Throughout medicine there’s many areas of uncertainty, a range of views, and if you’ve got a product in the market and you’re choosing the speaker, it’s very understandable that you will choose experts whose views are closest to yours on that spectrum.

Ray Moynihan: In recent years the world has witnessed major scandals over the side effects of anti-depressants, new arthritis drugs, and hormone replacement therapy, all aggressively marketed, including at seminars attended by your local GPs.

That’s the reason that many doctors around the world are worried about the impacts of sponsorship, including London GP Dr Iona Heath, who chairs the International Committee of the Royal College of General Practitioners.

Iona Heath: There will be times, and there have been times, when a heavily promoted drug has turned out not to be as safe as was previously thought, and the levels of consumption would not have been as great without this sort of sponsorship.

Dr Iona Heath argues it’s not just doctors who should be worried about sponsorship.

Iona Heath: Well I think that patients and citizens should care about where doctors are getting their education, because it’s very important that doctors think. And they need doctors who think independently; think about them as a particular patient in a particular situation, needing a particular solution. Not this label, this glossy brochure, this product because it’s got a nice photograph on the front, or because it paid for my education.

Ray Moynihan: The concerns are echoed across the Atlantic at Harvard University in Boston, by Professor David Blumenthal, an internationally recognised authority on the relationships between industry and the medical profession.

David Blumenthal: The question you always have to ask is why would a for-profit company in this country at least, the United States, pour more than a billion dollars a year into continuing medical education without the expectation of gaining anything from it?

Ray Moynihan: We put that question of what companies get in return for their investment to the industry representative, Ian Chalmers.

Ian Chalmers: Pharmaceutical companies see these events as being important in the establishment of long-term value-added relationships with clinicians that are active in the relevant therapeutic field. They also see the events as being an important opportunity to provide relevant, up-to-date information about therapeutic strategies and the use of medicines, the appropriate use of medicines in this particular area. And of course, in order to ensure that the research program can continue and that companies can remain viable, there is an entirely legitimate commercial imperative in the operation of a shareholder-owned company.

Ray Moynihan: Just how effective these sponsored seminars are at boosting prescriptions is uncertain, but it’s clear that many GPs believe they are not influenced.

Dr Maqsood Hassan.

Maqsood Hassan: I think sponsorship does not affect the GPs decision-making.

Ray Moynihan: Dr Camilla Andrews.

Camilla Andrews: We’re not computers where we just get programmed by something, and spit out what we’ve been programmed with, we are capable of independent thought.

Ray Moynihan: Harvard Professor David Blumenthal has spent a lot of time studying the relationships between doctors and drug companies.

David Blumenthal: Doctors tend to believe that they have almost superhuman powers of discrimination and almost superhuman levels of objectivity. The fact is that people are influenced by what they hear. And the companies know that, and continue to pay for these programs because they know it. In the United States when we survey physicians and ask them if they’re influenced by drug company programs or by the gifts that drug companies give, they always say exactly what your physicians say. Then we ask them if any of their colleagues are influenced, and they say, Oh yes, they may be. It is hurtful to the pride of the physician to even contemplate that they might be susceptible to a bias message. But they’re human and they are potentially influenced.

Ray Moynihan: The group, Healthy Scepticism has been campaigning against the influence of misleading marketing of medicines for a long time and its spokesperson is an Adelaide academic and GP, Dr Peter Mansfield.

Peter Mansfield: I think the situation that we are in now is similar to in the 1840s, doctors didn’t believe that we needed to wash our hands before we did surgery. We couldn’t believe that we could be infected by something invisible that could cause harm to our patient. Bias that comes from promotion is like a bacteria in that it is invisible, and at the moment, if you suggest to a doctor that they could have become biased, many of us will take that as a personal insult, in the same way that doctors in the 1840s felt insulted by the suggestion that they could be carrying infections.

Ray Moynihan: Where Peter Mansfield sees invisible influence, others see companies transparently promoting their pills, and argue that sponsorship doesn’t carry influence over educational content.

Dr Basil Donovan is Professor of Sexual Health at the University of New South Wales.

Basil Donovan: In general, and I can only speak from my perspective, but in general they’re just trying to promote a warm feeling between them and their potential market.

Ray Moynihan: Basil Donovan gives the example of a presentation he gave to hundreds of GPs at a Healthed seminar last year, where as a speaker, he made some disparaging remarks about the sponsor’s drug.

Basil Donovan: During my talk I just said that this is a very fine product, it seems to do what it sets out to do, but for the sake of your patients, just be mindful that it’s three times more expensive and somewhat slower than some of the traditional alternatives.

Ray Moynihan: And what happened after you gave that speech?

Basil Donovan: Well unknown to me, the company who had the product at the time, were in fact sponsoring the session, and afterwards one of them came up to me and asked if they had done something to offend me, which I thought was a bit curious and I said, ‘No, you’ve never done anything to offend me’, which is not entirely true, but nothing on that day. And it was amicable enough, and I just walked away.

Ray Moynihan: The fact that you had a very positive view of that product, would that have had anything to do with the selection of you as a speaker for that session?

Basil Donovan: No, no, I don’t think so.

Ray Moynihan: Do you think that it’s important that the GPs knew that that session was sponsored by the makers of Aldara?

Basil Donovan: I don’t think it’s all that pivotal.

Ray Moynihan: What if it was the case that the sponsor did actually suggest a list of speakers to the educational provider, is that sort of information that should have been disclosed?

Basil Donovan: Oh, I never really thought about that. It all gets a little bit precious, going to those sorts of lengths to disclose. I mean they know that there are corporate sponsors, they probably suspect that the sponsors might have had some sort of mild coercive pressure because they’re the source of the cash.

Ray Moynihan: While Basil Donovan and many of his colleagues are relaxed about that mild coercive pressure from industry, others see that this has no place in the education of our doctors.

Two years ago, David Blumenthal was part of a group that called for an end to direct sponsorship of doctors’ education at leading universities, and the creation of blind trusts, where sponsors collectively contribute to a large pool of funding, which is used for education by people totally unconnected to the sponsors.

Adelaide GP, Peter Mansfield has a similar idea.

Peter Mansfield: At the moment medical education is funded by governments paying very high prices for drugs and then the drug companies use some of that money to pay for education. I think that that is not a good way to use taxpayers’ money. It would be much better for taxpayers to pay for medical education more directly. I think that the best way is by competitive grant. Let those organisations who’ve got skills and experience at providing education, compete for grants to fund their activities.

Ray Moynihan: Today we’ve looked closely at the workings of one popular provider of education, and revealed details of its relationships with sponsors.

But as we’ve heard, the influence of sponsors is widespread at events that are supposed to be independent, raising questions about whether the College of GPs is enforcing its own guidelines that are supposed to ensure independent education for your doctor.

College Council member, Peter Maguire.

Peter Maguire: If there was a way that that were differently funded, there may be merit in that suggestion. I guess the risk is that – I think one of the fears of practitioners is that the sponsorship will be taken away and it will become a user-pays system, which I think would worry the profession.

Ray Moynihan: Some doctors may worry about having to pay more from their own pockets, but others worry about hidden sponsor influence, causing people like Professor Gary Eggar to add his voice to the calls for a clean-up.

Gary Eggar: The other way to do it may be to levy pharmaceutical manufacturers for a certain amount, based on their turnover for particular drugs, and the government take that money and put it all in a big pool and pay for medical education that way. But at this stage there’s no indication that government is interested in doing that sort of thing.

Ray Moynihan: Would you like to see something like that?

Gary Eggar: I think it would make it cleaner for all of us.

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Ray Moynihan: Background Briefing’s Co-ordinating Producer is Linda McGinness. Website by Anna Whitfeld. Research and production by Miranda Burne and Wendy Carlisle. The Technical Operator is Mark Don. The Executive Producer is Kirsten Garrett.

I’m Ray Moynihan.

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