Healthy Skepticism Library item: 15518

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: Journal Article

Shipp DH, Mallarkey G.
Liaison between public hospital staff and the pharmaceutical industry: guidance from the NSW Therapeutic Advisory Group
MJA 2009 Feb 19; 190:(8):406-407
http://www.mja.com.au/public/issues/190_08_200409/shi11384_fm.html

Full text:

In Australia, provision of specialised product information and promotion by the pharmaceutical industry of drugs approved by the Therapeutic Goods Administration is an integral part of the health care environment. The pharmaceutical industry provides information and training to health professionals about new products; funding for conferences; support for professional and social activities secondary to medical education; support for the conduct of research and information about its outcomes; and opportunities to meet with peers. However, the primary goals of the pharmaceutical industry and health professionals differ: the pharmaceutical industry has a financial responsibility to shareholders, while health professionals have a moral responsibility to their patients. The challenge for both is to manage their responsibilities when interacting with one another.

The pharmaceutical industry’s code of conduct1 upholds the principles of Australia’s Quality Use of Medicines program and National Medicines Policy. However, an interaction between pharmaceutical representatives and hospital employees will ultimately have a promotional intent. In itself, an indirect promotional activity is not a problem. However, the interaction will often influence prescribing.2 Many health professionals deny that such activity influences their behaviour, although, paradoxically, they believe their peers may be more easily swayed.3 Appropriate provision of patient care requires health professionals to understand these influences and keep them in mind in order to maintain independence of judgement.

Ethics relating to promotional activities of pharmaceutical companies and managing conflicts of interest have been recently reviewed.4-10 Some researchers have argued that contact with the pharmaceutical industry should be more restricted and certain activities prohibited. In the United States, steps have been taken to prohibit all gifts (including meals) and to institute central management of product samples.8 A US report commented that “bias, either by appearance or reality, has been woven into the very fabric of continuing education” and called for cessation of commercial support from pharmaceutical and medical device companies.11

In Australia, while the move to state and federal funding and other non-commercial sources for educational and drug information activities is currently being debated, it is unrealistic to prohibit contact between health professionals and the pharmaceutical industry. It may be argued that industry plays an important role in health education – indeed, constructive engagement between industry and health professionals may be in the interests of patients. Severing all contact between industry and health care providers could limit open dialogue, hamper innovation and create a huge gap in educational support for health professionals. Initiatives to bridge the gap have been suggested.4-6 In the meantime, hospital staff must analyse the nature of their current interactions with the pharmaceutical industry and aim to improve it to optimise benefit to the patient.

Codes of practice have been developed by professional bodies, societies, hospitals, government and the pharmaceutical industry in an attempt to ensure that interactions between hospital-based health professionals and the pharmaceutical industry are ethical and in the interests of the patient. However, a more practical framework is required to evaluate these interactions and to work towards achieving the highest standards of patient care and quality use of medicines.

At the request of its members, the New South Wales Therapeutic Advisory Group (NSW TAG) recently updated its existing position statement on liaison between hospital staff in NSW and the pharmaceutical industry. The position statement provides evidence-based guidelines to help hospital staff recognise the activities that enhance clinical practice and those that potentially damage the relationship between health professionals and patients.12 It suggests steps to minimise potential conflicts of interest and ways to support ethical interaction, including making full use of independent sources of evidence-based medicine. It proposes that all health professionals adopt the approach of the Royal Australasian College of Physicians with regard to identifying and managing dualities and conflicts of interest.13 A duality of interest (where two or more interests coexist) is not unethical, but the key issue is to recognise when one interest is compromising the other (ie, when a conflict of interest is present). It is not enough to voluntarily disclose a duality of interest and then feel justified in proceeding regardless.

Members of NSW TAG have discussed establishing a system of review and authorisation, deciding whether steps are necessary to separate or prohibit the conflicting activities and how open communication contributes to the transparency of the process. Our intention has been to ensure that the primary objective of professional interactions with pharmaceutical companies is to advance the health and wellbeing of patients. A recent article called for a set of guidelines for academic medical centres and opinion leaders.4 Extension of practical guidelines to all health professionals is a necessary next step.

The pharmaceutical industry has established a system of self-regulation.1 In authorising the Medicines Australia code of conduct, currently under review, the Australian Competition and Consumer Commission requires details to be published of educational events provided or sponsored by member companies. All events have been reviewed by an independent auditor, and the first of these 6-monthly reports is now available.14 The audit had limitations with regard to investigation of high-cost activities and verification of data supplied. Nevertheless, such measures from industry to increase transparency support the intentions of NSW TAG’s position statement.12

The issues discussed in the position statement extend well beyond the pharmaceutical industry. They also include providers of medical devices, chemicals in pathology laboratories, and machines and consumables in radiology departments.

Understanding the differences between the role of the health professional and that of the pharmaceutical industry is fundamental to understanding how to handle the interaction between the two groups. This process is evolving and the NSW TAG position statement is considered a “work in progress” to provide guidance within existing codes. The pharmaceutical industry and health professionals need to continue to foster a process of introspective challenge and regulation. Ongoing discussion by all stakeholders to find solutions that benefit patients is paramount.