Friday, March 14, 2008
The Invisible Hand in Medical Education
BY SUSAN GILBERT

The drumbeat to restrict those “unrestricted grants” by drug companies for continuing medical education is sounding louder now that the trickle of medical journal articles raising concern has become a steady stream. One recent article stands apart: it was an expose in the British Medical Journal’s February 23 issue on the back-door deals involved in selecting speakers for CME meetings.

With leaked emails and other documents, “The Invisible Influence” showed that a medical education company rewarded drug company sponsors with opportunities to suggest speakers favorable to their products. Some of the speakers were for an educational seminar promoted to general practitioners with a brochure promising, “all content is independent of industry influence.”

The leaked documents show just how hollow those words were. The bigger the sponsorship, the more influence the drug companies were given. An email sent to Schering-Plough by HealthEd, a large medical education company in Australia, said that “platinum” sponsors could “work with us to determine a speaker and a topic.”

In another email exchange, a drug company cut to the chase about selecting just the right speaker for a talk on headache. A representative of CSL, manufacturer of the painkiller tramadol (Tramal) in Australia, asked HealthEd to “determine the speaker’s opinion re: Tramal as I would like to ensure he positions it appropriately.”

The expose focused on Australia but offered evidence from drug company employees that similar practices occur in the United Kingdom. I know from personal experience that they occur in this country, too. I worked briefly as a writer for a medical education company in New York. Last year, the company organized several CME meetings on pain management geared to primary care physicians. The meetings looked legitimate: the CME provider was a major American medical school; the literature expressed thanks to several drug companies for unrestricted grants.

But pain management was not a subject chosen at random. Nor was it selected because of a humanitarian concern that pain is undertreated. It was selected to provide a platform for one of the sponsors, which was working to develop three “abuse-deterrent” forms of oxycodone, an opioid. A neurologist who helped plan the meetings and who spoke at them was also a part-time employee of the med ed company, information he took care not to reveal to fellow speakers or to the attendees.

I attended one of the pain meetings. Prior to the plenary talks there was a workshop in which primary care physicians could sit at small tables and have informal chats with experts in pain management. In fact, these experts were physicians hired by the med ed company who supported opioid-maker’s message: that primary care clinicians should not be afraid to prescribe opioids to more patients in their office practices.

My job was to sit at one of the tables and take notes on the conversation. When an attendee expressed concern about using opioids for anything but severe pain because of the risks of addiction and drug abuse, the doctor downplayed the risks, even to patients with a history of drug abuse, and emphasized that they could be effectively managed. No brand names were mentioned lest the program seem promotional. But the message was clear: Opioids are great painkillers, and safer than you think.

After the meeting, the med ed company staff got together to discuss what objections doctors in the workshop raised about opioids. This information would be used to create future medical education programs aimed at breaking down doctors’ resistance to the drugs.

Now that those unrestricted grants have been outed as anything but, something has to be done, fast, to stop drug companies from manipulating medical education. Otherwise, doctors will practice medicine based on distorted information, patients will suffer, and health care costs will continue to spiral out of control. Some appealing solutions are given in a commentary in the March 10 issue of the Journal of the American Medical Association. Ideally, the commentary said, commercial funding of medical education would be banned. But that’s probably unrealistic, given that most CME funding now comes from industry. Another option would be to channel industry dollars into a central pool of funds, which would be distributed to accredited educational programs.

Such approaches “would decrease CME funding – in which case physicians or their employers would pay more of the true costs,” notes the commentary. But that’s a fair price for restoring the integrity of medical education.

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