Pearls and Irritations

A new study of powerful medical leaders in the US finds around three-quarters have financial relationships with drug companies – with some doctors accepting millions. The study could not have been done in Australia, where many doctor-drug company payments remain in the dark. 

Our study on drug company payments to the medical leaders of ten influential United States doctors’ groups was published last week in the BMJ, and it brings some good news and some bad news.

The bad news is that many powerful doctors in important positions of leadership are still horribly conflicted, accepting large and regular payments from drug and device companies for research, consultancies, royalties and hospitality.  A group of just 330 leaders across ten major medical societies accepted US$130 million over about a five-year period.

The good news is that for some of these groups, the payments to leaders were negligible, suggesting there is indeed a movement towards much greater independence from Big Pharma.

The global influence of these medical societies, like the American College of Cardiology, ACC, for example, reaches far beyond the US. Importantly, they can play a major role in setting the boundaries of disease and diagnostic thresholds which define who’s sick and who’s healthy. The ACC for example dramatically lowered the threshold defining hypertension a few years ago, reclassifying 30 million Americans as having high blood pressure, overnight.

Our research team used the US government’s amazing Open Payments database. This was created by a bi-partisan Sunshine Act, and it publishes details of almost all payments to doctors from drug and device companies. These payments, also called transfers of value, can range from a $10 meal to a $10,000 consultancy to a $10 million research grant.

The great scandal in Australia is that we still have nothing like this level of transparency. Instead we have a self-regulatory system that limps along and still leaves many payments in the dark. For example, a “reform” in Australia in 2017  saw all of the drug company funding for medical education events – over 25,000 a year, including at lavish restaurants and resorts – removed from public scrutiny.

In the US – due to the Sunshine Act and the Open Payments database– all of that flow of distorting influence is documented and publicly accessible, down to a $10 slice of pizza. And for good reason. Recent evidence shows that accepting just one sponsored meal is associated with a doctor prescribing more of that sponsor’s drugs.

In the latest study published last week, we investigated flows of industry payments to recent leaders of 10 influential professional medical associations, such as the American Society for Clinical Oncology and the American Psychiatric Association.  We looked at the amount they received in their year as a board member, the 4 years before and the year after.

While overall there was a staggering US$130 million of payments to a group of just 330 medical leaders, there was enormous variation between the different medical societies. Over five years or so, the leaders of the American College of Physicians each received a median of just $400, in total. The figure for the psychiatrists’ association board was only $200 each.

This was particularly surprising for psychiatrists.  As readers may remember, it was the obscene levels of entanglement between some psychiatrists  and drug companies revealed in US congressional hearings over ten years ago which helped produce the bi-partisan Sunshine Act, to help shine a light on the mess of undue industry influence in medicine.

But while the psychiatrist leaders only accepted $200 – the cancer specialist leaders had median payments of over $500,000. And total payments to the board members of the American Society of Clinical Oncology – mainly for company-sponsored research – were $54 million. Another finding was that the drug giant Astra Zeneca funded almost $17 million for the leaders of the heart specialists’ college over the time period that our study looked at.

Of course, there are differing views on the appropriateness of influential medical leaders having such extensive ties to industry. A common argument is that the best and brightest doctors will have these ties because they’re the ones drug companies seek to work with. Another related argument is that a doctor’s decision about which drug to prescribe, or their conclusions about a study they have run, are unaffected by the company sponsoring their education or research.

While we can respect those views, they fly in the face of a mountain of evidence that these financial conflicts of interest can and do distort medical research, education and practice. This is not just an academic concern. This influence contributes to a medical culture that overstates treatment benefits, downplays harms and labels far too many healthy people as sick.

The role of these medical leaders is so vital in setting the tone of medical culture, they should be entirely free of financial ties to industry. And the time is long overdue to start taking pathways to more independence from commercial interests in healthcare, which is the focus of a current BMJ themed collection and a call to action which you can sign.

There is often a sense that all the pharma junkets and speaker’s fees and wining and dining of doctors has stopped, and it’s all been cleaned up. Nothing could be further from the truth – many of those in senior leadership positions are still far too cosy with drug and device makers. And the COVID pandemic will not change these long-established marketing strategies. Pfizer for example, with a twist of the oxymoronic, is currently offering millions of dollars to fund “independent medical education” about managing COVID-19.

The other motivation for moving to genuine independence between doctors and industry is the urgent need to tackle the urgent problem of too much medicine – overtesting, overtreatment and overdiagnosis – which causes untold harm to people and wastes billions worldwide.

When the horror of this pandemic has passed, the problem of medical excess will remain a key challenge for health systems everywhere, including in Australia. Tackling that excess will require medical leaders who are independent from the companies who profit from it.

Full transparency is of course only the first step towards such independence from industry influence, but it’s an important one. And Australia is yet to even take it.

Dr Ray Moynihan is an Assistant Professor at Bond University’s Institute for Evidence-Based Healthcare, an honorary Associate Professor at the University of Sydney, and author of four books on the business of medicine.  This article was informed by an opinion piece published in BMJ.

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