Sunday, September 25, 2005
Should we throw the bums (drug reps) out?
The medical blogging about the dispute between No Free Lunch and the American Academy of Family Physicians has been mostly favorable to No Free Lunch. I am glad to see that AAFP has finally decided to allow No Free Lunch (NFL) to exhibit and I hope ACP follows suit next year. I believe in a free market place of ideas, and theirs deserve to see the light of day.
I said before that while I agree with the basic premise of NFL (“that pharmaceutical promotion should not guide clinical practice”) I am concerned that some of their positions are extreme, or are taken to extremes by their supporters. My intention here is to state my specific areas of concern and issue a call for moderation. (Disclaimer: try as I will to avoid the straw man argument, I could be perceived as misstating the NFL position. NFL has eloquently stated its principles, but with the possible exception of the pledge these principles have not been codified in any formal way. As I express my concerns I realize that the opinions of NFL supporters occupy a spectrum. If this shoe doesn’t fit don’t wear it).
One of my differences with NFL lies in the distinction between skepticism and cynicism. At a recent CME conference at McGill Dr. Jerome Hoffman, professor of emergency medicine at UCLA and a supporter of NFL, pointed out the difference between these two approaches to evaluating claims and evidence. The cynic, he said, seeks to knock everything down; the skeptic, by contrast, thinks critically and questions claims, but all the while with an open mind. Webster defines the cynic as “contemptuously distrustful of human nature and motives” (italics mine). My perspective about the pharmaceutical industry is skeptical, while I view the attitude of many NFL supporters as cynical.
The cynic’s position might be that the drug companies care only about their stock holders, never have the public good in mind and that their interests are always in conflict with those of patients. The cynic might feel that the medical profession should have no interaction with the industry and never believe anything they say.
As a skeptic I believe that while there are conflicts of interest, in perception and in fact, the interests of the drug companies are sometimes but not always in conflict with good patient care. (Good patient outcomes can help increase profits). Unlike the cynic I believe win-win situations are possible. My skepticism says not to believe everything they claim and to always check primary sources. However, out of hand rejection of every claim based solely on source (the ad hominem fallacy) is unreasonable.
What about the practical consequences of the NFL objections? Are we ready to give up industry supported CME? I enjoy attending CME meetings. Although I can do without the pharmaceutical company exhibits, were it not for partial industry support the registration fees would be prohibitively expensive for many meetings. Not all physicians are wealthy. Those who attend AAFP and ACP meetings are among the least likely to be wealthy. I dare say many would not be able to attend at all without industry support.
There are other examples. Many of us enjoy (and often link to) emedicine and Medscape. I don’t want those free resources to go away. What about all the open access medical journals which would not survive without pharmaceutical advertising?
So to those who want to “throw the bums out” I urge caution. This highly nuanced issue does not lend itself to simplistic ideas.