Monday, July 19, 2010

Mark Crislip on drug reps and industry supported CME

Mark Crislip, writing for Science Based Medicine, declares his biases about pharmaceutical industry promotion right up front: he’s a crank. True to form, in the screed which follows he offers impassioned opinions based on popular belief but little in the way of evidence to support his self described absolutist position regarding drug companies and their interactions with physicians. So let’s parse his arguments and try and apply a sober assessment.

He opens (italics mine):

Drug companies are somewhat schizophrenic. They have amazing scientists who invent drugs that treat an astounding array of diseases. Then, they take these drugs and turn them over to marketing, to be sold with all the enthusiasm and truthiness of a late night infomercial.

Although drug company promotions are biased and unbalanced they are required by FDA regs to be factually correct. He goes on:

As an Infectious Diseases fellow I was the on call physician for the hospitals antibiotic stewardship program where expensive or problematic drugs had to be approved before they could be released from pharmacy. It was curious how there would be spikes in approval requests, often for drugs that the surgical resident couldn’t pronounce correctly. Ain’t no drug called ciprofloxacillin, although there should be. Investigation revealed that these spikes often occurred shortly after a service was treated to a good dinner by the drug rep. Hmm. Funny thing, that.

Although that story might shock the consumer public I know of no one close to this debate who would deny that industry promotions influence prescribing. The staunchest defenders of drug rep promotions would acknowledge that.

In the next paragraph of his rant things get a little tricky:

Over the years it has been rare to find a physician as extremist as I am. It is curious, since the literature supports the concept that interaction with pharmaceutical reps is detrimental to patient care: docs who interact with reps are more likely to prescribe expensive and/or inappropriate drugs after being detailed.

That deserves careful scrutiny. Let’s save the part about “detrimental to patient care” for later. But are docs who interact with reps more likely to prescribe expensive and/or inappropriate drugs after being detailed? Expensive, probably yes. Inappropriate? Some published literature suggests so, but that literature is imbalanced. As I said in our Medscape Roundtable piece on this subject a couple of years ago (italics added here):

Studies in support of this argument do not give a balanced view. Surveys of the effects of drug detailing on doctors' prescribing have focused selectively on areas of overuse, such as antibiotics in the ambulatory setting and new expensive drugs compared with equally effective generics. Although some promotions undermine evidence-based practice, others may enhance it. Because promotional literature is a mix of good and bad information, the net effect on patient care is not known. Many heavily promoted treatments are evidence-based and known to be underutilized by doctors. A good example is the inadequate use of low-molecular-weight heparin for thromboembolism prophylaxis.[11] The promotion of statin drugs[12-14] and angiotensin-converting enzyme inhibitors for appropriate patients[15-17] is another example. Such a promotion toward best practice has been ignored in published studies. Research in a broader range of clinical situations is needed before conclusions can be made about the overall effect on evidence-based practice.

Dr. Crislip goes on to cite the literature on this topic (my italics):

Most of the literature on the topic is collected at, which appears to be under construction. It all may be publication bias, but I know of no reference that demonstrates improved patient care as a result of physicians interacting with drug companies. (More on the italicized part below).

Nofreelunch, rather than being under construction, appears no longer to be maintained. Their original focus was fighting the promotional gifts from drug reps. They won their inquisition when the drug companies ceased dispensing the gifts a year or so ago. Mission accomplished. But I digress. They still have links posted to a large repository of the literature referred to by Dr. Crislip, especially this one which, until very recently, contained just about everything that had been published on the topic. I’ve gone over that literature with a fine toothed comb. I participated on the nofreelunch listserv for several years and I know the arguments based on that literature inside out. The short version of what that body of literature says is as follows:

Drug company promotional activities influence doctors’ attitudes and actual prescribing.

Docs underestimate the degree to which they as individuals are influenced.

Studies which focused selectively on areas of previously suspected overutilization show that promotional activities sway doctors away from best evidence.

None of these studies looked at how promotions influenced areas of known underutilization of evidence based therapies and until very recently (more on that in a minute) there had been no studies, not a shred of evidence, contrary to the popular belief Dr. Crislip and others like to appeal to, of how this influence on prescribing affected patient outcomes. After all, that’s what matters, right?

Well, something happened recently to change all that. Finally a study was done on the effects of a pharmaceutical industry promotion on patient outcomes. And it wasn’t just any promotion. It was arguably the most maligned pharmaceutical industry promotion in all of medicine----maligned as a gigantic marketing campaign disguised as evidence based medicine. I’m talking about the Surviving Sepsis Campaign. The study was presented at SCCM in 2009 and published in Critical Care Medicine about a year later. Following implementation of the promotion there was improved adherence to evidence based sepsis care and reduced sepsis mortality.

Dr. Crislip seems to favor a ban on industry funding of CME, which seems strange in light of this paragraph:

Of course, I don’t know how I manage to keep up in my field with no pharmaceutical support. I can’t read journals, can’t use websites like Medscape (I am a paid blogger for Medscape, so of course I suggest them), can’t go to conferences, can’t listen to podcasts, can’t attend meetings, can’t do the MKSAP. There is such a wealth of educational opportunities in medicine to keep up you have to be either lazy or stupid not to find them. It does takes discipline and time to keep up. I spend a minimum of 24 hours a month on CME.

What’s strange about that is that many of those conferences and meetings, as well as those Medscape offerings, are industry supported. Dr. Crislip is an ID guy. Does he go the IDSA national meeting? It’s awash in industry support.

It’s not hard to imagine the unintended consequences of an industry ban. Given such consequences, those who call for a ban have a burden of proof that industry supported CME is inferior or leads to patient harm. The ban proponents are unable to sustain that burden because they lack evidence. Dr. Crislip has an interesting anecdote about Neurontin, but it’s more about one on one promotion than CME. There are other disturbing anecdotes out there, but a collection of anecdotes does not equal evidence. Occasional egregious cases are dealt with individually. They don’t form the basis for rules. All CME is biased but the evidence suggests that, in the aggregate, industry supported CME is no more biased than non-supported CME. I recently reviewed that body of evidence here.

Toward the end Dr. Crislip throws in the well worn social justice argument:

In the end, our patients pay for it. The price of drugs, in part, takes into account the cost of advertisement. Maybe you feel it is fine for the underinsured to pay $1500 out of pocket for a 10-day course of linezolid, but I can’t justify my patients indirectly subsidizing my pizza and education.

There’s a huge flaw there. The drug companies are going to spend whatever they want on advertising regardless of whether they help support my CME. Ban the industry support for CME and the funds will be diverted to other avenues of promotion such as direct-to-consumer advertising.

Finally Dr. Crislip points out that we doctors should be responsible for our own continuing education. I agree. But we will be less in charge of our education if a ban is put in place because such a ban will restrict our choices.

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