No blind trust in guidelines

15. November 2010
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The more successful the physician and researcher the more wooing is done about him or her. They get support from the industry, but also from associations, publishers and other stakeholders. And at the same time they are the ones developing guidelines and expert assessments. Only those openly presenting their relations deserve our trust.

For those knowing the close intertwining between industry, lobbies and the stars of medicine the news report published a few weeks ago didn’t come as a surprise: Top-earners of US orthopedy are very reluctant when it comes to revealing conflicts of interests due to financial gratuities.

David Rothman at the New York Institute of Medicine compared the statements of large orthopedic companies regarding the recipients of sponsoring funds with those of authors in according professional magazines. Here, Rothman and his comrades-in-arms only took amounts larger than one million dollars into account. But only about half of the articles display clues in regard to according connections with the industry – although nearly all editorial offices by now demand exactly that from their authors when turning in their scripts. Only seven of the 95 examined articles included a note that the grants for the researchers were more than 10,000 Dollars.

Avarice and ambition collide with well-being of the patient

In his article, David Rothman talks about “sceptical questions, whether the unpublished grants … lead to prejudiced scientific conclusions”. This problem is not unknown in Germany as well. In spring 2010, a working group of the scientific medical associations (AWMF) published “Recommendations of the AWMF regarding the handling of conflicts of interests in associations“. Obviously even the guidelines of the AWMF are not totally immune against lobbyists. To the AWMF, conflicts of interests are here in accordance with the definition by Thompson and Emanuel created in the nineties “circumstances which create a risk to professional handling where secondary interests unduly influence a primary interest”. They cause that striving after reputation or wealth jeopardizes the well-being of the patient or the verifiable research result.

Everyone involved in developping treatment guidelines has to be independent. Thus the AWMF calls for disclosing the financing of the process and supports an “inhibition-gamut” regarding conflicts of interests for all involved. Conferences should be planned in accordance with their scientific objectives and not due to leisure interests of participants, which means for example: No exclusive sponsoring of the supporting program or super-expensive VIP gala dinners instead of a working lunch.

“Forgotten“ information in the annex

There are black sheep in Germany as well. If you read the “Deutsches Ärzteblatt” for example on a regular basis, you might find several weeks after the publication of a review article an amendment handing conflicts of interest in “later”. According connections – also of financial nature – you will find in reviews about the colorectale carcinoma, the safety of vaccines or about obesity.

Destroyed trust

If you as a physician accept support from interest groups, you will no longer act independently, even if you try. Patients look at it like that as well. The American consumer magazine “Consumer Report” reports about a patient survey regarding “target group physician” of pharmaceutical companies. The majority of the patients treated think that “sponsored” physicians prefer drugs – also those of inferior quality – of the generous companies.

But also physicians believe that for example intensive relations with a pharmaceutical sales representative are not without consequences. In a survey, 21 percent were convinced that company representatives influence their colleagues. But more than 90 percent consider themselves immune against any whisperers.

Strategic ghostwriting

And even the physician wanting to get information independently from visits of representatives in his office, hardly gets around subliminal marketing. Last summer the professional magazine PLoS Medicine published about 1500 documents showing how interest groups cooperate with “ghostwriters”. Time and again, highly reputed academics are ready to have their name put in the headline of an article in professional magazines which the PR department has already prepared confirming the superior features of a therapy. After all – that’s another contribution to the own publication list and thus to the market value. You don’t even have to mentioned the according product. Most of the time, it’s enough to paraphrase the treatment clearly or point out the weak spots of the competitor. Welcome are also comments and letters to the editor referring to the publication.

Voluntary self-control for the good reputation

Some time ago, David Klemperer, chairman of the network for evidence based medicine and active in the AWMF elaborated on the topic conflicts of interests in an article in the Deutsches Ärzteblatt. He made an overview list on his homepage for himself about the efforts and “services in return” for all his activities. A similar transparency and independence is the target of “MEZIS – Initiative unabhängiger Ärztinnen und Ärzte” (MEZIS – initiative of independent physicians), advertising their ideas with the catchy slogan “I pay for my food myself”.

And finally, the opposite side makes efforts with according initiatives to avoid its reputation tarnished even more. Already in 2004, 40 pharmaceutical companies merged to an association “voluntary self-control for the pharmaceutical industry”. There, the members commit themselves – among other things – to strict rules regarding financing of application observations, gifts or drug samples.

Until today, interest groups like for example drug manufacturers a large share of further education for physicians although those course units are supposed to be neutral. According to the “New England Journal of Medicine“, half of the medical researchers have relations with the industry; the truly successful even more than others. But without a close cooperation between associations, companies, self-help groups and physicians, the progress in research is rather slow. Thus the only way out is to reveal dependencies. A reminder: Whether secondary interests actually influence the judgment of the physician or researcher does not play any role. Just simply pointing out the danger evaporates suspicions.

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