Many things undermine good prescribing. Of particular ethical concern is the role of thought leaders or key opinion leaders (KOLs). Whenever a doctor who has the potential to influence the practice of others engages with the pharmaceutical industry in any way, whether as an advisor, researcher or educator, a KOL is created. Whatever else happens in the relationship or as a result of the relationship the pharmaceutical company will be watching the KOLs impact on sales. It will nurture and invest in those who have or have the potential to have a positive impact.
There is a growing literature on the ways in which the pharmaceutical industry compromises medical science but KOLs have not attracted the same level of attention as ghost writing, selective publication, conflict of interest etc. However, four papers have appeared in June in the BMJ, Prescrire International, Australian & New Zealand Journal of Psychiatry, and the Medical Journal of Australia (by Ray Moynihan, perhaps the leading authority on this issue).
The term KOL is widely used within the pharmaceutical industry as demonstrated by a number of references in the above articles. It seems that industry sees itself as managing we doctors. Not managed in the way that a supervisor instructs a clerk in an office, but managed as an investor manages her portfolio, or perhaps as a spy is managed in a Le Carre novel, without knowing for sure who is in charge and who he is working for.
The sad conclusion is that, at least in Australia, almost every prominent psychiatrist is being managed in this way by the pharmaceutical industry. Most KOLs will have had interactions with the pharmaceutical industry that have furthered their career. Most receive at least some current funding from industry.
Of course the individuals involved would likely strongly deny they are being even influenced by industry, let alone managed. But industry documents provide a fairly compelling case that KOLs are closely monitored for return on investment.
I am not talking about fraud or corruption; the kind of KOLs I’m talking about are not lining their pockets or even deliberately distorting the data; they are however allowing themselves to be used as a marketing tool by industry.
Those who advocate for experts with affiliations with industry to be excluded from positions of authority (journal editors, protocol development etc.) are often told that there simply are not enough people with sufficient expertise who don’t have affiliations with industry. This cannot be used as an excuse for inaction; those who lead in medicine must be demonstrably independent, and those who are independent must be supported in leadership.
“perhaps as a spy is managed in a Le Carre novel” — yes, recruited, indoctrinated (or manipulated), and sent on missions.
I used to work for a biotech (no psychiatric drugs) and got to see how they trained sales reps to recruit KOLs. They targeted likely doctors and set out to seduce them just as deliberately as any spymaster looked to recruit agents.
It sure humbles the profession, to see intellectually arrogant physicians fall for flattery, favors, and barely disguised bribery, and so readily go off to do pharma’s bidding.
OK. So as you say: ” Those who advocate for experts with affiliations with industry to be excluded from positions of authority (journal editors, protocol development etc.) are often told that there simply are not enough people with sufficient expertise who don’t have affiliations with industry.”
No problem. The best tack would be to create positions from the non-expert, student category who would perform the role of researching *opposing viewpoints and criticisms of articles, protocols*. Creating a forum for productive dialogue and debate, in the tradition of academic medicine!
Returning to the days when students did the *fact checking* to enhance or even rebut the main points of an *expert* author or professor. Returning to the tradition of what academia stands for in the practice of medicine.
The problem is not so much that most experts are affiliated with PHARMA , the real problem is that the term, EXPERT now means: above reproach; above questioning! A standard of Virtue Ethics is in place, rather than ethical standards based on guidelines that ALL must adhere to.
BEST practices cannot be formulated from the pronouncements made by an expert on a podium , speaking as an untouchable! The homework must be done in advance—before the pronouncement is absorbed as FACT. The debates and rebuttals need to occur in REAL TIME–as in demonstrating a shared goal to arrive at the BEST evidence for practice.
AND in some cases, the expert should be made to stand down BEFORE he/she can use title and status to propagate fraudulent information.
So many drug reps are nurses looking for higher pay and a chance to tell doctors what to do for a change. I was offered a job as a drug rep by one of the big boys in Australia, but I couldn’t bear the idea of “selling” a drug just because I was paid to rather than by researching it and perhaps discovering it DID work. How do doctors get talked into becoming “attached” to particular drugs if they have no evidence that they really work? I guess some might be tempted by the thought of direct research/trial funding, but surely most would see that as bias? It’s very discouraging to see people like Pat McGorry being funded by drug companies then being chosen to represent the rest of his profession on supposedly objective government committees.
1boringoldman.com has returned from vacation with an excellent article on KOLs and pharma money http://www.guardian.co.uk/science/2011/jun/13/research-brain-disorders-under-threat?INTCMP=SRCH
As usual, 1boringoldman names names of the most nefarious — Nemeroff, Biederman, Rush, Keller, Schatzberg — plus Thomas Insel of the NIMH.
This would all be very concerning if a real medical profession was being corrupted by drug company influence.
Thankfully, he’s only talking about the quackery known as ‘psychiatry’, and when a corrupt, worthless and debased fake medical specialty gets ‘corrupted’ it is just corruption to the power of ten.
What remains to be explained is what ‘key opinion leader’ takes promising young medical students who COULD become brain surgeons, and instead convinces them to specialize as brain poisoners and life destroyers, in ‘psychiatry’.
It is pieces like these, which seem to say oh if only the pharma KOLs could be knocked out psychiatry would be a real science, that are ridiculous.
“This would all be very concerning if a real medical profession was being corrupted by drug company influence.”
I hate to be the one to break it to you, Anonymous, but this is actually a pervasive crisis for —even the *real medical profession* .And much to your dismay, I’m sure, it is a psychiatrist who has brought the whole bloody mess to public attention.
I dare you to read Pharmageddon. My personal motivation for urging you to get a big picture view of the medical profession is that I see great potential for you to make a valuable contribution–based on your proven abilities to articulate exactly what people need to hear!