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.