International interest in the interaction between physicians and industry has been mounting since the Physician Payment Sunshine Act (PPSA) was passed in the United States in 2012. The first data made available as a consequence of this act were published last week by the Centers for Medicare and Medicaid Services (CMS). The BMJ published their own rapid analysis of this information, which covers all payments made by US drug and device makers to US doctors in the last five months of 2013.
The headline message from this data dump was that $3.5 billion worth of payments were made to physicians and teaching hospitals by US drug and device makers in this period. Interestingly, the website names physicians individually, so we know that Dr John Le Donne received $78 200 in payments for food and beverage and Mr Stephen Buckhart received $7.4 million in non-research payments in this five month period. I wonder how their patients have interpreted this information. Only time and possibly their future position in the same league table will tell.
The only headline on the issue of doctor-industry relations from a UK perspective is that we are currently lagging far behind this level of regulation and transparency in our own system.
Earlier this month, The BMJ and the Royal College of Physicians (RCP) held a joint meeting at BMA House to address this issue. Healthcare professionals and patient representatives were invited from a variety of organisations to discuss the interaction between physicians and industry, with a view to establishing some broad principles for future guidance and even regulation in the UK.
The first question attendees were asked was, “How well does the current relationship and system work?” The resounding answer was “what system?” There was overriding agreement that the current state of affairs relies on self regulation and “ad hockery.”
The only other matter on which there was absolute consensus was the need for transparency, transparency, transparency, transparency in all interactions—echoed in the feedback from each of the four workshops on the day.
Other areas were more controversial. As a junior doctor, it is often difficult to see how one might be influenced by industry—other than perhaps by accepting a cheese sandwich from a drug rep. However, education and training were hotly debated topics: how often are we informed of the amount that sponsors contribute to the conferences and training courses we attend? What proportion of training is industry provided in each medical specialty? Without this information, can we know to what extent we are truly conflicted?
Opinion was split. Some attendees argued that there should be absolutely no formal role for industry in training NHS doctors, while others highlighted the innovative and cost effective education opportunities it introduces, particularly in surgical training. Indeed, as trainees in a system with increasing private provider involvement and (arguably) diminishing training opportunities in certain specialties, can we afford to be fussy about who we accept our education from? I believe that we can and should be. But, at the very least, we should aim to know who we are accepting it from and how much they are investing in us.
While there was resolute agreement on the need for regulation and transparency, there were few suggestions as to who might be responsible for implementing this or how they could go about it. The General Medical Council pointed to their updated 2013 guidance on financial and commercial arrangements and conflicts of interest. Some there questioned how (or if) the GMC was enforcing these guidelines, and whether declarations of interests should be placed more formally on the GMC register or elsewhere.
It was noted that the website www.whopaysthisdoctor.org already allows doctors to declare their interests, but sadly few in the room admitted to using it. Perhaps here is a good starting point for interested parties—both doctors and patients. Unfortunately, with such voluntary tools, those with the most to declare are presumably the least likely to engage.
What other voices are important in this debate? Patient involvement was seen to be key: how will the public interpret this information? Do they care? Will it undermine trust? We were grateful to have one patient representative in the room, but one is not enough if we want to capture a 360 degree patient view. Given recent reports, it was noted that charities and patient groups should be encouraged to be open about their own competing interests.
As a female doctor, does my voice add a different perspective to the debate? More than 90% of payments in the US were made to male doctors, while 32% of active physicians in the US were female, according to 2013 figures from the Association of American Medical Colleges. Is this another example of the glass ceiling in senior research and clinical positions? Or does it point to certain individual factors that lead to increased self regulation among physicians?
One might anticipate resistance from the pharmaceutical industry. In fact, they are leading the way in the UK, with the Association of the British Pharmaceutical Industry independently planning to commence reporting of all payments by their members to physicians in April 2016. When will the medical devices industry follow?
One speaker from the US shared an anecdote from his state of Massachusetts, where a 2008 law was introduced banning industry provided meals for physicians and healthcare professionals. The surprise opponent to this law was the local restaurant industry who, fearing the impact it would have on their business, successfully lobbied to have the law repealed. The new law was dubbed the Restaurant Rejuvenation Act, and is a lesson in how hostility often comes from unexpected sources.
Perhaps the draft guiding principles from The BMJ-RCP meeting should be pre-emptively labelled the Patient Protection Principles in recognition of the true issue at the heart of this debate.
Kate Adlington is a clinical fellow at The BMJ. Follow Kate on Twitter @kateadlington
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.