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Point and Counterpoint |

COUNTERPOINT: Should Academic Physicians Lecture as Members of Industry Speaker Bureaus? NoPhysicians on Speaker Bureaus? No FREE TO VIEW

Ian Nathanson, MD, FCCP
Author and Funding Information

From Humana.

CORRESPONDENCE TO: Ian Nathanson, MD, FCCP, Humana, 838 Lake Catherine Court, Maitland, FL 32751; e-mail: inathanson@cfl.rr.com


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(2):252-254. doi:10.1378/chest.14-0687
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Few would argue that developing a novel drug or device that improves the health of humans carries a high price tag and requires a company’s research and development teams to work with skilled clinical investigators. The stakes become even higher once the product becomes available to the public as attention focuses on efficacy, effectiveness, and appropriate use of the product in the clinical setting. Students, trainees, and experienced clinicians trying to understand indications for the new drug or device often seek clarification from academic medical centers (AMCs). After all, who better to help us sort out complicated data than those dedicating their professional lives to education?

The Hippocratic Oath, for centuries a moral beacon for physicians, emphasizes the importance of sharing knowledge with others. Teaching patients, students, and colleagues serves as an essential part in the practice of good medicine, and, in fact, the discipline of medicine will not advance unless we pass on to others critical scientific and clinical observations. If educating others is so important, how is it, then, that we engage in debates about the merits of academic physicians participating in speakers’ bureaus? I confess that I firmly believe that interaction between physicians and industry has led to so many important advances in health care that such interactions must continue. Nevertheless, while I embrace academic-industry relationships I fear that even the most ethical physicians can become too chummy with industry, making them vulnerable to compromising their objectivity. To guard against this, we encourage transparency by declaring possible conflicts of interest (COIs) by physicians who receive funding from industry for research, serve on advisory boards, and give lectures at national meetings. However, we must ask ourselves if there is an academic-industry interaction that puts our trustworthiness in jeopardy. I contend that participation in a speakers’ bureau and relying on material prepared by the marketing division of a company does just that.

In 2000, Boyd and Bero1 reported that 34% of faculty researchers at the University of California San Francisco disclosed paid speaking engagements. The range in fees was $250 to $20,000/y although >90% reported earning <$10,000/y. Also noted was a substantial increase in research faculty disclosing financial ties to industry between 1980 and 1999.1 More recently, it was reported that 94% of physicians had a relationship with industry including funding for research, consultation, advisory boards, and speakers’ bureaus.2 Although the largest proportion was related to gifts and drug sampling, 16% reported receiving payment as a speaker or from being on a speakers’ bureau. Campbell et al3 surveyed 140 academic institutions including allopathic medical schools and the largest independent teaching hospitals in the United States and found that 21% of clinical department chairs were members of speakers’ bureaus. In response to increasing concerns about COIs, in 2009 the Institute of Medicine issued a comprehensive report entitled Conflict of Interest in Medical Research, Education, and Practice. Among the recommendations was prohibiting faculty participation in speakers’ bureaus.4 A number of professional societies followed suit although the constraints on participating in speakers’ bureaus varied.5 In general, medical schools seem to have tightened up policies related to COIs from 2008 to 2011 although the overall strength of policies related to speakers’ bureaus remains between permissive and stringent.6 To be a panel member of a clinical practice guideline for the American College of Chest Physicians (CHEST), one must agree to refrain from being a member of a speakers’ bureau.

The scholarly and financial relationships between AMCs and industry (drug, device, or biotechnology companies) are complex, and even strong advocates of the academic-industrial relationship acknowledge that these relationships require oversight.7 Although both AMCs and industry focus on improving health and health-care delivery, significant differences exist in their respective missions. The principal role of AMCs is to engage in scholarly pursuits by furthering our understanding of health and disease through research, clinical care, and training. In contrast, the principal role of industry is to develop new products that will generate profits and sales.8 In business, the marketing division bears responsibility for creating a message that will improve name recognition and increase sales. Because marketing divisions manage speakers’ bureaus, one can assume that a major, measurable goal of speakers’ bureaus is to increase sales of a product. Over the past few years, AMCs have limited physician access to industry gifts, samples, and detail representatives. This, coupled with Sunshine laws reporting industry payments to physicians, is forcing marketing divisions to find alternative means to advertise their products. Speakers’ bureaus use speakers reputed to be highly respected in their field or local opinion leaders who may change their own prescribing habits. Although speakers do not necessarily follow a script, they do address specific topics relevant to a specific product using teaching materials supplied by industry and approved as marketing materials by the US Food and Drug Administration (FDA). Although the FDA prohibits industry detail representatives from discussing off-label use of a product, physicians are free to do so, and, thereby, contribute to promotion of sales. A qui tam lawsuit in 2010 alleged that Novartis hired most physician speakers related to prescription writing not expertise. Novartis settled the suit for $422.5 million in civil and criminal fines but admitted no wrongdoing.9

I believe that the principal reason that academic physicians should not serve on speakers’ bureaus is an erosion of trust. In 2008, the Pew Charitable Trust polled 1,009 adults across the United States and found that 80% believe speaking fees should not be allowed. Also, 71% would support legislation that enables clinical experts to provide unbiased noncommercial information about drugs to physicians in their offices.10 Yet, it is not only the public’s perception that physicians might be influenced by enticements from industry. Over 2 decades ago, Orlowski and Wateska11 reported that prescribing patterns changed after physicians attended all-expenses-paid symposia sponsored by drug companies. Even more telling was the perception by the majority of these physicians that enticements would not alter their prescribing patterns. Others reached similar conclusions.12,13 After screening 538 publications, Wazana13 used 29 papers to assess the impact of the physician-industry relationship on physician knowledge and behavior, concluding that drug-sponsored continuing medical education preferentially highlighted that company’s product which resulted in greater sales. Dana and Loewenstein14 provided evidence that self-interest distorts how individuals weigh arguments. Students are also concerned. A single-center study reported that of the 81 residents (69.2%) and 196 faculty (75.7%) who responded to an anonymous survey, > 60% in each group felt that annual industry income <$10,000 could influence teaching by an attending physician.15 Another single-institution study reported that even after COI disclosures 72% of first-year and second-year medical students felt that medical school educators who had financial relationships with industry were more likely to recommend those companies’ products during a learning session.16 The American Medical Student Association evaluates COI policies at all 158 allopathic and osteopathic medical schools in the United States. A model policy prevents participating in speakers’ bureaus. The number of schools complying with this policy in 2013 is 44 compared with four in 2008.17

Some argue that speakers’ bureaus systems are peer selling18 whereas proponents of speakers’ bureaus claim that ethical physicians avoid such traps. Every physician I know who is a member of a speakers’ bureau is ethical and would cringe at the thought of being viewed as a salesperson. However, this debate is not about ethics; it is about trust. In my opinion, the evidence shows that physicians participating in speakers’ bureaus unwittingly imperil their credibility for their most important audiences. The growing number of AMCs restricting the participation of the faculty in speakers’ bureaus dictates that we find better ways than speakers’ bureaus to engage good teachers and recapture some of our lost credibility. Just imagine how refreshing it would be for our patients, students, and colleagues to truly believe a teacher who says, “Trust me…I’m a doctor.”

References

Boyd EA, Bero LA. Assessing faculty financial relationships with industry: a case study. JAMA. 2000;284(17):2209-2214. [CrossRef] [PubMed]
 
Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician-industry relationships. N Engl J Med. 2007;356(17):1742-1750. [CrossRef] [PubMed]
 
Campbell EG, Weissman JS, Ehringhaus S, et al. Institutional academic industry relationships. JAMA. 2007;298(15):1779-1786. [CrossRef] [PubMed]
 
Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: National Academies Press; 2009. http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx. Accessed April 10, 2014.
 
Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73. [CrossRef] [PubMed]
 
Chimonas S, Evarts SD, Littlehale SK, Rothman DJ. Managing conflicts of interest in clinical care: the “race to the middle” at US medical schools. Acad Med. 2013;88(10):1464-1470. [CrossRef] [PubMed]
 
Stossel TP. Regulating academic-industrial research relationships—solving problems or stifling progress? N Engl J Med. 2005;353(10):1060-1065. [CrossRef] [PubMed]
 
Lo B. Serving two masters—conflicts of interest in academic medicine. N Engl J Med. 2010;362(8):669-671. [CrossRef] [PubMed]
 
Boumil MM, Cutrell ES, Lowney KE, Berman HA. Pharmaceutical speakers’ bureaus, academic freedom, and the management of promotional speaking at academic medical centers. J Law Med Ethics. 2012;40(2):311-325. [PubMed]
 
Pew Prescription Project. Consumer survey. Disclosure of industry payments to physicians. The Pew Charitable Trusts website. http://www.pewhealth.org/reports-analysis/issue-briefs/consumer-survey-disclosure-of-industry-payments-to-physicians-85899367979. Accessed April 10, 2014.
 
Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns. There’s no such thing as a free lunch. Chest. 1992;102(1):270-273. [CrossRef] [PubMed]
 
Robertson C, Rose S, Kesselheim AS. Effect of financial relationships on the behaviors of health care professionals: a review of the evidence. J Law Med Ethics. 2012;40(3):452-466. [PubMed]
 
Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283(3):373-380. [CrossRef] [PubMed]
 
Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290(2):252-255. [CrossRef] [PubMed]
 
Watson PY, Khandelwal AK, Musial JL, Buckley JD. Resident and faculty perceptions of conflict of interest in medical education. J Gen Intern Med. 2005;20(4):357-359. [CrossRef] [PubMed]
 
Kim A, Mumm LA, Korenstein D. Routine conflict of interest disclosure by preclinical lecturers and medical students’ attitudes toward the pharmaceutical and device industries. JAMA. 2012;308(21):2187-2189. [CrossRef] [PubMed]
 
American Medical Student Association. AMSA PharmFree Scorecard 2013. Conflict of interest policies at academic medical centers. American Medical Student Association website. http://www.amsascorecard.org. Accessed April 10, 2014.
 
Reid L, Herder M. The speakers’ bureau system: a form of peer selling. Open Med. 2013;7(2):e31-e39. [PubMed]
 

Figures

Tables

References

Boyd EA, Bero LA. Assessing faculty financial relationships with industry: a case study. JAMA. 2000;284(17):2209-2214. [CrossRef] [PubMed]
 
Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician-industry relationships. N Engl J Med. 2007;356(17):1742-1750. [CrossRef] [PubMed]
 
Campbell EG, Weissman JS, Ehringhaus S, et al. Institutional academic industry relationships. JAMA. 2007;298(15):1779-1786. [CrossRef] [PubMed]
 
Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: National Academies Press; 2009. http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx. Accessed April 10, 2014.
 
Dubovsky SL, Kaye DL, Pristach CA, DelRegno P, Pessar L, Stiles K. Can academic departments maintain industry relationships while promoting physician professionalism? Acad Med. 2010;85(1):68-73. [CrossRef] [PubMed]
 
Chimonas S, Evarts SD, Littlehale SK, Rothman DJ. Managing conflicts of interest in clinical care: the “race to the middle” at US medical schools. Acad Med. 2013;88(10):1464-1470. [CrossRef] [PubMed]
 
Stossel TP. Regulating academic-industrial research relationships—solving problems or stifling progress? N Engl J Med. 2005;353(10):1060-1065. [CrossRef] [PubMed]
 
Lo B. Serving two masters—conflicts of interest in academic medicine. N Engl J Med. 2010;362(8):669-671. [CrossRef] [PubMed]
 
Boumil MM, Cutrell ES, Lowney KE, Berman HA. Pharmaceutical speakers’ bureaus, academic freedom, and the management of promotional speaking at academic medical centers. J Law Med Ethics. 2012;40(2):311-325. [PubMed]
 
Pew Prescription Project. Consumer survey. Disclosure of industry payments to physicians. The Pew Charitable Trusts website. http://www.pewhealth.org/reports-analysis/issue-briefs/consumer-survey-disclosure-of-industry-payments-to-physicians-85899367979. Accessed April 10, 2014.
 
Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns. There’s no such thing as a free lunch. Chest. 1992;102(1):270-273. [CrossRef] [PubMed]
 
Robertson C, Rose S, Kesselheim AS. Effect of financial relationships on the behaviors of health care professionals: a review of the evidence. J Law Med Ethics. 2012;40(3):452-466. [PubMed]
 
Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283(3):373-380. [CrossRef] [PubMed]
 
Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290(2):252-255. [CrossRef] [PubMed]
 
Watson PY, Khandelwal AK, Musial JL, Buckley JD. Resident and faculty perceptions of conflict of interest in medical education. J Gen Intern Med. 2005;20(4):357-359. [CrossRef] [PubMed]
 
Kim A, Mumm LA, Korenstein D. Routine conflict of interest disclosure by preclinical lecturers and medical students’ attitudes toward the pharmaceutical and device industries. JAMA. 2012;308(21):2187-2189. [CrossRef] [PubMed]
 
American Medical Student Association. AMSA PharmFree Scorecard 2013. Conflict of interest policies at academic medical centers. American Medical Student Association website. http://www.amsascorecard.org. Accessed April 10, 2014.
 
Reid L, Herder M. The speakers’ bureau system: a form of peer selling. Open Med. 2013;7(2):e31-e39. [PubMed]
 
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