Saturday, May 7, 2011

Undue Influence: Corporate Sponsorship of Professional Society Meetings

There was a great report in one of the most influential medical periodicals today.  Not NEJM, or JAMA, or Annals of Internal Medicine.  I'm talking about the USA Today.  The story concerned corporate sponsorship of medical societies.  The reporting, by ProPublica in conjunction with USA Today editors, is terrific.

The primary expose is of the Heart Rhythm Society, a group that has gone from 38% corporate sponsorship to 50% between 2006 and 2010, totaling $4 million last year.  During this same time we've seen an explosion in the insertion of implantable cardiac defibrillators (ICDs), primarily in older adults.   An ICD can cost more than $30,000.  World sales of ICD's totaled $6.7 billion last year.  12 of the 18 board members of the Heart Rhythm Society are paid speakers or consultants for ICD manufacturers.

At the annual meeting of the Heart Rhythm Society, going on right now in San Francisco, Medtronic has a 12,000 square foot booth, and Boston Scientific has a 8,100 square foot booth.  These ICD makers paid $1.6 and $1.5 million respectively to advertise at the 2010 annual meeting.

I don't usually read USA today.  But I read it today because I'm not in San Francisco, where I live, I'm in Phoenix, at the annual meeting of a professional society of physicians that has taken a decidedly different approach to corporate sponsorship: the Society of General Internal Medicine (SGIM).  The USA today was outside my hotel room door.  SGIM, I am proud to say, does not accept corporate sponsorship.

The American Geriatric Society (AGS) and the American Academy of Hospice and Palliative Medicine (AAHPM)/Hospice and Palliative Nurses Association (HPNA) do accept corporate funding for their annual meetings.  At one recent AGS meeting, you had to walk through giant annoying sponsor booths in order to reach the poster session.  The meeting costs are about the same at SGIM, AGS, and AAHPM, about $500-600 for a 3 day meeting.

Why might corporate sponsorship of clinicians and medical societies be problematic?

  • Steinman and colleauges surveyed medical residents, finding that a majority of them didn't believe corporate sponsorship of lunches and pens contributed to their prescribing practices.  These same residents overwhelming believed that practicing physicians are influenced by corporate sponsorship.  In other words, "sure it has an effect, but not on me!"
  • Chuck Grassley, the top Republican on the senate judiciary committee, says he doesn't believe doctors are unaffected, "There are a lot of incestuous relationships that really bother me."  Senator Grassley is pushing for mandatory disclosure of corporate sponsorship of professional societies.  
  • Cardiologists movements were monitored at a recent annual meeting using radio frequency tags ID tags in their conference badges.  This information is sold to industry sponsors who exhibit at the conference, presumably in aggregate, detailing what sort of person visited your booth, for how long, etc.
  • Corporate influence on the development of Guideline recommendations for hemoglobin targets in dialysis patients (sponsored by the makers of Epo) and hemoglobin A1c targets (sponsored by the makers of Lantus) was described in this GeriPal post.
  • Pfizer, the drug company that makes the epilepsy drug Neurontin (gapabentin), had to pay $142 million in racketeering charges for marketing this drug to physicians for off-label prescriptions, including pain.  See Steinman's careful analysis of internal company documents here.
Do you think it's time that the major geriatrics and palliative care organizations joined with their general internist colleagues and rejected corporate sponsorship?

by: Alex Smith

12 comments:

Anonymous said...

Yes!! Overdue. And maybe it will help stop the wanton prescribing of useless, expensive drugs falsely promoted to alter the course of dementia.

ken covinsky said...

The Heart Rhythm Society really seems to have lost its moral compass. A society accepting such a huge portion of its budget from industry can not possibly be seen as a acting primarily in the interests of the patients it is supposed to serve. No guideline with their stamp can really be seen as having any credibility.

I am proud that SGIM has taken a strong stand that meetings should be supported by attendees and members and not with industry handouts.

David Tribble said...

The common denominator is all this, unfortunately, is the practicing physician, who is apparently considered to be a weak-willed sheep among the corporate wolves. It is a sad commentary on American Medical Education that the product of our medical schools is seen as so lacking in any form of discernment.

I have some difficulty, as well, with the "guilt by association" mentality. Before we castigate such organizations as the Heart Rhythm Society, I would propose that we look at their output, see how defensible it is in terms of available data, who was involved in the development of its recommendations. Were the recommendations regarding Hgb targets in dialysis patients or HgbA1c levels in diabetics supported by available data?

I would think that it would take a great deal of suspension of disbelief to accept comments about "incestuous relationships" from a senator, given the magnitude of the lobbying effort in the United States. When all lobbyists are excluded from Washington, DC, I will be much more willing to take such commentary from our politicians.

As a hospice and palliative care physician, I note that we have been using not only gabapentin, but almost every other anticonvulstant in the treatment of neuropathic pain for decades. I have trouble seeing that as racketeering.

In short, we have only ourselves to blame if meds are prescribed inappropriately, devices are used too frequently. We all know how to look at data, do discern good research from bad. Shame on us if we have to make a rule because we are too weak or too lazy to be critical on a daily basis.

Porter Storey said...

What this blog post misses is that professional societies like AAHPM do have missions that require resources to be accomplished.
Effective staff and elected leadership must carefully decide where they can utilize revenues from Pharma without compromising their integrity or do much less toward their mission with only dues and product sales for revenue.

Would it best serve hospice and palliative medicine physicians and their patients to have no voice in Washington, double our dues so few could join, or to accept unrestricted grants to pay lobbyists for our priorities?

An organization that uses only dues revenues will not accomplish much for it's members! The balance is to remain transparent about which activities are supported and to carefully channel Pharma grants into specific activities where they will not have undue influence.

David Tribble said...

Well said, Porter!

Dan Matlock said...

So the end justifies the means...?

Steve Smith, CEO, AAHPM said...

Alex and others have surfaced a number of very important questions about medical organization stewardship. If we want to maintain trust, credibility, and integrity with members and the public, we must be diligent when it comes to corporate support and industry relations.

The American Academy of Hospice and Palliative Medicine (AAHPM) has been a leader among medical associations in working ethically and transparently with industry. More than a decade ago in 2000, AAHPM was one of the first medical societies to develop and implement ethical guidelines for working with industry. These guidelines have been regularly reviewed and revised by the Board (in 2003, 2008 and 2010) and focus on identification, disclosure and management of conflict of interests for leadership and faculty.

AAHPM was proud and pleased to be accepted into membership of the Council of Medical Specialty Societies (CMSS) in 2009 and voluntarily signed onto the Code for Interactions with Companies referenced in the USA Today article and discussed in this GeriPal post. In fact, Norman Kahn MD, executive vice President of CMSS, presented to the AAHPM Board on this topic in October 2010, as part of the Board's ongoing education regarding compliance with voluntary standards. The Academy continues to meet and exceed requirements associated with ACCME accreditation -- another key measure and benchmark for providers of medical education within the U.S.

In addition to disclosure, transparency is also important. AAHPM currently identifies all corporate support on signage, printed materials and its web site which is open to not only members, but the public, media and government. All related policies are posted, as are conflict of interest disclosures for faculty and elected volunteer leaders. Currently, less than 5 percent of the Academy’s entire annual revenue is derived from commercial support; less than 10 percent when advertising (mostly job-related) and exhibits (which include a small number of pharmaceutical companies) are added.

During these times of increased scrutiny and sensitivity, it is important to ensure that patient care and communication between physicians and key partners is not adversely affected. Technical exhibitions, advertising, job boards and appropriate interaction with those who work in the corporate sector – including for-profit hospices, contracted pharmacies, and others – can provide useful opportunities for information exchange and education about what hospice and palliative physicians, nurses and other members of the IDT do and what products/services others provide that could be helpful.

The debate will continue and AAHPM leadership will remain actively engaged. We appreciate this open forum to discuss these important issues and to clarify our current practices.

Anonymous said...

So can I use a drug company pen, or even better go on an all expensed drug company vacation, as long as I'm transparent that I accept drug company funds? Maybe post something on the wall of my office in small print saying that I've received funds from big pharma.

If not, why is it ok for the medical associations to do this? Is it because I, as a lowly provider, would be easily influenced, but the ones running these institutions wouldn't. It is time that we all wake up. Drug companies wouldn't be giving anyone money if they didnt think it bought influence. And yes, anyone does include the likes of AGS and AAHPM. The big question is whether the harms of accepting this money is greater than any benefits.

So the next time a drug company offers me a pen, I'll just say yes, and that I'm following the lead of my disciplines national leaders.

Christian Sinclair, MD said...

(Disclaimer: While I am a AAHPM board member, I am not officially speaking for the AAHPM here]

In residency I chose halfway through my internship year to now take any drug lunches, pens, books, etc. I was chastised (gently) by some of my peers for 'making them feel guilty.' I noted it was my choice and was not intended to be a judgement on their actions. So I get the industry influence issue very well.

Many associations and doctors have been tarnished by industry affiliations in the past leading to an era where transparency is being emphasized. Personally, I feel transparency is the first step towards being completely independent.

For large organizations I think a relationship with industry is important and it needs to be held accountable and hopefully not founded on financial exchange.

I do not believe the end justifies the means, but declaring guilt by association is not a high moral ground either.

ken covinsky said...

This is a very informative discussion. I find it very helpful to hear the different points of view.

I think those of us who feel professional societies should not take money from industry sometimes do a bad job of presenting our positions---often doing so in a way that will inevitably make our colleagues defensive. For example:

1) We may be too quick to imply that people and organizations should not accept industry resources because "bad" people or organizations might be influenced.
The problem with accepting gifts is that GOOD people are influenced by gifts.

It is a natural human tendency to want to reciprocate when someone has been nice to you. And it is natural to avoid criticizing those who have been kind to you.

Many doctors and medical organizations insist they can not be influenced gifts. But the psychological influence of gifts is often subconscious. Your behavior will change even if you do not realize it.

The evidence that these gifts have large influences is absolutely OVERWHELMING. The evidence is so profound that I tend to be more worried about persons and organizations who claim immunity to this universal human trait. People and organizations that acknowledge that they (yes you and not just others) are capable of being influenced are at least in a position to take steps to minimize that influence.

2) We too often pose pharma and industry as the "bad guys."

Yes, there are quite a few examples of very bad industry behavior over the past decade. But, it is wrong to make overly sweeping generalizations. It is especially wrong when we personalize to all who work in pharma. I know a number of really wonderful people who work for pharma who I think of as models of ethics and decency.

However, the issue as to whether one's industry contact is decent or not is immaterial to the question of whether medical society/industry collaborations are appropriate.

Medical societies foremost mission should be to serve their patients. Pharma has a mission to sell their product. (and Milton Friedman would note, they have an ethical responsibility to their shareholders to make money).

When professional societies issue guidelines, the public should be able to believe that the guidelines are based on nothing other than the best interests of patients.

And when societies educate their members, patients should be able to trust that the all aspects of the educational program are grounded in their best interests.

When professional societies accept $$ from industry in order to gain influence, it undermines this trust. This is the case even if one views the company or its representative as a good or bad corporate citizen.

sei said...

I received my AGS conference badge today and was upset to find an RFID transmitter affixed to the back.

Rehashing some of the discussion here, I immediately thought that AGS was going to sell data on which exhibits I spent my time at the conference. However, looking at the brochure they disclose:

At this year’s Annual Meeting, AGS will be using RFID technology
for session tracking. Simply hold your name badge in front of the
CE station in the rear of each session and collect your printed
receipt. You will be sent an email the week following the meeting, with a link to the online session evaluation and CE Certificate service.

I will be contacting AGS member services as well to see if they are using RFID data for any other purposes.

Helen Chen said...

This does explain why I am holding my nonwoven almost disposable AGS bag and the guy across the aisle from me on the flight to DC from SFO was stowing two lovely ballistic nylon laptop bags embroidered with 'Heart Rhythm Society 2011" in the overhead bin. I agree with Ken. Marketing people are not inherently evil; they are specialists in knowing what works to sell product. Despite our protests to the contrary, industry money affects physician behavior. We may choose to accept that risk or not, but our societies need to be honest about this.