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As outlined by Wyber and colleagues in this issue of the NZMJ,1, New Zealand doctors have a complex, at times ambivalent, relationship with drug companies. On the one hand, we benefit from a remarkable range of products essential to modern healthcare; thanks to the purchasing power and negotiation skills of PHARMAC these are available at relatively low cost in comparison to other developed countries.Apart from bringing drugs to market, other activities of the industry benefit us and public health less clearly. These other activities deserve scrutiny, and range from the overtly promotional (product detailing, provision of samples) through sponsored education (journal clubs, grand rounds, CME) to other, more ‘collegial' activities (clinical and research support, literature searches) with no obvious link to product sales.Over the past 20 years, both industry strategies and doctors' debates about engagement have evolved. A changed ‘playing field' has resulted in part from revelations that various companies have manipulated research outcomes, ghost-written journal articles, and influenced treatment guidelines with the (sometimes unwitting) collusion of doctors, including eminent academics.2,3 At the same time, evidence has accumulated that exposure to promotional information from pharmaceutical companies is associated with both increased cost and poorer quality of prescribing.4Advances in the social sciences have helped to explain how even subtle, apparently non-promotional contacts still effectively influence medical behaviour,5 due in part to doctors' rather optimistic views of themselves as rational prescribers, invulnerable to advertising and other persuasion.6,7 These same attitudes may also underlie resistance to current proposals to exclude drug reps from hospital and other clinical settings; nonetheless, a number of teaching hospitals and professional colleges, particularly in the USA, have now taken bold steps to do just that, strengthened by a comprehensive report from the Institute of Medicine.8Just as water flows downhill, commercial pressure inevitably finds the path of least resistance; the pharmaceutical industry is of course no exception. Facing intense competition and challenged by restrictions to their access to hospital doctors, companies now also woo nurses, who influence prescribing and other purchasing in various ways.9 Similarly, companies are keen to foster contacts with medical students; as shown in a large American survey, students are commonly exposed to sponsored lunches and ‘education'.10Like their seniors, students generally feel entitled to "freebies" (food and small gifts), and see themselves as unlikely to be influenced by biased information. Moreover, a recent systematic review found that undergraduate contact appears to promote positive attitudes toward industry and to diminish scepticism about such interactions.11In this context, the current issue's Perspective by Wyber and colleagues is timely, as NZ medical schools and teaching hospitals need to effectively address the issues raised by student-industry interaction.. University and district health board conflict of interest policies are germane but non-specific, while compliance with Otago's concise 2010 guideline (http://micn.otago.ac.nz/wp-content/uploads/micn/2008/03/Guidelines-Industry-Support-for-Ed-Activities-2010.pdf) is uncertain and likely to vary across its many teaching sites. In accord with an Australian survey,12 Wyber et al are right to stress our students' need for more teaching in clinical pharmacology and specifically about drug promotion.13In view of dubious benefits and clear evidence of harm, it is time to address doctors' and medical students' exposure to pharmaceutical marketing in the workplace. Codes of conduct, including declarations of conflicts and limits on gift value, are problematic and liable to abuse; a simple prohibition of sponsored education within clinical teaching areas would be easier to implement, monitor, and enforce. Put simply, the industry cannot (and should not) be relied upon to provide education for doctors and nurses. This will, of course, leave gaps in many CME programmes and other teaching sessions across NZ that have come to rely on industry largesse.A gradual phase out of commercially sponsored education is both desirable and attainable; we are fortunate in this country to have generous CME allowances for hospital doctors, a fraction of which could be diverted to support quality in-house CME and visiting speakers. Likewise, our own specialist expertise, assisted by drug information pharmacists, could be used to assess and disseminate information about new products, indications, and warnings. As the Perspective by Wyber et al shows, it is vital that senior doctors provide good role models for our students and junior colleagues. Local experience shows that phasing out industry presence and ‘free' food at educational meetings can gain broad support without compromising attendance.14The evidence indicates that pharmaceutical promotion poses avoidable risks to evidence-based practice4,15 and that commercially sponsored education needs to be phased out and replaced with viable alternatives, as above. The question then arises: are there other relationships with industry that should be retained or encouraged? Research collaboration, if appropriately managed and subject to stringent ethical standards, may fall into this category.Clinical trials conducted in NZ have the potential to inform and develop practice in our unique setting, and with a push from government are set to expand over the next decade.16 Despite calls to disentangle research from industry,17 many drug trials will doubtless continue to be commercially funded, and it remains important to clarify how to protect results from bias and to ensure useful outcomes for NZ public health.Active involvement of our own clinicians and academics in the conception, design, execution, and analysis of trials should be encouraged, with due attention to the distortions that may beset commercially sponsored work.3,18 For doctors involved in such research, disclosure of competing interests remains a vital, if imperfect, tool to promote transparency and minimise bias.19

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

David B Menkes, Associate Professor of Psychiatry, Waikato Clinical School, University of Auckland

Acknowledgements

Correspondence

Assoc Prof David B Menkes, Waikato Clinical School, PO Box 3200, Hamilton, New Zealand.

Correspondence Email

david.menkes@waikatodhb.health.nz

Competing Interests

The author is a member of Healthy Skepticism (www.healthyskepticism.org).

Wyber R, Fancourt N, Stone B. Relationships between medical students and drug companies in New Zealand. N Z Med J. 2011;124(1341). http://www.nzma.org.nz/journal/124-1341/4842Lacasse JR, Leo J. Ghostwriting at elite academic medical centers in the United States. PLoS Med. 2010;7(2):e1000230.Menkes DB. Calling the piper's tune. Prim Care Community Psychiatry. 2006;11:147-9.Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS Med. 2010;7(10):e1000352.Chaiken S, Trope Y. Dual-process theories in social psychology. New York: Guilford Press; 1999.Mansfield P. Accepting what we can learn from advertising's mirror of desire. BMJ. 2004;329(7480):1487-8.Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol. 2002;83:526-41.Lo B, Field MJ. Conflict of Interest in Medical Research, Education, and Practice. Consensus Report. Washington: Institute of Medicine; 2009 21 April.Jutel A, Menkes DB. Soft targets: nurses and the pharmaceutical industry. PLoS Med. 2008;5(2):e5.Sierles FS, Brodkey AC, Cleary LM, et al. Medical students' exposure to and attitudes about drug company interactions: a national survey. JAMA. 2005;294(9):1034-42.Austad KE, Avorn J, Kesselheim AS. Medical students' exposure to and attitudes about the pharmaceutical industry: a systematic review. PLoS Med. 2011;8(5):e1001037.Carmody D, Mansfield PR. What do medical students think about pharmaceutical promotion? Aust Med Student J. 2010;1:54-7.Mansfield PR, Lexchin J, Wen LS, et al. Educating health professionals about drug and device promotion: advocates' recommendations. PLoS Med. 2006;3(11):e451.Menkes DB, Maharajh M. Just saying \"no\" to pharmaceutical sponsorship. N Z Med J. 2007;120(1251).http://www.nzma.org.nz/journal/120-1251/2471/Duggal R, Menkes DB. Evidence-based medicine in practice. Int J Clin Pract. 2011;65:639-44.Inquiry into improving New Zealand's environment to support innovation through clinical trials. Wellington: New Zealand Parliament, Health Committee; 8 June 2011. http://www.parliament.nz/en-NZ/PB/SC/Documents/Reports/e/8/2/49DBSCH_SCR5154_1-Inquiry-into-improving-New-Zealand-s-environment.htmGodlee F. Can we tame the monster? BMJ. 2006;333(7558). http://www.bmj.com/content/333/7558/0.7.fullLexchin J, Light DW. Commercial influence and the content of medical journals. BMJ. 2006;332(7555):1444-7.Cain DM, Detsky AS. Everyone's a little bit biased (even physicians). JAMA. 2008;299:2893-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

As outlined by Wyber and colleagues in this issue of the NZMJ,1, New Zealand doctors have a complex, at times ambivalent, relationship with drug companies. On the one hand, we benefit from a remarkable range of products essential to modern healthcare; thanks to the purchasing power and negotiation skills of PHARMAC these are available at relatively low cost in comparison to other developed countries.Apart from bringing drugs to market, other activities of the industry benefit us and public health less clearly. These other activities deserve scrutiny, and range from the overtly promotional (product detailing, provision of samples) through sponsored education (journal clubs, grand rounds, CME) to other, more ‘collegial' activities (clinical and research support, literature searches) with no obvious link to product sales.Over the past 20 years, both industry strategies and doctors' debates about engagement have evolved. A changed ‘playing field' has resulted in part from revelations that various companies have manipulated research outcomes, ghost-written journal articles, and influenced treatment guidelines with the (sometimes unwitting) collusion of doctors, including eminent academics.2,3 At the same time, evidence has accumulated that exposure to promotional information from pharmaceutical companies is associated with both increased cost and poorer quality of prescribing.4Advances in the social sciences have helped to explain how even subtle, apparently non-promotional contacts still effectively influence medical behaviour,5 due in part to doctors' rather optimistic views of themselves as rational prescribers, invulnerable to advertising and other persuasion.6,7 These same attitudes may also underlie resistance to current proposals to exclude drug reps from hospital and other clinical settings; nonetheless, a number of teaching hospitals and professional colleges, particularly in the USA, have now taken bold steps to do just that, strengthened by a comprehensive report from the Institute of Medicine.8Just as water flows downhill, commercial pressure inevitably finds the path of least resistance; the pharmaceutical industry is of course no exception. Facing intense competition and challenged by restrictions to their access to hospital doctors, companies now also woo nurses, who influence prescribing and other purchasing in various ways.9 Similarly, companies are keen to foster contacts with medical students; as shown in a large American survey, students are commonly exposed to sponsored lunches and ‘education'.10Like their seniors, students generally feel entitled to "freebies" (food and small gifts), and see themselves as unlikely to be influenced by biased information. Moreover, a recent systematic review found that undergraduate contact appears to promote positive attitudes toward industry and to diminish scepticism about such interactions.11In this context, the current issue's Perspective by Wyber and colleagues is timely, as NZ medical schools and teaching hospitals need to effectively address the issues raised by student-industry interaction.. University and district health board conflict of interest policies are germane but non-specific, while compliance with Otago's concise 2010 guideline (http://micn.otago.ac.nz/wp-content/uploads/micn/2008/03/Guidelines-Industry-Support-for-Ed-Activities-2010.pdf) is uncertain and likely to vary across its many teaching sites. In accord with an Australian survey,12 Wyber et al are right to stress our students' need for more teaching in clinical pharmacology and specifically about drug promotion.13In view of dubious benefits and clear evidence of harm, it is time to address doctors' and medical students' exposure to pharmaceutical marketing in the workplace. Codes of conduct, including declarations of conflicts and limits on gift value, are problematic and liable to abuse; a simple prohibition of sponsored education within clinical teaching areas would be easier to implement, monitor, and enforce. Put simply, the industry cannot (and should not) be relied upon to provide education for doctors and nurses. This will, of course, leave gaps in many CME programmes and other teaching sessions across NZ that have come to rely on industry largesse.A gradual phase out of commercially sponsored education is both desirable and attainable; we are fortunate in this country to have generous CME allowances for hospital doctors, a fraction of which could be diverted to support quality in-house CME and visiting speakers. Likewise, our own specialist expertise, assisted by drug information pharmacists, could be used to assess and disseminate information about new products, indications, and warnings. As the Perspective by Wyber et al shows, it is vital that senior doctors provide good role models for our students and junior colleagues. Local experience shows that phasing out industry presence and ‘free' food at educational meetings can gain broad support without compromising attendance.14The evidence indicates that pharmaceutical promotion poses avoidable risks to evidence-based practice4,15 and that commercially sponsored education needs to be phased out and replaced with viable alternatives, as above. The question then arises: are there other relationships with industry that should be retained or encouraged? Research collaboration, if appropriately managed and subject to stringent ethical standards, may fall into this category.Clinical trials conducted in NZ have the potential to inform and develop practice in our unique setting, and with a push from government are set to expand over the next decade.16 Despite calls to disentangle research from industry,17 many drug trials will doubtless continue to be commercially funded, and it remains important to clarify how to protect results from bias and to ensure useful outcomes for NZ public health.Active involvement of our own clinicians and academics in the conception, design, execution, and analysis of trials should be encouraged, with due attention to the distortions that may beset commercially sponsored work.3,18 For doctors involved in such research, disclosure of competing interests remains a vital, if imperfect, tool to promote transparency and minimise bias.19

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

David B Menkes, Associate Professor of Psychiatry, Waikato Clinical School, University of Auckland

Acknowledgements

Correspondence

Assoc Prof David B Menkes, Waikato Clinical School, PO Box 3200, Hamilton, New Zealand.

Correspondence Email

david.menkes@waikatodhb.health.nz

Competing Interests

The author is a member of Healthy Skepticism (www.healthyskepticism.org).

Wyber R, Fancourt N, Stone B. Relationships between medical students and drug companies in New Zealand. N Z Med J. 2011;124(1341). http://www.nzma.org.nz/journal/124-1341/4842Lacasse JR, Leo J. Ghostwriting at elite academic medical centers in the United States. PLoS Med. 2010;7(2):e1000230.Menkes DB. Calling the piper's tune. Prim Care Community Psychiatry. 2006;11:147-9.Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS Med. 2010;7(10):e1000352.Chaiken S, Trope Y. Dual-process theories in social psychology. New York: Guilford Press; 1999.Mansfield P. Accepting what we can learn from advertising's mirror of desire. BMJ. 2004;329(7480):1487-8.Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol. 2002;83:526-41.Lo B, Field MJ. Conflict of Interest in Medical Research, Education, and Practice. Consensus Report. Washington: Institute of Medicine; 2009 21 April.Jutel A, Menkes DB. Soft targets: nurses and the pharmaceutical industry. PLoS Med. 2008;5(2):e5.Sierles FS, Brodkey AC, Cleary LM, et al. Medical students' exposure to and attitudes about drug company interactions: a national survey. JAMA. 2005;294(9):1034-42.Austad KE, Avorn J, Kesselheim AS. Medical students' exposure to and attitudes about the pharmaceutical industry: a systematic review. PLoS Med. 2011;8(5):e1001037.Carmody D, Mansfield PR. What do medical students think about pharmaceutical promotion? Aust Med Student J. 2010;1:54-7.Mansfield PR, Lexchin J, Wen LS, et al. Educating health professionals about drug and device promotion: advocates' recommendations. PLoS Med. 2006;3(11):e451.Menkes DB, Maharajh M. Just saying \"no\" to pharmaceutical sponsorship. N Z Med J. 2007;120(1251).http://www.nzma.org.nz/journal/120-1251/2471/Duggal R, Menkes DB. Evidence-based medicine in practice. Int J Clin Pract. 2011;65:639-44.Inquiry into improving New Zealand's environment to support innovation through clinical trials. Wellington: New Zealand Parliament, Health Committee; 8 June 2011. http://www.parliament.nz/en-NZ/PB/SC/Documents/Reports/e/8/2/49DBSCH_SCR5154_1-Inquiry-into-improving-New-Zealand-s-environment.htmGodlee F. Can we tame the monster? BMJ. 2006;333(7558). http://www.bmj.com/content/333/7558/0.7.fullLexchin J, Light DW. Commercial influence and the content of medical journals. BMJ. 2006;332(7555):1444-7.Cain DM, Detsky AS. Everyone's a little bit biased (even physicians). JAMA. 2008;299:2893-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

As outlined by Wyber and colleagues in this issue of the NZMJ,1, New Zealand doctors have a complex, at times ambivalent, relationship with drug companies. On the one hand, we benefit from a remarkable range of products essential to modern healthcare; thanks to the purchasing power and negotiation skills of PHARMAC these are available at relatively low cost in comparison to other developed countries.Apart from bringing drugs to market, other activities of the industry benefit us and public health less clearly. These other activities deserve scrutiny, and range from the overtly promotional (product detailing, provision of samples) through sponsored education (journal clubs, grand rounds, CME) to other, more ‘collegial' activities (clinical and research support, literature searches) with no obvious link to product sales.Over the past 20 years, both industry strategies and doctors' debates about engagement have evolved. A changed ‘playing field' has resulted in part from revelations that various companies have manipulated research outcomes, ghost-written journal articles, and influenced treatment guidelines with the (sometimes unwitting) collusion of doctors, including eminent academics.2,3 At the same time, evidence has accumulated that exposure to promotional information from pharmaceutical companies is associated with both increased cost and poorer quality of prescribing.4Advances in the social sciences have helped to explain how even subtle, apparently non-promotional contacts still effectively influence medical behaviour,5 due in part to doctors' rather optimistic views of themselves as rational prescribers, invulnerable to advertising and other persuasion.6,7 These same attitudes may also underlie resistance to current proposals to exclude drug reps from hospital and other clinical settings; nonetheless, a number of teaching hospitals and professional colleges, particularly in the USA, have now taken bold steps to do just that, strengthened by a comprehensive report from the Institute of Medicine.8Just as water flows downhill, commercial pressure inevitably finds the path of least resistance; the pharmaceutical industry is of course no exception. Facing intense competition and challenged by restrictions to their access to hospital doctors, companies now also woo nurses, who influence prescribing and other purchasing in various ways.9 Similarly, companies are keen to foster contacts with medical students; as shown in a large American survey, students are commonly exposed to sponsored lunches and ‘education'.10Like their seniors, students generally feel entitled to "freebies" (food and small gifts), and see themselves as unlikely to be influenced by biased information. Moreover, a recent systematic review found that undergraduate contact appears to promote positive attitudes toward industry and to diminish scepticism about such interactions.11In this context, the current issue's Perspective by Wyber and colleagues is timely, as NZ medical schools and teaching hospitals need to effectively address the issues raised by student-industry interaction.. University and district health board conflict of interest policies are germane but non-specific, while compliance with Otago's concise 2010 guideline (http://micn.otago.ac.nz/wp-content/uploads/micn/2008/03/Guidelines-Industry-Support-for-Ed-Activities-2010.pdf) is uncertain and likely to vary across its many teaching sites. In accord with an Australian survey,12 Wyber et al are right to stress our students' need for more teaching in clinical pharmacology and specifically about drug promotion.13In view of dubious benefits and clear evidence of harm, it is time to address doctors' and medical students' exposure to pharmaceutical marketing in the workplace. Codes of conduct, including declarations of conflicts and limits on gift value, are problematic and liable to abuse; a simple prohibition of sponsored education within clinical teaching areas would be easier to implement, monitor, and enforce. Put simply, the industry cannot (and should not) be relied upon to provide education for doctors and nurses. This will, of course, leave gaps in many CME programmes and other teaching sessions across NZ that have come to rely on industry largesse.A gradual phase out of commercially sponsored education is both desirable and attainable; we are fortunate in this country to have generous CME allowances for hospital doctors, a fraction of which could be diverted to support quality in-house CME and visiting speakers. Likewise, our own specialist expertise, assisted by drug information pharmacists, could be used to assess and disseminate information about new products, indications, and warnings. As the Perspective by Wyber et al shows, it is vital that senior doctors provide good role models for our students and junior colleagues. Local experience shows that phasing out industry presence and ‘free' food at educational meetings can gain broad support without compromising attendance.14The evidence indicates that pharmaceutical promotion poses avoidable risks to evidence-based practice4,15 and that commercially sponsored education needs to be phased out and replaced with viable alternatives, as above. The question then arises: are there other relationships with industry that should be retained or encouraged? Research collaboration, if appropriately managed and subject to stringent ethical standards, may fall into this category.Clinical trials conducted in NZ have the potential to inform and develop practice in our unique setting, and with a push from government are set to expand over the next decade.16 Despite calls to disentangle research from industry,17 many drug trials will doubtless continue to be commercially funded, and it remains important to clarify how to protect results from bias and to ensure useful outcomes for NZ public health.Active involvement of our own clinicians and academics in the conception, design, execution, and analysis of trials should be encouraged, with due attention to the distortions that may beset commercially sponsored work.3,18 For doctors involved in such research, disclosure of competing interests remains a vital, if imperfect, tool to promote transparency and minimise bias.19

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

David B Menkes, Associate Professor of Psychiatry, Waikato Clinical School, University of Auckland

Acknowledgements

Correspondence

Assoc Prof David B Menkes, Waikato Clinical School, PO Box 3200, Hamilton, New Zealand.

Correspondence Email

david.menkes@waikatodhb.health.nz

Competing Interests

The author is a member of Healthy Skepticism (www.healthyskepticism.org).

Wyber R, Fancourt N, Stone B. Relationships between medical students and drug companies in New Zealand. N Z Med J. 2011;124(1341). http://www.nzma.org.nz/journal/124-1341/4842Lacasse JR, Leo J. Ghostwriting at elite academic medical centers in the United States. PLoS Med. 2010;7(2):e1000230.Menkes DB. Calling the piper's tune. Prim Care Community Psychiatry. 2006;11:147-9.Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS Med. 2010;7(10):e1000352.Chaiken S, Trope Y. Dual-process theories in social psychology. New York: Guilford Press; 1999.Mansfield P. Accepting what we can learn from advertising's mirror of desire. BMJ. 2004;329(7480):1487-8.Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol. 2002;83:526-41.Lo B, Field MJ. Conflict of Interest in Medical Research, Education, and Practice. Consensus Report. Washington: Institute of Medicine; 2009 21 April.Jutel A, Menkes DB. Soft targets: nurses and the pharmaceutical industry. PLoS Med. 2008;5(2):e5.Sierles FS, Brodkey AC, Cleary LM, et al. Medical students' exposure to and attitudes about drug company interactions: a national survey. JAMA. 2005;294(9):1034-42.Austad KE, Avorn J, Kesselheim AS. Medical students' exposure to and attitudes about the pharmaceutical industry: a systematic review. PLoS Med. 2011;8(5):e1001037.Carmody D, Mansfield PR. What do medical students think about pharmaceutical promotion? Aust Med Student J. 2010;1:54-7.Mansfield PR, Lexchin J, Wen LS, et al. Educating health professionals about drug and device promotion: advocates' recommendations. PLoS Med. 2006;3(11):e451.Menkes DB, Maharajh M. Just saying \"no\" to pharmaceutical sponsorship. N Z Med J. 2007;120(1251).http://www.nzma.org.nz/journal/120-1251/2471/Duggal R, Menkes DB. Evidence-based medicine in practice. Int J Clin Pract. 2011;65:639-44.Inquiry into improving New Zealand's environment to support innovation through clinical trials. Wellington: New Zealand Parliament, Health Committee; 8 June 2011. http://www.parliament.nz/en-NZ/PB/SC/Documents/Reports/e/8/2/49DBSCH_SCR5154_1-Inquiry-into-improving-New-Zealand-s-environment.htmGodlee F. Can we tame the monster? BMJ. 2006;333(7558). http://www.bmj.com/content/333/7558/0.7.fullLexchin J, Light DW. Commercial influence and the content of medical journals. BMJ. 2006;332(7555):1444-7.Cain DM, Detsky AS. Everyone's a little bit biased (even physicians). JAMA. 2008;299:2893-5.

Contact diana@nzma.org.nz
for the PDF of this article

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