Domino Fifteen: Influence of pharmaceutical industry on the practice of medicine.
When I entered medical school in 1985, I was unaware of the deeply entrenched influence of pharmaceutical industry on the practice of medicine and medical education.
It was accepted practice that representatives of drug companies visited doctors with information about studies that described trials where drugs were tested on humans, and laid out their therapeutic effects and side effects.
Our medical conferences had industry sponsors and hosted booths where you could get information about the latest drugs and educational material describing their use.
Drug reps presented information clearly, were friendly and after the first meeting, would arrive at doctor’s offices with samples of the new drugs. Harmless, business as usual, efficiently offered to help me keep up with latest advances in medicine.
This naïve view of industry was shattered when I read the commentary Dancing with the Porcupine by Steven Lewis et al.
“The duty of universities is to seek truth. The duty of pharmaceutical companies is to make money for their shareholders. Drug companies that fail to do so go out of business. Universities that subordinate the search for truth to other ends lose credibility and their claim to a privileged status in society. Research can either serve or subvert the public interest. The capacities and integrity of researchers, and their universities, can be enhanced or corrupted in the process. Whatever ethical bed we make, we lie in,” wrote Lewis in the piece.
I was shocked and didn’t want to believe that it could not be that bad. So, I started to ask questions and critically observe this “business as usual” practice of dealing with industry.
The drug reps often held lunch and learn sessions, which we attended as students mainly to get lunch. Then I learned, “There is no free lunch.”
What did that mean?
I delved into the process for new drugs to come to market and patents that protected brand name drugs for up to twenty years. Drug companies put out a lot of money in research and development, and have limited time left to recoup the costs of developing new drugs. They put out even more money for marketing. I began to understand that when doctors get into the habit of meeting drug reps regularly, they develop trust in the relationship.
Over time, and with busy schedules, they relied less on critically reviewing the ever-increasing amount of information, and preferred short summaries provided by drug reps. They rationalized this practice because free samples offered could be used for patients that could not afford drugs.
I decided to experiment and stopped seeing drug reps in 2005. I did my own legwork to find balanced sources of information, found other ways to help patients gain access to drugs and noted a change in my prescribing practice.
I learned that clinical practice guidelines were influenced by industry.
Doctors working on drug trials were silenced when dangerous adverse effects were uncovered. Highly regarded expert university professors were involved in ‘ghost writing’ papers that supported drugs by suppressing negative trials and highlighting positive ones.
Universities were receiving large sums of money to build centres of excellence that raised their prominence. Patient groups were influenced to lobby for new drugs that were steadily increasing in price.
I observed that doctors were influenced to believe there was no way to cure or heal manifestations of illness and effects of injury in patients, other than with drugs. I noted specialist colleagues with significant conflicts of interest, presenting biased information at medical conferences, developing clinical practice guidelines, rising to become experts and no longer being critically questioned by their peers.
A disturbing “creep” was evident in prescribing practices. Medicines like stomach acid lowering drugs that were studied for up to six weeks, with no safety information beyond that, were being prescribed for up to 12 months, at high doses, because patients developed more symptoms when they stopped them.
This was happening during the rise of “evidence based care” and ironically the evidence was heavily tainted with industry influence.
By 2014, outspoken critics like Ben Goldacre were developing ways to counter what had taken place.
In his book, Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients, he lays out what I have described and much more.
To paraphrase him: I suspect most people who work in the industry are fundamentally good hearted. Drug companies around the world have produced amazing innovations in the past 50 years, saving lives on an epic scale. But that does not allow them to hide data, mislead doctors and harm patients.
We like to imagine that doctors are familiar with the research literature, but much of it is hidden from them by drug companies; that doctors are well-educated, but much of their education is funded by industry; that regulators let only effective drugs onto the market, but they approve hopeless drugs, with data on side effects casually withheld from doctors and patients.
The whole edifice of medicine is broken, because the evidence we use to make decisions is hopelessly and systematically distorted.
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Dr. A.J., Ajantha Jayabarathan, has 25 years of experience in medicine, broadcasting, e-health and education.