On October 3rd the New York Times reported that several prominent research psychiatrists are under Congressional investigation for failing to report income derived from consulting and speaking for pharmaceutical companies. One of the field’s most renowned and prolific researchers, Charles B. Nemeroff MD of Emory University, stands accused of concealing over $1 million since 2000, thereby violating federal rules aimed at avoiding conflicts of interest in medical research. Senator Charles E. Grassley (R-Iowa), leader of the Congressional inquiry, has also sponsored the “Physician Payment Sunshine Act,” which would require industry to publicly list payments to doctors. Several states already require this, and two drug companies recently announced they will voluntarily list payments to doctors starting next year, even without legislation.
Senate allegations of million-dollar malfeasance are, unfortunately, just the tip of the iceberg. While professional journal articles, newspaper op-ed contributors, and bloggers (e.g., here, here, and here) have documented the problem for years, the public still has little grasp that over half of all continuing medical education (CME) in the US is paid for, legally, by commercial interests. This often takes the form of sponsored talks: Prominent physicians like Dr. Nemeroff are paid to speak to medical audiences about a specific disorder and its various treatments — one of which is nearly always a product of the sponsoring company.
To address the clear potential for bias, CME speakers are required to disclose to the audience any financial ties to industry. However, it is unclear to what extent disclosure matters if the talk is subtly biased anyway. After all, television commercials clearly disclose the company behind an overtly biased sales pitch, yet this form of advertising remains effective. Corporate sponsors also argue that competition among products leads to the necessary scrutiny to arrive at the truth — speakers for Company A will critique drug B, and vice versa. Meanwhile, the sponsored speakers themselves declare their own neutrality (“Money can’t buy me!”), sometimes pointing out that, like Dr. Nemeroff, they are sponsored by so many different companies that they favor no particular product.
Since regular attendance at CME activities is required to maintain a medical license, the mere possibility that this information is slanted ought to raise alarms in the medical community and in the public at large. Yet only a few studies have been done to find out. A recent review of ten empirical studies concluded that “there is no empirical evidence to support or refute the hypothesis that CME activities are biased.” This conclusion has been systematically critiqued by psychiatrist Daniel Carlat MD here and here.
The ethical issues here are almost too obvious to point out. Physicians are duty-bound to recommend the best treatment for a given patient, not the treatment presented most persuasively by an industry-paid speaker. Willing receptivity to a possibly biased talk is little better than prescribing possibly tainted medication. Sponsored speakers themselves ought to reflect on the ethics of giving talks they may subtly slant despite their own best intentions. It may be sheer hubris to imagine that one can avoid any hint of favoritism when one’s speaking fee is paid by the manufacturer of a product under discussion. Stepping further back, educational institutions such as medical centers that review and approve CME ought to consider whether the industry money coming in justifies the potential bias coming out. And stepping back again, the medical community as a whole should assess the price paid in professionalism and public trust when it accepts industry largesse.
I’m sorry to report that psychiatry is one of the medical specialties most accepting of Big Pharma money. As a matter of principle, I avoid nearly all industry-sponsored CME (occasionally it is virtually unavoidable), as well as all direct marketing contact with sales representatives. In my next post, I will tell how I nearly became an industry speaker myself without realizing it.