After the plates were cleared, the speaker, a general practitioner with a specialty in chronic pain, wrapped up his lecture and slide show.
While discussing effective drugs for lower back pain that is moderate but persistent, he zeroed in: The best medication for that is Cymbalta.
Cymbalta is a prescription drug made by Eli Lilly — the company that organized the event, paid for the wine and food, and paid the doctor giving the talk.
A Star investigation has found drug companies routinely host and fund these dinners at upscale restaurants as training events for family doctors. Toronto-area spots include Sassafraz in Yorkville, ORO on Elm Street and, in the case of the back pain event, Italian restaurant Sarpa in Richmond Hill. These events are called continuing medical education.
There is growing concern among critics that these dinners — which are sanctioned by a national medical organization — encourage doctors to prescribe the sponsoring companies’ drugs.
Family doctors are most often responsible for choosing what drugs Canadians are prescribed.
In Ontario, where there have been more than 500 industry-sponsored events in the last two years, physicians are required to attend “continuing medical education” to keep their licence in good standing.
These medical education events are vetted and approved by the College of Family Physicians of Canada, which represents more than 30,000 physicians.
A task force created by the College acknowledged that the drug industry’s interests are “not always aligned with the best interests” of family doctors or their patients.
“There have been instances in which marketing messages have been portrayed as education, and health care and pharmaceutical industries have attempted in this way to influence physicians’ behaviour or practices,” said the recently released report.
The report did not specifically deal with drug dinners but looked more broadly on the College’s relationships with the industry.
A Star investigation into these drug dinners has found drug reps interacting with doctors. In one case, just days after a dinner, a sales rep showed up at one of the attendees’ clinic with drug samples and promotional material.
The Star found roughly 70 per cent of the events listed on the College’s website were put on by drug companies, sometimes indirectly through hired communication firms.
“It’s disturbing and disappointing,” said Dr. Sheryl Spithoff, a family physician at Women’s College Hospital and a lecturer at the University of Toronto. “We’ve allowed people to educate us who have other goals.”
Representatives from the drug industry say the events provide important medical information to doctors and follow strict guidelines meant to keep promotional messages out of the presentations.
However, the College’s task force report cited evidence suggesting drug companies can have “significant influence” over doctors who are offered gifts or other support.
The report, finished in 2013 but only released in December 2015 after calls for it to be made public, outlines 20 recommendations on curtailing industry influence and potential conflicts of interests, including developing more educational content without ties to industry.
The College says it will, by summer, require more stringent standards on how scientific information is presented at drug dinners, but the policing of the accredited events will be based only on complaints from the doctors who are being wined and dined.
“We’ve never pretended we have a perfect system. We build the best system that we can,” said Dr. Jamie Meuser, who oversees medical education programming for the College.
Some U.S. organizations, including Oregon’s college of family physicians, have outright banned all industry involvement with medical education out of concern it is biasing doctors and leading to poorer prescribing.
Still, Canada’s family physician college said it has no plans to cut ties with drug companies.
“The College is just tinkering around the edges,” said Alan Cassels, a drug policy researcher at the University of Victoria. “I would say we need clean, clear health information as urgently as we need clean, clear water. And the College is saying, ‘It’s OK if some of that water is tainted.’ ”
Many educational programs for family physicians are born inside a drug company’s offices, said the College’s Dr. Meuser.
The company, or a hired medical communications firm or consultant, comes up with an idea for a lecture, then pulls together a planning committee made up of experts. The committee must, according to College rules, include at least one family physician.
The committee puts together the presentation, including a slide show, which then goes to the college for approval.
The sponsoring drug companies “can’t be involved in the final decision-making on the content,” Dr. Meuser said.
When the College vets a dinner, he said it’s looking for whether the PowerPoint presentation is “scientifically valid and balanced,” as well as free of bias or promotional material. The company’s role in the dinner must be disclosed at the beginning of the presentation.
“If this company is putting out a drug for Type 2 diabetes, we have to make sure in the presentation they talk about all the treatments available for Type 2 diabetes, not just their drug,” Dr. Meuser said.
The College said it recently sent out several notices of violation after it was found presentations deviated from the approved script.
The College also tries to ensure the venue and menu do not outshine the content of the presentation.
Sometimes things slip through.
At Sassafraz, a high-end restaurant in Yorkville, doctors gathered in 2014 to hear a leading specialist talk about diabetes treatments were given their choice of a Californian red or Italian white.
For the starter, they had either butternut squash soup, a fried green tomato dish, or arugula salad garnished with cumin cashews, grapefruit, toasted coconut and rhubarb citrus vinaigrette. That was followed by an entrée of Cornish hen, organic B.C. Chinook salmon, pasta, or artisanal beef tenderloin. The meal ended with a pineapple confection or a milk chocolate mousse.
The 2014 dinner, sponsored by drug company Boehringer-Ingelheim, was approved by the College for one credit.
“I honestly don’t know how that (menu) would have gotten past our ethical review,” Dr. Meuser told the Star.
Ontario’s doctor regulator, the College of Physicians and Surgeons, said enjoying a lavish meal on a drug company’s dime could be professional misconduct. (The regulator — a separate body from the national family physician college that oversees drug dinners — requires that physicians attend medical education events through the national college in order to keep their licence in good standing.)
A Boehringer spokeswoman said the company supports hundreds of medical education events each year — including several at Sassafraz in 2014 — and follows guidelines established by a drug industry association to help ensure the programs are fair and balanced. There is no information suggesting a specific drug was promoted during the presentation at Sassafraz.
“All elements of the program, including the venue and meal costs, for these events were reviewed and approved” by the College, the spokeswoman said.
The College of family physicians has no control over what a presenter will say or recommend during question-and-answer periods.
Dr. Andre Lalonde, a general practitioner from Laval, presented the drug dinner on treating lower back pain at Richmond Hill’s Sarpa restaurant in 2014.
While discussing back pain that is not extreme but constant, he told the audience that he prefers Cymbalta — the drug made by the company paying him to be there — sometimes combined with other medications, the Star has learned.
In an interview, Dr. Lalonde said he was not marketing for Eli Lilly. He said he shared his medical opinion, based on information he has learned from experience and research.
Neither Dr. Lalonde nor the company would say how much Eli Lilly paid him for his talk on lower back pain. Dr. Lalonde said the fee was about the same as a day of work in his practice.
Dr. Lalonde added that he does the same presentation whether the event host is a drug company or doctor college. “(The company knows) that I am free and independent and I speak my mind, not theirs. . . . I do not sell anything.”
He says that family doctors have very few available resources for the latest news and research on lower back pain and drug company-sponsored events fill that void.
Eli Lilly, who funded the dinner, said the presentation met the College’s standards of fairness, balance and non-promotional content. “Full editorial control of (continuing medical education) initiatives sponsored by Lilly resides with the presenter or the accrediting body,” a company spokeswoman said.
Dr. Rick Ward, a longtime member of planning committees for medical education events, says the events provide a forum for expert doctors to spread their knowledge and make an impact on patients’ lives.
“Pharma wants their medications to be prescribed responsibly to the right patients. They want physicians to understand disease processes and gaps in care. That’s not dis-aligned with where physicians are,” he said.
Others think there are better ways to keep doctors up to date on new treatments. Some U.S. hospitals and physician organizations in Oregon, Michigan and elsewhere have banned industry funding of their medical education. Their decisions, said Toronto’s Dr. Spithoff, are supported by research showing industry sponsorship biases content, emphasizing medication — often the company’s own products — while ignoring other treatments like diet and exercise.
The bias can then spread to doctors’ prescribing, with patients getting unnecessary medications or newer, more expensive drugs when older treatments are just as effective, Dr. Spithoff added.
Periodically since 2014, the Star has analyzed the college’s online calendar of approved continuing medical education events. Doctors use the website to sign up for events that, once attended, help them earn the 250 credits they need to accumulate every five years.
One of the events, held at ORO restaurant in downtown Toronto, was a lecture on managing symptoms of irritable bowel syndrome and severe constipation. The dinner was sponsored by pharmaceutical company Actavis.
Before the College-approved presentation began, the speaker told the crowd about a new and exciting Actavis drug called Constella.
“I agreed to speak because not only was there learning values to the audience, but I had also used the drug with my patients and had seen good results to treat my patients with this condition,” Dr. Louis Liu, who was the speaker, told the Star.
Liu said he discussed other drugs during the presentation and that he has “no part in the marketing” of Constella.
Within a week of the dinner, an Actavis sales rep visited the clinic of one of the doctors who attended.
“Just stopped in to say hi & drop off Constella samples,” the rep wrote in a note.
A company representative said the event followed ethical guidelines and was developed independently by experts “to ensure integrity of the clinical and scientific content.” He did not answer questions about the sales rep’s visit to the doctor.
The University of Victoria’s Cassels said drug companies may use the list of event attendees as a Rolodex for sales reps, who target the doctors as part of their efforts to boost prescriptions of their brand drugs.
In the future, doctors will have more options for their educational events, said Dr. Meuser of the College of family physicians.
The College is creating a fund to develop educational programs free of drug industry involvement. The fund will be bankrolled mainly by doctors’ subscriptions.
“High-quality learning is expensive to develop and deliver,” Dr. Meuser said. “Right now, many of those costs . . . are being borne by people with a private interest.”
“We believe, however, there is an appetite, if the quality of learning is high enough, for members to pay something for their own learning.”
The College’s board approved the fund “in principle” at a meeting in late January and, over the coming months, will develop how the fund will operate.
Dr. Meuser said he hopes it will produce popular courses that make drug dinners “less necessary,” but said the two events could coexist.
Cutting ties right now with the drug industry would create a “big hole” in education for doctors and could hurt patients, he said.
How big of a hole? The College won’t say. It has conducted a cost-benefit analysis on ending industry funding but refuses to release the report publicly.
“We are not a public organization. . . Our accountability is to our members,” said the College’s executive director, Dr. Francine Lemire, who said the results may be released to member doctors who ask for it.
Dr. Lemire said the public should know the College is addressing issues around its relationship with the industry “in an evolutionary manner.”
Original Article
Source: thestar.com/
Author: David Bruser, Jesse McLean, Andrew Bailey
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