However we believe that within these broad limits (education funds donated to a central office not individuals and departments, and prohibition of gifts to students), the pharmaceutical industry does have an important and positive part to play in medical education. Industry has a distinctive voice that students deserve to hear. (Royal College of Physicians’ (RCP) Working Group Recommendations.)
This week, a RCPs’ working party issued a recommendation paper entitled, Innovating for Health: Patients, physicians, the pharmaceutical industry and the National Health Service (NHS). The working party consisted of representatives from academia, patient care, industry, and public health.
The Executive Summary states familiar themes:
Medicines and medicine are inextricably connected. Today, the NHS, academic medicine, and the pharmaceutical industry have a symbiotic relationship. Each depends on the others for success. And there have been enormous successes clinically, scientifically, and economically.
However, in recent years, diverse critics in the medical profession, politics, and the media have questioned the strength and integrity of these relationships.
On Education:
Education is one of the most contentious areas between doctors, scientists, and industry. Respected physicians, at home and abroad, have attacked pharmaceutical companies for using educational initiatives as promotional tools..
It is also clear that medical schools are often not adequately preparing new doctors for prescribing. A stronger and more consistent undergraduate curriculum could do much to improve prescribing knowledge, understanding, skills, and attitudes.
Students also need to be protected from undue pharmaceutical marketing. Many of the same issues pertain to doctors in training.
Continuing professional development programs are too dependent on industry support.
Royal colleges and faculties, together with NHS institutions, need to rethink their role in post-graduate education.
Industry and its institutions must work harder to disseminate and enforce the Association of the British Pharmaceutical Industry (ABPI) Code of Practice…
Meanwhile, all parties need to strive to find an acceptable way for the pharmaceutical industry to contribute to medical education. Doctors, too, must take greater financial responsibility for their own post-graduate education.
As in all things British, you have to read through pages and pages of what could be considered random and conflicting thoughts to get to whatever point they are trying to make.
Some examples:
The Working Party received conflicting views about the role of industry in post-graduate medical education. Joe Collier spoke of the ‘excesses’ of industry. By contrast, several general practitioners argued that much of the pharmaceutical educational material they received was helpful. It raised their awareness about new medicines. Novartis suggested that, ”Access for pharmaceutical representatives to see NHS personnel should be wider, where the majority of pharmaceutical representatives provide a valuable role informing [doctors] about new and existing medicines..”
But there is a danger that we over emphasize the responsibility of industry in post-graduate medical education. As Kent Woods pointed out, surely the NHS should have a stronger interest in providing unbiased information to practitioners. Industry has simply stepped in to fill the vacuum left by a health service that has cared too little about the educational and training needs of its professional staff.
The provision of information to doctors is highly regulated. The ABPI Code of Practice sets out rules on advertising, claims, comparisons, provision of reprints, the use of quotations, distribution of promotional material, disguised promotion, the activities of representatives, gifts, inducements, educational goods and services, promotional aids, and meetings.
This guidance has been toughened in recent years in response to higher public expectations about the industry’s behavior. The organizing principle of these industry-led reforms has been that industry must be more strongly governed by its scientists, not its marketing force.
The RCP has developed specific guidance about the relationship between doctors and industry.
The College’s concern has focused on the way pharmaceutical promotions might adversely interfere with a physician’s independent professional judgment. The Working Party received several examples of guidance on how doctors should interact with industry in educational settings.
These recommendations uniformly require the highest standards of independence on the part of doctors to ensure patient safety and public trust.
Many of the points our British colleagues makes are totally true, the bodies that traditionally helped to underwrite graduate and continuing medical education (governments (PHS for Britain), hospitals, universities, and insurance companies) have abdicated their responsibilities and others, i.e., manufacturers have stepped into the gap to help out. The medical profession should be grateful for manufacturers’ participation and not alienate companies just because they conduct research, manufacture, and sell products.
In the U.S., even in the case of National Institutes of Health Grants, support for graduate education is hidden in “overhead” fees on research grants.
There has been some confusion around the recommendation. “The goal should be to wean the education of doctors in training off pharmaceutical industry support over a time bound period, such as five years.” Several writers have stated that the recommendations include phasing out CME funding. But in reading the document, it simply states that the system should wean off funding from Graduate Medical Education (
The Working Parties’ recommendations are as follows:
· Medical schools must take a stronger role in exposing students to medicines: their discovery, basic pharmacology, development, manufacture and delivery; medicines regulation; pharmacovigilance; the appropriate relationships between doctors and industry representatives (the Principles of Public Life); and the commercial aspects of the pharmaceutical industry. Once this curriculum has been developed, industry will have a valuable contribution to make aspects of undergraduate teaching (Paragraph 3.20).
· Medical schools’ responsibility for the quality of prescribing among newly qualified graduates must be acknowledged more explicitly. We believe that a mechanism should be sought to introduce a more standardized assessment across medical schools in order to test the prospective doctor’s prescribing skills. This would offer the public a level of confidence and quality assurance about prescribing practices. We encourage its consideration (Paragraph 3.21).
· There should be clear guidance to remove any uncertainties about students’ interactions with industry:
–All gifts by industry to students, including food and travel, should be prohibited.
–Educational funds donated by industry should be disbursed by a centralized administrative unit, not by a company directly to a department or individual.
However, we believe that within these broad limits, the pharmaceutical industry does have an important and positive part to play in medical education. Industry has a distinctive voice that students deserve to hear (Paragraph 3.22).
· For the benefit of doctors in training, the royal colleges, the MHRA, NICE, the ABPI, and the GMC should together adopt a stronger role in promoting standards of safer prescribing and interactions between doctors and industry representatives (Paragraph 3.29).
· The NHS should assume explicit and transparent educational funding responsibility for doctors in training, for example, through personalized and portable study leave and education budgets. The goal should be to wean the education of doctors in training off pharmaceutical industry support over a time-bound period, such as five years. All gifts to doctors in training, including food and travel, should end (Paragraph 3.30).
· The NHS must collectively revitalize its role in supporting and disseminating evidence-based resources to strengthen post-graduate medical education. In addition to the commitments made to establish NHS Evidence as an extension of NICE,5 an important first step would be to secure as soon as possible the long-term future of the BNF and to ensure that a hard copy reaches all doctors in the U.K. (Paragraph 3.37).
· Relevant royal colleges and faculties, on behalf of the Academy of Medical Royal Colleges, together with the GMC, should convene a conference to define a framework, guidance and code of conduct about how doctors, NHS institutions and industry should work together to support post-graduate medical education. The intention would be to clarify the relationships between industry educational support for the individual, the department and the institution (Paragraph 3.38).
· Employers must take greater steps to assume responsibility for prescribing quality after the Foundation 1 year. The Healthcare Commission – and its successor, the Care Quality Commission – should monitor the educational outcomes of NHS institutions (Paragraph 3.39).
· New ways should be found to reduce the reliance of post-graduate medical education on sponsorship by pharmaceutical companies and the wider biomedical industry. Alternative sources of sustainable funding should be sought – for example, through the royal colleges and DH. In doing this, the implications for individual organizations such as royal colleges and specialist societies should be considered carefully (Paragraph 3.40).
· In rewriting the relationship between medicine and the pharmaceutical industry, and in the spirit of a more balanced and mutually respectful partnership, all gifts to doctors, including food and travel, become untenable and should end (Paragraph 3.41).
· The ABPI and its members should establish a pooled fund to invest in medical education. Such a fund would unlink financing from a single company, diminishing the perception of undue commercial influence and bias (Paragraph 3.42).
· Any honorarium or fee, commercial or otherwise, paid to a doctor should be declared on a publicly accessible database. If the work being remunerated is completed in NHS time, that fee should be paid to the doctor’s host institution to reinvest back into the NHS. If the work is conducted outside of NHS time, this payment should simply be made transparent. We urge the RCP, the Academy of Medical Royal Colleges and scientific societies to adopt this recommendation quickly. We urge employers to implement it in collaboration with professional bodies (Paragraph 3.43).
Overall, these are thoughtful recommendations.
In the U.K., manufacturers still pay for participants’ travel, meals, and expenses to international medical congresses, this is a practice that has been banned for at least ten years in the U.S.
Reports like these are needed to help reduce the unsupported ridiculous rhetoric of Marcia Angell, M.D. and others that industry has no place in working with physicians and patients. If we work together, in the end, everyone (industry, providers and patients) will benefit.
Resource Documents
RoyalCollege of Physicians — Innovating for Health: Patients, physicians, the pharmaceutical industry and the NHS.
In addition to the recommendations, the British Medical Journal published a lengthy list of editorials on the issue of the relationship between the drug industry, academia, healthcare professionals, and patients.
- Editor's choice: Doctors, patients and the drug industry. “Despite these positive recommendations the product of the working parties’ deliberations is weakened by a flawed process, and so a real opportunity has been lost.”
- Ian Gilmore: Build bridges with the drugs industry—but keep patients in mind. “The preparation, prescribing, and dispensing of medicines have been intertwined with the practice of medicine for centuries and the close relationship between doctors and the pharmaceutical industry has been key to many therapeutic advances.”
- Harlan M Krumholz and Joseph S Ross: More regulation, greater transparency. “The relationship between drug and device companies, the medical profession and the public is at a critical juncture. Individuals who have placed their interests in profit and influence over patients and public health have overshadowed much of the good work and reputations of those who have engaged in constructive interaction.”
- Marcia Angell: Keep at arm’s length. “I believe there should be no relationship between the drug industry and either prescribers or patients.”
- Scott Gottlieb: Build trust based on good science. “Medical treatments are becoming increasingly more individualized, with respect to both disease and patient. They are also becoming more complex, and precise diagnoses and close monitoring are needed to optimize their use. In this environment, consumers and doctors need to work more closely with product developers.”
- Richard Tiner: Focus on better information. “The industry believes it has a legitimate right to provide information about the benefits of its medicines to prescribers.”