Continous Professional Development And The Pharmaceutical Industry-Education Or Marketing ?

Pharmaceutical Promotion It is perfectly understandable for the pharmaceutical industry to aggressively promote products on which huge sums of money have been invested at the developmental phase. The rigor of testing applied to modern pharmaceuticals has little parallel in other industry. Unlike most other products, pharmaceuticals have the potential to not only improve health but also to cause harm. As such the ethics of promotional activities in the marketing of pharmaceuticals has to be clearly defined. It should not influence doctors' autonomy in making decision although that has been previously showed to be insidiously influenced 1.


Promotion and Education
One popular way to market a product is to promote it via educational activities.These can range from personalised delivery of educational materials by drug representatives to the doctor's office, company sponsored journal clubs, product presentations during lunch breaks, company sponsored Continuing Professional Development (CPD) programmes (ranging from one-off dinner talk to a full weekend workshop or seminar), company assisted conferences with industry sponsored symposia ( in the main programme to satellite symposia) as part of the programme and sponsoring of doctors (and pharmacists) to attend conferences.Indeed many companies will have their own dedicated "Educational Grants or Funds"for such activities.Some will utilize funds from the marketing and sales division because they see it as part and parcel of a common goal; that of promotion and successful marketing of their products Ideally speaking, marketing should be more than just a promotional or selling effort to increase and satisfy demand for existing products and services.It should also seek to identify and respond to the needs, requirements, expectations and perception of its client; doctors and patients alike.It should lead to better overall performance of a doctor in managing their patients.This in turn should lead to better patient care and clinical outcome.However not all interactions between the medical profession and the pharmaceutical industry end up with positive patient outcomes.The emphasis tends to be more inclined to fulfilling the industry's objectives rather than the educational goals.Indeed a report from an extensive literature review found that doctors are affected by their interaction with pharmaceutical industry 7.There is evidence to show that doctors prescribing pattern is influenced after attending industry sponsored education programmes even when the programme is conducted in an academic environment governed by pre set ethical guidelines 8. Another survey conducted with the use of self-reported questionnaire to psychiatry residents, interns and clerks showed that psychiatrist-in-training perceive little educational value in pharmaceutical representatives contact 9. However a more recent metanalysis showed there is no clear evidence that information prescribers get from pharmaceutical industry affect their prescribing habits positively or otherwise 10.

Continuing Professional Development-Education or Promotion?
The very nature of medical practice demands lifelong learning.The need for life long learning is never more pressing than in this era of "Information Technology" and "Patient Empowerment".The need to continuously develop oneself professionally has given rise to a concept the scope of which is much more than just attending the odd Continuing Medical Education (CME) lectures.Continuing Professional Development (CPD) includes a comprehensive approach in personal and professional development of a practitioner to meet the ever challenging demands of modern day medicine.
Any development programme (CPD not an exception) requires adequate resources be it financial, infrastructural or human resources.Practically every other CPD activity is assisted either directly or indirectly by the pharmaceutical industry.In marketing sense, there is no better avenue than that provided by CPD activities.Not only is the logistics of addressing a wide audience of potential client achieved, the marketing strategy can be masqueraded by a neutral 'educational platform'.This can take the form of sponsoring the development of 'Evidenced Based Clinical Practice Guidelines (CPGs) to the plainly overt product launch in a desert island resort.
In between those extremes there are other types of activities in which pharmaceutical companies may be involved in.This include u providing secretarial and financial support for activities as diverse as international scientific meetings, professional societies and patient support group, u sponsoring local meetings of specialist groups which usually have an independent organiser or organising committee, u hospital grand rounds and departmental scientific meeting.u providing assistance in the form of subscription to journals and other independent educational materials u sponsoring awards and grants for academic excellence While these activities usually have a clearly defined primary educational aim, they may be potentially open to the suspicion of unethical interaction between doctors and the pharmaceutical industry.Doctors involved in organising or participating in such activities need to have a high level of awareness of this risk.They should ensure they could meet any allegations of unethical behaviour, through avoiding any secrecy regarding the source and extent of sponsorship, and by ensuring that the provision of food or other attractions at these meetings is not on so lavish a scale as to cast doubt on the primary educational purpose of the meeting.The cost should not exceed that level which recipients might reasonably be expected to incur for themselves under similar circumstances.Sponsors of such activities must be prepared to accept that not all such activities will generate marketing spin-offs.Among the important points to highlight is that doctors (often called key opinion leader or KOLs) should not participate in promotional activities that could in any way damage their public standing or reputation for independence of the profession in the eyes of: u peers, colleagues and co-workers u the media u patients and their relatives and u the general public.
Key opinion leaders have been viewed with skepticism by some 12,13,14,15.Key opinion leaders are typically experts in their own field and most are also renowned researchers generating knowledge in relevant field of expertise.As clinician scientist, many will deny that their independence is influenced by the industry.Others have argued that they should remain independent and not work with industry.
Opinion on this has been split 16, 17.It is however not that difficult to identify independent from heavily industry-influenced key opinion leaders 18. Key opinion leaders themselves must ask some soul searching questions before accepting invitations to give lectures especially if it is industry sponsored.An important principle guiding ethical interaction between doctors and the industry is the dictum "would you be willing to have these arrangements generally known?" 19.Another question which should always be asked, and be capable of comfortable answer is "can this presentation stand on its own without the financial support and influence of an outside body?" 20.Indeed these questions should not only be asked by the key opinion leaders to themselves but also by the public.In other words what is needed as an antidote to concerns about unhealthy relationship between key opinion leaders and the industry is more transparency 21.It is worth remembering that the pharmaceutical industry in mainly staffed by professionals who are trained pharmacists.Ethical guidelines should equally be applicable to members of this profession more so when they are industry based.This guideline is well spelt out by the American College of Clinical Pharmacist 22.A closer scrutiny of these guidelines for doctors and pharmacist show strikingly similarities.As such if these are adhered to, unethical practices should be an exception rather than the rule.Problems arise when 'double standards" are applied by either party.It is encouraging to note that a survey among doctors across several specialties showed positive attitude towards guideline on this issue with willingness to comply with it 23.Even recent federal laws in the US (Anti-Kickback Statute and Federal Health Reform Law) do not prohibit doctors involvement with industry in research and education 24.

Between Promotion and Education -Stick to the Evidence!
The last few decades has seen an exponential increase in our understanding of disease pathogenesis and therapeutics.The science of epidemiology has also evolved from being restricted to the closet of public health to that of clinical medicine.Application of clinical epidemiology to daily clinical practice has given rise to a discipline of knowledge called 'Evidence Based Medicine' (EBM).Unfortunately there are at times too much lip service paid to EBM, when what is really required is for it to be practiced 25, 26.When there is good evidence that a particular drug is clinically beneficial than there should be no hesitation in its promotion.It can even be argued that once credible evidence has been generated, not applying it is unethical.The argument has always been how really credible is the evidence.Teaching doctors and medical students EBM is now a routine repertoire in many medical schools both at the post graduate and undergraduate levels.The right understanding of EBM will be an important pre requisite for doctors to navigate the sometimes confusing world of medical literature and continuing professional development programmes, many of which are directly or indirectly linked to the industry..There is however one important limitation with depending on EBM to help reconcile between promotion and education.The science of clinical epidemiology ( not to mention that of biostatistics !) which forms the foundation of EBM is not well taught and not well understood by many .This include doctors who contribute directly to educational programme as speakers.Such a vacuum in correct understanding of EBM will be readily capitalized by the industry in the promotion of certain products.In such an environment, promoting and marketing of products of dubious benefits to patients will take precedence over genuine education.Thus it is not the relationship between the industry and the medical fraternity which should be frown upon.
The interaction though fraud with potential ethical minefields is symbiotic, provided the interest is focused not on the doctors or the industry's interest but that of the patients 27 and is strictly evidenced based.In fact eliminating ethical interaction between the industry and doctors may hinder continuing professional developments of doctors which may be a disservice to patients 28.

Conclusion
Educating medical students or doctors early in their training regarding the importance of professional ethics will promote and enhance their ethical behaviour as practicing doctors or specialists.Moreover, continuing education of doctors at all stages of professional development on ethical standards and con-duct will facilitate maintenance of high ethical standard throughout the profession.Experts who are invariably looked upon as key opinion leaders should maintain high ethical standards and act as role models, setting excellent examples for trainees and colleagues.To maintain the respect of patients and health care professionals as therapy expert, opinion leaders should always present therapeutic information in a fair, balanced, and evidenced based manner.Opinion leaders who allow themselves to be used as conduit for pharmaceutical manufacturers on a product when no credible evidence exist, are putting their reputations at stake.The industry in the meantime should avoid practicing double standards when it comes to the ethics of marketing, either via direct promotional activities or indirectly through educational programme.