ESSENTIAL PARTICIPATION
Industry's participation in ophthalmic meetings is essential to our ability to provide the best care to our patients. There are no better places than the exhibit hall and wet labs at the AAO Annual Meeting to see and evaluate the new technologies that are revolutionizing the care of patients with macular disease, glaucoma, cataracts, or ametropia. Manufacturers' exhibits also bring value to regional, state, and subspecialty meetings. A lecture in an academic setting may convince you to adopt a new technology, but you have to try it, buy it, and arrange the follow-up training in your facility, where a representative from the manufacturer will assist you and your technicians in mastering the use of the product. All of that takes direct contact with the companies.
PROMOTION OF SCIENTIFIC INVESTIGATION
The presence of representatives of industry at ophthalmic meetings promotes corporate interaction with clinicians and basic scientists. Such communication helps companies to identify potential research opportunities and to decide with whom they might contract to perform basic research or phase 3 studies. Conversely, these interactions assist potential investigators in connecting with support. Patients eventually benefit from resultant advances.
CME
Indirect
The support of CME serves the interests of our patients. Industry's bolstering of the general budgets of local, state, and national meetings is an appropriate charitable payback to society when all of the major companies participate. In an era of drastically reduced reimbursements for physicians' services from Medicare and other third-party payers, manufacturers help to keep the cost of ophthalmic meetings affordable, which increases attendance and keeps physicians up to date in a rapidly changing field.
Of course, there are tradeoffs in this arrangement. Only a portion of industry's contributions is charitably taken from their profits. The remaining expense of advertising increases the cost of therapy. I would argue, however, that the overall interests of our patients are nevertheless served, because we are kept abreast of better diagnostic and therapeutic options.
Direct
Perhaps most controversial is industry's direct support of educational symposia. Companies organize and sponsor a large number of meetings, either to showcase their new products or to update physicians through presentations by speakers on their bureaus. Such meetings follow three formats: (1) evening seminars appended to national or subspecialty societies' meetings; (2) regional meetings held in hotels on weekends; and (3) local dinner meetings held on weeknights. Attendees are sought through advertisements in journals and trade publications for the bigger meetings and are invited by sales representatives to the local meetings. Most of these events include a reception or meal as an inducement for attendance.
The evening seminar or weekend regional meeting frequently serves a purpose not met by the usual 5- to 10-minute presentations at the annual meetings of the AAO or AGS. These events allow physicians to hear one or more authorities deliver substantial presentations of 30 minutes or more that combine current knowledge on a particular subject with its practical application. I have found some of these presentations to be outstanding and very helpful. Physicians who have attended such meetings frequently comment to me that they found devoting an evening or a weekend to studying glaucoma in depth quite beneficial to them and, therefore, to their patients.
Local dinner meetings offer both in-depth presentations on a subject and an opportunity for a meaningful question-and-answer session. In areas that are remote from medical schools, these sessions may constitute a majority of the available CME. Advantages of these events are that attendees (aside from the speakers, perhaps) need not travel a long distance, stay overnight at a hotel, or close their practices for a day. Attendees have made comments to me such as, "I did not realize that gonioscopy needed to be done in the dark to find angle closure," "Okay, I think I understand what this target pressure concept is," "Now, I see how to use mitomycin C with less risk of infection or hypotony," and "That pearl about using a 30-gauge–needle paracentesis to clear the cornea in an angle-closure attack has really helped me with several patients." Such remarks indicate that the ophthalmologists and their patients benefited.
Of course, industry-sponsored CME sometimes consists of shameless infomercials. Overall, however, I believe that there is value in attending industry-sponsored meetings on a selective basis.
CONCLUSION
On the whole, industry's support for ophthalmic meetings is beneficial to our patients' interests. We rely on our contacts with industry to learn about and master new diagnostic and treatment options, and companies depend on us to identify opportunities to produce new products. Industry's support of our meetings is a proper charitable activity that promotes attendance by keeping it affordable. Other meetings supported by industry can provide the in-depth coverage of subjects that integrates the disconnected pieces of information found in journals and the formal gatherings of ophthalmic societies. Our patients benefit when we are better prepared to provide them with the best care possible.
Paul F. Palmberg, MD, PhD, is Professor of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine. He acknowledged no financial interest in the subject matter of this article. Dr. Palmberg may be reached at (305) 326-6386; ppalmberg@med.miami.edu.
No, the introduction of bias is real and detrimental to our profession and patients.
By William L. Rich III, MD
Not a month goes by that there is not an article in the lay press detailing the problems associated with physicians' conflicts of interest. A financial conflict of interest arises when financial or personal considerations interfere with a physician's obligation to make unbiased decisions when choosing therapeutic options.
The problem is a big one. In March 2008, The New York Times reported on a $310 million settlement between the federal government and the five leading manufacturers of artificial joints for the illegal inducement of physicians.1 The consent decree included rescinding over $6 million in industry's support of an orthopedic society. Investigations are underway of individual doctors for their influence on the choice of devices at facilities in which they operate. More than four states require the public reporting of all industrial support to individual physicians, including meals, travel expenses, and fees for attending meetings. In 12 other states, similar legislation is pending that will require the publication of each physician's benefits. Bills on disclosure are pending in both the US Senate and the House, and they have widespread support.
The integrity of our profession is threatened when conflicts introduce bias.
RESEARCH AND CONTINUING MEDICAL EDUCATION
Because the public funding of research has gradually diminished, the private sector is now responsible for the majority of medical innovation and product development. There is no outcry to increase public funding, which would require tax hikes or offsets in other sectors to meet congressionally mandated "pay go" policies.
Most professional organizations are evaluating the long-term funding of continuing medical education (CME). Manufacturers only fund CME that demonstrably increases the sale of their products. For some organizations, such as the AAO, industry is the source of a very small percentage of revenue (less than 6%). Some medical associations rely on industry for more than 70% of their operating budgets, an obvious source of conflicting interests.
By subtly threatening to cut off educational support, companies are trying to influence organized ophthalmology's positions on the issues of coverage and payment policy. To think that industry does not exert such pressure is na•ve. All medical specialties should attempt to limit their dependence on industry by exploring other sources of funding for operations and education.
INFLUENCE
The manufacturers of pharmaceuticals and devices play an integral role in the health of the world's population through their dedication to research and product development. Only 11% of pharmaceutical companies' expenditures, however, are dedicated to research. More than 36% ($21 billion) is spent on marketing, and the vast majority of those funds are directed to physicians, with only 10% of marketing budgets spent on direct-to-consumer advertising.
These efforts are incredibly effective at influencing physicians' behavior. Studies in the social sciences and pharmaceutical literature report that even small items like pens and pizza can change a physician's prescribing habits. Interestingly, 61% of surveyed residents reported not being influenced by pharmaceutical marketing, but they believed that only 16% of their colleagues were not.2 In reality, we are all influenced. Ophthalmologists have the lowest prescribing rate for generic medications of any medical specialty, so, obviously, our partners in ophthalmic industry are doing a good job.
Gifts, meals, payments for CME, and fees for lecturing or serving on advisory boards are not the only effective marketing inducements. The provision of samples provides easy access to our offices for salespersons and leads to higher prescribing rates by doctors. If you think your samples mainly benefit indigent patients, you are wrong. Only a small percentage of samples provided in the office are given to patients without a pharmaceutical benefit, and only 4% of elderly patients lack a drug benefit.
ACTION
Patients are required to pay an ever-increasing percentage of their medical bills. Their growing concerns about the value of the medical services they are purchasing have led to a national demand for measures of quality and cost. Public scrutiny of the costs of the devices and drugs physicians prescribe has increased.
What can each of us do to ensure that our prescribing habits and use of devices are based on evidence? At my office, we have taken a number of steps. First, through the AMA's Web site, we blocked the sale of our prescribing data to industry. Next, we banned all manufacturers' access to our office and refused their support of our CME and any offers of marketing dinners, lunches, etc. We were surprised that the quantity of samples mailed to our office subsequently increased dramatically. Finally, we began refusing all of them. The net effect of our hard-line stance was an office that runs more smoothly and an assurance that our prescribing decisions are in the best interest of our patients. When the Washingtonian Magazine publishes each physician's financial support from industry (a figure that includes the value of samples), we will feel relieved to see a zero next to our names.
An individual ophthalmologist is powerless to influence society's decision not to increase the public funding of science or our professional associations' attempts to regain control of CME, but each of us can help to increase patients' faith in the integrity of our profession.
William L. Rich III, MD, is Senior Partner at Northern Virginia Ophthalmology Associates. Dr. Rich may be reached at hyasxa@aol.com.
