Conflicts of Interest and Industry Relationships – General Consultation (Discussion Page) (CLOSED)
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15. Such a CME event which I have many times attended and many times learned a great deal (I am an adult & a professional, I know which content is biased; these days, it is exceedingly rare to see biased content since Pharma is under close watch, and physicians don’t tolerate it), should allow for travel/flight & hotel to be covered as part of it.
16. e – consider that more years of clinical experience should be rewarded as one’s value/expertise increases over time. E.g. Higher pay for those over 10 years in practice
21. a – a “modest” finder’s fee is not unreasonable. Most docs can’t be bothered to refer to trials because they would need to know the nature of the trial, who’s a good candidate, & mention a few things about the trial to the prospective patient. There is little chance other than the trial PI/SI of other doctors referring to trials unless completely desperate.
Given that industry representatives only provide information in a promotional capacity, subsection a) of this clause creates confusion. either we can accept gifts (eg meal) or can not.
I would suggest the following revision:
63 services, physicians are not permitted to accept meals
this should also apply at section 15, lines 98-100
I think the draft is helpful and addresses a number of potential issues but I find it somewhat weak in its recommendations. A tremendous number of resources are expended to influence physicians by the pharmaceutical industry, and I think it is a bit naive to think that physicians won’t be influenced by this. A common trait in physicians is having a strong sense of reciprocity, the sense that if someone does something for me, then I should do something for them. The pharmaceutical industry is well aware of this and hence offer meals, gifts, etc to physicians or their staff. Their research shows that this is very effective. I think that the policy should discourage all physicians from having medication samples in their office. Typically, any sample offerings are for new and expensive medication (e.g. 2nd or 3rd line antibiotics). This has no place in our offices. I also think the policy should discourage accepting any gifts including “modest meals”. Medication samples should exist in pharmacies and not in physician offices in my opinion.
Our current system of research and advancing patient interests would not exist without financial support from industry. Look at patient care groups take the canadian breast cancer network – these would simply not exist without industry support. There sponsors are all pharma companies. How much did they receive hundreds of thousands ? Millions of dollars. … we will never know. It is opaque and this drives increased costs.
I have to say I find that interaction (direct support of patient advocacy groups by pharma) to be a greater concern than the interaction with MDs and actually more and more disturbing. Really there is no way to police or control this but they are able to manipulate patients into demanding MDs to prescribe costly treatments. Has this even been looked at. I understand it is outside the scope of CPSO but there are millions of dollars being pumped into these groups and this ultimately is what is influencing patients and our prescribing practices. The reality is as a physician I am in a position to interpret and question data presented by pharma. But patients are not as sophisticated.
I appreciate the opportunity to present my views to the College of Physicians and Surgeons of Ontario regarding its draft policy on Conflicts of Interest and Industry Relationships. As a researcher and academic, I have been examining physician-industry interactions both in Canada and internationally and have presented and published my findings in multiple different fora including commissioned reports, peer reviewed journals and before parliamentary committees.
Overall, I find the draft policy far too permissive. The document Advice to the Profession: Conflicts of Interest and Industry Relationships summarizes some of the most relevant literature on the topic but the findings from that literature are not reflected in the draft policy.
1. There are three important principles that the draft policy fails to incorporate when setting out its positions.
a. Disclosing conflicts-of-interest is not sufficient
The literature shows that after disclosing conflicts physicians can actually can offer more biased information to their audiences – other physicians and/or patients. Two mechanisms involved are strategic exaggeration (the tendency to provide more biased advice to counteract anticipated discounting) and moral licensing (the often unconscious feeling that biased advice is justifiable because the advisee has been warned). Furthermore, audiences are less sceptical and more likely to believe the advice that physicians offer on the grounds that being honest and having disclosed conflicts, the physician is trustworthy (Loewenstein et al. JAMA 2012;307(7):669-670).
b. Physicians are not aware of their vulnerability
Physicians frequently express the opinion that they will not be influenced by their interactions with industry, although they are not as confident about their colleagues (Steinman et al. American Journal of Medicine 2001;110:551-557). However, evidence from the United States shows that meals with a value of US $20 are sufficient to change prescribing behaviour (DeJong C et al. JAMA Intern Med. 2016;176(8):1114-22).
c. Interactions between physicians and industry are not beneficial to the practice of medicine
The systematic review and meta-analysis by Spurling et al (PLoS Med 7(10): e1000352) that is referred to in the Advice document looked at the effects on prescribing in three dimensions – cost, quantity and appropriateness – after physicians received information from the pharmaceutical industry. Only a single study out of the 58 analyzed, showed improvement in prescribing and then in only one of the three dimensions. All the other studies either did not show any change in prescribing or showed that prescribing deteriorated in one or more of the three dimensions.
2. Specific types of interactions that are not adequately dealt with
a. Sales representatives
Sales representatives are not objective sources of information. A study based on primary care physicians in Vancouver and Montreal filling out questionnaires after a visit from sales representatives found that no safety information was provided in almost two-thirds of visits, serious adverse events and contraindications were only mentioned 5% and 14%, respectively, of the time and sales representatives mentioned unapproved indications in 13% of their visits. In addition, after listening to these biased and incomplete presentations nearly two-thirds of physicians said that they were likely or very likely to start or increase prescribing the drug in question (Mintzes et al. Journal of General Internal Medicine 2013;28:1368-1375). Sales representatives in these two cities also exaggerated the benefits and played down the harms of opioids (Mintzes et al. Journal of General Internal Medicine 2020;35(12):3730-3732).
85% of 2200 Canadian physicians surveyed reported that the reason that they continue to see sales representatives is to access samples (http://www.stacommunications.com/journals/cpm/2009/04-April%2009/029-Prism.pdf). One third of Quebec family medicine teaching units did not have a policy to regulate their use of samples (Rhéaume et al. CFP 2018;64:e531-539) and 51% of physicians had provided their patients with a drug sample that was not their first choice for treatment (Lussier et al. CPF 2018;64:e546-e552). A recent narrative review of the literature about sampling concluded that “Samples are not a charitable activity, but are instead a highly effective form of drug marketing. Samples remain the largest marketing investment among most companies.
Pharmaceutical companies would not invest so much in optimizing sampling distribution if they did not see a return on investment from these strategies” (Alagha et al. Journal of Pharmaceutical Policy and Practice 2022;15:78).
c. Continuing Medical Education
I strongly support requiring physicians who participate in industry-sponsored accredited CME to comply with the National standard for support of accredited CPD activities. But the National standards have weakenesses that are not acknowledged. They state that sponsors cannot participate in decisions around the development and delivery of content and that the “specific interests of any sponsor must have no direct or indirect influence on the content and/or materials of an accredited CPD activity”. However, neither of these provisions explicitly prohibits sponsors from offering to help speakers develop the content of their talks. Although speakers are required to disclose their conflicts there is nothing about how that disclosure should take place. One study looking at disclosures at the start of oral talks found that slides containing this information were shown for a median of 2 seconds (Grey et al. BMJ Open 2017;7:e017019).
d. Dissemination of research results
The policy about the dissemination of research results does not comment about bias in clinical trials note when principal investigators have financial ties with pharmaceutical company sponsors. In that case, financial ties (payment as advisors or consultants, receipt of honorariums, travel fees, stock ownership) was an independent predictor of positive clinical trial results (Ahn et al. BMJ 2017;356:i16770).
3. Missing elements from the policy
The policy should explicitly state that physicians cannot, under any circumstances, require medical students, residents or fellows to attend industry sponsored events.
4. The need for ongoing proactive promotion of the policy
Finally, even stringent policies will not be successful in guiding behaviour if they remain just on paper. The leadership of the CPSO must make strong and ongoing efforts to explain why its policy is necessary and do so through a variety of mechanisms. Studies about changes in clinical behaviour show that a positive result is only achieved when multiple assorted activities are used to deliver the same message over time (Gilman et al. Journal of Continuing Education in the Health Professions 2001;21:134-139).
Now that Mr. Ford and his colleagues are promoting the use of for profit surgical clinics will the dialogue be opened to include this Industry in the Conflict of Interest discussion – should my patients not go to my for profit surgical clinic for the best possible care?
I am greatly disturbed by the ever increasing infringement on physician liberties.
Having lived and practised in a communist regime for years, the ever increasing levels of control is bringing back bad memories.
Especially find I the definition of a “modest” meal at a CME event ridiculous.
Do you expect me to call my patients and ask for permission what I can eat ahead of
Professional Association of Residents of Ontario (PARO)
Thank you for the invitation to provide feedback on the CPSO Conflicts of Interest and Industry Relationships Policy document.
Overall we found it to be clearly written and to provide useful guidance.
We appreciated how “reasonable compensation” (pg.4) was defined in a footnote, and wondered if it would be more clear to have a “modest value meal” (pg.3) explained in a footnote as well instead of in the entirely separate Advice to the Profession document, or at minimum to have a footnote referring to the Advice to the Profession document for the explanation given there.
Similarly, there is a reference to “reasonable honoraria” (pg.4) that would also benefit from a similar footnote to that for “reasonable compensation”.
Thank you for the opportunity to contribute to the review of this policy.
Re: Need for conflict of interest regulations for all prescribing clinicians in Ontario
With the recent grant in Ontario of pharmacists of the right to prescribe medications, I think the conflict of interest discussion needs to be considered from a broader perspective. If pharmacists are prescribing medications to patients, is it appropriate that they also sell the same medications to the patient? Is it also appropriate that they also sell various products in the “wellness” vertical that are not rooted in evidence-based medicine (e.g. my local pharmacy sells various over the counter “herbal” lotions and treatments, versions of “Dr. Ho’s Pain Therapy system” etc) or are in fact clearly deleterious to health and patient wellbeing (junk food, lottery tickets).
It’s important that there be a discussion about conflict of interest–but these rules should apply to all prescribing clinicians (MDs, NPs, pharmacists who prescribe) rather than just singling out MDs. I applaud the CPSO for reviewing this, but I think this may need to be clear standards that are shared by all colleges representing prescribing clinicians rather than just the CPSO.
Ontario Medical Association (OMA)
Response in PDF format.
18.b- overall I like the policy but I want to make a comment regarding disclosing the type of benefit and amount of compensation
I totally agree that it should be disclosed that physician is paid for industry sponsored research but disclosing the amount is not reasonable as the research participant is not aware of the expenses to conduct the research. So it is not possible to disclose the actual compensation the physician retains.
In my opinion the requirement to disclose the actual amount should be deleted.
Very few physicians get involved in clinical research and this requirement may further discourage the physician participation.
I feel the need to request that there be more concrete language addressing these specific areas:
1. I ran into difficulty after I accepted a prescriber’s advice and decided to discontinue a drug I had taken for many years. When I tried to find more information in places I have always found reliable, like tier-one academic literature, I found almost every paper contained long conflict disclosures. I was actually unable to find any paper that did not resemble what is commonly called “grey literature,” and which I would normally just ignore or read with an unusual amount of attention. It looks like “normalization of deviance” is present to a surprising degree.
In any private sector job, if a client gives me some small gift, I thank them and disclose it to my boss. Usually it will be given away through an office lottery. The reason is that these gifts would never be given if they did not infliuence me in an unconscious way. If I am caught accepting an emolument or inducement, it is taken very seriously. My regulator would take a strong interest considering my duty to the public.
The situation is very serious considering the story of oxycontin and benzodiazepines, just as examples.
I wonder if this document could not benefit from a clear statement that such disclosures should not be common in academic papers authored or co-authored by regulated persons, because they are expected to avoid situations so obviously fraught with moral hazard.
This link to the Canadian federal government standard applying to civil servants in relation to apparent conflict of interest may be helpful:
2. In the family health team office, I have noticed pads resembling the ones used to write prescriptions in wall holders in exam rooms. The pads bear prominent logos for individual product and services suppliers, e.g. orthotics, physiotherapy companies. Because there are always some minutes waiting for clinical staff, I have had time to wonder whether the physician is receiving an emolument or inducement to make sure I have many “impressions” as they are called in the advertising industry. I could easily tell you the name of the orthotics supplier many years before their products were suggested to me, so it worked.
It undermines my confidence that I am getting reliable advice, unalloyed by commercial interest.
FAIR Association of Victims for Accident Insurance Reform
Response in PDF format.
Medications samples :
I think that it helps a lot of patients.
Many patients ( due to inflation after covid ) ask if any sample is available for their regular or any newly prescribed medications.
Response in PDF format.