Physician (including retired)
[March 23, 2022 3:38 PM]
It has been 8 years since the CPSO’s last version of the guidance document on relations with industry, and yet, the problematic influence of industry in our profession remains as strong as ever. Inappropriate polypharmacy is an increasing problem, especially among Canadian seniors. Physicians continue to be persuaded to prescribe the newest on-patent drugs. Commercially-driven CMEs abound, in which colleagues on pharmaceutical company speaker’s bureaus continue to tout the latest concepts and interventions, invariably favouring their latest products. At this point, there have been hundreds of studies about the impact of the pharmaceutical industry on physician prescribing behaviour: it is associated with lower quality, higher quantity, and higher cost of prescribing, with no evidence of improvement. Even as we are witnessing an opioid catastrophe, which was contributed to by the opioid pill mills from a number of years ago, we continue to see a mushrooming of for-profit clinics touting the latest fads. Unfortunately, I don’t know if the CPSO, our self-regulating body, is capable of the reforms required for meaningful improvement. Such reforms would be faced with fierce opposition from industry, and from many of our medical colleagues, likely including from within the CPSO itself. As such, this issue may be an example of the limits of self-regulation. Has even a single individual ever been disciplined for contravening the CPSO guidelines? If the CPSO is willing and able to lead on this issue, there should be more forceful language related to avoiding industry influence. For example, the current guideline states that “Physicians must critically evaluate any information provided by industry representatives and not solely rely on this information when making clinical decisions regarding patient care”. This is wishful thinking. Such language may have been acceptable 20 years ago, when some physicians would make such naïve and uninformed statements as “I’ll take the pizza and prescribe what I want / it doesn’t influence me”. Given what we now know about influence, why should physicians continue to get input and meals from people whose primary job it is to persuade them to use their product? Similar changes are sorely needed throughout the guideline. Conflict of interest disclosure has very limited utility on its own. Physicians should be explicitly prohibited from being on pharmaceutical and medical device companies’ speaker’s bureau, whereby they are paid to promote interventions on behalf of industry. Finally, the CPSO needs to seriously consider how it can enforce its policies on these issues.
Organization
[March 23, 2022 10:49 AM]
Ontario Medical Association (OMA)
Response in PDF format.
Other health care professional (including retired)
[March 22, 2022 9:57 AM]
The current guidelines are inadequate and became even more inadequate after the changes you made based upon your previous consultation. If CPSO were sincerely committed to EBM it would acknowledge the considerable body of evidence - much of it generated by Canadian scholars, such as Joel Lexchin - which demonstrates unequivocally that (1) industry funded biomedical research tends to show bias towards the sponsors' products, while (2) Industry funded educational programmes (including continuing medical education) leads to poor/inferior prescribing practices. If CPSO wishes to respect its fundamental commitment to patient well-being and research integrity it would adopt a policy of strict sequestration between medical research and clinical practice, on the one hand, and industry funding/gifts/benefits on the other. Clinical practitioners should not be accepting any gifts or benefits from industry and researcher should not be funded by for-profit companies. If requested, I would be pleased to send some of the research I have published in recent years on biomedical conflicts of interest and their malign effects on medical/research integrity and patient safety. I have for the past two decades lectured on COI at research hospitals and medical schools across North America and the UK. I have never met a physician or researched who believed that his/her judgement could be biased by industry funding/gifts. The knee-jerk response from your colleagues is, invariably: "I can't be bought for ... "(fill in the blank with a range of gifts from the pens to frisbees to sandwich lunches to five-Michelin-starred restaurants, laptop computers to exotic travel to significant honoraria). But a growing body of empirical research demonstrates that all of us "can be bought", and often for the cost of a free lunch. That is, the impartial/disinterested judgement which is owed to patients can be biased by trinkets as well as gold bars. Years from now, the medical profession will look back at the ineffectual COI policies of CPSO with embarrassment and shame. It's time to reverse the moral decline of the past few decades. Be brave and be bold.
Physician (including retired)
[March 07, 2022 8:28 PM]
Disclosure to the patient should occur when the physician has attended an industry sponsored event where the drug to be prescribed was discussed.
Physician (including retired)
[February 28, 2022 7:29 PM]
Reading through the current policy, it became clear that while the CPSO recognizes that doctors are influenced by industry inducements even when they do not believe they are, it nevertheless seems to endorse on-going self-regulated assessment of when situations may be tainted by conflict of interest. It seems to me that any cozying up to industry by physicians is subject to unconscious influence and that therefore some greater means of distancing between industry and the medical professions' clinical practitioners needs to be achieved.
Physician (including retired)
[February 24, 2022 5:17 PM]
While I recognise this may not be a popular view, I believe there is no role for industry support for educational programs for physicians. I also believe there is no good reason for physicians and their staff to accept ANY meals/refreshment from industry. Thank you.
Member of the public
[February 13, 2022 6:16 PM]
Note: Some content has been edited in accordance with our posting guidelines. Hello, As a mature member of the public and as I invited to provide my thoughts starting with the draft stage of the MAID at least 5-7 years ago, for this 2014 policy for edit, I have little to contribute aside from my present role as a research subject in an ongoing [redacted] COVID-19 vaccine surveillance study. I note the comprehensive recent message by a group including [redacted] among other contributors. At my first vaccine appointment during spring 2021, at a [redacted clinic], when I arrived I was invited to participate in the [redacted] study and agreed to that study now concluded at six months. My initial consent and e-mail address allowed for further contact about COVID-19 vaccine research studies. Before my second vaccine appointment the [redacted] vaccine surveillance study conducted by [redacted] was the second research I was invited to consider. My consent and eligibility for the [redacted] study were confirmed. It was a 48 week study with online diary and dried blood specimens at intervals, extended to a 96 week study with my consent after the third vaccine dose was offered to Ontario residents. Further, during winter 2022 an additional option I agreed, again by formal consent, to is a six week study of rapid antigen testing twice a week with online diary to further learn from vaccine surveillance research. All has been very well explained, the study materials sent for all aspects of the research and with my online study file and periodic sharing of my vaccine antibody results as obtained by dried blood specimens at defined intervals. Whenever there is a need to contact the study team, they respond very promptly by both phone or email. This is a well experienced research group and their perspective with respect to the current policy review might be welcome.
Organization
[February 11, 2022 4:21 PM]
Information and Privacy Commissioner of Ontario
Response in PDF format.
Physician (including retired)
[February 04, 2022 11:36 PM]
Note: Some content has been edited in accordance with our posting guidelines. Introduction We appreciate the opportunity to present our views regarding the development of an updated policy on the relationship between physicians and industry. Collectively, as researchers and academics we have been examining physician-industry interactions both in Canada and internationally and have presented and published our findings in multiple different fora including commissioned reports, peer reviewed journals and before parliamentary committees. Since the 2014 revision of the College of Physicians and Surgeons of Ontario policy statement on Physicians’ Relationships with Industry: Practice, Education and Research there has been a considerable increase in knowledge about the nature and impacts of interactions between physicians and the pharmaceutical industry. These developments have come about through two major policy and legal developments: 1) the public release of company documents through United States (US) legal proceedings on fraudulent marketing; and 2) the creation of the United States (US) Open Payments Database through the Physician Payments Sunshine Act. Consequently, we offer some recommendations to strengthen the 2014 policy statement that are grounded in this now substantial body of evidence. The evidence The first major new body of evidence that has arisen comes from public release of company documents in United States (US) legal cases on fraudulent marketing. US whistleblower protection legislation has been key to these court cases, with documentary evidence becoming public during evidentiary review. All the major multinational corporations found guilty also operate in Canada as well as other countries internationally and therefore it is impossible to believe that what has happened in the US does not also happen in Canada. These documents indicate extensive involvement of physicians in activities that have had deleterious health consequences, such as misrepresentation of the research evidence on benefits and harmful effects of medicines. Company documents detail physicians’ involvement on company advisory boards and speaker bureaus which contributed to off-label marketing activities and physicians as targets and recipients of misleading and inaccurate messages which led to poorer patient care. This recent US legal experience highlights the need for stronger safeguards of physician autonomy here in Canada. The recent high-profile lawsuits brought against opioid manufacturers has greatly enhanced knowledge about the relationship between industry promotion, including sponsored education, and devastating patient and population health outcomes. The epidemic of opioid overuse, with dire consequences for public health in Canada, has been fuelled in part by overpromotion of opioids beginning with the launch of oxycodone and its broad promotion for use in primary care and for chronic non-cancer pain. This experience has highlighted the harm to public and patient health that can occur through physicians’ vulnerability to unethical and misleading marketing of a class of medicines. In Canada, this has included misleading education on opioids – recommending broader use than is warranted – including being provided through industry financing of undergraduate medical education at the University of Toronto. This experience highlights the need to prevent similar harm in the future both in relation to physicians’ vulnerability to overpromotion and also ensuring that all medical education, both of students and in Continuing Medical Education, is independent of industry influences. Second, the US Open Payments data, released annually since 2013, has enabled researchers to understand the extent, distribution, and implications of industry payments to physicians at a national level. Evidence from analyses of data from the US Open Payments database combined with prescribing data, has shown the extent to which payments and gifts provided by industry are associated with shifts in prescribing. Challenging assumptions that influence can only occur through high-value gifts and payments, researchers have found that shifts in prescribing are associated even with the provision of low-cost meals. We have conducted research into physicians’ relationships with industry specifically in the Canadian context. Our research on conflict-of-interest policies at Canadian medical schools has indicated that medical students are not adequately protected against conflicts of interest in medical education, nor are they receiving adequate education on industry interactions they will experience once in practice. Second, we know from research involving random samples of primary care physicians in Vancouver and Montreal that the information physicians receive from pharmaceutical sales representatives is heavily biased towards mention of health benefits of medicines, with inadequate information both on common and on more serious rare harmful effects. The information Ontario physicians receive is likely to be broadly similar to that received in British Columbia and Quebec, with no harmful effects mentioned over half the time. Such incomplete information is inaccurate as it fails to provide a balanced understanding of the potential for benefit and harm from drug treatment. Reliance on sales representatives for information on medicines is therefore inconsistent with a physicians' fiduciary responsibility to patients. Core principles Any policy that the College of Physicians and Surgeons of Ontario (CPSO) develops must recognize core principles about how physicians and industry interact. The policy must: 1. Acknowledge the existence of a reciprocal gift relationship. When physicians receive anything from industry, including payments, meals, gifts, or even time, attention, and information, a sense of reciprocity is engendered and this relationship operates at a subconscious level; 2. Explicitly recognize that interactions with industry influence medical practice. Detailing, receipt of industry information, payments, or gifts, or attendance at sponsored events affects the way that physicians investigate, diagnose and treat patients and that physicians may not be aware of the effect of those interactions. There is abundant literature that demonstrates that physicians believe that individually they are not affected by their interactions; 3. Acknowledge that there is no evidence of benefit from industry information. There is no peer-reviewed, scholarly literature that shows that the cost, safety, or quality of patient care is improved when physicians get their information through interacting with industry; 4. Mandate that physicians disclose all relationships with industry. Transparency is a necessary first step and enables fair, open, and accountable processes for managing industry relationships. Physicians should publicly disclose the nature of their industry relationships and the value of compensation that they receive. In the remainder of our brief we highlight gaps in the existing CPSO policy, including in comparison with the previous 1992 policy and recommend changes that would more effectively safeguard patient care and professional practice. The Existing 2014 Policy The CPSO policy that regulates financial conflict-of-interest (FCOI) relationships between physicians and the pharmaceutical industry in Ontario is entitled Physicians’ Relationships with Industry: Practice, Education, and Research and was adopted in 2014. This policy was preceded by a 1992 policy, entitled MDs’ Relations with Drug Companies that was first developed and adopted by the Canadian Medical Association (CMA). What follows is a comparative analysis of these two policies. This comparison evaluates the extent to which both policies set standards for and regulates the interests and behaviours of physicians in Ontario. In the interest of providing adequate context, the table below includes verbatim quotes from the General Principles and Principles from the 1992 and 2014 policies, respectively. Following the table is a comparative analysis of not only these principles, but also some other key sections of each policy. COMPARISON OF THE PRINCIPLES OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO (CPSO) IN THE 1992 AND 2014 POLICIES. MDs’ Relations with Drug Companies (1992): General Principles (College of Physicians and Surgeons of Ontario, 1992) 1. The primary objective of professional interactions between physicians and the pharmaceutical industry should be the advancement of the health of Canadians rather than the private good of either physicians or industry. 2. The relationship between physicians and industry must always be in keeping with the fundamental ethical principles that govern social interactions in general. 3. The relationship between physicians and industry is constrained further by the CMA’s Code of Ethics. 4. The interactions between physicians and industry must always respect the fundamental values of Canadian society insofar as these values do not conflict with the fundamental principles of ethics. 5. The practising physician’s primary obligation is toward the patient. Relationships with industry are appropriate only if they do not affect the fiduciary nature of the physician-patient relationship. In particular, physicians should avoid any self-interest in their prescribing practices. 6. In any association between a physician who is not an employee of the pharmaceutical industry and the industry itself, the physician should always maintain professional autonomy, independence and commitment to the scientific method. Physicians’ Relationships with Industry: Practice, Education, and Research (2014): Principles (College of Physicians and Surgeons of Ontario, 2014) 1. Maintaining [physicians’] professional autonomy, clinical independence, and integrity; 2. Fulfilling their fiduciary duties by acting in the best interests of their patients; 3. Avoiding or recognizing and appropriately managing conflicts of interest that arise in relation to their professional duties; 4. Being transparent in their interactions with industry, and proactively disclosing the details of those interactions where they may be perceived to influence the physician judgment; 5. Participating in self-regulation of the medical profession by complying with the expectation set out in this policy. There are considerable differences between the General Principles of the 1992 and the Principles of the 2014 versions of the CPSO policies. First, the 2014 fails to clearly identify a physician’s “primary obligation,” which is necessary to evaluate whether a conflict of interest exists and how it should be managed. The 1992 policy repeatedly refers to the “primary obligations” of physicians, which is language that is consistent with the definition of conflicts of interest in medicine adopted by the US National Academy of Medicine (previously the Institute of Medicine), which has been widely cited definition: “A conflict of interest arises when there is a risk that their professional judgment or actions regarding a primary interest (i.e., the guideline) will be unduly influenced by a secondary interest (such as financial gain). In the 2014 policy, this language is absent not only in the Principles quoted above, but also throughout the remainder of the policy. The removal of this language from the 2014 policy is important to highlight because the absence of discussion about the primary obligations of physicians weakens the way that relationships with industry are presented to and conceptualized by physicians who are governed by this policy. Although Principle 2 in the 2014 policy states that physicians ought to “[f]ulfill their fiduciary duties by acting in the best interests of their patients”, the 1992 policy more clearly and effectively defines that the “[t]he practising physician’s primary obligation is toward the patient”, and ultimately, the “advancement of the health of Canadians,” which is also absent from the 2014 policy. In place of statements regarding physicians’ primary obligations in their professional roles, the 2014 policy is largely concerned with defining acceptable ways for physicians to engage in relationships with industry. For example, where the 1992 policy states that “…physicians should avoid any self-interest in their prescribing practices”, the 2014 policy does not. The term “self- interest” is used but is never further defined. Nevertheless, the removal of these important statements about physicians’ roles when it comes to their patients in the 2014 policy means that physicians may not be held to the standard that was previously enunciated. Physicians should be equipped with the necessary language and ideas to not only define their own professional roles in medicine, but also be able to successfully identify and mitigate conflict of interest relationships should they arise. Second, the 2014 widens the category of ‘acceptable’ research involvement, which may make physician susceptible to participating in research that does not further patients’ best interests. For example, the 1992 policy also includes statements, not included in the table above, about physicians’ participation in surveillance studies and accepting gifts. The 1992 policy states that “[p]hysicians are encouraged to participate only in surveillance studies (i.e., phase IV research studies) that are scientifically appropriate for drugs relevant to the area of practice”. However, the 2014 policy broadens the acceptable roles of physicians in clinical studies by stating that “[p]hysicians must only participate in research involving human participants, including post-marketing surveillance studies (phase IV clinical research), that has the approval of a research ethics board. This includes research that only involves the use of personal health information (PHI)”. Further, although both policies discuss remuneration, the 1992 policy is marginally more specific in the circumstantial parameters within which it is acceptable for a doctor to accept remuneration. The 1992 policy clearly states that: It is ethically acceptable for physicians to receive remuneration for participation in approved surveillance studies only if the participation exceeds their normal practice pattern. This remuneration should not constitute enticement…The amount of remuneration should be approved by the relevant review board, agency, or body mentioned previously. In contrast, remuneration is mentioned twice in the 2014 policy and in both cases, it is stated that “[r]emuneration must only be accepted if it is at fair market value and commensurate with the services provided”. In both these cases in the 2014 policy, this remuneration is considered in the context of consultation, advisory boards, or investigator meetings. The 2014 policy mentions nothing about requiring the amount of remuneration to be approved by a relevant committee and also does not set parameters for when this remuneration is acceptable. The 1992 policy stated that “[p]ractising physicians should not accept a fee or equivalent consideration from pharmaceutical manufacturers or distributors in exchange for seeing them in a promotional or similar capacity”. The 2014 includes a similar statement that “[p]hysicians must not request or accept a fee or equivalent compensation from industry in exchange for seeing industry representatives in a promotional or similar capacity”. A subtle difference in these statements between the two policies is that where the 1992 policy more broadly refers to “pharmaceutical manufacturers or distributors”, the 2014 policy refers more narrowly to “industry representatives”. Although the semantics here are subtle, the difference between “pharmaceutical manufacturers or distributors” and “industry representatives” is important to note. Another area of weakness in the 2014 CPSO policy, as compared with the 1992 policy, is CME. The 1992 policy states that “…CME clearly distinguishes between education, training…and product promotion”, while the 2014 policy makes no such statement. The 1992 policy tended to clearly prohibit or disapprove of relationships with the pharmaceutical industry, while the 2014 policy seems to be more concerned not with strong regulation of these relationships, but with the disclosure of conflict of interest relationships with industry in various scenarios. Despite the CPSO explanation that “…in all situations where a conflict of interest arises in the course of professional duties and activities, physicians should recognize the conflict, ensure that a patient’s best interests remain paramount and, where appropriate, disclose the conflict of interest to the patient”, in general, the 2014 policy is not strong enough for the CPSO or physicians to achieve this goal. The policy fails to define what it means by “where appropriate”, leaving this up to both voluntary disclosure and personal interpretation by the respective physician. The 2014 policy seems to provide weaker regulation of COI relationships between physicians and industry because it appears to be more tolerant of these relationships. Further, the 2014 policy contains nothing regarding the inclusion of any formal or informal conflict of interest training within the medical curricula. An additional important omission from the 2014 policy that was present in the 1992 policy is that “[m]edical curricula should include formal training that is based on [the 1992] guidelines.” We also note that the 2014 Principles and the remainder of the policy no longer state that physicians’ relationships with the pharmaceutical industry are also constrained by the CMA’s Code of Ethics. A weakness of both CPSO policies is that they fail to mention any penalties should the policies be breached. Finally, there are favourable additions to the 2014 CPSO policy. First, should physicians decide to participate in clinical trials, the trials must be “…registered prior to the enrolment of the first participant in a web-accessible research registry”. The reason that this provision was not included in the 1992 policy is likely because online publicly accessible clinical trial registries were not yet developed. Another positive addition to the 2014 policy is the definition of a conflict of interest. The 2014 policy defines COI as: A conflict of interest is created any time a reasonable person could perceive that a physician’s personal interest or relationship with industry is at odds with the physician’s professional responsibilities. It is important to note that a conflict of interest can exist even if the physician is confident that his or her professional judgement is not actually being influenced by the conflicting interest or relationship. However, we see in this comparative analysis that the omission of important language from other areas of the policy can render it difficult to enforce this definition of COI relationships, particularly the absence of discussion of the physician’s primary obligation in the form of “professional responsibilities.” Enforcement of the 2014 policy In order to determine whether any physician has been disciplined for violating the CPSO policy on COI relationships with industry, [redacted] contacted the CPSO with this question. According to a personal communication with the CPSO on 2 September 2015, it is not possible to filter search results for physicians that have been disciplined for violating a specific policy because the committees do not reference specific policies in their decisions. On advice from the CPSO on 2 September 2015, she attempted to locate CPSO decisions pertaining to violating its relations with industry policies from both 1992 and 2014 by searching for the key words “conflict of interest” (14 search results, 2 potentially relevant), “relations with industry” (0 search results), “relationship with industry” (4 search results, 0 potentially relevant), “drug company” (0 search results), “pharmaceutical company” (3 search results, 0 potentially relevant), and “pharmaceutical industry” (7 search results, 0 potentially relevant) in the site search. Out of the two potentially relevant search results from the key term “conflict of interest,” one concerned a physician who “…had a conflict of interest, in that he recommended cosmetic products in which he held a personal commercial interest to his patients” while the second referred to a physician who “…placed himself in a conflict of interest in that he ordered diagnostic testing for some of his patients, to be performed at his clinic, and failed to disclose his proprietary interest.” To summarize, there has been some focus on these issues, but it appears that the net outcome has been permissive policy development, no mention of penalties for policy violations, and no documented enforcement of the policies. Recommendations Taking into consideration the principles that we enunciated in the Introduction, our analysis of the 2014 policy and the lack of enforcement of that policy we offer the following recommendations. • The CPSO policy must be framed with a strong acknowledgment that interactions with industry affect prescribing habits, and that physicians may not be aware that their prescribing is affected. • The policy needs to explicitly acknowledge that conflicts of interest can affect physicians’ activities; in highlighting the need to declare conflicts of interest, an emphasis on avoiding conflicts that affect patient care should be maintained. • The policy must avoid the use of words such as “should” which implies that physicians have options. Should needs to be replaced with “must” to emphasize that the there is a clear ethical imperative on the part of physicians to always put the interests of patients first. • Interactions between physicians and company sales representatives lead to an overemphasis of the benefits of a product and an underemphasis on its harms. There is no literature that demonstrates that these interactions improve prescribing by any metric. The policy needs to be explicit about the harms of seeing sales representatives both in office and social situations. • All gifts of any size, even inexpensive meals, create a “gift relationship” that can negatively affect prescribing behaviour and acceptance of gifts should be banned. This prohibition needs to include “gifts” that are intended for patient education. • Medical students and residents are particularly vulnerable and the guidelines need to deal with their situation. They can feel coerced by their superiors into interacting with industry even when they feel ethically uncomfortable about doing so. The guidelines should make it clear that physicians cannot require medical students or residents to attend any function sponsored by a pharmaceutical company. Further, there must be avenues for students to confidentially report these types of activities if they occur with protection against reprisals. • Acknowledging a ghost writer does not mitigate the ghost author-guest author relationship. Physicians should not allow themselves to be listed as authors of publications that have been written by ghostwriters, even if the ghostwriter is listed in acknowledgements. • Industry funded continuing medical education is problematic. At best, even if there is no bias in its content, it focuses on a relatively narrow range of topics and emphasizes pharmacotherapy over other forms of treatment. The policy needs to explicitly acknowledge the problems with industry funded CME even when these events are organized utilizing the standards from the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. • Research, including Cochrane reviews, have repeatedly shown that there are biases when industry funds clinical trials and when principal investigators have a financial conflict of interest with companies. These biases are always in favour of the drug being studied. The policy needs to be explicit about this point. • Any new policy should more broadly define the term ‘industry representative’ to include not only drug company employees such as drug detailers, or drug representatives, but also physician or non-physician industry consultants, practice management consultants, key opinion leaders or thought leaders, clinical investigators seeking physicians’ assistance, or industry personnel who are involved in the planning and drafting of publication manuscripts. In conclusion, the lack of enforcement of the CPSO policies over time to cases of FCOI relationships between physicians and the pharmaceutical industry does not mean that these relationships are absent in Canada, or that these relationships do not have the potential to be harmful. Rather the lack of enforcement speaks to the lack of an aggressive policy of disseminating and implementing the policies. Policies that just exist on paper as ineffective. Dr. Robert Woollard, who was the driving force behind the CMA’s 1992 guidelines, felt that “The greatest disappointment of the [Canadian Medical Association] process has been the lack of effective implementation at the level at which physicians work and interact with the pharmaceutical and health care supply industries.” In light of Dr. Woollard’s comments we recommend that the CPSO leadership commits to a vigorous ongoing campaign to publicize the policy and the reasons why it is essential for patient health. [redacted] Faculty of Health York University and University Health Network and Faculty of Medicine University of Toronto [redacted] Faculty of Health York University [redacted] Faculty of Medicine and Health The University of Sydney and Faculty of Medicine University of British Columbia [redacted] Lawrence S. Bloomberg Faculty of Nursing University of Toronto
Physician (including retired)
[February 02, 2022 5:59 PM]
I speak as a physician who was a paid employee of a major pharmaceutical company for a year but am now a family physician who has spent many years studying drug companies' sales techniques. Since the success of Purdue's campaign to sell opioids their technique of using specialists(in their case pain specialists) to lecture other physicians about pharmaceutical products is now the norm for all drug sales. By providing lecture series to give physicians an easy and cheap way of meeting their postgraduate obligations, companies have direct access to physicians using doctors who they are paying to promote their sales message. The present guidelines need to be drastically upgraded to ban any physician from lecturing other physicians or serving on a guidelines committee if they are in any way receiving money from the pharmaceutical industry or their affiliates. Anything less will be manipulated by the companies and the doctors they pay to circumvent any rules the College tries to introduce to control what is now a disgrace to the profession and is ruinously costly to OHIP.
Other health care professional (including retired)
[January 27, 2022 6:37 PM]
I had an MBA instructor for a Marketing course who used to be a medical/sales representative for Pfizer. When he started to instruct us on how to influence the committee in charge of selecting drugs for hospital formularies, I was deeply bothered. I played the eager capitalist and asked how it can be done. Trust me, it can be done, he said. He held a sidebar conference with me and privately, I was aghast for the tactics he elaborated on and I was not surprised why he wanted them said in the strictest confidence. Only when I attended my first pharma shindig as an intern that I realized the truths in what I kept hearing about. The pressure to meet one's sales quota would be enough for a sales/med rep to be over-the-top creative in influencing prescribers. And many med reps I know are very proud of having these physicians in their pockets. How can many medical professionals who have sworn to do no harm, do exactly that? By being in the pocket of the pharma industry, treatment decisions can be very subjective, expensive and in many ways, harmful. Now, as a consumer of prescribed medications, I keep wondering if my physicians are looking out for my best interests, or theirs.
Organization
[January 24, 2022 9:30 AM]
Professional Association of Residents of Ontario (PARO)
Thank you for the invitation to provide feedback on the CPSO Physician's Relationships with Industry: Practice Education and Research Policy and accompanying Advice Document. We recognize and support the CPSO’s role to serve and protect the public and appreciate the privilege that we are afforded as physicians and surgeons to be a self-regulated profession. We appreciate that the CPSO has a very important role in protecting the best interests of patients and educating physicians on their ethical obligations towards their patients. We found this Policy and the accompanying Advice document to be comprehensive, provide clear guidance to physicians on the matters contained. One area where we thought it might be helpful to provide guidance is for trainees and medical students in a situation when their interpretation of what is compliant with the CPSO policy differs from their preceptors/leadership. We appreciate this may be something that falls under the CPSO Supervision of PGME trainees Policy and Medical Student Policy, if that is the case, then it could be expressly pointed out in this policy. We do, as always, appreciate being included in the CPSO's consultative process.
Other health care professional (including retired)
[January 18, 2022 3:37 AM]
It is very sad to see how the pharmaceutical industry exerts a HUGE influence on many practicing physicians. For example, many times Actonel DR is being prescribed NO SUB, when the generic generic risedronate and its DR counterpart are available, and the patient's preference is the cheapest as he can still remember to take them on empty stomach. Placing a NO SUB on the Rx means another $100++ out of pocket for 90-days supply as most insurance would only cover the generic price OR ... a back-and-forth faxing to justify the NO SUB or removing the NO SUB, entailing a delay on the patient's treatment Another disappointing issue is that biosimilars are not interchangeable and when undesirable side effects are experienced, the patients are beholden to physicians who would not switch to another biosimilar, even when requested. I am aware of these many cases as I am a practicing pharmacist in both US and Canada. Why is that?, I would ask myself, because I cannot obviously confront the prescribing doctor, as I have been told to study another 4 years and attend medical conferences so I can prescribe them myself (this is a true story). The answer is clearly the payments many pharmaceutical firms are paying these doctors as part of their marketing schemes. It takes two to tango, I say. CPSO may have these ethical guidelines, including not to take more than "modest" amount of meals from pharm reps. But are they being followed? Obviously not, especially in the field of rheumatology, dermatology and gastroenterology, where outpatient physicians are not restricted in following hospital formularies and where immunosuppressants for Crohn's disease, psoriasis, rheumatoid arthritis, etc, cost thousands of dollars. The solution: pharmaceutical companies and physicians should file every dollar they give and take, respectively, similar to what is being practised in the US in recent years. The money being exchanged is very easy to track and should be published online. This, I believe, will lower the cost of many drugs, as publication of promotional expenses can serve as a deterrent against biased prescribing.
Physician (including retired)
[December 28, 2021 6:14 PM]
2014 guidelines are outdated and must urgently be reviewed by the CPSO Post pandemia, a lot has been learned Confusion should not be allowed. One interlocutor, one voice, public health advised by NACI
Physician (including retired)
[December 22, 2021 12:35 PM]
Note: Some content has been edited in accordance with our posting guidelines. [Dermatology publication] is approved for self-learning by the Royal College. The Journal lists 4 editors and at least 2 of them do work for a myriad of drug companies with hundreds of publications. (medical writers). The article on onychomycosis is a veiled add for topicals, presumably, Jublia. This product has received widespread scientific criticism, particularly by CVS drug chain in the States, who questioned its use. This journal is just one of many in all specialties. The Royal College is aware of this problem, but must rely on input from our various specialty societies, who largely rely on industry for their funding. This circle cannot change, unless the various provincial colleges bring in punitive measures against the use of ghost writers, physicians serving on marketing advisory boards, use of industry prepared lectures, et al. The Ontario College could be a world pioneer in leading the way. Thank-you.
Physician (including retired)
[December 17, 2021 10:33 AM]
Drug companies do not do any funding without an expectation of a return. Their mandate is the bottom line. Societal benefits are usually a distant second.
Physician (including retired)
[December 16, 2021 10:06 PM]
Note: Some content has been edited in accordance with our posting guidelines. CPSO industry submission---December 2021. Dear CPSO : I am grateful that you are soliciting input on this important issue. Industry (big pharma, devices, testing facilities) ) is essential to our well-being;---- but so are automobiles and planes. However, the latter have strict regulations considering their safety and use. Similar regulations are lacking concerning the relationship of physicians to Industry. Industry bias is affecting scientific integrity, patient health, health care costs, and the honour of our profession. Too many university professors and KOL's are involved,--sometimes unknowingly. The CPSO physician guidelines are not being followed,, and will continue not to be,--unless the CPSO acts and introduces punitive measures. The American sunset disclosure laws and disclosures for presentations and publications are ignored, and often untrue.. He who pays the piper calls the tune. Punitive measures are required. Many industry physicians are earning large sums. A. The attachment contains considerable portions of a letter that I sent to all council members and senior CPSO executives in February 2019. Please note the 1/2 to 1 page gap after the first page in the attachment. I could not correct. Total 7 pages. B. Additional comments. i) I recently attended a lecture by a 'giant' in our field, who is the author of a major textbook. He/she spontaneously said: " Lectures are being given by doctors who are paid, whether they believe it or not. " In subsequent correspondence they noted: "I hope you realize that I have worked very hard to have a balanced approach in the textbook regarding therapies. I do not receive any funds from pharma. This allows me to mouth off anytime. In addition, I have deleted numerous pages of submitted chapters which I felt represented infomercials. I have also been approached by pharma via the publisher and have basically said------ no infomercials. " The influence of industry is profound and they specialize in key opinion leaders, residents, CME, and CME programs (including modules submitted to Royal College). c. An innovative trial i) Last year I submitted a poster to the Canadian Dermatology Association discussing the negative views of 31 Toronto dermatologists concerning their use of topical crisaborloe (Eucrisa by Pfizer). The poster was rejected without explanation, Pfizer is a big CDA funder. [redacted]. The CDA has accepted about 25 of my previous submissions. ii) I was wondering about making complaints to the CPSO about clear cut cases of ghost writing and other activities, but have not done so,-----because of colleague relationships, and because it is probably not fair to single out an individual, when so many are involved. D. So ubiquitous that it has become a standard of practice. The CPSO has the opportunity to be a world leader if it acts firmly on this matter, Thank-you