Parang N. Mehta

Reprint requests: Dr. Parang N. Mehta, Consultant Pediatrician, Mehta Hospital, 
Opposite Putli, Sagrampura, Surat 395 002, India.

Modern medicine demands that its practitioners make efforts to update their knowledge and enhance their skills at frequent intervals. Continuing medical education programs ( CMEs) are arranged by medical associations and other bodies for this purpose. In some countries, attendance at CME programs is essential for a doctor to continue in clinical practice. Even where it is not, its value is apparent to all conscientious medical practitioners.

Of late, there is a trend of conferences being held at luxurious and expensive venues. The cost of these opulent events is many times that which is strictly necessary, and the expenses are often borne by pharmaceutical firms. Grants, sponsorship, and other financial aid to CME activities is an established practice, but there has been much concern about the influence wielded by the sponsors. It is a truism that the man who pays the piper calls the tune; how independent can a CME program be which is being paid for by a pharmaceutical firm which can gain substantial amounts of money by convincing doctors to prescribe their drug or brand?

CME programs are seen by many pharmaceutical firms as opportunities to promote their products. It is well known that sponsoring pharmaceutical firms try to influence the selection of topics and speakers at CME events, as well as the contents of the course. Many pharmaceutical firms employ doctors who join the faculty of the CME program that is sponsored by the firm. At its extreme, the excessive influence of a sponsor can change a conference or seminar from a scientific exchange of ideas to a promotional vehicle for a particular drug or brand.

IAP Surat Branch has been arranging CME programs for several years now, and we have faced the same issues. An analysis of our records over the past three years was done, with some predictable results. Over this period (1997, 1998 and 1999), we have arranged nine one day CME programs, five half day CME programs, twenty six clinical meetings and a few miscellaneous programs like guest lectures, practising pediatricians quiz, undergraduate quiz, etc. Considering that the main objective of our association is to provide continuing medical education to our members, it is not surprising that the bulk of our expenses went towards this objective (Table I).

Table I: Expenses of IAP Surat 1997-1999

As can be seen from Table II, annual subscriptions and CME fees contributed only small portions of the total annual income of the society. More than half (54.5%) of the association’s income was generated from pharmaceutical firms. While this has been necessary for making ends meet, we have been following certain guidelines while raising funds:

1. We do not accept any sponsorship from makers of ayurvedic and homeopathic drugs, or from makers of products that a rational doctor would not prescribe.

2. We do not accept any sponsorship that contravenes the Infant Milk Substitutes Act, in letter or in spirit.

3. Pharmaceutical firms are asked to pay a fixed sum in return for a stall at the CME venue. No pharmaceutical firm is asked, or allowed, to sponsor an entire program by meeting all its expenses (single source sponsorship is associated with outcomes favourable to the sponsor’s product(s)). As only a fixed, small sum is being received, the society has the need and incentive for economy and austerity. This ensures that there are no lavish banquets and inappropriate entertainments.

4. The payment of the fixed sponsorship amount entitles the pharmaceutical firms to a stall at the venue to display their products. They also hand out literature and samples to the delegates who visit their stall, and put up banners at the venue.

5. The sponsors have no say in the selection of topics of the conference, or in the selection of speakers. No employee of a pharmaceutical firm is allowed to address the delegates from the dais. By so doing, we attempt to keep the contents of the continuing medical education secure and trustworthy, untainted by commercial interests.

6. These terms are made clear to the pharmaceutical firms in writing at the time of requesting sponsorship. No other guarantees are given, though obviously the sponsors do expect to benefit.

7. We give no gifts to the delegates, save those that are needed in the CME (pen, paper, etc). The hospitality provided is in consonance with the occasion, and of the level which the delegates would normally have if paying for it themselves.

8. It is a great temptation to accept offers of having a well known speaker brought to the program by a drug company at their expense. However, we do not accept these offers, as it is difficult to ensure freedom from obligation of the speaker concerned.

9. The pharmaceutical firms are not given the option of sponsoring a meal. The members/delegates do not feel indebted to any drug company for their meals or coffee.

Over the past few years, we have been gradually raising the delegate fees at our CME programs, so that nearly half of our expenses are met in this way. In course of time, we may be forced to do away with sponsorship in the interests of ethical and reliable continuing medical education. This is a future reality that all organizers of CME programs should contemplate. It is unrealistic to expect that pharmaceutical firms will contribute large sums of money to our programs, and not try to influence the contents of the program.

Table II: IAP Surat Income, 1997-1999

Drug firms’ influence on CME programs has been long debated in the medical literature. A recent meta analysis(1) found that pharma-ceutical firm sponsored continuing medical education preferentially highlighted the sponsor’s drug(s) compared with other CME programs. Attending sponsored CME events and accepting funding for travel or accommodation for CME programs were associated with increased prescriptions of the sponsor’s products. Worst of all, attendance at presentations by pharmaceutical industry speakers was associated with nonrational prescribing.

A CME program which has lectures by employees of pharmaceutical firms is dangerous. Most doctors are on their guard when a product is detailed by a drug company representative. However, a conference speaker who appears to be objective, but subtly favours one product, or interprets data in a slightly skewed manner, carries conviction, especially as the delegates are often unaware of his/her affiliation.

A conference does not, of course, become ineffectual or untrustworthy by the very fact of industry sponsorship. Drug-company sponsor-ship is not harmful in itself, but it is if the money affects the integrity of the faculty, the association, or the delegates. The following questions should be answered about any sponsored event. Is the information presented unbiased, complete, and truthful? Is it fair and balanced? Do any of the speakers have drug industry affiliations? Does the course content increase the delegates’ knowledge base? Did the sponsors influence the choice of topics or speakers at the conference?

A recent study from our country(2) shows some disturbing results. Delegates at a CME program organized by a city unit of the IAP were probed about the sponsorship issue. It was disheartening to see that only 13% of delegates were willing to pay for a conference entirely on their own. Obviously, we doctors have become used to having other people pay for our continuing education, even though it is an essential part of our professional needs. Equally upsetting is the fact that as many as 68% of the participants wanted to pay only a small fraction (Rs. 200-300) of the expected expenditure of a conference. This attitude forces the organizers to turn to the drug makers, perhaps at the cost of having a motivated and biased CME program.

This study(2) discloses that our members are not willing to pay for their own education, meals, and recreation. Since this will inevitably compel CME organizers to accept financial aid from pharmaceutical firms, it is incumbent on the Indian Academy of Pediatrics to discuss the issue and formulate appropriate guidelines.

As the basis for any such effort, it is essential to recognize that acceptance of money, gifts, or hospitality establishes a relationship between the receiving doctor and the giving company(3). This relationship has a component of obligation to respond, which may sway our decisions regarding patient treatment. This is especially so when food is involved; a fine meal can create an atmosphere of conviviality and agreement, and a special relationship is often formed(3). The company’s ultimate goal in this relationship is to increase sales and profits.

Pharmaceutical firms seek an advantage for their brands by arranging the CME program itself, or the recreational and other associated activities, at luxurious venues(4). The meetings could be held at a much lower cost by choosing less expensive venues. CME organizers who agree to such exotic and expensive sites play into the hands of the sponsors. The support of pharmaceutical houses for educational purposes is perhaps justifiable; their patronage for social activities or banquets can have no legitimacy.

Physicians have a duty of self improvement. To provide the best possible care to their patients, they must add constantly to their knowledge and skills. Their participation in CME programs is a fulfilment of this duty. Drug companies participate in these programs to increase prescription support for their products, and they ensure this in a number of ways– gifts to delegates, dinner receptions, sponsoring the travel and stay of delegates, and even accompanying persons. Accepting fund-ing for travel or accommodation for CME programs has been seen to be associated with increased prescriptions of the sponsor’s products. No doctor would prescribe an obviously incorrect drug to a patient, but it is quite possible that the fund giving company’s product would be chosen over a cheaper or slightly superior competing one. Making a treatment decision on any grounds other than what is best for the patient is immoral and unethical.

It is an accepted fact that unproductive expenditure does not survive long in the world of commerce(5). If gifts and financial support to doctors and their associations did not influence prescribing practices and increase market share, drug companies would not spend their money thus. No drug company gives away its shareholders’ money in an act of dis-interested generosity.

Most gifts by pharmaceutical firms are desk ornaments, decorative items, and trinkets of small value. However, drug companies are also known to sponsor all the expenses of a doctor for attending a conference, including delegates fees, travel, accommodation, and local enter-tainment expenses. Expenses of a spouse and family are also sometimes covered similarly. What effect such a high value gift has on integrity and prescribing behaviour can only be conjectured.

A debate will serve to sensitize IAP members about this issue. While a code of conduct may prove impossible to enforce, it would enhance ethical awareness and promote the ideal. Pharmaceutical industry support of CME programs is likely to persist for some time, and it is essential for the IAP to formulate guidelines on what is acceptable in this regard. When driven into the drug makers’ arms, CME organizers should not fall into their hands.

Contributor: The paper is the personal viewpoint of PNM, and was entirely concieved and written by him.

Funding: None.
Competing interests: None stated.

1. Wazana A. Physicians and the pharmaceutical industry: Is a gift ever just a gift? JAMA 2000; 283: 373-380.

2. Jain MM, Khatib SA, Shenoi A. Questionnaire survey on sponsorship of continuing medical education program by pharmaceutical companies. Indian Pediatr 2000; 37: 190-192.

3. Chren MM, Landefeld S, Murray TH. Doctors, drug companies and gifts. JAMA 1989; 262: 3448-3451.

4. Margolis LH. The ethics of accepting gifts from pharmaceutical companies. Pediatrics 1991; 88: 1233-1237.

5. Kohrman AF. Pediatricians’ relations to for-profit corporations. Pediatrics (Indian Edition) 1992; 4: 110-112.