“ For the triumph of evil it is only necessary for good men to do nothing.” Edmund Burke

1. “For the triumph of evil it is only necessary for good men to do nothing.” Edmund Burke

2. Institutional corruption • No individual within an institution wants misconduct to flourish, but nobody is directly responsible--so it does flourish.

3. Bristol: another example?

4. Doctors and drug companies. Too close for comfort?

6. 16 forms of entanglement between doctors and drug companies • Face to face visits from drug company representatives • Acceptance of direct gifts of equipment, travel, or accommodation (“Will you advertise my drug on your person for a year if I pay you 20p?”) • Acceptance of indirect gifts, through sponsorship of software or travel

7. 16 forms of entanglement between doctors and drug companies • Attendance at sponsored dinners and social or recreational events (“If they have to pay the full whack they won’t come?”) • Attendance at sponsored educational events, continuing medical education, workshops, or seminars (“Could you hurry up so we can get to the vol au vents?”) • Attendance at sponsored scientific conferences (“Bugger Bognor, but the Gritti Palace in Venice sounds good.”)

8. 16 forms of entanglement between doctors and drug companies • Ownership of stock or equity holdings • Conducting sponsored research (“It’s so hard to get money from the MRC and £800 for registering a patient is not bad.”) • Company funding for medical schools, academic chairs, or lecture halls • Membership of sponsored professional societies and associations • Advising a sponsored disease foundation or patients' group

9. 16 forms of entanglement between doctors and drug companies • Involvement with or use of sponsored clinical guidelines • Undertaking paid consultancy work for companies (“A return flight on Concorde, five nights at the Ritz Carlton, and 20 grand is not bad for two hours of blah.”) • Membership of company advisory boards of "thought leaders" or "speakers' bureaux” (“Flattery and money: I can resist everything except temptation.”)

10. 16 forms of entanglement between doctors and drug companies • Authoring "ghostwritten" scientific articles (A critic on Naomi Campbell’s autobiography: “If she can’t be bothered to write it I can’t be bothered to read it.”) • Medical journals' reliance on drug company advertising, company purchased reprints, and sponsored supplements (“It’s a million quid and £800 000 profit for reprints of a major trial. Without it I might have to lay off staff. But we’re not influenced in our decision making.”)

11. Does all this matter? • Virtually all new drugs, which have been so important for medicine, have come from drug companies • Drug companies must have the right to market their products • Prescribing is influenced--often to be unnecessarily expensive

12. Does all this matter? • Information is biased • Doctors are too dependent on drug companies for both education and information • Companies spend more on marketing than on research • Costs are inflated

13. Corruption in medicine? Evidence from medical publishing

14. Corruption in medical publishing • Redundant publication occurs in around a fifth of published papers • About a fifth of authors of studies in medical journals have done little or nothing • Most authors of studies in medical journals have conflicts of interest, yet they are declared in less than 5% of cases

15. Conflict of interest: a case study in poor performance within biomedicine

16. How common are competing interests? • 75 articles on calcium channel anatagonists • 89 authors • 69 (80%) responded • 45 (63%) had financial conflicts of interest • Only 2 of 70 articles disclosed the conflicts of interest • Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium channel antagonists. N Engl J Med 1998; 338: 101-105

17. Why don’t authors declare conflicts of interest? • Some journals don’t require disclosure • The culture is one of not disclosing • Authors think that it’s somehow “naughty” • Authors are confident that they are not affected by conflicts of interest

18. Does conflict of interest matter? • Financial benefit makes doctors more likely to refer patients for tests, operations, or hospital admission, or to ask that drugs be stocked by a hospital pharmacy. • Original papers published in journal supplements sponsored by pharmaceutical companies are inferior to those published in the parent journal. • Reviews that acknowledge sponsorship by the pharmaceutical or tobacco industry are more likely to draw conclusions that are favourable to the industry.

19. Does conflict of interest matter? • Is there a relationship between whether authors are supportive of the use of calcium channel antagonists and whether they have a financial relationship with the manufacturers of the drugs? • Stelfox HT, Chua G, O'Rourke K, Detsky AS. Conflict of interest in the debate over calcium channel antagonists. N Engl J Med 1998; 338: 101-105

21. Does conflict of interest matter? • 106 reviews, with 37% concluding that passive smoking was not harmful and the rest that it was. • Multiple regression analysis controlling for article quality, peer review status, article topic, and year of publication found that the only factor associated with the review's conclusion was whether the author was affiliated with the tobacco industry. • Only 23% of reviews disclosed the sources of funding for research. • Barnes DE, Bero LA. Why review articles on the health effects of passive smoking reach different conclusions. JAMA 1998; 279: 1566-1570

22. Does conflict of interest matter?: third generation contraceptive pills • At the end of 1998 three major studies without sponsoring from the industry found a higher risk of venous thrombosis for third generation contraceptives; three sponsored studies did not. • To date, of nine studies without sponsoring, one study found no difference and the other eight found relative risks from 1.5 to 4.0 (summary relative risk 2.4); four sponsored studies found relative risks between 0.8 and 1.5 (summary relative risk 1.1) • The sponsored study with a relative risk of 1.5 has been reanalysed several times, yielding lower relative risks; after this failed to convince, a new reanalysis was sponsored by another company.

23. Other topics I might have covered • Private practice • “X has had a heart attack. Who’ll do his on call?” • “Whover does it normally, when he’s doing his private practice.” • Merit awards • Fundholding: keeping prescribing deliberately high in order to maximise next year’s budget • Racism • “Lucragrams”

24. Why do we have corruption? • Why wouldn’t we? • Much of medicine operates on trust • Inadequate accountability • Inadequate training • Poor role models • “Pressure to publish”

25. Why do we have corruption? • The main target of one of the world’s richest industries • Tribal loyalty • “Under no circumstances would I shop another doctor” • “Not even if he was murdering his patients, like Harold Shipman.” • “Not even then. I know how hard it is to be a doctor.”

26. Why do we have corruption? • “There but for the grace of God go I.” • “The bogus contract” • Patient: “Modern medicine is wonderful. You can see inside me, fix my problems” • Doctor: “I’m more impressed with what medicine can’t do than it can do. I can’t fix this. I’d better keep quiet. My salary and my status comes from my ‘magical’ powers.”

27. What can be done about corruption in medicine? • Set high standards • Increase transparency in appointments, merit awards, private practice • Increase accountability: appraisal, revalidation, CHAI, etc • Interact more professionally with the drug industry

28. Survey on bmj.com: 1479 responding • Would you like doctors to stop seeing drug company representatives, replacing them with more independent sources of health information? • Yes 79% • Would you like doctors to stop receiving all forms of direct and indirect gifts from drug companies? • Yes 84%

29. Survey on bmj.com: 1479 responding • Would you like industry-funded education of doctors replaced by education funded by more independent sources? • Yes 84% • Would you like all financial relationships between doctors and drug companies conducted with transparent contracts that are disclosed to patients and the public? • Yes 96%

30. What can be done about corruption in medicine? • Teaching/discussions on best practice in relating to patients, research, etc • Leadership (“Tone at the top”)

31. Finally, recognise something that I didn’t recognise until I was fifty and three quarters

32. “Integrity is not something you have and hope not to lose but something you must work at every day.”