GlaxoSmithKline Not to Pay Physicians for Endorsements: Meh

James Hamblin writing at The Atlantic has a short piece on the announcement by GlaxoSmithKline to Stop Paying Doctors for Endorsements. Hamblin’s primary point is that GSK will not pay physicians to “give speeches about their products at medical conferences”. And further down Hamblin writes

Doctors still have to learn about new medications somewhere, of course. It is in everyone’s interest that doctors are made aware of the newest pharmaceutical developments. We are most likely to trust that information when it comes through the filter of respected colleagues. How many such doctors would misinform their peers just to get paid?

A couple of points I believe are missing from this piece. If you refer to the NYT article that had the original announcement a second change was being made, pharmaceutical sales people will no longer be paid in part based on number of Rx written. That tied with physician payments may have a more positive effect. 

Physician speakers/lecturers/KOL’s at medical meetings are not out and out hocking drugs like barkers in a side show. These national and state medical meetings are run by medical societies and associations like the American Heart Association, ASCO, American Academy of Dermatology, etc. Pharma gets to side show their products in the exhibit halls. The lectures are primarily CME programs and as such are under very strict and managed rules dictating bias, fair balance, and disclosure of speakers conflicts of interest, identified needs assessment, etc. And most, if not all, of these lectures are the product of third party educational companies or medical societies etc. They are not executed by pharma nor are they dictated by pharma. Pharma will give grants to companies who identify topics, speakers, needs, etc all to solve a clinical issue. So we do not know if GSK will stop supporting CME through medical education companies and societies. The Sunshine Act allows speakers paid by a medical education company or a medical society not to have to disclose that fee for speaking was from pharma since it was from a third party. Kind of money laundering? 

Truth be told pharma does hold and pay for non-CME promotional education. There is no hiding pharma sponsored education. Those who attend these meetings come to learn about the drug straight from the horses mouth. Of course we all know studies that were even slightly negative about the drug never get into the monograph.Good luck in critical appraisal without full disclosure. So at these promotional education activities GSK won’t be paying physicians. I doubt if they will be abandoned all together. The speakers may be in house physicians. But physicians will be paid for CME just not directly from phama. And these CME lectures will have balance and transparency and address a clinical need. 

It is also important to note that those physicians who are speaking at the CME events are most likely investigators on the clinical trials and are very knowledgeable about the therapeutic area and disease. That is why they are speaking and are trusted. So directly paying physicians to lecture on a drug/disease will not amount to much. We will have CME doing the lions share of the educational work. But there is much to not known right now and we will have to wait and see how GSK executes this portion of their announcement. 

Pharmaceutical sales people not having income linked to Rx is big. I have seen this question asked in other places, how will GSK know who is producing? I imagine management will know because pharma will never surrender knowing the number of Rx each physician is writing. The issue is going to be, GSK can’t fire the underproducing sales person based on Rx since they are not being paid for that. So what will be the measure? How well educated on a disease or drug topic is the physician, does knowledge translate into Rx, is the sales persons physicians satisfied with GSK, etc? Also this may change that whole I don’t want to see a pharma rep attitude of physicians. Since the rep is not being paid for Rx perhaps the physician would be willing to spend more time or even speak with them. Nah the sales person is a GSK shill. Will the sales person still stock the sample closet? 

There are some bigger issues here that are not addressed by this window dressing. First and foremost is the product monograph. When a drug is approved by the FDA based on clinical trials it has a single product monograph identifying all known knowledge about the drug, the disease, side effects, etc. We now know trials that impact the drug negatively do not make it into the monograph. We need full disclosure to the FDA during the approval phase so that all data is known. This is important so a physician can truly perform a critical appraisal. 

I am not fooling myself, most physicians are busy wire to wire day in and day out. They do not have the time or inclination to deconstruct a monograph or a sales aid in order to make a critical appraisal of the drug. They trust that the FDA has done its job when it approved a drug for sale for an indication. And consider that most practices are made up of different types of patients some with a plethora of issues that need to be weighed against the drug. That is where the pharma company sales person, promotional materials etc help the busy physician. By identifying the salient issues and science. Of course truth in advertising and selling is similar to the Easter Bunny. And pharma is rated in trustworthiness at the bottom of the trust barrel. So how do we return pharma to a trusted place? While helping the overworked physician to make head or tails out of promotional material. 

I would like to think that GSK would want to provide a series of educational programs CME or otherwise to teach HCPs how to perform critical appraisal on clinical trial data. Make the HCP the gate keeper not of Rx alone but of how to access and use knowledge. Give them the tools to reject, accept, or apply appropriately where drug xyz can be used and on whom. A wise man once said a pharma should not seek a 100% share of a market but a 100% share of those patients who will benefit the most and most appropriately from the drug. Differentiation in a crowded marketplace will come from educating your audience to see the value and designing the drug and its clinical trial to show that value.

I just saw this post on The Healthcare Marketer Blog “Should Physicians Disclose Potential Conflicts of Interest to Patients?“. The simple answer is yes. And it fits with the discussion above the more the patient knows the better he or she can align their values to their physician. This drives the physician to improve their knowledge and care since the patient is facing them asking questions. This post introduces the Who’s My Doctor a movement promoting and driving transparency on the part of the physician. 

Check out the Total Transparency Manifesto for Dr. Leana Wen to see what real transparency looks like. 

There are a lot of moving parts in this discussion and finding the right balance is going to be a long fought battle. We are seeing more and more patients raising questions about their care and making demands to know and understand treatment. Patient engagement is at the heart of this change and will continue to drive it. Perhaps we have a bright future in our healthcare system to spite current events. And GSK has drawn a line in the sand that we will see if others cross.