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Heart Docs Reject Claims Of Bias From Industry Money

Many physicians attending the Heart Rhythm Society conference see little cause for concern in the heavy financial support drug and medical device industries provide to medical specialist societies, saying the ties are informative and beneficial to patient care.

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A scooter tows a St. Jude ad in San Francisco where the Heart Rhythm Society convention was held. Photo by Robert Durell for ProPublica.

SAN FRANCISCO—Outside the giant Moscone Center, Dr. Mark Englehardt paused as a gaggle of scooters drove by carting ads for products made by St. Jude Medical.

“This is kind of silly, isn’t it?” the Raleigh, N.C., electrophysiologist said, gesturing at the surrounding scene.

Idling just feet away were several large buses emblazoned with ads for competing medical device makers Medtronic and Boston Scientific, ready to shuttle attendees of the Heart Rhythm Society’s annual conference back to their hotels.

The society, representing 5,100 professionals who treat patients with irregular heartbeats, received nearly half of its revenues last year from drug and medical device companies. That included more than $5 million from its conference alone.

As ProPublica reported last week, researchers who study conflicts of interest in medicine say such a heavy reliance on industry money can be unhealthy if it influences practice guidelines and medical advice that such professional groups give. But while Englehardt said the barrage of promotions seemed “peculiar,” it didn’t bother him. The drug and device industries are essential, he said, to the millions of patients with irregular heartbeats and the thousands of doctors who treat them.

“I’ve always been rather offended that people who aren’t doctors think I’m susceptible to bribes and corruption,” Englehardt said. “A lot of what you learn about products is from people that sell the products. … You have to learn it somewhere.”

Englehardt was typical of conference attendees interviewed about the relationship between the society and industry. On the whole, doctors said they weren’t worried that the money might bias their decisions or the society’s.

The extent of industry funding has grown within the Heart Rhythm Society—from 37.5 percent of revenues in fiscal year 2006 to nearly half last year, according to the group’s financials

In a blog post Friday about ProPublica’s story, one researcher said doctors need to look at their societies more skeptically.

“The take home message here is how these organizations sell their own membership to industry as a way to add to their funding potential,” wrote Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch at Galveston.

Before attending annual conferences, Brody said, doctors should check their professional society’s web site to see what kind of pitch is made to exhibitors, who pay large sums for booth space and advertising.

“See how you yourself is [sic] being marketed to the drug and device companies as advertising fodder, whose behavior your society more or less promises to deliver over to the industry if only they invest enough funds in supporting the meeting,” Brody wrote.

In the Heart Society’s case, exhibitors were reminded of the enormous financial clout of its members.

“Physicians and allied health professionals who attend scientific sessions write billions of dollars a year in prescriptions; invest hundreds of millions of dollars a year in equipment; spend tens of millions of dollars a year in product and service purchasing and leasing,” says the exhibitor prospectus for last week’s meeting.

One implantable cardioverter defibrillator, a device to shock the heart back into normal rhythm, can cost more than $30,000. A single electrophysiologist may implant dozens a year.

At the Heart Society event, which ended Saturday, defibrillator makers and other firms splashed promos on hotel key cards, newspapers left at each doctor’s door, staircases and cell phone charging stations, in addition to the buses and billboards.

“I’m pretty immune to it,” said Dr. Jeffrey Moak of Washington, D.C.

Said Dr. Khalid Almuti of Cincinnati: “I’m not going to decide what kind of a device I’m going to put in a patient just because I see a bus that says Medtronic.”

Some doctors acknowledged that the corporate barrage must have some effect. “I hope not, but I’m certain that it does,” said Dr. Christopher Conley of Nashville, Tenn. “I’m sure the companies do their own research. They wouldn’t be here, they wouldn’t be putting all this money out if it didn’t influence people.”

Dr. Edward J. Schloss, also of Cincinnati, suggested another reason for the pervasive ads: Companies may be leery of showing weakness.

“I think it would be great if everybody scaled it down,” he said. “But it may be difficult for one company to scale it down unilaterally without looking inferior in the eyes of the doctors.”

Doctors said the heart society meeting was an important opportunity to learn about new research in their field and see new products on the market. Unlike in many other areas of medicine, they said, electrophysiologists work hand-in-hand with device company representatives to program implantable defibrillators and diagnose problems.

Device company employees are in the operating room during procedures and come to the hospital to respond if a patient’s defibrillator delivers a shock.

“The people in the industry are people I work with every day,” said Dr. Richard T. Smith Jr., a pediatric cardiologist in Charlotte, N.C. “I know all these companies. I know all the people that work for them. They’re actually my friends. Many of my friends are actually competitors with one another.”

Besides, several doctors said, much has changed in the past decade as public attention has focused on conflicts of interest in medicine. Pens and notebooks emblazoned with company logos are verboten at conferences. And corporate sponsored bashes with live music acts disappeared years ago.

Doctors said they were unconcerned by ProPublica’s finding that the society, on several occasions, left out or downplayed information about the risks and limitations of cardiac devices and procedures.

“It’s not their job to educate the public,” Conley said of the society. “The person who actually does the procedure, that is his job.”

One society member who was not at the conference praised the Heart Rhythm Society on his blog for posting details of the money it receives from industry on its website so the public and media can examine it. Many professional groups don’t offer such detailed information.

“It will be interesting to see if other medical societies are as forthcoming as the Heart Rhythm Society has been,” wrote Dr. Westby Fisher of Evanston, Ill. “What is clear is that as dollars get tighter and tighter for health care, the scrutiny of these practices and their potential to influence doctors will only continue to intensify.”

At a sparsely attended conference session Thursday, the society’s leaders laid out their philosophy and policy on industry relationships, why they consider them important and what limits the society imposes on them.

Still, incoming society President Bruce Wilkoff wondered whether the focus on the potential conflicts posed by industry support had become too great.

“We have demonized relationships to such an extent that no self-respecting” young physician or scientist would choose to work with industry, he told the audience.

“It’s time to push back,” he said, adding that the society should publicly stand behind collaborations that can result in improved patient care.

At the end of the session, there were no questions or comments from the doctors in the room.

So why are we bombarded with “Ask your doctor"adds from the drug companies? For the same reaspn the doc’s are being schmoozed by these folks. As for taking a doc’s word regarding any med’s or implants,I for one would ask the doc if they receive any form of compensation or gratuity from the maker of the product the doc wants me to use. Great job Pro Publica. You are doing a better job than our government!

It should be noted that many of Dr. Brody’s remarks are predicated on the social medicine theory of medicalization - a theory that can neither be proven or disproven.

Unfortunately, leaving ideological context out of any article can cause distortions. Journalists report political affiliations as a matter of course, but much less so in health and medical reporting.

This theory of medicalization has been important and pervasive in medical sociology and other psychosocial viewpoints.

Also known as naturophilists, adherents such as Dr. Brody decry the increasing “medicalization of society” in which formerly natural functions have come to be regarded as medical conditions requiring intervention or treatment.

However, history suggests that naturophilia is usually undermined by any new medical technology that offers clear, safe, and immediate benefits to patients.

For example, prior to 1842, intense pain was viewed as the natural outcome of being cut with a scalpel during surgery. It had always been so—how could it ever be otherwise?

The invention of anesthesia in 1842 suddenly altered this natural outcome and replaced it with a less painful artificial outcome, despite anguished cries from naturophiles (including feminist Elizabeth Stanton Cady) within the medical community that eliminating pain might somehow diminish the human character.

Others believe the natural process of childbirth has been medicalized, but fail to note that medical intervention when needed has substantially reduced the mortality rate for women and children.

It is important to include such context when writing about so-called artificial interventions. In fact it is just as important as noting financial affiliations because as the Lancet says in its conflict of interest statement ideology can be a conflict as well.

Kate’s comments are learned but not germane to this problem. The ads work, most especially on a subliminal level. This is why the companies, who are not stupid in these matters, spend such a vast amount of money upon them. Their research is quite often much more evidence-based than the practice habits of their customers, sad to say.

The doctors who think that they are not influenced by them, especially on a subliminal level, are at best naifs. The doctors who feel that “A lot of what you learn about products is from people that sell the products. … You have to learn it somewhere” are at best suckers.

As a physician active in a specialty society that has striven mightily to rid itself of this stuff, at considerable cost to its budget, I have no sympathy for the docs and organization who feel entitled to this stuff, or who think that they can swim in scum without picking up so much as a bad smell.

Now you know my “ideological context.” Et tu?

Gerald Zuckier

May 10, 2011, 10:23 a.m.

Well, as we all know, cardiologists are hurting pretty badly for money so they could hardly afford to have meetings without sponsorship. Luckily the altruism of the industry is such that they cheerfully donate anonymously for the public good, rather than as a marketing tool.

What’s funniest about all of this is that cardiology is far in the forefront of Evidence Based Medicine and reliance on statistical evidence; but apparently, corporate statisticians’ estimates of the therapeutic efficacy of a product after adusting for clinical factors are convincing, but the company’s internal analyses done by the same statisticians of the increase of sales of a product due to corporate sponsorship after adjusting for medical factors are disregardable.

This article would have been more complete by comparing the marketing and numbers for procedural based treatment, implants, etc in the US as opposed to other developed countries.  I have read several accounts that seem to show that the US healthcare system, in particular, has been hijacked by corporate marketing and a profit based pricing incentive.  Doctors can deny that they are being influenced by all the marketing but if they are prescribing expensive treatments at a higher rate than doctors in other developed countries, their denials are self delusion.

As a journalist who writes about health and medicine, my ideological context is excellence in journalism. Without appropriate context regarding sources facts may be neither reliable or accurate. That “ideology” which can be found on the Excellence in Journalism website, it is not unique to me, and applies regardless of the subject.

If a source has a specific thought process behind their thinking (ideology) then readers need that information to determine what, if any, influence this has regarding the information given by the source.

In this case, Dr. Brody’s orientation toward artificial interventions is germane. It helps place his remarks in context.

Quite simple really.

Uhhhh…okay…..I accept that we need to know about the source…, it enhances critical review - or at least the motivation to do critical review…but the data, if they are valid, can stand by themselves. Res ipsa loquitur, and all that.

This reflects a difference between journalism and science: data vs story. Both can be important…and most often the use of either by itself is incomplete. The story, the narrative if you would, is enriching and validating. OTOH, it may also disguise the data. However, it cannot obliterate them. In this case the data are even more germane than the narrative. Because the ads work.

Of Course, M.D.

May 10, 2011, 2:25 p.m.

According to Dr. Brody, everything that is wrong with the practice of medicine in this country is the physicians’ fault. Please! I don’t believe Dr. Brody has seen a patient in a long time. He may have good intentions and some of his criticisms may be justified at times; however, his constant diatribe will only help take away whatever little professional freedom physicians have left in this country, which is not very much at all anymore. As far as pharma, I strongly believe most physicians do their best for their patients, industry or not. We are all under a never-ending number of external influences all the time anyway, including our own political convictions, place of training, religion, cultural upbringing, peers, inherent biases, and of course industry, etc. So what? Do you go out to buy a new TV or car without thinking only because you just saw a TV ad? Most physicians retain their critical clinical thinking just fine in the face of all these external influences, of which industry is only a part. Besides, most patients don’t care about pharma, only a few vocal self-righteous zealots do.

A conflict of interest (COI) exists if a reasonable observer might find it plausible that a physician could be (not necessarily would be) swayed by a particular secondary interest (herein marketing).  Certainly this is the case at this cardiology meeting.  CsOI have the potential to create bias that might influence the care of patients.  Many MDs feel they can resist the effects of the CsOI by virtue of their intelligence, education, experience, and training, but multiple research studies have shown that is not the case. MDs (not all, but some if not most) can be influenced.  In some studies 2/3 of responders felt they were not influenced by pharma’s marketing but felt that most of their colleagues were!  If this type of marketing were not effective, industry would not spend all that money. These cardiologists strive to practice evidence-based medicine, relying on best available published science to guide their decisions.  Yet they seem to ignore the published evidence with regard to COI, bias, and its potential to influence medical care.  The influence is subconscious, powerful, and outside our rational awareness. It is a neurological and psychological phenomenon; deeply ingrained.  So it becomes essential to separate marketing from education.  It is true that if industry monies were scaled back, professional medical associations might need to charge more for annual meeting tuitions and raise dues while scaling back some of their activities. But in the bigger picture, care of patients would be influenced by best science, not best marketing.

Of Course, MD

May 10, 2011, 8:39 p.m.

Jerome, being “influenced” is not enough even if this is the case with most pohysicians, which in fact it is not. However, for the sake of argument, let’s pretend that pharma influences most physicians. This is not a valid research endpoint. We are all “influenced” by a myriad different things all the time so “documenting” this really proves nothing. The only valid research endpoint here would be to conclusively demonstrate that such an influence (and we can still argue that this exists to any meaningful degree) directly translates into a medical clinical action that hurts patients, society, or both. There is absolutely no evidence that this is the case. And this is the only thing that matters. Presently, in medicine, with all these denunciations and criticisms, we are just treating a potential “misperception”; however, this is not a good enough reason to take away the professional freedom of US physicians. It is this constant never-ending erosion of our professional freedom that I decry. In fact, medicine has now ceased to be a free profession in this country. We are currently living in an overly regulated “Big Brother” system that is slowly and insidiosculy proving to be much worse than comunist Russia ever was.

I started out in practice with a POV somewhat like that of “Of Course, MD,” at least with respect to pharma. After thirty years out of fellowship, I am in essentially total agreement with Jerome. Both experience and evidence, data and narrative if you would, concur. Certainly, Brody is somewhat of a crank in many respects. However, that does not erase the validity of his observations in this matter, nor in the conclusions that logically derive from them.

I do appreciate O.C.MD’s comment at the end of his post - they clarify his ideology. So much of what many regard as “freedom, on all sides of our society, is illusory. Professional freedom, as many docs would define it,  is a social, economic, and legal construct, requiring a myriad of laws, economic interventions, and privileges. One could posit that docs in Canada (that awful, pinko, communist hellhole) have more profession freedom than we do - they certainly do in the cognitive specialties. Of course, the proceduralists don’t make as much money as ours do, and they encounter more resistance for elective or boutique stuff.

‘Nuff said.

As I follow this somewhat prejudicial storyline about doctors and their relationship with pharmacuetical companies (a tightly regulated relationship that has been overblown with recent Hollywood portrayals ie Love and Other Drugs) a leftward bias is starting to emerge. Does Pro Publica reveal it’s close relationship and fund awards through multiple George Soros fronted non-profits? Do people know about this relationship? Seems you are pushing the agenda for a socialized single payor medical system but systematically demonizing the pharmaceutical industry. 
http://www.foxnews.com/opinion/2011/05/11/dont-hear-george-soros-ties-30-major-news-organizations/

Of Course, MD

May 12, 2011, 10:45 a.m.

I stick to my views about the constant erosion of physicians’ professional freedom in this country, the overly regulated status of US medicine, the demonization of pharma, and ultimately, the “witch hunt” against physicians that results from all this. Unless this is properly denounced and recognized for what it is, medicine in this country will continue to go down, deteriorate in its quality, be increasingly practiced by non-physicians, become truly mediocre, and be avoided in the very near future by our best and brightest. Is this what we want?

This article is part of an ongoing investigation:
Dollars for Doctors

Dollars for Doctors: How Industry Money Reaches Physicians

ProPublica is tracking the financial ties between doctors and medical companies.

The Story So Far

ProPublica is investigating the financial ties between the medical community and the drug and device industry. In October 2010, ProPublica compiled the list of payments that drug companies make to physicians and built a publicly searchable database so that patients could look up their doctors.

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