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Skip to 0 minutes and 5 secondsIf there's one simple thing that people can do to protect themselves against unnecessary tests and diagnoses and treatments, it's to be a healthy sceptic, to ask more questions, to interrogate your health professionals, to try and seek out evidence that's not tainted by vested interests, and to really question as much as possible. Do I really need that test? Do I really need that diagnosis? Do I really need that treatment or intervention? And gather the evidence and discuss it with your loved ones and use as much evidence as you can to inform your decision-making. There's little doubt that particularly in wealthy, developed nations, we're going through a period of excess in medicine. The problem of too much medicine is attracting increasing attention.

Skip to 1 minute and 0 secondsAnd one of the challenges in the 21st century for all of us is to try and work out how to wind back that excess safely and fairly. Clearly, medicine has enormous value. Sophisticated diagnostic tests and treatments can save lives, can extend lives and ameliorate suffering. But there is little doubt that we have too much of a good thing. And so the potential for the public to become better informed about the problem of excess-- to become better informed about where to seek out more independent sources of evidence-- is going to be a very valuable part of this story of medicine in the 21st century.

Skip to 1 minute and 48 secondsPart of the problem when we're looking for evidence in medicine is that so much evidence comes from vested interests, largely the pharmaceutical companies who run large amounts of the clinical trials that provide the evidence base for medicine. Sadly, we know that company-funded studies are much more likely to find favourable results than independently run studies. And so there's a real challenge for us to start producing more independently funded studies, but also to seek them out. There's a problem with medical experts. Many senior medical experts are taking money, directly or indirectly, from pharmaceutical companies. And again, we need to seek out more independent experts to rely on, to discuss the benefits and harms of medical interventions.

Skip to 2 minutes and 41 secondsSadly, a lot of patient groups are also reliant on industry funding. And so we have to be sceptical about claims that are made by patient groups that we know to be taking industry money. And lastly, unbelievably, the very definitions of disease can be tainted by industry influence. A study that I and colleagues have done showed that many of the panels of experts that actually define diseases, that set diagnostic thresholds, that decide whether or not you are a patient or a person, many of those experts are taking money from the very companies that stand to benefit from those decisions. Across medicine, there are multilayered marketing campaigns that impact on medical evidence and the way it's disseminated.

Skip to 3 minutes and 33 secondsAnd we really need to be much clearer about those vested interests and their influence, and to try and move away from them. Pharmaceutical marketing is extremely sophisticated. It's multilayered. And doctors and other health professionals are really targeted from the cradle to the grave. The marketing starts in medical school and moves through the professional lives of doctors. Education is funded. Clinical studies are funded. Key opinion leaders are funded. Public awareness campaigns are funded. So marketing is multilayered. It starts at medical school. It moves through the drug rep going into the doctor's office or the doctor's surgery. Then it's about taking the doctor to dinner. Then once you're a senior specialist, it's about flying you to exotic locations for conferences.

Skip to 4 minutes and 30 secondsAll of these things still occur despite what we might hear to the contrary. And there is increasing unease about the impacts of marketing on medical research and medical education and medical practise. So there's a real opportunity at the moment for us all to be seeking out more independent sources of information to inform our decision-making, for ourselves and our loved ones. One of the good things in medicine at the moment is that we're getting a lot more transparency, particularly about the connections between health professionals and pharmaceutical companies. It's been a long time coming, but it is happening. And the United States has actually raised the bar internationally.

Skip to 5 minutes and 15 secondsThey've got a new law called the Sunshine Act, which now means that every payment by every drug company to every doctor has to be recorded and revealed on publicly accessible websites. This is really setting a new threshold in transparency that the rest of the world is slowly trying to catch up with. So if you're a person in the United States, you can check out just how much your health care professional receives from pharmaceutical companies, whether it's a small lunch or a trip overseas. And surely, this level of transparency is something that we all deserve.

Skip to 5 minutes and 55 secondsOne of the key arguments for why pharmaceutical companies have to work with senior specialists is that they need the intelligence and the advice of those senior specialists to guide their behaviour, to guide their research. Now, there is validity in that argument. And there are situations where it's utterly legitimate for a pharmaceutical company to work with a senior specialist. But until now, we haven't been able to see those relationships. We have had senior specialists purport to be independent and purport to give us independent advice, when they're privately receiving payments from drug companies. So we need to lift this transparency bar in the way that the United States has with the Sunshine Act.

Skip to 6 minutes and 48 secondsIt's also important to remember that just because a doctor takes a dinner from a drug company or takes a trip from a drug company or gives a lecture from a drug company doesn't mean that that doctor is crudely influenced or is being bribed. It's much more sophisticated and nuanced than that. It's about a lifetime of exposure to marketing. It's about the regular interactions between senior specialists and GPs and pharmaceutical companies that can subtly distort the ways in which doctors practise. And so it's not a simple or crude bribe. It's much more about a pattern of influence.

Skip to 7 minutes and 35 secondsAnd indeed, this is why august bodies like the Institute of Medicine in the United States have recommended a disentangling of this influence between the medical profession and the industry. Of course, some level of collaboration is valuable and important for new drug discovery, and so on. But all of the interconnected, marketing-based relationships are simply unhealthy. They're causing harm, and they're causing waste. And rational health care systems are going to move to wind them back. One idea that's often floated is that we create some sort of pot or several pots around the world, and drug companies can pull money into that pot, and researchers can independently take the money out the other end.

Skip to 8 minutes and 27 secondsOne of the problems with that is I think a lot of drug companies wouldn't be that keen if they couldn't have some sort of control of where their research dollar was going. The other thing is that's starting to sound awfully like a tax. And so if we are interested in creating larger pools of public money for medical research, one way to do that is to increase taxation on the companies that are profiting from health care.

Skip to 8 minutes and 56 secondsAnd indeed, given the problems we're aware of at the moment with tax avoidance behaviour on the part of some of the drug companies, it may well be that if those companies start paying their fair share of tax in national jurisdictions, we may find ourselves with a larger pot potentially that could be spent on medical research. There exists a kind of systematic bias in a lot of the medical research. This is very problematic. It means that benefits are exaggerated and the potential harms of treatment played down. And so we have to, in the longer term, move away from this situation we have at the moment where so much research is sponsored by industry with vested interests.

Skip to 9 minutes and 48 secondsBut in the meantime, we need to be as critical as we can be about analysing the evidence that we have. We can't take it on face value. We need to drill down. We need to systematically review. We need to look at all of the studies, not just one study. And we need to be very sceptical about the claims that are made for how well things work.

Funding, bias and transparency

Dr Ray Moynihan is a Senior Research Fellow at Bond University in Australia who has written extensively on the relationship between industry, health research and treatment. We interviewed Ray about the importance of scepticism, bias and the calls for greater transparency about pharmaceutical marketing and funding.

As the audio on the call with Ray was not ideal, we’ve reproduced the transcript below.

Ray Moynihan: “If there’s one simple thing that people can do to protect themselves against unnecessary tests and diagnoses and treatments, it’s to be a healthy sceptic - to ask more questions, to interrogate your health professionals, to try to seek out evidence that is not tainted by vested interests and to really question as much as possible:

“Do I really need that test? Do I really need that diagnosis? Do I really need that treatment or intervention?”

And gather the evidence and discuss it with your loved ones and use as much evidence as you can to inform your decision making.

There’s little doubt that particularly in wealthy, developed nations, we’re going through a period of excess in medicine - the problem of too much medicine is attracting increasing attention. One of the challenges in the 21st century is work out how to wind back that excess safely and fairly.

Clearly medicine has enormous value. Sophisticated diagnostic tests and treatments can save lives, can extend lives and ameliorate suffering. But there is little doubt that we have too much of a good thing. And so the potential for the public to become better informed about the problem of excess, to become better informed about where to seek out more independent sources of evidence is going to be a very valuable part of this story of medicine in the 21st century.

Vested interests

Part of the problem when we’re looking for evidence in medicine is that so much of evidence comes from vested interests, largely the pharmaceutical companies who run large amounts of the clinical trials that provide the evidence base for medicine. Sadly, we know that company funded studies are much more likely to find favourable results than independently run studies and so there’s a real challenge for us to start producing more independently funded studies but also to seek them out.

There’s a problem with medical experts. Many senior medical experts are taking money, directly or indirectly, from pharmaceutical companies and again we need to seek out independent experts to rely on to discuss the benefits and harms of medical interventions.

Sadly, a lot of patient groups are also reliant on industry funding so we have to be sceptical about claims that are made by patient groups that we know to be taking industry money.

And lastly, unbelievably, the very definitions of disease can be tainted by industry influence. A study that I and colleagues have done showed that many of the panels of experts that actually define diseases, that set diagnostic thresholds, that decide whether or not you’re a patient or a person: many of those experts are taking money from the very companies that stand to benefit from those decisions.

Industry and marketing

Across medicine, there are multi-layered marketing campaigns that impact on medical evidence and the way it’s disseminated and we really need to be much clearer about those vested interests and their influence and to try and move away from them.

Pharmaceutical marketing is extremely sophisticated. It’s multi-layered and doctors and other medical professionals are really targeted from the cradle to the grave. The marketing starts at medical school and moves through the professional lives of doctors. Education is funded, clinical studies are funded, key opinion leaders are funded, public awareness campaigns are funded. It moves through the drug rep going into the doctor’s office, then it’s about taking the doctor to dinner, then once you’re a senior specialist, it’s about flying you to exotic locations for conferences. All of these things still occur, despite what we hear to the contrary and there is increasing unease about the impacts of marketing on medical research and medical education and medical practice. So there’s a real opportunity at the moment for us all to be seeking out more independent sources of information to inform our decision making for ourselves and our loved ones.

The growing calls for transparency

One of the good things about medicine at the moment is that we’re getting a lot more transparency, particularly about the connections between health professionals and pharmaceutical companies. It’s been a long time coming but it is happening and the US has really raised the bar internationally. They’ve got a new law called the Sunshine Act which now means that every payment by every drug company to every doctor has to be recorded and revealed on publically accessible websites. This is really setting a new threshold in transparency that the rest of the world is slowly trying to catch up with. So if you’re a person in the United States you can check out just how much your healthcare professional receives from pharmaceutical companies whether it’s a small lunch or a trip overseas. And surely this level of transparency is something that we all deserve.

One of the key arguments for why pharmaceutical companies have to work with senior specialists is that they need the intelligence and the advice of those senior specialists to guide their behaviour, to guide their research. Now there is validity to that argument and there are situations when it is utterly legitimate for a pharmaceutical company to work with a senior specialist but until now we haven’t been able to see those relationships. We have had senior specialists purport to be independent and purport to give us independent advice, when they are privately receiving payments from drug companies. So we need to lift this transparency bar in the way that the United States has with the Sunshine Act.

It’s also important to remember that just because a doctor takes a dinner from a drug company or takes a trip from a drug company, it doesn’t mean that the doctor is crudely influenced or is being bribed: it’s much more sophisticated and nuanced than that. It’s about a lifetime exposure to marketing. It’s about the regular interactions between senior specialists (and GPs) and pharmaceutical companies that can subtly distort the ways in which doctors practice. And so it’s not a simple or crude bribe: it’s much more about a pattern of influence. And this is why august bodies like the Institute of Medicine in the United States have recommended a disentangling of this influence between the medical profession and the industry. Of course some level of collaboration is valuable and important for new drug discovery and so on, but all of the interconnecting marketing-based relationships are simply unhealthy. They are causing harm, and they are causing waste and rational healthcare systems are going to move to wind them back.

One idea that’s often floated is that we create some sort of pot, or several pots, around the world and drug companies can pour money into that pot and researchers can independently take money out the other end. One of the problems with that is that I think a lot of drug companies wouldn’t be that keen if they couldn’t have some sort of control over where their research dollar was going. And the other thing is that’s starting to sound awfully like a tax. And so if we are interested in creating larger pools of public money for medical research, one way to do that is to increase taxation on the companies that are profiting from healthcare. And indeed given the problems that we’re aware of at the moment with tax avoidance behaviour on the part of some of the drug companies it may well be that if those companies start paying their fair share of tax in national jurisdictions, we may find ourselves with a larger pot that potentially could be spent on medical research.

Conclusions

So there exists a kind of systematic bias in a lot of the medical research. This is very problematic. It means that benefits are exaggerated and the potential harms of treatments are played down and so we have to in the long term move away from the situation we have at the moment where so much research is sponsored by industry with vested interests but in the meantime we need to be as critical as we can be about analysing the evidence that we have. We can’t take it on face value. We need to drill down. We need to systematically review. We need to look at all the studies, not just one study. And we need to be very sceptical about the claims about how well things work.”

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This video is from the free online course:

Making Sense of Health Evidence: The Informed Consumer

Cardiff University