tag:blogger.com,1999:blog-7655407863660711763.post4354585091390567077..comments2023-04-13T15:43:17.917-04:00Comments on Billy Rubin's Blog: CME Funding: Family Fight ReduxBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.comBlogger5125tag:blogger.com,1999:blog-7655407863660711763.post-13435855938640581722009-02-12T13:34:00.000-05:002009-02-12T13:34:00.000-05:00Dr. Rubin,You don’t avail yourself of the freebies...Dr. Rubin,<BR/>You don’t avail yourself of the freebies at those meetings. That’s well and good, but you (or your medical group which pays your registration fees) do benefit from the largesse of the drug companies in terms of reduced fees. In one of the comments above you said “I'm not going to cut off my nose to spite my face…”<BR/><BR/>But, if you and others who advocate for a ban on industry support are successful, won’t you have done just that? IDSA meetings and others like it would cease to exist altogether, or in anything near their present form without support. That was one of the points I made in the Medscape piece under the category of unintended consequences. I didn’t want to cite personal communications in that piece (maybe I should have) but leaders of CME meetings have said that such meetings would not exist without support. I recently asked Bob Wachter, for example, if he could continue his UCSF hospital medicine course without support. His answer was, essentially, “no way.”<BR/><BR/>I’m still curious as to why you even bother to go to IDSA in view of your answer:<BR/>“Anyway--how do I deal with the pervasive bias at the premiere meeting for ID docs? The quick answer is: not very well.” If that’s true wouldn’t you be better off, and save yourself considerable time away from practice and family, to get the same information from sources like Medical Letter, UptoDate, or independent literature searches?<BR/><BR/>In reference to some comments you made in your post, I want you to understand my position. I am not advocating for CME credit for a dinner meeting with a drug rep and a paid speaker. I thought it would be clear to readers that that type of activity is not on the table for this discussion. Such activities (at least in my state!) are no longer accredited, (haven’t been for some time) nor should they be. And if you can cite an example of accredited “CME” which promotes Nexium or Ketek over better alternatives I’ll be the first to agree that such activities should never have been accredited. That’s a far cry from a total ban of industry support.Robert W Donnellhttps://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-7655407863660711763.post-76708498693911454682009-02-12T12:33:00.000-05:002009-02-12T12:33:00.000-05:00I think a mildly-prolonged back & forth is not...I think a mildly-prolonged back & forth is not a bad idea, actually; I'd be perfectly willing to have a point-counterpoint like we're having in the main post of both your blog and mine. (Shall we invite Dr. Carlat, too?) Seriously, I think there's more to explore about this issue, and I'm genuinely curious about how a physician of your obvious thoughtfulness about medical issues (I didn't read -all- of the February entries, but many--and thanks for the heads-up on fondiparinux!) manages to square the circle with respect to conflict-of-interest issues regarding the relationship between drug companies and docs. So from my point of view there's more to hash out, though I would appreciate laying off the hyperbole about thought-police & witch-hunting & whatnot.<BR/><BR/>Anyway--how do I deal with the pervasive bias at the premiere meeting for ID docs? The quick answer is: not very well. I suspect that a certain percentage of what I "know" as an internist and an ID physician is bunk. Some of it is bunk because we've just got the wrong scientific model (this was the topic of my post on the JUPITER study, which I think is genuinely interesting because the lower-your-cholesterol angle may be totally wrong, even though that's been the central model for atherosclerosis for over two decades); that's unavoidable and how science works. Some of the time it's because somebody's got some other agenda, and given the huge financial rewards for producing a blockbuster drug, that other agenda is most commonly associated with large pharmaceutical firms. These organizations are highly-organized and determined. Normally in business I think that's a -good- thing, but the evidence that the large, multinational firms try to game the system at every opportunity--via conventions, friendly chats at the office with drug reps, the cushy dinners, and yes, ensuring favorable articles in theoretically objective journals--is to me simply overwhelming. So I have no illusions that at least some of what I take as gospel may be either flawed or the product of manipulation by people who stand to gain lots of money by influencing which medications I prescribe. I have difficulty understanding how other physicians, including those capable of zeroing in on a potential confounder of a study with lighting-fast speed and the vengance of an archangel, can't see the obvious problem this poses. So how do I deal with it? Not well, but with what limited influence I have I can argue that perhaps we should consider doing what we can to create a firewall between Us & Them so that our objectives remain uncontaminated, and their objectives don't place us in any compromising positions (that is, the kind that you read about almost daily in the NYT, WaPost, WSJ, LAT and the rest).<BR/><BR/>For your second question--how do I separate the wheat from the chaff?--I have two replies. I make no pretense that I have some remarkable ability to divine which drugs are fabulous and which are stinkers, and as I noted above I would guess that some of my prescription patterns are directly influenced by the system or because I don't have the time to chase down all the articles on medications, particularly trivial ones.* That said, I have a few rules that I try to apply:<BR/><BR/>a. Be suspicious of fantastical claims of new drugs ("new" being vaguely defined as "approved by the FDA over the past 2 to 3 years").<BR/>b. Be HIGHLY suspicious of "me-too" drugs, i.e. newly patented drugs in the same class as some other previously-approved drug. I have seen nothing to indicate why Prevacid is better than Protonix is better than Nexium is better than Prilosec--and omeprazole, Prilosec's generic name, should in theory be made by generic companies at a theoretical substantial savings to the entire healthcare system. But you, Dr. Donnell, know as well as I that most hospital formularies carry no such drug--they've been wheeled & dealed by the makers of the patented drugs, often at substantial discounts, so that they can develop brand loyalty when they are discharged and can be customers-for-life as outpatients. So, if it isn't the original in its class, and especially a new one out, I think it has, as Desi Arnaz observed, a lotta 'splainin to do.<BR/>c. When possible (not always the case), be suspicious of brand-name claims when there is an equivalent generic available in its class. In ID, you see people (sometimes even ID docs! but usually unaware hospitalists and primary care folks) often inappropriately prescribing really important drugs like Invanz (generic name ertapenem) in place of the considerably-cheaper ceftriaxone or cefazolin because they got lazy and were told a some lunch how great Invanz was. Well--it IS an important drug, one of the most helpful for people with serious and/or resistant infections, but it sure as hell won't be if everyone prescribes it for routine cellulitis or community-acquired pneumonia! <BR/>d. I try to attend University clinical case conferences as often as possible. The University where I work, like many in this part of the country, has strict policies on whether drug reps are allowed to bring goodies and discuss their products (in brief, they're mostly not).<BR/><BR/>None of these are failsafes, and each have exceptions (e.g. I am a big big fan of Atripla for HIV, which came out about 2 years ago, is only a reformulation of previous drugs, and is a cash cow for its makers), but following these precepts certainly help. Or at least I hope they do.<BR/>--br<BR/><BR/>*(For instance--is Zofran REALLY that much better than Compazine or Phenergan for non-oncologic cases of nausea? I know it's a lot more expensive, yet the hospital that I do my part-time work for has Zofran as the default anti-emetic in the automatic drop-down order menu in the computer. In other words, you have to go -out of your way- to order the cheaper drugs that for all I know have never been shown to be less effective. But then the nurse calls me later in the night because she's -heard- of Zofran, and why didn't I prescribe that? Sometimes it's not worth fighting the fight, and Zofran is of course a fine medication.)Billy Rubinhttps://www.blogger.com/profile/04850166742797443954noreply@blogger.comtag:blogger.com,1999:blog-7655407863660711763.post-80188992960277122662009-02-12T11:29:00.000-05:002009-02-12T11:29:00.000-05:00Dr. Rubin,Thanks for your prompt reply. I promise...Dr. Rubin,<BR/>Thanks for your prompt reply. I promise not to make this an endless back-and-forth. We may reach a point where we have to agree to disagree. However, I hope you will be patient and indulge me in some questions, as I struggle to find the consistency in your position.<BR/><BR/>Let’s start with this. You’ve explained why you feel it important to attend IDSA. But my real question is that given the pervasive influence and huge potential for bias (see page 2 of the pdf below!) how do you deal with it? How do separate the wheat from the chaff to make it a worthwhile learning experience?<BR/><BR/>http://www.icaacidsa2008.org/documents/2008SupportOpportunities_000.pdfRobert W Donnellhttps://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-7655407863660711763.post-39115732156129179012009-02-12T08:27:00.000-05:002009-02-12T08:27:00.000-05:00You left your reply at 1:44 AM? We gotta get you o...You left your reply at 1:44 AM? We gotta get you out more. I finished the post at midnight and it nearly killed me. I guess this explains how you can come up with 30 posts just in February alone (and I mean that with genuine admiration--I certainly don't have the time or the energy to keep up with that pace). <BR/><BR/>Anyway, thanks for the extensive list! I'm certain that without the complete version your point would have been totally misunderstood. My answer is that I go to such meetings fully aware of the heavy corporate underwriting and the potential influence it has on the physicians who attend meetings like IDSA or ICAAC, and would prefer to have the system minimize that influence. Several of those companies above offer "travel scholarships" so that medical and graduate students, fellows, and international physicians can attend; several others do no market pharmaceuticals. Others still might not have sponsored IDSA alone but were on board for the ICAAC component, which has a similar but slightly different audience and relationship to industry. (Without getting too technical for the non-specialists reading this, the ICAAC convention focuses heavily on drug discovery and development, so many who attend that conference either work for or have close ties to the pharmaceutical or diagnostics industries. This past year they merged the two conventions, which happens every so often so that participants don't have to choose which one they'd prefer given travel & conference costs.)<BR/><BR/>The point is that meetings of the size and magnitude of either IDSA (annual attendance usually 10,000), ICAAC (attendance usually 15,000) or the third large North American ID conference, CROI (Conference on Retroviruses and Opportunistic Infections, annual attendance ~5,000) can't easily be ignored by any ID specialist, regardless of the corporate sponsorship of the event. I'm not going to cut off my nose to spite my face because the system works the way it does right now. But aside from the genuinely helpful industry contributions like scholarships and fellowships, there are obvious and egregious attempts to get in drug advertisements, and these should clearly be eliminated. <BR/><BR/>A few examples: when I went to the ICAAC convention in San Francisco in 2006 my electronic hotel room key didn't bear the name of the hotel, but rather had the corporate logo of Sanofi-Aventis and advertised the then hot-new-macrolide Ketek. (Ketek didn't stay hot for long though, as it was withdrawn from the market for being associated with several cases of acute liver toxicity--cases which the FDA alleges were suppressed by the company in order to grease the rails for FDA approval.) <BR/><BR/>At a different convention, the bookbag I received to carry around convention materials had a big Novartis logo plastered across it. It's one thing to allow drug companies to advertise their products at a convention; it's a totally separate matter to FORCE physicians to advertise their products by just showing up to the convention. And yes, in case you were wondering, I refused to use that bag, thankfully having brought the previous year's edition along which does not sport any corporation's name.<BR/><BR/>The idea that one can avoid all possible sources of industry bias by refusing to participate in professional meetings is about as naive as supposing that one can find a way to read journal articles that are free of taint. As I noted in the post, even reputable journals have difficulty ferreting out studies where the data have been sufficiently massaged to ensure outcomes favorable to drug companies (file under: Vioxx, Celebrex, Neurontin, and the list goes on). And Medscape too, a website that I find very useful, has a lot of corporate sponsorship. So what am I going to do? Stop reading articles? No, of course not. I'm not a Luddite, though perhaps you believe it to be so. I'm simply proposing that our professional groups should try to minimize their involvement with groups whose job is something other than treating patients, and that if the corporations themselves behaved more responsibly perhaps we wouldn't be at this crossroads. But as a group they don't behave well--I mean, they really, really don't behave well--and you don't exactly have to get out a pair of binoculars to find evidence of it.Billy Rubinhttps://www.blogger.com/profile/04850166742797443954noreply@blogger.comtag:blogger.com,1999:blog-7655407863660711763.post-69125872831451156212009-02-12T04:44:00.000-05:002009-02-12T04:44:00.000-05:00Dr. Rubin,I gather from your post you attend IDSA....Dr. Rubin,<BR/>I gather from your post you attend IDSA. How do you resolve their commercial bias? It appears they are calling for industry exhibitors for their 2009 meeting. Here’s a partial list of supporters of past meetings I copied and pasted from their web page. It appears the degree of support is substantial. How can you even go to their meetings with all that potentialfor bias?<BR/><BR/><BR/><BR/>IDSA is grateful to the following companies that supported the Society’s mission through their participation at IDSA 2007 and the 2008 ICAAC/IDSA Joint Meeting*:<BR/>3M Medical Diagnostics<BR/>AAIPharma<BR/>AB BIODISK<BR/>Abraxis Pharmaceutical Products<BR/>Advanced Life Sciences<BR/>AdvanDx, Inc.<BR/>Aids Healthcare Foundation<BR/>Alliance Biosciences<BR/>American Academy of HIV Medicine (AAHIVM)<BR/>American Academy of Pediatrics<BR/>American College of Physicians/Annals of Internal Medicine<BR/>Amerifit Brands<BR/>AMMI Canada<BR/>Angiotech<BR/>Antimicrobial Therapy, Inc.<BR/>Applied Maths, Inc.<BR/>ARFID<BR/>ARPIDA LTD<BR/>ASM Press<BR/>Associates of Cape Cod, Inc.<BR/>Association of Medical Microbiology & Infectious Disease Canada<BR/>Astellas Pharma US, Inc.<BR/>AstraZeneca<BR/>ATCC<BR/>AutoGenomics, Inc.<BR/>Banner Health<BR/>Bard Medical Division<BR/>Basilea Pharmaceutica<BR/>Baxter Healthcare Corporation<BR/>BD Diagnostics<BR/>BEI Resources<BR/>Berna Products<BR/>BioCryst Pharmaceuticals<BR/>bioMerieux, Inc.<BR/>BIOQUELL, Inc.<BR/>Bio-Rad Laboratories<BR/>Bio-Synthesis, Inc.<BR/>Boehringer Ingelheim Pharma, Inc.<BR/>BRAHMS USA, Inc.<BR/>Bristol-Myers Squibb<BR/>CAEAR Foundation<BR/>Cambridge University Press<BR/>Cardinal Health<BR/>CDC MMWR<BR/>CDC/Division of HIV/AIDS Prevention<BR/>Cellestis, Inc.<BR/>Center for Biosecurity of UPMC<BR/>Centers for Disease Control and Prevention/Porter Novelli<BR/>Cepheid<BR/>Clinical and Laboratory Standards Institute<BR/>Clinical Care Options<BR/>Clinical Infectious Diseases<BR/>Clongen Laboratories, LLC<BR/>Copan Diagnostics<BR/>Core Health Services Inc/www.Can-R.ca<BR/>Cornerstone BioPharma, Inc.<BR/>Covance Central Laboratories<BR/>Crescent Healthcare, Inc.<BR/>CSL Biotherapies<BR/>Cubist Pharmaceuticals<BR/>Diagnostic Hybrids<BR/>DiaSorin<BR/>Duke Clinical Research Institute<BR/>eENZYME LLC<BR/>Elan Pharmaceuticals, Inc.<BR/>EMD Serono, Inc.<BR/>Emerging Infections Network<BR/>Enzon Pharmaceuticals<BR/>Esterline Advanced Input Systems<BR/>Eurofins Medinet<BR/>European Society of Clinical Microbiology and Infectious Diseases (ESCMID)<BR/>FDA/Med Watch<BR/>FiberCell Systems, Inc.<BR/>Focus Diagnostics<BR/>Food and Drug Administration/Office of New Drugs<BR/>Forest Laboratories, Inc.<BR/>Future Science Group<BR/>Genzyme Corporation<BR/>Gilead Sciences<BR/>GlaxoSmithKline<BR/>HEALIX<BR/>HHI Infusion Services<BR/>HRA Research<BR/>i3 Research<BR/>IBIS Biosciences, Inc.<BR/>IBIS Biosciences, Inc./Abbott Molecular, Inc.<BR/>IBT Laboratories<BR/>Immunizations for Public Health <BR/>Immuno-Mycologic’s Inc.<BR/>INC Research<BR/>Infectious Disease Special Edition<BR/>Informa Healthcare<BR/>Institute for Clinical PharmacodynamicsOrdway Research Inst.<BR/>IntegReview Ethical Review Board<BR/>Integrium<BR/>International Center for Equal Healthcare Access <BR/>International Health Management Associates, Inc.<BR/>International Immunocompromised Host Society<BR/>International Society for Infectious Diseases<BR/>International Society of Travel Medicine<BR/>International Symposium on Viral Hepatitis and Liver Disease<BR/>Inverness Medical Professional Diagnostics<BR/>iSentio AS<BR/>JMI Laboratories<BR/>Johns Hopkins POC-IT<BR/>Journal Watch<BR/>Kadlec Health System<BR/>Kaiser Permanente<BR/>Kenwood Therapeutics<BR/>LABORATORIOS BAGO S.A.<BR/>Lippincott Williams & Wilkins<BR/>Logical Images, Inc.<BR/>MarLin Medical<BR/>Medical Diagnostic Laboratories, LLC<BR/>MedImmune<BR/>MedPage Today, LLC<BR/>Medtronic ENT<BR/>Merck & Co., Inc.<BR/>Microbiology International<BR/>Micron Group-US Micron<BR/>MicroPhage, Inc.<BR/>Millipore<BR/>MiraVista Diagnostics<BR/>Monogram Biosciences<BR/>Myconostica Ltd.<BR/>NanoBio Corporation<BR/>Nanogen, Inc.<BR/>National Foundation for Infectious Diseases<BR/>National Institute of Allergy and Infectious Diseases<BR/>National Network of Prevention Training Centers<BR/>NeilMed Pharmaceuticals<BR/>Neutec Group, Inc.<BR/>New England Journal of Medicine<BR/>NM Travel Health<BR/>Northrop Grumman<BR/>Northstar Business Consultants LLC<BR/>Novartis Vaccines & Diagnostics<BR/>OpGen, Inc.<BR/>Optimer Pharmaceuticals<BR/>OraSure Technologies, Inc.<BR/>Ortho-McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.<BR/>Oxford Immunotec LTD<BR/>Oxford University Press<BR/>Pall Medical<BR/>PAR Pharmaceutical<BR/>Paragon Biomedical, Inc.<BR/>Pediatric Infectious Diseases Society<BR/>Pfizer Global Pharmaceuticals<BR/>Poz, A Smart + Strong Publication<BR/>PPD<BR/>Premier, Inc.<BR/>PrimeraDx<BR/>ProActive Billing & Management Solutions, Inc.<BR/>Prodesse, Inc.<BR/>PSI<BR/>QUIDEL Corporation<BR/>Quintiles, Inc.<BR/>Quotient Bioresearch<BR/>Replidyne, Inc.<BR/>Rib-X Pharmaceuticals, Inc.<BR/>Ricerca, LLC<BR/>Robert Michael Educational Institute LLC<BR/>Roche<BR/>Romark Laboratories, L.C.<BR/>SAIC - Frederick<BR/>Salix Pharmaceuticals, Inc.<BR/>sanofi pasteur<BR/>Saunders/Mosby-Elsevier<BR/>Schering-Plough<BR/>SciMed<BR/>Seegene, Inc.<BR/>Sequenom Inc<BR/>SGS Life Science Services<BR/>SLACK Incorporated<BR/>Soaptronic, LLC<BR/>Society for Healthcare Epidemiology of America<BR/>Society of Teachers of Family Medicine - Group on Immunization Education<BR/>Spiral Biotech, Inc.<BR/>Springer<BR/>Sprixx<BR/>SRI International<BR/>Strativa Pharmaceuticals: A division of Par Pharmaceuticals<BR/>Targanta Therapeutics<BR/>VISIT: www.idsociety.orgRobert W Donnellhttps://www.blogger.com/profile/16944231400440786271noreply@blogger.com