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

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

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Bristol another example?
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Doctors and drug companies. Too close for comfort?
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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

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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 wont 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.)

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16 forms of entanglement between doctors and drug
companies

• Ownership of stock or equity holdings
• Conducting sponsored research (Its 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

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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.)

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16 forms of entanglement between doctors and drug
companies

• Authoring "ghostwritten" scientific articles (A
  critic on Naomi Campbells autobiography If she
  cant be bothered to write it I cant be bothered
  to read it.)
• Medical journals' reliance on drug company
  advertising, company purchased reprints, and
  sponsored supplements (Its a million quid and
  800 000 profit for reprints of a major trial.
  Without it I might have to lay off staff. But
  were not influenced in our decision making.)

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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

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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

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Corruption in medicine? Evidence from medical
publishing
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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

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Conflict of interest a case study in poor
performance within biomedicine
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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

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Why dont authors declare conflicts of interest?

• Some journals dont require disclosure
• The culture is one of not disclosing
• Authors think that its somehow naughty
• Authors are confident that they are not affected
  by conflicts of interest

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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.

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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

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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

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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.

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Other topics I might have covered

• Private practice
• X has had a heart attack. Wholl do his on
  call?
• Whover does it normally, when hes doing his
  private practice.
• Merit awards
• Fundholding keeping prescribing deliberately
  high in order to maximise next years budget
• Racism
• Lucragrams

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Why do we have corruption?

• Why wouldnt we?
• Much of medicine operates on trust
• Inadequate accountability
• Inadequate training
• Poor role models
• Pressure to publish

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Why do we have corruption?

• The main target of one of the worlds 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.

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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 Im more impressed with what medicine
  cant do than it can do. I cant fix this. Id
  better keep quiet. My salary and my status comes
  from my magical powers.

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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

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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

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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

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What can be done about corruption in medicine?

• Teaching/discussions on best practice in relating
  to patients, research, etc
• Leadership (Tone at the top)

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Finally, recognise something that I didnt
recognise until I was fifty and three quarters
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Integrity is not something you have and hope
not to lose but something you must work at every
day.