I made a discovery this week about the novel anticoagulant medications, dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Lixiana). I was looking into the often-asked question of how these new drugs compare to the old standard, warfarin.
The discovery felt like a Eureka moment. I ran it by my stats guy–my son–and a couple of colleagues, and they confirmed, that my discovery was truth. I’m working on a post now that discusses the details of how the medical world has been misled about these drugs. Stay tuned.
For now, though, this revelation got me thinking about medical education. How does it happen that doctors (and patients) can be misled?
Many smart people think medical misinformation occurs in large part because industry pervades medical education. Examples abound, but look no further than the dronedarone (Multaq) blemish. The short story is that dronedarone was touted as a new wonder drug for AF. The marketing held it up as a metabolite of amiodarone that had the mother drug’s efficacy but none of its toxicity–an amiodarone light. This was hogwash. The drug was evaluated in studies designed to obfuscate. It was hyped by thought leaders with deep financial ties to the drug maker. And then, even when trial data and real-world experience demonstrated inefficacy, the hype persisted. Thought leaders continued to make dinner rounds in cities throughout Europe and the US. Not until the PALLAS trial showed that dronedarone increased mortality in patients with permanent AF, did the noise die down. The excessive hype was an embarrassment for the cardiology community.
This brings me back to continuing medical education or CME. Currently, most CME is offered to doctors free of charge. But, of course, everyone knows about free lunches. The way doctors get free (or discounted) CME is through industry funding. For-profit medical companies happily provide dollars and expertise for medical education. They hire thought leaders, often guideline writers, to do lectures and webinars. They fund medical societies who then curate the content of the education. Industry entwines itself in medical education.
Medical education, however, is not supposed to be like an advertisement. Ads are declared as ads. The lines blur when industry sponsors CME.
A skeptic might posit that a thought leader can easily tout a dubious drug during a CME activity. Mind you, not in a criminal ProVasic kind of way. Rather, the nimble-of-mind academic can hide behind relative risk ratios and dodgy study designs. The skeptic might say this is worse than an evening news ad or glossy spread in a print journal. I wonder: is it worse because itâ€™s tricky? Or worse because itâ€™s effective? Or both?
The same idea holds true for medical journal editors. They suspect a study is dubious but let it pass because they are conflicted by the need to sell journals and advertising space. A possible scenario: Let’s say a pacemaker company supports a journal with big advertising dollars. Then let’s say that pacemaker company suffers a ghastly lead recall. How easy will it be for editors to publish negative editorials or studies on that lead? I’m just asking. These are humans playing the game after all.
This stuff is important. I often find myself shaking my head at conferences. I think to myself: Are doctors really this gullible? They canâ€™t see the manipulation?
Such examples lead some skeptics to say that medical education should be funded by only one source–the person consuming the education. Namely the doctors. This makes a lot of sense on paper. The problem comes in deciding how much CME should cost? How much will the teachers make? Who will do the teaching? Who will certify the teachers and the information?
Consider that I give CME lectures at my hospital. Lots of regular doctors do. We do it for nearly nothing. We do it as an avocation, not a vocation. But lectures at the home hospital are just a drop in the bucket of CME need. And who is to say that an unpaid Mandrola lecture is worthy? I gave lectures before I read Ben Goldacre. Maybe I misled the herd?
Social media — a potential solution?
Perhaps social media can outsource/crowdsource medical education? Social media and the Internet is changing the landscape of learning. Look at the FOAM experience, and PLOS, for instance. In education, look at what Sal Kahn has done.
Medical education is a tough problem. The practice of Medicine depends on the availability of effective medicines and devices. We need industry to educate us about their products. I can’t easily ablate AF without eye-popping technology from Johnson & Johnson.
The line separating skepticism from paranoia and nihilism is also blurry. One has to believe that humans, for the most part, are good. Medical thought leaders are no less human than any of us. We are all just ambling along trying to better ourselves first and humanity second. Right?
Call me naive, but I believe it’s possible that doctors and patients could be (partially) inoculated against industry manipulation. We can teach ourselves to look at absolute risks, NNT and study design. We can learn from the work of Drs. Harlan Krumholz, Sanjay Kaul, Eric Topol, Ben Goldacre, and many other voices of reason. We can learn to discern quality journalism from hype. Go read my colleagues at heartwire. I challenge you to find industry hype in their reporting.
And yes, doctors might even be able to learn from each other, on platforms like this.
18 replies on “Are doctors being duped through medical education? Could social media help?”
Well said! I shake my head at some conferences/inv mtgs as well, and I am “just a ” research nurse!
….and I have always learned something from Mandrola lectures and blogs, so keep teaching…….and keep teaching nurses!
John, I couldn’t agree more with your comments. Natrecor is another cardiac drug that was shamelessly promoted by thought leaders, horribly overused and ultimately proven to be worthless. The newer oral anticoagulant agents are being promoted to doctors constantly. I receive ,from what are supposed to be reputable physician information sites, multiple times a day emails that contain advertisements for them. I can’t watch a football game without hearing an old guy talking about “a fib” and the new wonder drug to prevent stroke. Even the email I get from the ACC giving me the table of contents for JACC is surrounded by a plug for Xarelto!
Yes, doctors need to continuously update their knowledge base. Unfortunately, what the big money from big pharma thrown into advertising does is make it much more likely that the majority of information most doctors are getting is about the latest, most expensive drugs. For this reason, we doctors must meticulously work on getting unbiased information. I believe this means avoiding all pharma-sponsored talks, lunches, dinners, webinars, etc.. It’s tough to turn down the “free lunch” but it is the right thing to do.
I can hardly wait to read your comments on Dabigatran. Unfortunately I had to find out about the damage it can cause the hard way.
Thank you, Dr. Mandrola for investigating these issues and sharing the information with us. As a layperson, I truly appreciate the time and effort you put into educating us all. With so much knowledge out there, and with so many ways to “slant” it, your posts on behalf of the truth are very refreshing.
What? CME may be tainted by drug money? I am shocked – SHOCKED – at your allegations. Welcome to the Gang of Skeptics. The DTIs and xabans are promoted as “better than warfarin” based on marginal studies with minimal benefit. They are also touted as superior because you don’t have to follow an INR. I kind of miss the point here – why is it a BAD thing to follow someone with laboratory results when they are taking a potentially lethal drug? As an ER doc I preach about the dangers of these things, especially in trauma patients. And yet there are GOBSAT* recommendations on how to reverse them from austere bodies of solemn people – “consider Factor VIIa, consider dialysis, consider DDAVP.” What a crock – none of these things work, but since they are recommended we are more or less obliged to try them. It’s only going to get worse.
*GOBSAT = Good Old Boys Sitting Around Talking
Hallelujah! If only more and more physicians like you would come forward like this to sound warnings about the Emperor’s new clothes, perhaps there is indeed hope for those of us who are the end users of these drugs, devices and treatments – those whose docs have been “educated” by industry.
We already know that there’s often a demonstrated difference between internal drug company documents about the trial results they fund, and the papers reporting that research that end up in the journals my doctors read. The NEJM once referred to this practice as “selective outcome reporting”.
But for the sake of clarity, letâ€™s just call it “lying”.
Meanwhile, medicine has finally embraced – well, perhaps “embraced” isn’t quite the word – this move towards compulsory disclosure of financial conflicts of interest in medical research, Speakers Bureau presentations or CME education. But the COI disclosure lists from many “thought leaders” (oh, please!) read like the “Who’s Who” of Big Pharma. Disclosure’s not the issue here – being on the take from industry is.
If this were happening in the world of professional sports, we would never tolerate referees, umpires and game officials taking cash from club owners. So why does medicine turn a blind eye to the same reality – particularly in CME education?
If I, merely a dull-witted heart patient, have been able to educate myself about absolute risks, NNT and study design, I’m pretty sure those with the letters M.D. after their names should be able to do as you suggest.
Whether we disagree or agree, I feel like I’ve done well if you weigh in. Thanks.
PS. Love *GOBSAT = Good Old Boys Sitting Around Talking – from Dr. Joe Lex
Agree entirely with your post Dr. John – and with the excellent comments by readers. I’ll reflect on the evolution of bias in CME over the past 35 years – with the “good news” being that awareness of this problem HAS increased – and in many places there ARE things being done about it (ie, no longer accepting pharmaceutical sponsorship in certain venues – or insisting such sponsorship is anonymous if accepted). CME committees in major institutions are more discriminating before contemplating sponsorship. There is however a “fine line” as you indicate – since without pharmaceutical companies there would be no drugs (same for many devices). My “Golden Rule” was always that a medical talk instantly loses credibility the moment you can guess which drug company sponsored the speaker. That rule still holds true. Social media (the “FOAM” experience, as you cite) is truly changing the scope of things – as more and more providers (as well as patients) are learning from the many available sources of free info on the internet (never existed back in my training and early practice days) – though the challenge now is to sort out which FOAM or other free internet sources are worthwhile and reliable (not always an easy task). Your Blog Dr. John – is one of the best! KEEP IT UP! – 🙂
Thanks for your supportive words and keen commentary Ken. Please keep writing.
November 24, 2013 “The statin story and new guidelines are compelling. I will weigh in soon enough on that one. Stay tuned.”
And now, the new anticoagulants: “The statin story and new guidelines are compelling. I will weigh in soon enough on that one. Stay tuned.”
“Science” based medicine, ha! The whole thing is human based, with all the attendant ramifications.
Help us here, Dr John.
(That should read: And now the new anticoagulants: “Iâ€™m working on a post now that discusses the details of how the medical world has been misled about these drugs. Stay tuned.” Dr John.)
And if you ever use conditional probability to make a treat with fancy new drug vs don’t treat with fancy new drug, and include the alternative meds along the “don’t treat with fancy new drug” arm…well then things get REALLY interesting.
Fair points but less of an issue than a decade ago. Industry sponsored CME is on the wane with ACCME guidelines and Pharma code and more and more academic health centers disallowing faculty to do promotional lectures. As course director for Grand Rounds at UMCPP, we have rigorous oversight for promotional bias in CME. That said, the number of sponsored programs is only one or two a year at my institution down from 5 to 7 a year five years ago and one or two a month when I was in training in the mid 1980’s. Also note the Physican Payment Sunshine Act
Important to be vigilant but the stringent fire walls for CME are real. I would be much more atuned for bias at promotional talks
Thanks for the comment. I am with you on the issue of Sunshine. http://www.drjohnm.org/2013/08/how-much-sunshine-is-just-the-right-amount/
I think skeptics might argue with you that bias and COI exist even with the measures you describe. I’ve always considered the dinner talks and overtly sponsored talks as ads. They are at least more transparent. The bigger problem, skeptics might say, is when COI and bias is disguised. Things like showing a disclosure slide at a national meeting for less than a second. Or, letting academics with financial interests write clinical guidelines. Or, using relative rather than absolute risks to promote superiority in one treatment over another.
I happened on your website sometime ago and have enjoyed your perspective on biking and medicine, two of my new interests, as I have become a road bike fanatic, and out of necessity, a 65 year old patient for the first time. I have been on Xarelto for 12 months following a massive one time PE event. Now your comments have me concerned. I await with interest and concern, your observations on these new drugs. Be careful, you are about to take on the big boys! But you already know that.
Only the US and New Zealand allow big pharma adverts. Recently watched documentary footage of Cleveland Clinic Chief of Cardiology take on big Pharma over a massively marketed drug for diabetics…that swiftely created a 30 % increase in heart attacks and heart attack deaths. He went on-line, found only partial disclosures and rooted out the real test trail results. Next move was a Senate hearing to force the information into the public domain. (pharma had set aside 6 billion dollars in a settlement fund, knowing what was coming before, during and after their product was ‘released’. Only had to pony up $3 billion).
I’m going to lobby The Great Courses to ask you to create a course for ‘the masses’ on the ‘electric’ heart issues… your specialties. There is a yawning gap between swift diagnoses and patient understanding. I saw a bright UVA ER dr try to subtley get her male heart attack patient to consider dietary changes…His response: “Well, I eat the usual healthy breakfast…bacon, eggs, sausages, hash browns. I’ll change what I eat when I find out what is wrong with me.” ???? This was his 4th heart attack and he lit up as soon as he left. Had never been to doctors in his childhood. Popped open a can of Vienna saugages for lunch. ?????
We badly need doctors teaching courses to this segment of the patient population. Your eloquence at connecting the dots for civilians has the potential to slice through the thickest noggins.
PLEASE so hurry and tell us–sounds like we’re gonna be screwed on this one
“I made a discovery this week about the novel anticoagulant medications, dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Lixiana). I was looking into the often-asked question of how these new drugs compare to the old standard, warfarin.
The discovery felt like a Eureka moment. I ran it by my stats guyâ€“my sonâ€“and a couple of colleagues, and they confirmed, that my discovery was truth. Iâ€™m working on a post now that discusses the details of how the medical world has been misled about these drugs. Stay tuned.”