Saturday, September 7, 2013

An Update on KOLs

In the previous post I mentioned a collection of essays on institutional corruption in Pharma. One of the essays:
--by our old acquaintance Sergio Sismondo at Queen's University in Canada, provides something of an update on the status of KOLs, who were discussed here last with:

Trying to hit the high points, I note that Sismondo is engaged in an ongoing study of KOLs and their influence that includes having attended a number of industry conferences on KOL identification and management, and interviews with a number of highly paid KOLs and Pharma insiders. He agrees with earlier posts here that the drug firms are increasingly outsourcing KOL management to firms specifically devoted to that enterprise. I have previously tended to stress the KOL who's usually a big fish in a small pond, the physician who's supposedly being paid to talk to other docs, but in reality is being paid bribes for her own high rate of prescribing of the company's drug. Sismondo is concerned more about the other end of the spectrum, the big-pond fish who truly can exert influence across large numbers of docs and are being paid especially to do that. The small-pond types typically command $500 to $1000 per lecture, Sismondo tells us, while the big-pond KOLs can draw down $2500.

One interesting and suggestive observation is that as one moves up the food chain to the truly influential docs, the industry treats them more as partners and with kid gloves, because (as one experienced industry consultant told Sismondo): "the number-one requirement specified by KOLs is: 'protect my reputation.' He goes on to reiterate that KOLs desperately want to avoid the 'appearance of...being an industry 'sell-out.'" This seems extremely important because it suggests that the efforts of us pharmascolds over the past decade has actually had an impact. Since KOLs are, indeed, industry sell-outs, this suggests to me at least that a serious campaign within medicine and biomedical science to thus label them publicly could have a significant impact on the general level of professional behavior. On the other hand, Sismondo is skeptical about transparency alone as a vehicle for positive change, and argues that the new U.S. Sunshine Act will have relatively little impact on KOL activity. If anything, the industry is betting on the continued thriving of KOLs; Sismondo notes that currently 15 to 25 percent of total marketing budgets go to speaking events.

I just now suggested that a possible strategy to reduce the number and the influence of KOLs would be to shame them more. Sismondo seems unsure that this would work: "...the medical profession has been corrupted because a small number of companies with well-defined and narrow interests have inordinate influence over how medical knowledge is produced, circulated, and finally used by physicians to make decisions concerning their patients....Most physicians see the companies as playing legitimate roles when the companies promote products in clinics, when they create and distribute medical research, and when they fund and provide continuing medical education." That is, even if KOLs personally wish to avoid looking like sell-outs to industry, Sismondo claims that the larger profession is quite blasé about whether or not these folks have actually sold out. I'm not sure I totally agree with Sismondo on this pessimistic take on general professional values; see for example:

OK, so what do we do about all this, if Sismondo is unsure that shaming KOLs gets us any traction? The big-enchilada solution, for Sismondo, is to break up the industry, separating the research-and-development portion of pharmaceuticals from the selling-and-marketing part. One set of firms would discover new drugs, and once those drugs had been shown to meet high standards of efficacy and safety, those firms would auction off licenses to make and sell the drugs to other firms. This would, Sismondo thinks, remove many of the perverse financial incentives that arise from marketing getting mixed up with research.

Sismondo agrees that this grand solution won't happen anytime soon, so his temporary backup plan is: ban physicians speaking on behalf of drug companies. He argues that nothing is served by this and while firms have every right to market, they could just as well have sales reps give the talks. Of course this ban is just as likely to happen anytime soon as the other proposal, unfortunately. But the point for medical ethics and professionalism is that it could effective happen tomorrow--if only physicians would grow an ethical spine and simply refuse to attend company-sponsored talks.

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