Clinical Practice Guidelines or Legalized Bribery?

Clinical guidelines are theoretically very useful, gathering leading experts to help front-line clinicians care for patients. Experts often spend decades doing research into a single clinical problem. Clinicians, on the other hand deal with a multitude of problems. A general practitioner may deal with cancer, heart disease, and obstetrical problems all in the space of 1 hour. So guidelines should serve to document ‘best practices’ and become a standard of care. Good guidelines identify and disseminate the most scientifically sound advice available.

Thus it is extremely important to monitor the integrity of the guidelines. Financial conflicts of interest (COI) among authors and sponsors of guidelines has the potential to turn these guidelines into nothing more than marketing tools for drugs and other devices. It is already well known these financial COI are extremely common among doctors and considered both widespread and acceptable. Biased guidelines harm patients by exposing them to medications unnecessarily, and puts other physicians in a dilemma, because they may be accused of falling short of the standard of care if they do not follow accepted guidelines.

Many authors have suggested the rather common sense precaution that doctors that write guidelines have no financial COI. This way, we can be sure that they are truly representing the scientific ideal of medicine. The public deserves no less. The problem with evidence based medicine already exists that virtually all good ‘evidence’ is written by Big Pharma. Negative studies tend to be neglected, and positive studies are strongly emphasized and widely disseminated. Thus, it is especially important to take steps to ensure that the ‘best evidence’ remains free of financial COI.

There are many ways that Big Pharma pays doctors. The more prominent the status of a doctor, the more likely he/she has been paid off. The most common are speaker’s fees and consulting fees. In the former, a pharmacy company will pay a doctor to deliver a canned talk (one that is written almost entirely by the pharmaceutical company) to an audience of other physicians. It is purely advertising, for which the doctor is usually paid $1500 – $2000. Not bad for an hour’s work, considering that he/she did not have to think about the lecture, write the slides or even know what needed to be said.

The second form of graft is consulting fees. The company will pay the doctor for his/her ‘advice’ as a consultant on how to market a drug. Of course, the company cares not at all about what he/she says. It is an opportunity to give these doctors a 2 hour advertisement disguised as a consultation. For this the doctor is paid $2000-$5000. It is no different than those free tickets you can get for sitting through some high pressure sales pitch from the time share company near Orlando. But doctors love these, because they are lucrative, and they get to listen to some drug rep tell them over and over how smart they are, and how influential. Flattery will get you everywhere.

The most insidious form of corruption is ‘research’ money. While it sounds great, it is usually another thinly disguised form of bribery. Some research project is usually set up with little or no academic merit. The universities setting this up are well paid. The doctors who participate are well paid. Best of all, research meetings are held regularly in lovely locations like Vienna and Hawaii. ‘Researchers’, of course, are invited to participate, all expenses paid. The public only sees that the company has donated ‘research’ money and that the doctor is doing ‘research’. These shenanigans happen every day, in every university. If you’ve ever wondered why there is so much money being raised for heart disease or cancer or diabetes, and why there is so little real medical progress – this is the reason. It is estimated that 80% of research studies are cited less than 10 times. That is the number of times another researcher had read the research and thought it was important enough to reference it. Less than 10 times means that only the authors themselves had even bothered to read it.

Because of the extraordinary power of guidelines from national organizations (American Heart Association or National Comprehensive Cancer Network, for example) to influence the practice of medicine, it is important that these guidelines be free of financial COI. For example, imagine your local school board and trustees. Imagine that the chair of the committee is also a paid consultant to a marijuana company. Now the school comes out that says that ‘Smoking weed is not really that bad for you. In fact, you should smoke more because it makes you good-looking and smart’. Would that be acceptable?

Imagine that your local neighbourhood planning office was led by a man who was receiving kickbacks from drug dealers. Now a dictum comes out that ‘Crack houses, grow ops and protection of dealers is great! Let’s get some more’. Would that be acceptable? We have names for this kind of behaviour. Kickbacks, bribes, corruption, graft. In medicine, we call it ‘acceptable, widespread and welcomed’.

In both cases, there is a clear financial conflict of interest, and both cases are completely unacceptable because committee members have a fiduciary duty to protect the interests of its group, and must be free of financial COI. Doctors also have a fiduciary duty to protect the public health, but it seems that nobody takes this COI very seriously. A survey found that 71% of clinical policy committee chairs and 91% of committee co-chairs had financial COI! Since these leaders determine who sits on the committee it is no surprise that “what is to be decided (by committees producing guidelines) is often already decided by with the selection of the deciders”. That is, if you stack the committee with people who love drug treatments, then the guideline will reflect this, even if the individual committee members are not complicit. Converting raw data into clinical recommendations requires the use of subjective judgement, so it is vital that people are unbiased.

The Institute of Medicine has clear policy guidelines and the article states that we have had “Two more decades of little, if any, progress”. That’s a clear condemnation of the failure of doctors to police themselves. Academic physicians cannot help but gorge themselves on the fountain of blood money coming from pharmaceuticals. They help write guidelines to promote big money drugs, lining their own pockets with ill-gained lucre. Even when clear guidelines exist for the creation of committees, they willfully flout these guidelines because they are not enforced, and it exists in a culture of denial.

As of 2011, 130 guidelines were reviewed to see how many complied with 18 of 25 Institute of Medicine standards. We’re not looking for perfection here. The median number of IOM standards (out of 18) was only 8. F***. That’s 44.4%. An ‘F’ grade for sure. Most guidelines written today are not worth the paper they’re written on.

Much evidence exists that financial COI influences doctors perceptions about medications. That’s no surprise. Doctors are human and as prone to advertising as anybody else. But doctors do not acknowledge that these financial COI plays any role in their medical decision making, when it is obvious and well proven that this is true. Good evidence exists that guidelines play a key role in promoting MORE care, but not BETTER care. Guidelines are better thought of as marketing materials rather than road maps to improved medical care. This stems directly from the root corruption of the people writing these tainted reports that now guide all of clinical medicine.

Compared to 1999, that last time a thorough survey was done, there has been no improvement in the quality of guidelines writing. There has been no reduction in corruption over the last 20 years, and there certainly is nobody in medicine pushing for more accountability. Why? Those that can push, are all on the take. Journals, universities, professors, doctors – all paid by pharmaceutical companies. It’s a complete travesty. Doctors make a very good living being doctors. Accepting tainted cash is not acceptable. Pharmaceutical companies exist to make drugs and sell them. They have no conflict of interest. Their interests are plain and obvious for all to see. No, it’s the doctors that accept this money that need to reform.

Let’s look at some specific examples.

The US Preventative Services Task Force determined that a blood test, PSA was NOT useful in the early detection of prostate cancer. Compare this to the American Urological Association, whose guidelines were chock full of conflicts of interest, which promotes screening.

This increased screening would mean more work for urologists, whose members make up the AUA and this whole thing means more $$$.

In another example, the National Cholesterol Education Program (NCEP) cholesterol guidelines update in 2004 considered 3 studies on primary prevention published since the 2001 update.

The ALLHAT study showed no benefits to statin medications in primary prevention. The PROSPER study showed that elderly people (>70 years) without evidence of disease showed no benefits from statins. The ASCOT study showed no benefit in primary prevention in women. Yet still, the NCEP 2004 update greatly expanded the indication for statin treatment. WTF??? All becomes clear when looking at who wrote the biased guidelines. It appears that when companies pay doctors a lot of $$$, they write nice things about who should be given drugs, making more $$$ for the company. In 2001, all 14 of the committee members had financial COI. In 2004, 8 of 9 (89%) of members had COI. Nice….For doctors and big Pharma, it’s a win-win situation. Doctors make more money, Big Pharma makes more money. Who loses? Everybody else. More patients take more drugs that don’t make them healthier, but expose them unnecessarily to side effects.

A last example comes from the use of anti-depressant medications.

Once again, we note that the NICE guidelines, which contains no red flags for COI, explicitly recommends AGAINST antidepressant medications. On the other hand, the American Psychiatric Association, which was in 2010 estimated to get $14 million in funding from drug companies, LOVES antidepressant medications and thinks they should be distributed like Halloween candy. Your mother died – you need drugs! Your dog is sick – you need drugs! You have marital problems – you need drugs!

Just recently, the American College of Cardiology (ACC) released new guidelines lowering the definition of high blood pressure to 130/80. This immediately makes over half of Americans defined as having high blood pressure. While the committee was relatively free of COI, it was not noted that on average, each editor of the Journal of the American College of Cardiology (JACC) received $475,072 in 2014 from Big Pharma. Who made this change? Oh, right. The ACC. Where was it published? Oh, right. JACC. The fact that millions more patients would be looking at starting new medications for the newly diagnosed ‘high blood pressure’ surely did not escape the notice of those pharmaceutical companies paying off the editors.

The reason there is so little public trust in doctors is really quite simple. We’re not that trustworthy. A few bad apples are destroying our reputation. It’s time to end the graft. The solution is very simple. If you write a guideline – neither your organization nor any individuals should be taking drug money. This is already true in virtually every other sphere of public service. We don’t allow politicians to take kickbacks. Why don’t allow government employees to take kickbacks. We don’t allow school boards to take kickbacks. Why allow doctors, universities and professors?

 

2017-11-21T10:16:24+00:00 28 Comments

About the Author:

Dr. Fung is a Toronto based kidney specialist, having graduated from the University of Toronto and finishing his medical specialty at the University of California, Los Angeles in 2001. He is the author of the bestsellers ‘The Obesity Code’ and ‘The Complete Guide to Fasting’. He has pioneered the use of therapeutic fasting for weight loss and type 2 diabetes reversal in his IDM clinic.

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Nate
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Nate

Has anyone looked at the DGAC’s current financial COI?

Stephen T
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Stephen T

I’d be fired and maybe prosecuted if I behaved in this way. The standards in medicine are far below those expected in far less important jobs. Thank goodness for doctors like Dr Fung, Kendrick, Hallberg and all the others. The internet, for all its faults, gives us a chance to hear and learn from such people.

Kurt
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Kurt

I agree. Thank goodness for the likes of Dr. Fung, Dr. Tim Noakes, Gary Taubes, Nina Teicholz, Dr. Michael Eades, Dr. Campbell-Mcbride, et.el. I don’t think people know the risks these people have taken, and the amount of ridicule they have received from their “peers”. They truly are heroes.

Stephen T
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Stephen T

An excellent list, Kurt. These people have done much more for public health than most people who we pay to help us and often do the opposite. I’m grateful to them.

I’d add sane and brave people in nutrition – Zoe Harcombe, Caryn Zinn and Trudi Deacon. Not easy in a field that persecutes people who make their patients better ‘inappropriately’.

Lilly
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Lilly

I’d like to add Dr Gary Fettke from Tasmania, Australia to that list. He has been sanctioned for giving low carb nutrition advise to his diabetic patients in an effort to avoid amputating their feet. He has since been told that if he speaks of nutrition to his patients, or publically, he will lose his license to practice medicine. He has chosen to ignore the sanction. Go Dr Fettke!

Stephen T
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Stephen T

Spot on, Lilly. I shouldn’t have forgotten him. The list is getting longer!

Anthony
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Anthony

Correct.

Kurt
Guest
Kurt

You can’t get people to see what is going on. Everyone just knows that doctors and researchers are just it in for the truth and to help people. LOL. I think this quote from Dr. Marcia Angell who was an editor-in-chief at the New England Journal of Medicine should scare everyone: “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor… Read more »

Roger Bird
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Roger Bird

I beat Dr. Maricia Angell by 40 years because I looked at the results and I looked at the type of thinking that medical doctors were doing, which was exclusively reductionistic, which means that the whole is equal to the sum of the part. Holism included reductionism and the exclusively holistic approach. Reductionism eschew holism. The result means that every time that I tried to do AnYtHiNg to help build my health, some medical doctor or organization told me that it was useless or harmful, and yet it usually worked for me. In the mid 1960’s, two medical doctors told… Read more »

Shane Carlson
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Dr. Jason Fung is definitely Canada’s top doctor. He should be minister of health for Canada.

Roger Bird
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Roger Bird

By my calculations of his educational history, Dr. Jason Fung was a genuine child prodigy. Eventually it will be obvious that he is the best of the lot. He is just now getting traction and will be accelerating his impact on society.

Thea Rodriguez
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Thea Rodriguez

Jason Fung and Aseem Mahltora are such plagiarists really not even preaching their own thoughts… social and media, money-makers these men are they are a part of the very practice they are attempting to expose themselves!

Stephen T
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Stephen T

Do you have criticism of the science?

People interested in money would find it a lot easier taking it from pharma. These doctors take on a failed but profitable orthodoxy and get thanks only from the public.

Roger Bird
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Roger Bird

No one gives a S— whether they are plagiarist or not, and no one gives S— what you think. I had the exact same thoughts 40 years ago that Jason Fung is having now, but I don’t fault him. You find fault because you still have your lips super-glued to the rear-ends of the medical profession and still haven’t realized that modern medicine is at least as destructive as either Nazism or communism.

Thea Fraudriguez
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Thea Fraudriguez

Ignore this account, this is either a bot or a pharma-funded negative comment. zzzzz….zzzzz….zzzzzz…..ignore.

Dr Fung and others with true courage of their convictions are single-handedly changing people’s lives for the better.

Lucy
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Lucy

I hope your doctors don’t over treat you because you could die. People are dying. If you give an old person too much medicine they die. If you drive down the blood pressure too low, old people fall and break their bones. The elderly and the young are being over medicated. Some of these drugs can make them suicidal. People are getting brain damage from drugs. People are hooked on pain killers.

Phil Campbell
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Phil Campbell

This is how the Swamp of Lobbyists gets things done. They put a bought-and-paid-for doctor on a committee that makes policy recommendations. when can argue with a committee of doctors. This is exactly why we have a pain medication crisis in the US. One articulate physician persuades a committee of colleagues to add a new accreditation standard that makes providers ask, “on a scale of one to ten, what is your level of pain.” This one policy change by a group of physicians is what fueled the opioid crisis the US has today. This committee just incentivized all US physicians… Read more »

Carl-Etienne Juneau, PhD
Guest

Wow. Thanks for posting this. I’m shocked.

Jennifer.E
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Jennifer.E

I have followed Ben Goldacre for some time in his discussions of “Bad Science.” Quite distressing. I note in friends and acquaintances as they become skeptics of anything associated with “western medicine” some of them have had the dangerous, tendency to reject all common-sense, turning to alternative, naturopathic, homepathic quackery, refusing to vaccinate their children, and in general, embracing the nonsense of anyone who supports their anger of being deceived by pharma and a corrupt, medical system. Most dangerous, the quacks and fraudsters offer another belief system for them to attach themselves to, often using pseudo-scientific terminology, citing non-existent or… Read more »

Stephen T
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Stephen T

The problem is putting everything in the same category. I agree that homepathy isn’t remotely credible, but there’s good reason to question the ever growing list of vaccinations and the refusal to look at the results. A real analysis of vaccinated and unvaccinated children would answer the question, and the data is probably available now, but there is an absolute determination to prevent this happening. Why? Pharma already knows the answer.

sten bjorsell
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sten bjorsell

Great Summary of the ongoing lethal corruption.
What about “further education” of doctors. I saw that in Sweden typically 80% was arranged by the medical practice/hospital in question and 20% direct by pharma industry.
But is the industry also “sponsoring” the “further education” provided by medical practices/hospitals, for instance with materials, talks, and videos? Anybody knows?

WereBear
Guest

I love you, Dr. Fung.

Roger Bird
Guest
Roger Bird

“The reason there is so little public trust in doctors is really quite simple. We’re not that trustworthy.” It must be very painful and discouraging for Dr. Fung to realize (recently) what I and many other people have realized for 45 freaking years. Of course we did not know the details of the corruption. Dr. Fung, one of the few people in North America who deserve the title “Doctor”, is providing a tremendous public service. I am surprised he still has his license and/or his life. Do you still worship at the Altar of Modern Medicine?

Helen C
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Helen C

Enjoy Dr Fung’s blog as always! While as a primary physician I’m seeing this happening daily, like patient come in asking for a PSA, lipid test or antidepressants; or my colleges doing PSA screening and giving statin to everybody whose total cholesterol is greater than 6mmol/l, regardless whether they are >70 years old, women or without disease… I feel so helpless and was unable to do anything about it. I tried to take some patients off their statins but other colleges will add it back. Or the patient would decide that he/she want to take it anyway, because they are… Read more »

sten bjorsell
Guest
sten bjorsell

There are also many other doctors making progress in the same field! Dr Unwin in the UK has transformed the clinic he is working on and getting diabetics type 2 off their medication faster than any other UK clinic. Now notice by the UK health board for being one of the lowest costing centres per person in the area! https://www.youtube.com/watch?v=KxbWw5jwzHs There are a few youtube videos with this very modest and progressive doctor. He is also a medical advisor and/or member of diabetes.co.uk, another web gathering of diabetes sufferers that are getting off medications and listening to each other’s experiences.… Read more »

David Carmichael
Guest

This is an excellent post. Many of the issues raised about Big Pharma reinforce why we need Vanessa’s Law (Protecting Canadians from Unsafe Drugs Act) to be enforced. It became a federal law in 2014 but has to be implemented by Health Canada.

Myles Omel
Guest

I have followed Dr. Fung on You Tube for over 4 months, and it goes without saying that he is simply correct in everything he prescribes for controlling obesity. I just finished yet another of his latest videos and I especially agree with one particular concept he stressed: It related to “context” – when one is evaluating what particular information is best to utilize: What is good for a 20-year-old body builder is not good for the 70-year-old patient who is struggling with diabetes. “Context” is a pithy word that this 80-yer-old pre-diabetes man can relate to and explains why… Read more »

Myles Omel
Guest

I forgot to add that I have lost 25 pounds in 11 months by using a combination of HFLC dieting and a daily 16/8 fasting regimen. This was all possible because this kind of regimen completely eliminates hunger pangs while providing ample energy from the moment I wake up. I also eliminated all my medications that I had been on for 40 years.