Doctors, drugs and disclosure

prescribing.jpg  These two articles were just published in JAMA and the Journal of Clinical Oncology [subscription required]:

Ross JS, Lackner JE, Lurie P, Gross CP, Wolfe S, Krumholz HM. Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. JAMA 2007; 297(11):1216-1223.

CONTEXT: Recent legislation in 5 states and the District of Columbia mandated state disclosure of payments made to physicians by pharmaceutical companies. In 2 of these states, Vermont and Minnesota, payment disclosures are publicly available.
OBJECTIVES: To determine the accessibility and quality of the data available in Vermont and Minnesota and to describe the prevalence and magnitude of disclosed payments.
DESIGN AND SETTING: Cross-sectional analysis of publicly available data from July 1, 2002, through June 30, 2004, in Vermont and from January 1, 2002, through December 31, 2004, in Minnesota.
MAIN OUTCOME MEASURES: Accessibility and quality of disclosure data and the number, value, and type of payments of $100 or more to physicians.
RESULTS: Access to payment data required extensive negotiation with the Office of the Vermont Attorney General and manual photocopying of individual disclosure forms at Minnesota’s State Board of Pharmacy. In Vermont, 61% of payments were not released to the public because pharmaceutical companies designated them as trade secrets and 75% of publicly disclosed payments were missing information necessary to identify the recipient. In Minnesota, 25% of companies reported in each of the 3 years. In Vermont, among 12,227 payments totaling $2.18 million publicly disclosed, there were 2416 payments of $100 or more to physicians; total, $1.01 million; median payment, $177 (range, $100-$20,000). In Minnesota, among 6946 payments totaling $30.96 million publicly disclosed, there were 6238 payments of $100 or more to physicians; total, $22.39 million; median payment, $1000 (range, $100-$922,239). Physician-specific analyses were possible only in Minnesota, identifying 2388 distinct physicians who received payment of $100 or more; median number of payments received, 1 (range, 1-88) and the median amount received, $1000 (range, $100-$1,178,203).
CONCLUSIONS: The Vermont and Minnesota laws requiring disclosure of payments do not provide easy access to payment information for the public and are of limited quality once accessed. However, substantial numbers of payments of $100 or more were made to physicians by pharmaceutical companies.

Jagsi R. Conflicts of interest and the physician-patient relationship in the era of direct-to-patient advertising. J Clin Oncol 2007; 25(7):902-905.

Conclusion: The matter at the heart of all of the cases discussed in this article is the increasingly empowered consumer-patient’s desperate need for unbiased information. The proliferation of advertisements from parties with financial interest is particularly dangerous when the physician cannot serve in an unbiased intermediary role. As illustrated by the cases herein, these situations are far from uncommon. As a result, physicians owe their patients disclosure of potential conflicts of interest. In addition, physicians should avoid becoming entangled in the potential conflicts of interest created by direct gift relationships with industry and should advocate for restraint in DTC advertising when other conflicts of interest are particularly acute, as in the cases of ads for physician services or equipment with high capital costs in which physicians have an ownership interest. Efforts to improve the quality of information available to patients through advertising and other media must be accompanied by concomitant efforts on the part of the medical profession to improve the ways in which physicians communicate with their patients, not only about the medical issues themselves but also about the conflicts of interest that are an inherent part of every physician-patient relationship.

Learning book technology and what dogs do best

book.png    Here are some little videos for your amusement. They all made me laugh out loud and they are not sexist, racist or political, so they are good Friday Fun candidates.

The first is a hilarious video called Training for a New Technology–“The Book”.  Here is a copy, on a blog entitled The Bamboo Project.

toby.png   The second is a series of dogs doing what they do best, from Purina. My personal favourites are Buster, Toby and Spike.

Physicians and drug representatives: Exploring the dynamics of the relationship

jgim.gif   Here is an intriguing article from the February 2007 issue the Journal of General Internal Medicine:

Chimonas S, Brennan TA, Rothman DJ. Physicians and drug representatives: exploring the dynamics of the relationship. J Gen Intern Med 2007; 22(2):184-190.    Related Articles

BACKGROUND: Interactions between physicians and drug representatives are common, even though research shows that physicians understand the conflict of interest between marketing and patient care. Little is known about how physicians resolve this contradiction.

OBJECTIVE: To determine physicians’ techniques for managing cognitive inconsistencies within their relationships with drug representatives.

DESIGN, SETTING, AND PARTICIPANTS: Six focus groups were conducted with 32 academic and community physicians in San Diego, Atlanta, and Chicago.

MEASUREMENTS: Qualitative analysis of focus group transcripts to determine physicians’ attitudes towards conflict of interest and detailing, their beliefs about the quality of information conveyed and the impact on prescribing, and their resolution of the conflict between detailers’ desire to sell product and patient care.

RESULTS: Physicians understood the concept of conflict of interest and applied it to relationships with detailers. However, they maintained favorable views of physician-detailer exchanges. Holding these mutually contradictory attitudes, physicians were in a position of cognitive dissonance. To resolve the dissonance, they used a variety of denials and rationalizations: They avoided thinking about the conflict of interest, they disagreed that industry relationships affected physician behavior, they denied responsibility for the problem, they enumerated techniques for remaining impartial, and they reasoned that meetings with detailers were educational and benefited patients.

CONCLUSIONS: Although physicians understood the concept of conflict of interest, relationships with detailers set up psychological dynamics that influenced their reasoning. Our findings suggest that voluntary guidelines, like those proposed by most major medical societies, are inadequate. It may be that only the prohibition of physician-detailer interactions will be effective.

Drug Information Databases: an analysis

drugs.jpg  If you use online drug information databases, or are in the market for one, you might find this article useful. It was just published online in BMC Medical Informatics and Decision Making. I have looked up the URLs for the tools analyzed and you can link to them through the abstract below.

Clauson KA, Marsh WA, Polen HH, Seamon MJ, Ortiz BI. Clinical decision support tools: analysis of online drug information databases. BMC Med Inform Decis Mak 2007; 7(1):7.

BACKGROUND: Online drug information databases are used to assist in enhancing clinical decision support. However, the choice of which online database to consult, purchase or subscribe to is likely made based on subjective elements such as history of use, familiarity, or availability during professional training. The purpose of this study was to evaluate clinical decision support tools for drug information by systematically comparing the most commonly used online drug information databases.

METHODS: Five commercially available and two freely available online drug information databases were evaluated according to scope (presence or absence of answer), completeness (the comprehensiveness of the answers), and ease of use. Additionally, a composite score integrating all three criteria was utilized. Fifteen weighted categories comprised of 158 questions were used to conduct the analysis. Descriptive statistics and Chi-square were used to summarize the evaluation components and make comparisons between databases. Scheffe’s multiple comparison procedure was used to determine statistically different scope and completeness scores. The composite score was subjected to sensitivity analysis to investigate the effect of the choice of percentages for scope and completeness.

RESULTS: The rankings for the databases from highest to lowest, based on composite scores were
Clinical Pharmacology,
Lexi-Comp Online,
Facts & Comparisons 4.0,
Epocrates Online Premium, [free], and
Epocrates Online Free.

Differences in scope produced three statistical groupings with Group 1 (best) performers being: Clinical Pharmacology, Micromedex, Facts & Comparisons 4.0, Lexi-Comp Online, Group 2: Epocrates Premium and and Group 3: Epocrates Free (p<0.05). Completeness scores were similarly stratified. Collapsing the databases into two groups by access (subscription or free), showed the subscription databases performed better than the free databases in the measured criteria (p<0.001).

CONCLUSION: Online drug information databases, which belong to clinical decision support, vary in their ability to answer questions across a range of categories.

Free internal medicine case-based education through the World Wide Web

mayoclinic.gif Here is a very useful resource from the February 2007 issue of the Mayo Clinic Proceedings [subscription required]:

Pappas G, Falagas ME. Free internal medicine case-based education through the World Wide Web: how, where, and with what? Mayo Clin Proc 2007; 82(2):203-207.

OBJECTIVE: To identify and evaluate electronic internal medicine educational sources and develop a list of major Web sites for interested practitioners.

MATERIAL AND METHODS: From July 1 to August 20, 2006, we searched Web sites derived from academic and nonacademic institutions, medical journal Web sites, and medical Web sites based on selection criteria, including extent of information, update periods, and validity of the source.

RESULTS: We present a list of related Web sites that have been selected as practical, valid, and freely accessed. Brief descriptions and particular characteristics of these sites are also provided.

CONCLUSION: Physicians willing to augment their education on decision making and advances in the field of internal medicine can consult abundant Internet resources, many derived from leading academic and nonacademic sources. The future may see entire educational courses being conducted on the World Wide Web, unifying the medical community, provided some forms of free access are implemented.

Table 1: Web Sites from Academic Institutions
Table 2: Web Sites from Other Institutions and Organizations
Table 3: Medical Journals With Relevant Rubrics
Table 4: Medical Web Sites
All tables include Source/Web site address/Title of relevant Web page/Relevant Web page address/Comments

See also The Annotated List of Online Continuing Medical Education

Folksonomies and Mashups?

scream.gif  Here is an article that makes me want to go off the grid and live in a log cabin, with only a canoe and a bicycle for transportation. (But I have printed it and will dutifully read it.) The article was published recently in  the Health Information and Libraries Journal [subscription required]:

Kamel Boulos MN, Wheeler S. The emerging Web 2.0 social software: an enabling suite of sociable technologies in health and health care education. Health Info Libr J 2007; 24(1):2-23.

Abstract: Web 2.0 sociable technologies and social software are presented as enablers in health and health care, for organizations, clinicians, patients and laypersons. They include social networking services, collaborative filtering, social bookmarking, folksonomies, social search engines, file sharing and tagging, mashups, instant messaging, and online multi-player games. The more popular Web 2.0 applications in education, namely wikis, blogs and podcasts, are but the tip of the social software iceberg. Web 2.0 technologies represent a quite revolutionary way of managing and repurposing/remixing online information and knowledge repositories, including clinical and research information, in comparison with the traditional Web 1.0 model.

The paper also offers a glimpse of future software, touching on Web 3.0 (the Semantic Web) and how it could be combined with Web 2.0 to produce the ultimate architecture of participation. Although the tools presented in this review look very promising and potentially fit for purpose in many health care applications and scenarios, careful thinking, testing and evaluation research are still needed in order to establish ‘best practice models’ for leveraging these emerging technologies to boost our teaching and learning productivity, foster stronger ‘communities of practice’, and support continuing medical education/professional development (CME/CPD) and patient education.

Definitions from Wikipedia:
Folksonomy: A folksonomy is a user generated taxonomy used to categorize and retrieve Web pages, photographs, Web links and other web content using open ended labels called tags. Typically, folksonomies are Internet-based, but their use may occur in other contexts as well. The process of folksonomic tagging is intended to make a body of information increasingly easier to search, discover, and navigate over time. A well-developed folksonomy is ideally accessible as a shared vocabulary that is both originated by, and familiar to, its primary users. Two widely cited examples of websites using folksonomic tagging are Flickr and, although it has been suggested that Flickr is not a good example of folksonomy.

Mashup: In popular culture, Mashup usually means:
– Mashup (music), a musical genre of songs that consist entirely of parts of other songs
– Mashup (web application hybrid), a website or web application that combines content from more than one source
– Mashup (video), a video that is edited from more than one source to appear as one
– Mashup, in parts of the UK also means a brew, or a pot of tea (colloq. Yorkshire)
– Mashup, is tools for web designers to make links portable wireless and useful, such as stock reports, weather, breaking news, mapping software, direction finder, business locator, service reviews.

Web 2.0    Web 3.0    Semantic Web
Web 1.0 is Read Only, static data with simple markup for reading
Web 2.0 is Read/Write, dynamic data through web services customize websites and manage items
Web 3.0 is Read/Write/Execute, web 1.0 + web2.0 + programme web according to your needs [build modules and plugin]

whatsthatbook.jpg  Is there a book you once read and would like to read again, but you just can’t remember the author or title?  Well, a former Google Answers researcher named Juggler will try to find the answer for you. You can register for free with and ask a question about that elusive book.

I have submitted a question and am awaiting an answer. You can browse the categories and read the Juggler’s answers. Lots of informative replies, complete with links and keywords.

By the way, Google Answers has been retired. Yahoo! Answers, However, is alive and well.